The Long Delay

Intern year is done. Let us reflect.

The best way to describe my sentiments on residency to date is: one long delay. For three years my life will be on hold and, hopefully, once these three years are over with I will emerge from hibernation three years older, a little smarter, a little slower, and a little more grizzled; ready to live my life once more. Aside from the rapid accumulation of medical knowledge I do not anticipate this experience netting me anything of significance. Which is a shame, because most of it has nothing to do with residency.

Don't get me wrong. I dislike residency as much as the next medical resident. It's just I don't have very good reason to. Aside from my ample complainings already documented, it ain't that bad. Things are busy and the hours are long, but not so long as to preclude a life outside the hospital for those with enough pluck. Unfortunately that life never seems to have taken place. I don't often do the things I like for lack of like-minded friends, don't often spend time with good friends for lack of common interests, and my chastity has never been less questioned. I got no God, no dog, no woman, waning patriotism, and little time or idea where to find these things. I'm not sad or mad, just frustrated. I've got it good -- That is one thing I do know even if I don't always feel it -- but unfortunately blessings don't necessarily a good life make. And so I wait. Twiddle my thumbs a little longer, hold my breath a little longer, futz around a little longer. (Longer with Big Red!) Keep going to work because that's what I do, and keep going home because that's where I live. I wait for the job to reset, friend pool to refresh, and for the time to once again look forward to something.

So that's how I feel about intern year. I did a lot of things, and then I moved on. End of Act One.

At least I got money. Mmmm assets....

A picture from my apartment. If only I had a balcony. Or a little gratitude.

A Profit Motive for Your Life

Eddie Spaghetti is a man of means. Looking to multiply those means he looks around for a good investment. Upon doing so he discovers Jose Conseco's Steroids and Bats Emporium. Jose, wanting to expand into the baseball business as well, is in need of some fresh investment capital. They talk, they sign contracts, and shortly Jose Conseco's Steroids and Bats Emporium becomes JC's Steroids, Bats, and Balls Super Center. The very first day Joe, Mo, and Flo all arrive in need of steroids, bats, and balls respectively. They collect their products, pay the cashier, and the transactions are completed. Everyone is happy; it's a fine business. It is not from kindness that Jose sells Joe, Mo, and Flo their goods, however, nor the charity of Eddie which leads him to lend money to Jose, but rather because what they all hope to obtain from the deal: profit. It is the profit motive which compels them to act, and it is the profit motive which makes them good people.

Eddie Spaghetti, now enriched, looks for another business opportunity. He finds Darryl Strawberry and his Baseball Glove and Medical Insurance Warehouse. Looking to expand, they talk, they sign contracts, and shortly D. Strawberry's Baseball Glove and Medical Insurance Warehouse expands into four neighboring territories. The very first day Joe, Mo, and Flo arrive at the store all coincidentally in need of health insurance. They peruse the options, discuss with the agent, and the transactions are completed. Joe and Mo leave with insurance, but Flo does not. Flo, it seems, is from San Antonio and her diabetes, polycystic ovarian syndrome, hairy chin, and compulsive cigarette use have precluded her from being insurance eligible. Mo has chronic medical issues himself, having lingering lung problems from contracting tuberculosis while working in the Peace Corps years back, and so has to pay a higher premium, but he is simply happy to have any coverage at all. That year Mo's tuberculosis, thought beaten, returns and is found to be multi-drug resistant. Due to pre existing condition exclusions and high copayments Mo is later led to file for bankruptcy. Some people are happy, some people are not; it's the health insurance business. It is not from the stinginess of Darryl that he denies Flo coverage, nor the greediness of Eddie that leads him to reject the claims of Mo, but rather because of what they all hope to obtain from the deal: profit. It is the profit motive which compels them to act, and it is the profit motive which makes them bad people.

As often stated I make no claims of being an economist. I did my two semesters in college, found them to be moderately interesting, and then moved on. Pareto efficiency and fiduciary relationships tend to give me seizures. Thankfully, the economics of health insurance are relatively straightforward. Whereas in most industries the profit motive spurs towards better products for less money produced more efficiently -- by practically speaking reducing costs and competitively pricing -- this is not so with the business of medical coverage. Instead in the health insurance industry product supply and demand are both constrained by the nondiscretionary nature of most medical care, cost management is limited by the science of medicine, and negative selection drives insurers to discriminatory distributions of coverage. Practically speaking, profit is obtained by maximizing coverage of healthy people and minimizing coverage of the sick. This may work for a large percentage of the population that is healthy or only mildly ill, but it will never and can never succeed in providing adequate care at reasonable prices to that sizable segment of the population with serious, chronic medical disease or the significant portion of the population that will find itself one day burdened with the same. It is not because of lack of competition nor lack of compassion, but simple, straightforward economics. You can not make money off of a Down Syndrome child and there is no profit to be had from lymphoma and leukemia.

And so socialism.

Socialism as a theory is currently empty. It is no way to run an economy. Nevertheless, there are lessons to be learned and numerous possible isolated applications to be had, and it is essential that we as Americans, with our historical fear of anything smelling of communism, remember this. Especially in our current and likely numerous future debates about health care. Socialized fire protection, socialized police security, socialized national defense, and socialized park systems are all industries long since collectivized, and happily so. Although there is today some debate about further privatizing education and many utilities the fact is for most these industries' histories they have contributed to a better and more prosperous nation and even today they continue to provide reliable, cost-effective business to those desiring their services. Few complain that the police department has a monopoly on preserving domestic order or that there is no competition to watch over our parks and maintain our monuments. Whether we realize it or not, we are in many ways a partially socialized nation already. Somethings are best tackled in spite of any profit that can be derived.

Such it is with health care. We can tweak and adjust, modify and massage, hope and pray, and we will never find a comprehensive solution or even a partial coverage solution at a reasonable price using private coverage. No matter how deductibles are calculated or plans are managed, medical insurance will remain expensive and outside the hands of a good number of people. Even Obama's hybrid system that satisfies no one and confuses everyone will not likely significantly change things. Universal coverage on the other hand abandons the false pretense that money can be made providing adequate health care and simply focuses on doing the best for the most with what we've got. It will certainly add some to our waits and reduce some efficiency, no doubt, but what do we have now? Our hospitals are already full, good people already fall through the cracks, care is already being rationed. Without the burdensome bureaucracy that accompanies herding a dozen different insurance programs and without the waste pervasive in the system as a result of poor communication and repeat testing the added costs would by most calculations likely be minimal. If the entire rest of the Western world can get by doing it -- if the French and the Italians can manage it -- certainly we can do one better. In the end universal health care is much like democracy; it is not a great option, but it is certainly the best one. There is, unfortunately, no "good way" to take care of people. And nothing makes this more clear than the economics of it all.

The OECD, US, and health care.

Medical insurance and bankruptcy.

Conservative case for universal health coverage.

Socialism!

The Great Pee Pee Mystery

Today, from roughly 1100 to 1700, I waited for an old man to pee so that I may take it and look at it under a microscope. Around 1715 I was given word that the long awaited urination had taken place. Briefly taking care of other urgent matters, I attended to my wee sometime around 1745 only to find it was nowhere to be found. Some masked stranger had run off with my urine. I asked the nurse, she didn't know. I asked the patient, he said "a doc" took it. I asked my interns, they were clueless. Somebody, for whatever clearly no good reason, had absconded with my wiz. I was upset. Although few will every appreciate this, there are few things more frustrating then waiting an entire day for urine only to have it disappear. Nevertheless it seems to be the running average for Williford Hall these days. Most labs get sucked up by gremlins in the vacuum tubes, most daily radiographs become every other day radiographs by the x-ray tech fairy, and half of our electrolyte panels seem as if the masked stranger himself is urinating in them yielding the wildest most ridiculous and inaccurate of results. Wilford Hall, you're too much for me. I don't know what to do with you.

Someone will pay dearly for the pee, though. Someday I will have my revenge.

I Should Have Been a Christian

I love the ladies, but the ladies, well, apparently they don't love me.

Or at least so suggests the informal polls that are Match.com and E-Harmony.

After six months of the former and three of the latter, it can conclusively be said that we, myself and the ladies, can both do better. By and large the women I fancied did not fancy me back, and by and large the women who fancied me seemed to be either entirely unaware of what was written in my profile or not particularly picky in their mate. It appeared that most of my attempts failed at or shortly after introductions, and most of their attempts never made much sense. Why women who did not share my interests or goals or even any of the "what I am looking for" criteria would think we would have any significant romantic connection is admittedly a bit beyond me. Perhaps there's intimacy in having absolutely nothing to talk about.

My failed attempts at wooing aside, the greatest realization I came to amongst all of this woman hunting is that perhaps I ditched the Christian faith thing a bit too early. Although this is an entirely unsubstantiated assertion, it seemed the more a profile directly or indirectly referenced Adonai the more fetching the woman was. (Either there is a significant lack of devout Christian guys leading to a surplus of devout Christian women or religious zeal and Internet access correlate directly with attractiveness and amicable disposition.) Unfortunately, part of being pious for most involves dating only the like minded, something about 2 Corinthians and unequal yoking, so that meant no matter how fabulous and charming I was, or how much I begged and pleaded, further discourse was right out. I was left to choose from only the nonbelievers and carnal Christians. To think, if only I had not turned to empty hedonism so quickly I could right now be enjoying myself some empty hedonism. Oh, Lord, you're an ironic one if nothing else.

This is not all to say that I missed out, though. That I feel somehow as if my experience was incomplete or that I pine for an endless series of what ifs. Perhaps had I still been waving the Christian flag I would have met the love of my life -- I would have at the very least had a larger pool of possibilities -- but I don't care for such perspectives. You do the best with what you got, learn, and move on. I certainly cannot choose my faith or will myself to believe, and I definitely cannot go back in time even if I could wear religion like a hat. But dang, man, there're some cute Christian ladies out there.

So the six months went by. At first I felt uneasy about regularly judging and assessing whether I was interested in someone or not based solely on their profiles and pictures, but this gave way to acceptance, then amusement, and then finally disinterest. It seems the appraising of maidens like all things gets boring in time. I did meet a few girls throughout it all -- a young woman whose every conversation seemed to return to Friends being a lame knock off of Seinfeld and another polite lady whose conversation style consisted of an endless stream of unconnected questions, amongst others -- and I found it interesting to see how different people chose to sell themselves -- it seemed there was a pretty even balance between tomboys with a girly side, party girls with a dorky side, smart girls with a pretentious side, and characterless nitwits -- but the pickings got slim, I got self centered (or rather more so), and so the time came for my departure.

Curiously, the very last message I was to get the day my Match.com subscription expired was from a pleasant young woman from Georgia. In it she stated that she had seen that I had seen her profile (an odd feature of Match.com), and not typically catching the eye of dudes hundreds of miles away she out of curiosity clicked to view mine. After reading it she felt inclined to write a brief message stating simply that she did not see why I was on Match.com, that my profile was not typical of the profiles on the site, and although she imagined it would be a brief venture she wanted to wish the best of luck to me with my search. That was all. Very sweet. Very nice. Very random.

And I give up.

Befuddlement

It was the best of times. It was the worst of times.

Or so I am frequently told.

Frankly, I don't find the times very enjoyable. In all honesty, though, I have no idea how to interpret them. These times apparently be confusing.

Relatively speaking us Air Force residents have got it easy. Compared to the internal medicine residencies of yesterday where interns and residents were shackled to their wards, forced to work while sleeping, and generally treated like so much chattel, we live lives of luxury with slashed work hours, broken chains, and alleviated patient burdens. Everyone always says it was harder back in the day -- and I am inclined to believe them -- nevertheless I am also inclined to believe that back in the day there were infrequent CT scans, no MRIs, only a handful of blood tests, and a pharmacy consisting mostly of a few penicillins, ergotamine, and phenobarbital. Twenty patients ain't so bad when all you can do is lay on hands and hope for the best.

Beyond that we've got it easy in other ways too. Compared to many civilian programs we work less, see fewer patients, are paid better, and likely are showed more appreciation by our patients. And compared to the hobos living immediately outside my apartment at least I have more to come home to than cheap booze and some invisible pets.

In absolute terms, however, residency is so much balderdash. We still work harder, longer, and with less perks and less confidence than the vast majority of Americans. Our job is in its very design constructed to make us feel continuously ill prepared so as to constantly compel us to learn. And through a legacy of estrangement many who teach and guide us have no great sympathy for our lot.

So how am I supposed to feel? Frustrated that it's not better? Happy that it's not worse? Thankful that I get to train for the unique career of my choosing or upset that all I do is train for the unique career of my choosing? I am undoubtedly incomparably blessed, but this particular blessing comes with an odd trial before the spoils. I have no means of measure and so am constantly wavering between emotions; I find myself muttering under my breath perhaps more than is healthy, and am thinking of joining the hobos.

Perhaps they'll let me take care of the invisible cat.

Breaking News

We interrupt the previously scheduled post-election coverage of demonstrations in Iran in order to provide you with this late breaking news:

Michael Jackson is still dead!

Initially thought to have died on June 25th, 2009, a repeat autopsy was undertaken today to confirm that the legendary singer-song writer is still in fact deceased. He is. Further memorials and tributes are likely in light of this breaking revelation. Many have called for an official day of mourning to be followed by a national day of remembrance and a week long world wide candle light vigil. A stirring audio-visual tribute is scheduled for every multimedia awards show to take place for the rest of the year.

We will return to your regularly scheduled program once we have sufficiently beaten this story into the ground.

Welcome to the Circus

For my final act of intern year, a grand menagerie! A collection of things that shouldn't be; a hospital of patients that are not sick! Gather one, gather all to the myth, the mystery, the *greatest* show in history; the last month of inpatient Internal Medicine as an intern!

The Man Without Symptoms!
Straight from Bavaria and to our show exclusively, the man without symptoms! Not a single complaint. Not a single problem. Flawless, painless, soreless and completely disease free; solely in need of a complicated CT scan available only in our very own military institution! Watch as he is not only hospitalized, anesthetized, dialyzed, and lesion localized, but also canonized, exorcised, and cannibalized all over the course of a three day hospital stay. The man has no business being here but because no expense is too small and no admission to the hospital too trivial we will admit him for your viewing satisfaction anyway!

The Respiratorical Horror That Wasn't!
Also for your exclusive entertainment a man so sick, so ill, so reportedly toxic and pernicious, you'll be surprised to hear it's *all* fictitious; the man with a COPD exacerbation so stable it's exasperating! His symptoms are at baseline. His oxygen requirement is unchanged. His breathing is unlabored. He looks altogether all too good; but for a limited time only he will be admitted directly from clinic to receive the same care he'd of received at home!

The Woman that Communes with Spirits!
Next. Born with a terrible gift. A young woman scourged by the Almighty with a supernatural talent lain dormant for centuries. Our very own telegraph to another world. The Woman that Communes with Orthopedic Surgeons! She will be brought to the hospital for reasons unworldly, her care will guided by voices emanating from the very ether, and her entire stay will be determined by a presence heard but never seen! Truly, lads, you have not lived until you have communicated with those not living! Commune with the orthopods for just one shilling! *Never* has health care been so thrilling!

The Amazing Record Player Woman!
Imagine now madams and gents: every day the same thing, every day the same thing, every day the same thing. The next poor woman is bound by an inescapable cosmic cycle to call the police weekly raving of impending robbery at the hands of her neighbors. She is captured in an unbreakable celestial loop to be brought to the hospital on a seven day circuit to be treated for the exact same dementia. She will see exactly the same physicians. Decline exactly the same tests. And be discharged to exactly the same home exactly the same way every time; just like clockwork! It's a rotation so accurate you can mark your calendar by it -- I kid you not! And you're in luck with this one, folks, because if you miss this week's show just come back next week for the encore!

The Phantom Fibrillation!
And if that wasn't enough, friends, gather closer as I speak to you of a phenomenon that some say doesn't exist. A phantasm that materializes only to vanish seconds later. A cardiac conduction abnormality that few have ever seen! The Phantom Fibrillation! The poor bearer of this accursed arrhythmic spirit -- a gentleman from our very own town -- is forced to walk the Earth waiting for his next atrial possession. Come awe at the reports from the ER of his shortness of breath. Then astonish as the same ER reports him to be symptom free! And finally astound as we admit to monitor him, test him, and pursue a workup that could just as easily be done at the cardiac clinic anyway! Now we cannot guarantee that the specters will present themselves, but we *can* guarantee that if they do it will be an event you will not want to miss!

The Golden Crap!
But that's not all. No that's not all at all, folks. Don't even think about it -- not a bit! Our very last act -- our very last sensation, the topic of tomorrow's conversation, an aberration of constipation; ladies and gentleman I present to you the Golden Crap! The man has not pooed for days, some say months, possibly even years! Many have tried to disimpact him but some say he is undisimpactable. He will come into the hospital for one day and one day only to have what many believe will be the most expensive bowel movement ever!

(And cue curtain.)

In conclusion: sometimes my life is like a circus. But with less funnel cake.