Reader Q: Why Did You Sign with the Army?

Hi Dr. SW101,

Enjoyed reading some of your blog posts both older and the newer army related ones today. Lots of smiles and chuckles, Thanks.

Laughter? In response to this blog? That’s TERRIBLE. This was supposed to be serious stuff. Like taxes. This is information. Data. Recommend re-read.

I’m curious to know why you signed up?

I signed up for the Army for one major reason and one minor reason.

The major reason was the craven want of money. I wish it was something more patriotic, but the primary motivation was an offer of a loan repayment grant and monthly stipend during my years in residency. The Army required nothing in return during my training years. Faced with sneaking my 6-member family into a 2-bd apartment that allows only 4 people, I took the money. Instead of the apartment, I was able to put my family in a cute 3-bd home on a quiet corner two blocks away from my training hospital.

The second reason was patriotic. Despite my vehement opposition to the war in Iraq, and moderate opposition to the war in Afghanastan, I was fully aware that primary care was severely lacking in the U.S. Army at a time when young Americans were throwing themselves into war. Irrespective of how I felt about those conflicts, I remain an American. News of my countrymen dying or suffering partially due to lack of good medical care was something I couldn’t tolerate.

I have always been taken with depictions of how our nation pulled together and sacrificed during the second world war. Back then, those war efforts were truly a national affair. Virtually everyone gave to the effort in some fashion. And, I think a huge reason for the wealth and power we have enjoyed for the past 60 years are a direct result of those sacrifices made by our Greatest Generation.

Pretty Sure I Woulda Deserted

“Earn this,” CPT John Miller, dying from a mortal wound during the Battle of Ramelle, implored Private Ryan in the Spielberg movie. The message, as I took it, was our generation (and the Boomers before us) must understand that great sacrifices were made to allow us to live on the top of the world as we have as Americans. It remains our mandate to earn that sacrifice; it was made before we even deserved it.

So I signed.

I saw posts about officer training and an earlier one about trying to figure out the military scheme as a civilian. What got you in? 

I think you’re referring to how I got into the Army as a civilian. If so, the answer is website: http://www.usajobs.com. Everything runs through this site. I applied to this site in the winter of my senior year of residency, and forgot about it. Literally. When I was called by the clinic here in Germany for an interview in MARCH the following year, I had no idea why.
If you want to get a job overseas, however, this is one of THE best routes. You can’t work for the State Dept as a doctor until you’ve been in practice out of residency for 5 years. You can’t get a job with any of the aid organizations unless you know someone AND don’t need money. So, this is a good option because the pay is steady, only slightly beneath the national average, and comes with perks that don’t usually accompany private-sector jobs.
There’s lots of archane goofiness that come with Army medicine. There’s lots of unusual quirks that are a result of non-medical “commanders” decreeing all kinds of demands from on-high.
But, in reality, every managed care organization functions like this these days. I wouldn’t put Army medicine behind or beneath any of the major HMO’s (in principle, I haven’t worked with any of them). I think Army Med is about on-par with most of American medicine…approximately 18th best in the world.
Also wondering why Olympia was your first choice? You’ve said elsewhere that Ventura is probably the best FM program in the US. I’ve heard of a number of graduates going to Tacoma Family Medicine and lots of interest in Alaska, too. Can you comment on them?
I am very proud of my FP training program, and maintain the belief that it is one of the best programs on Earth, and THE best on all outlying planets. I firmly believe that Providence is one greatest healthcare organizations anywhere.
But in all honesty, I have to say that Olympia is not the best. Just MY best.
English: Statue of Father Junípero Serra. Vent...
Father Ventura, surely a surfer
Ventura is better. Better than anywhere else I know of (and I practically got a PhD in FP residency research during med school). The hands-on experience they allow there, assuming times haven’t changed, is second to none. The faculty are top-notch; some are dual-certified, etc. Facilities suck, too, which is great. I can think of no better means of preparing an FP to deal with a crappy, under-funded, under-supplied environment where the only thing you have to give to patients is your training.
I was told I had a shot there. What they told me likely sounded MUCH like what they tell EVERY short-white coat wearing minion worshipping at the altar of VCMC during their exit interview. But I still like believing I coulda made it in there. I never ranked them, however, because my large family would have needed to live in a box on the beach to afford the cost of living in Ventura. And, truth be told, since I could have reasonably placed that box at the point at Fairgrounds (read: KILLER surf spot), residency would have been AWESOME for me. Just not for my kids waking up with sand fleas in their eyes and facing yet another breakfast of seaweed and/or Wonderbread bologna plus peanut butter sandwiches at the local Rescue Mission.
One nuance Ventura is the dual FP/MPH program at Dartmouth which is as good as it gets if policy and health system design is your calling. Love it or hate it, the Obama Health Care plan wisely referred to the health resources utility research out of Dartmouth. Although barely ranked, I am of the opinion that Dartmouth is actually one of the best – if not THE best – MPH program in the country because the research and work they do is prescient, unassailable, repeatable, tested and longstanding.
Tacoma is a great program, but they have nothing on Olympia. Their city smells weird, their facilities aren’t any better than ours, and we do rotations at the Peds ER up there anyway. So I recommend ranking them 1/2 with the top choice going to the town you like best.
Alaska is probably a lot like Ventura. Sans wicked right point-break and unfortunate box.
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Reader Q, Probable Farewell

Q – I just discovered your blog and have had fun reading it, however, it seems that you have stopped blogging?

A – It’s true. I burned out a little. Well, that’s a simplification. Moving here (to Germany), emerging from survival mode from medical training and settling into a normal life opened up all kinds of new emotions in me that I didn’t anticipate. The most important of these was a distinct realization that I wanted to deepen and widen my relationship with my wife.

So instead of pounding out these blog posts, I’ve been cooking dinner once a week (“Daddy Dinners”) and spending the majority of my nights watching some show or other with my wife by my side as I run my fingers slowly through her hair.

I’m gradually putting together a new blog – “Lover, Daddy, Doctor” – that picks up where SW101 leaves off. But it reflects my new focus in life.  I’d anticipate some humor, occasionally more intensity, less medicine.  I’d even expect the occasional Bible verse to accompany an irrepressible proclivity to pepper my writing with a well-placed swear word (Hey, I’ve come a long way…plus I’ve long bet that God nods to honesty before Christian decorum).

To survive in medical training, you HAVE to make survival and success your number one priority. I would have sworn this wasn’t true for me, but it was. Failure anywhere along the training path is a conscription to a lifetime of insurmountable debt, even poverty. Now that I’ve survived, my genuine priorities have emerged. I love to write, so it’s natural that I would blog about this new direction in my life. But I’m not sure. This is personal. More personal than just the experiences of being a doctor trainee. Maybe the story of one guy’s quest to be a better man is better left to be pondered quietly in the heart.

So, I’m mulling my next “move”. Maybe I’ll just pick up where I left off and start up SW101 again (thanks, everyone of you who wrote in to ask where all the good times went). Maybe I’ll finally finish my book.

Ultimately, I just can’t tell you where I’m going because I myself don’t know.  I DO know that I’ve successfully grilled tuna fillets, invented a mango/pear/mint salad that everyone loved, and I can broil Portabello mushrooms all by myself.  I learned the difference between Goat Cheese and Feta Cheese.  I know where the measuring cups are in the kitchen.  I can tell you every character in Lost (and the top 4 theories about what the freaking show even means).

But what I REALLY know is that my wife looks at me with eyes I haven’t seen for 13 years.  And this stirs my soul in ways that make most of the rest of my life comfortably superfluous.  This blog got caught up in that eternal vortex…

When I know anything more than this, you will too.

SW101

“All that I am, all that I ever was, is there in your perfect eyes…they’re all I can see.”  -Chasing Cars, by Snow Patrol

What Price, Integrity?

2000 Euro, apparently.

Through a housing allowance loophole, I could have almost certainly been approved for an extra 1000 Euro per month for the next 2 months.  The arrangement would have been a classic “kick-back” scenario between me and the owner of the house we’re buying.

However, in a last-second surge of some strange amalgamated emotion at least distantly related to those of guilt, honesty, obligation and craven fear, I killed the deal.

We are, in fact, buying this house, but will rent it for 2 months until the financing officially comes through.  During this time, my housing allowance will cover the rent – nothing more.

Quite honestly (since we’re on this honest kick), I feel sick about it.  I feel like I walked by $3,000 cash in a bush, and left it there.  I also feel it was the right thing to do.  But believe me, I had all the paperwork set up to take advantage of the oversight up until the final hour.

I should mention that the stakes are high right now.  The move to Europe is turning out to be much more stressful than I imagined.  This place is UNBELIEVABLY expensive.  I don’t understand how anyone can afford to even breathe out here.  I need to get my family out of debt…not go further into it by moving out here.

Let me quickly describe a government “housing allowance” as it pertains to me.  Termed the “LQA” or Living Quarters Allowance, anyone approved to live “off base” (most of us civilians are) is put on a scaled allowance.  You get more money for your status on the hiring scale (I’m waaay up there), and your number of “dependents” (pretty thin air on that one too).

So, when initially told of my housing allowance, I rejoiced!  I’m allowed thousands of dollars a month to spend on housing and utilities.  What a sweet deal!  In deciding if I could afford to take this job, I added my allowance ceiling (close to 50,000 per year!) into my yearly salary.

Keep in mind that my government pay as a doctor is very low in comparison to my private colleagues.  But when I added my LQA – viola! – my salary magically became competitive with the rest of the new-entry family docs in the country.

Then I arrive here to find that, essentially, it’s impossible to spend my LQA.  The arrangement is a “use it or lose it” kind of thing.  If you only spend half of your allowance, you can’t have the rest in cash.

The allowance, really, is a virtual amount that allows me to live pretty much wherever I want during the time that I’m here.  But even the nicest places in the area don’t rent for anywhere near what I’m approved for.  It’s like being told that you just won 1 BILLION DOLLARS!  Buuut, you can only use the money on M&M’s, and they can only be eaten, not sold.  Effectively, I’ve been given a lifetime supply of all-I-can-eat M&M’s.

I can’t have the cash, and, as you might imagine, I also can’t go to a landlord and say, “You’re charging 1100 euros a month for rent.  I’m approved for 3000.  How ’bout you and me split the difference every month?”  A housing office has to approve the rent amount based on an inspection of the house, and it won’t pay above that amount.

This thinking is classic for government, where everything is about sustenance.  Nobody is supposed to capitalize on government money.  You can only be sustained by it.  If you’re important, you can be sustained in really nice conditions.  If you’re not important – crappy conditions.  But either way, you aren’t to actually make money.  It’s unapologetic communism.

Getting kickbacks from your landlord is considered unethical.  And, effectively, this is what I had the ability to do for the two months until we buy our house.  As mentioned, I didn’t go that route.  I feel sick about it.  Not noble.  Not honest.  Not righteous.  NOT cool.  And pretty dumb.

Here’s a few reasons I pondered to justify the choice:

-The unethical thing is that doctors are paid so little in government work. They should have a program that either pays salaries commensurate with the private sector, or add an actual and functional loan repayment component to the salary (most current guv repayment programs are worthless – at best – and complete deception at their worst).  I really, truly, don’t care about money.  But the debt I carry sickens me.  I’m left to fend for myself on their paltry salary and a lifetime supply of M&M’s.

-I was deceived about the LQA.  Sure, it wasn’t deliberate…probably.  All the details and stipulations were simply left out.  But I came out here thinking my salary was 50k better than reality, when it’s really only about 15k.  Yeah, it’s cool to pick virtually any place I want to live.  But not really.  I’m chained to my debt.  And those chains are pretty heavy…too heavy to allow for much swimming in my rented pool in my rented German villa.  I need to make financial choices that will free me and my wide-eyed children from this financial prison.  The system should allow for that and it doesn’t.  I need to exploit loopholes wherever I find them.

-Also as a wealth-building strategy that I would HAPPILY forgo were I debt-free, we are choosing to buy this house. This puts added pressure on me to be happy in my job, and to stay in Europe for 5-10 years, rather than my stipulated 3.  If I want to leave, owning a house highly complicates my exit strategy.

-My mortgage is nearly $600/month more than the housing office has approved for the house in its current condition. So, if I want to rent the house to someone, I can only charge the max amount approved by the Housing Office.

However, the house has an extra bedroom that was not counted during the last inspection because it needs renovation.  We could pour 2000 extra Euro into renovating that bedroom and adding a bathroom next to it.  This would increase the allowed amount I can charge to a renter. I’ll bet the house would get approved to an amount very close to my mortgage with some good renovation.  Then, I can go to work every day in the freedom that if I get fired, or if funding for my slot dries up, or if I hate the job and want to go home…I can rent the house out without going broke (houses don’t sell well in Germany…sometimes sitting on the market for years, but the rental market is hot because of the military activity).

-I won’t get caught. People do this kind of thing all the time.

-I’m only using what I’m approved for. Not more.

-The Realtor did it. I didn’t think this up.

-Maybe it’s ok in my case, since the loophole doesn’t exist for most others (my rental contract doesn’t need approval from the housing office).

Reasons Against:

My Dad’s face in my mind: The guy works every day.  Supported me every day since he adopted me.  And pays taxes, every day.  He got behind on taxes once, and getting square with the IRS nearly killed him.  But he did it.  Little by little, he gave them every dime they demanded of him.  My housing allowance is paid for by guys like him.  I’m not ripping off millionaire Senators with health care for life…I’m ripping off honest, real Americans who believe that their taxes are being used appropriately.

-Professionalism: Frankly, many of my generation’s colleagues, myself included, hate this word.  What once was a sterling understanding between every member of my profession has become an strategically ill-defined mechanism for manipulation, money-making and power-plays by Boomer Gen on Gen X/Y.  Happens all the time in residency, but banks play the game, insurance companies, lawyers too.

Still, a fundamental element of professionalism is a high standard of honesty.  We say what we mean, we mean what we say, we stand by our word and play it straight.  Doctors regard trust as immutable currency in the most sacred component of our profession, the doctor-patient relationship.  This is the very fabric of our livelihood, and it all is built on trust.

-My training: Let me be discreet here in saying that during residency, I had a few moments where I was *ahem* mildly cavalier regarding my whereabouts on certain mornings.  This lackadaisical approach to the exact truth led to some harsh responses from those who oversaw me.  I got my ducks in a row pretty quickly.  Now, the stringently honest approach is the only one that feels right.

-Sleeping well: Also a lesson learned in residency: if you didn’t do anything wrong, you don’t have to worry about getting caught.  In the movie, “The Hunt for Red October”, a submarine captain prepares to fire torpedoes at an enemy ship…but first he puts a safety on them so that they can’t explode until they have been swimming around for awhile.  “I don’t want those fish comin’ back on us!”  He says.

For me, the same thing is true.  I don’t know – really – how closely they’re watching what I do.  Maybe this is a big problem right now.  Maybe they’re working on closing the loophole and will be auditing everything once they get the new policy in place.  Maybe, maybe, maybe.  I can go to sleep tonight not worrying about the maybes.  I played by the rules.  If something is messed up, I know it’s an honest mistake – that I’m not “busted”.  Makes for an easier thought life (allows me to wring my hands about foreclosure without any messy distractions).

So there you have it, folks.  The emotional undulations I’ve endured over this weekend, mulling the ethical conundrum over and over in my mind.  I feel sick about it.  Improving the house doesn’t just help our investment.  It gives me freedom in my job, freedom to enjoy Europe, freedom from worry.  The pill has been a bitter one.

My brother told me recently that now, as a doctor, I’m not really going to care about a few thousand bucks here and there.  Sure, I’ll be careful with my money, but a few grand won’t be something I’ll break my back for like I would have in the past.

I hope he’s right.  Because that 3000 bucks sure feels like a lot of money at the moment.  I’d work pretty hard for those extra thousands right now because of how much they could help us.  But apparently, I won’t lie for them.  One day, finally out of debt, I suppose I’ll look on this choice as a good one.

For now, I regret it….although I am looking forward to a good night’s sleep.

Retirement Ain’t So Great

As mentioned, I managed to complete residency.

That was a few weeks ago, and I haven’t stopped celebrating.

Minimal blogging.  No professional reading.  Lots of sleeping.  Ice cream pretty much whenever I want it…as if I’ve just had my tonsils removed.

I’ve gone surfing twice and will go again in a few days, after I buy the GREATEST BOARD EVER KNOWN TO MAN.

It’s a far-cry from a bohemian life of decadence – no absinthe, no scantily-clad pixies, no pleasure nymphs to speak of – but I don’t remember being this lax, this flatly averse to self-denial.

But, I have to say, after a week of this…workin’s cool.

I like needing to be somewhere in the morning.  I like having a schedule and trying to be efficient.  Mostly, I just like the purpose that a job provides.  With so many people out of work around the country, I can understand how hard it must be to deal with such a life change.  Aside from the financial instability (which I don’t have), just the dramatic shift itself must be really difficult to bear.

Lucky for me, I’m working some moonlighting shifts at nearby practices.  So, we’ll have enough money until I start a real job next month.  And I have quite a few things to keep me busy until then also, because my next job will be in Germany.  So preparing takes lots of energy.

But after even just a week away from the job, I can see that I’m too young to retire.  There’s lots of things I would change about my last job, and I’m not depressed since leaving or wishing to go back.  NOT AT ALL.  But I am looking forward to many of those intangible things that a daily job brings.  Some people are built to work.  In many ways, I guess that’s me.

Graduated – No Crying

The last days of residency passed – perhaps with a bang, and certainly no whimpers – and I am now full into my first week as a real, live doctor.

Everything feels the same, but with more sleep.

My graduation ceremony occurred 4 days ago, on Saturday.  For as emotional as I felt that night, I managed to survive the entire ordeal without much blubbering.  This had largely to do with my particular approach to the ceremony itself, which involved a skateboard, a wacky helmet and some iffy poetry.

Since there are only 6 graduating residents from our program, each of us enjoys (or endures) a sizeable amount of limelight as we graduate.  It starts with a picture slide show of us from our earliest days up to the present.  Some of my shots were strange, if not embarrassing, as you might imagine.

We are then introduced – for an agonizingly long time – by a faculty member.  Here our history, foibles and dreams are put on display for all in attendance to see.  This part can also be rather painful too.

It was then my turn to speak.  We aren’t given time-limits on our speeches.  As mentioned, there’s only 6 of us, so I guess we have the berth and he right to ramble a bit if we want to.

I survived the process with almost zero public display of emotion.

I’m not sure why this was some sort of goal for me.  I’ve always been a lousy crier.  I’m good at complaining, whining, moaning and bellyaching, mind you.  Rather too good.  But my crying skills must have atrophied somewhere in my childhood.

If I were to guess, I suppose it happened when I was about 5 years old and my biological father had just punched his girlfriend in the face.  He then leered at me and asked, “You gonna cry about that like a little girl?” in a drunken haze.

“Nope.”  I said.  And I never have.  These days, I can only cry when Ariel gets her statue of Eric blown up by King Triton, or the Broncos trade their franchise quarterback to the Bears.

So, I have some issues.  Fine.  I’ll bet you do too.  Intellectually, I admire the Roger Federers of rhe world who can stand on the international stage with unabashed tears streaming down their cheeks when they lose (or even win, sometimes) their latest tennis match.  Emotionally, I want to smack them with their own tear-stained pink hankies, tell them to find their purse and go back to the parlour where life doesn’t hurt so much.

Anyway, I wasn’t going to cry.  Smash my thumb with a hammer…we’ll talk.  But for this?  No way.

So, my approach was to first ride my Sector 9 longboard skateboard up to the podium wearing a tin foil-wrapped, overly-festooned bike helmet.  Why such a rather dumb graduation display?  Why, especially, at a solemn ceremony for a new practitioner of the healing arts?

sector9Aside from the fact that medicine is frequently too pompous and full of itself, I figured that if I could keep it fun and light, I could keep my eyes dry.  Plus, I ride my longboard to work most days, and I religiously never wear a helmet of any kind, much to the dismay and consternation of virtually every person I meet on the hospital campus.  For 3 years I’ve put up with near-constant haranguing to wear a helmet.

Why don’t I wear a helmet?  Well, I just figure that anyone traveling less than a mile, at about a mile an hour, while less than 3 inches off the ground…should garner me the right to feel the wind in their hair.  Granted, there isn’t much wind at that speed…and I don’t have much hair.  But that’s my metaphorical argument, people, and I’m sticking to it.

I also think that Americans are too stupidly safe these days.  We think we have allergies to things that 6000 years of humanity had no problem with.  We pad every corner in our houses and put seatbelts on our T.V.’s just in case the wall trembles and pushes that deadly thing over on a kid.  We have warnings on things like plastic 5-gallon buckets and nylon shower curtains.  Frankly, the fact that my children will never ride barefoot in the back of a bouncing pick up truck, screaming like golden-haired eagles as the wind whips wildly into their eyes, brings me no end of sorrow.

I grew up burning leaves, shooting bottle-rockets out of my hand and hunting fish with a whittled stick.  I think life is risky, and living life is an exercise in managing that risk.  Knee-jerk safety measures without true analysis of risk leads to heard-mentality that rarely leads to anything but really really bad groupthink: racism, genocide, militant nationalism, day-glo, Milli Vanilli, toilet-seat-shaped pillows for airplane flights that everyone carries around airports but never actually use for more than 10 minutes, to name a few.

So, in truth, I don’t wear my helmet when longboarding because I’m determined to not become a Nazi.  Gotta admire a guy like that, right?

Anyway, I understand that most of you dear readers will find fault in my little tirade, and will probably want to admonish my opinion about helmets just like all of the faculty, nurses, staff and freaking maintenance workers I see.

But take heart!  You don’t need to worry!  I rode to the podium in a helmet for the first time.  Just to make everyone happy.  Just to acknowledge that I’ve finally heard the message.  I give up.  It’s time to be responsible and extra-duty safe.  I’m a doctor now.

‘Course, my helmet was covered in tin foil and had sticks extending from it in every direction with tinfoil balls on the end of the sticks…but it was a helmet.

Then I delivered a poem.  It was supposed to be a rap – with a thumping beat and maybe a couple of dancers and lights flashing/spinning with everyone on their feet, their hands in the air all hip-hoppin’ on the floor.

But I’m white.  I’m a doc.  I’m in a tie.

Forget it.  It’s a poem.  A really bad 1-2-3-2 rhyme sequence that rhythmically scans like ice cream might feel if you were dumb enough pick a pile of it out of a sandbox and eat it.  But, in honour of my creation and the initial inspiration for it, I allowed that I would not in fact be delivering a rap, OR a poem that night.  It would be an amalgam, a mixture…a PAP.

This is fitting, of course, since we were all gathered to celebrate my new status as a fully-trained family medicine doctor.

My Pap made my mom cry.  I think my Dad too.  Kinda my wife.  And most of the people I talked to afterward said it made them a bit misty.  My goofy, two-bit hyper-syllabic tossed salad?

Cool.  People cried.  I didn’t.  I was too busy looking goofy, or saying goofy things.

Dear old Dad would be proud.

The AMA – Trust At Your Own Risk

Adapted from an Op-Ed in today’s NYTimes by Nicolas Kristof

Some fun facts about the AMA (American Medical Association):

  • supported segregation
  • opposed President Harry Truman’s plans for national health insurance
  • backed tobacco
  • denounced Medicare
  • opposed President Bill Clinton’s health reform plan
  • probably represent less than 25% of practicing physicians, most of which are specialists who dearly want to protect incomes from $250,000/year to over a million per year

Here is their current position on a National Insurance system:

“The introduction of a new public plan threatens to restrict patient choice by driving out private insurers.”

They might have been right about opposing Clinton’s freakish health care plan.  They should have shaped the medicare debate instead of obtusely opposing it, and you can be the judge on the whole segregation and tobacco thing.

I think for-profit medical insurance is morally wrong.  Insurers should not make more money than patients, and not doctors, either.  If you want to be available to help someone in a time of weakness and need…you shouldn’t make 20% returns on them until that time arises.

*Disclaimer:  The AMA is a putrid organization from the inside out (and hopefully will be obsolete in 10 years)…but they do have it right on tort reform.

Post-Call Warfare

Muw-hahaha
Welcome home, OLD MAN..Mwhahaha

He waits for me.

Before I’ve even stumbled through the door, he scans me…probing for weakness. Huddled in shadows, he watches will all the patience he can command from his 3-year old body.

“Puffy eyes,” he reasons.  “Face a little long.  Weaving a bit.  Probably didn’t sleep last night in the hospital.  Excellent.”

Daddy’s home….may the best boy win.

I collapse on the mattress in our living room.  Placed there for my frequent late nights with the on-call pager, the patterned white expanse invites me in after nearly 25 straight hours of in-hospital work.

But I see him out of the corner of my eye.  The spiky hair, the blue eyes alive with anticipation, the little fingers wrapped around a pleather baseball.  Even a blink is risky.

Laying like a dead man, I pretend (with little effort) to sleep.  But I can’t relax.  Warily, I scan the room with the one eye not buried in a pillow.  He approaches, cat-like, on coiled springs for feet.  He’s nervous.  New to battle, he is.  He has none of the scars and experience an old hand like me carries into conflicts like this.  I’ve got the wisdom, but his energy stores easily transcend the average life-force of at least 2 functioning adults.

The Battlefield...
The Battlefield...

The boy is quite a shot, and he ends our fragile truce with his little baseball.  It slams into the bridge of my nose before I even see it coming.  Then with a shriek of joy mixed with complete and abject terror, he bolts.  Just out of reach on the far side of the mattress, the little perp streaks for the safety of the couch cushions; his legs an adrenaline-charged blur. I lunge, still on my stomach, grasping for quicksilver ankles that leap at just the right moment.  Another shriek of triumph becomes abruptly distant and distorted as a pillow wilts over my head.

Alright you little twerp.  Time to shake hands with DEATH!

I rise up on my knees, breathing fire and rrrowling with menacing finality.  Trapped in the “L” of our sectional couch that has endured too many such battles over the years, the boy realizes his exuberant mistake.  Quickly he tries to jump over the backside of the couch, but the seatback is too tall.  In desperation, he darts for the end of the couch, where the breeze of freedom swirls enticingly.

Now in control, I use his own weapon against him…and whip the pillow – AS HARD AS I CAN – at his little running feet.  If timed well and I hit low, that little kid is gonna flip upside down and land square on the far side of the mattress where I was trying to sleep! On the other hand, I could hit him high and watch in satisfaction as he curls over the pillow and crashes into the armrest.

I hit low.

With a squeal, he tumbles off the couch and onto the mattress – my lair – and I pounce.  Son or no son, the child receives no mercy.  Every tickle-point is fair game.  My cruel fingers send their message of revenge and he writhes beneath me like a possessed rabbit.  Once he gets too adept at protecting his vital ticklish flanks, I pick him up by a single ankle, and he stretches out like an accordion, exposing every protected square inch.

Just as he wriggles away, I smush him into the mattress with my entire body.  For a brief, blessed moment the living room settles into an eerie silence punctuated only be a weird, muffled warble.  But that, of course doesn’t last as his heel jams me in the gut.  I shift slightly.  Instantly he pops up, “GET ME, DAD!  HAHAHAHA!” loud enough to be clearly audible on a jumbo jet tarmac, and vanishes on those feet that never seemed to actually quit moving, even during his brief time as my prisoner of war.

The Armory...one stash, anyway.
The Armory...one cashe, anyway.

The boy vanishes around the back of the couch.  I rush after him, and he in turn squirts around to the mattress side.  We pause.  A kind of silence again, but filled with the deep breathing of two wounded Titans, warily forming their next strategy.

Suddenly a second pillow warps into my head, followed by 2 other balls of differing shapes and sizes.  From the other side of the couch, he pops his head up – fuzzy crown first – laughs hysterically and waits for my return volley of his ammo.  I oblige, he ducks, and an entire can of some sort of reed stand blasts into a thousand pieces behind him.  Slowly, the fuzz returns.  Then a pair of blue eyes, followed by a wide grin which, together with the eyes say silently, “YOU can explain that one to Mom.”

But I’m ready – with balls 2 and 3, and a second pillow I found.  I pelt his accusing smile full-force.  He topples backward onto the mattress, his legs straight up in the air.  I jump up and shower him with balls of every size and make.  Some squish into him, others carrom from his body off into lights, windows, the aquarium (sorry, fish…it’s life and death out here).

He rises, a bit woozy….looking about finished.  I’ve won.

Suddenly, girls stream at me from every direction.  Hair flying, screaming like highland goddesses, 6 hands descend upon me and topple me to the ground with ease.  Balls, pillows, blankets and an occasional doll rain upon me.  I am powerless in the onslaught.

Just before I black out, I see that terrible, terrible boy.  Jumping up and down in irrepressible excitement, he watches his secret weapon conquer his adversary with cruel efficiency.  Who can ever hope to conquer a boy with 3 older sisters?  This kid commands kryptonite, a cloaking device and a bazooka all rolled into one.

Some wars just can’t be won.

Overkill

I decided not long after I started this blog – quite some time ago now – to never apologize for not writing.  I’m a doctor.  Stuff comes up.

So, I haven’t blogged in awhile.  If you’re still one of the regulars, my thanks.

This latest distraction involved graduation from my residency program.  Or rather, not graduating…the specter of it, at least.  And while the problem is resolved…the emotions on my side still simmer with grim ebullience.

Arriving in the infuriatingly innocuous manner of many catastrophic announcements, I received the news recently that I had not spent a required week with an orthopedic surgeon during this last year of residency.  Setting up that week is one of what feels like 4 bujillion stipulations that lead to graduation.  I’d missed this one, and it was too late to change my schedule to fix it.

Through some fuse-burning mental gymnastics on my part, and some heroic situation-framing on my advisor’s part, the faculty of my program have just decided that I will, in fact, graduate with my class.  In essence, we found a workaround that keeps me on-track to finish with my peers in less that 4 weeks.

This experience however, reignited an old resentment in me that essentially boils down to oft-repeated theme in the “Jason Bourne” movie series about being required to give vastly more than expected when signing up.

The frank truth is that all the permutations of mid-level medical providers – from ARNP’s to PA’s to Dr. RN’s – have one thing in common…they’ve been subjected to roughly 1/3 the amount of training as I have.  Subsequently, they have 1/3 the debt, and probably have 1/3 the family problems, health problems, and 1/3 the incidents of depression, substance abuse and suicidality.

The result of that limited training?  They do the exact same job as me…and get paid about 80-90% what I will make.

Calculate how much money I lose in training when they’re out actually working, and I probably make less than your average P.A. over the course of a career.

I was so upset over this graduation snafu, that I rammed my fist through a wall in our house, and ended up driving hopelessly around the beaches of Washington until 7am this past weekend.  Then, thankfully, I got with the program and figured out a way to address the problem a little more professionally.

No, working an extra week after graduation wouldn’t be the end of the world.  But in so many ways I feel I’ve reached the end of my rope.  And, for lots of logistical reasons, another week of “work” would have really been tough on me and my family (and probably our walls).

I should mention that what I was deficient in – observing an ortho doc – falls into my category of ‘watching doctors be doctors’.  I’m not sure where anyone came up with the idea that people learn from this particular brand of education-theory rack-stretching, but frankly at my level if I don’t have responsibility, I don’t care.  If I don’t care…I don’t learn.

Watching doctors be doctors is  easily the least valuable learning experience I’ve had in my entire medical training…and residency is rife with this vacuous requirement.  I’m quite sure that the endless hours I’ve spent delivering Oscar-level performances of intellectual interest could be completely removed from my training and I would still be the same doctor I am today…just less poor because I would have started working at least 6 months sooner.  Maybe a whole year.

Simply put, I believe that my medical training is outmoded.  It’s destructively expensive.  If people can do my job with 1/3 the training, then I’m effectively over-qualified. 

The backside to this is that M.D.’s themselves will eventually become irrelevant in the marketplace because we’re just too expensive.  We spend so much money on school and inefficient training, that nobody can afford to pay off all of our debts.  How long will it take me to pay off the $330,000 I spent on my training?  How much more do I owe on that since I’ve piddled away another 3 years on training – watching orthopedic doctors and acting interested – while a number that big generated interest on itself?

I’m deeply grateful to my advisor especially in this case, because he presented my situation to our residency faculty in a light that was very favorable to me.  He is probably the reason I’m not in a padded room at the moment. I don’t really blame my residency program, either. 

The problem is the system:  tone-deaf, needlessly arduous, inefficently stubborn.  The mid-level system was created by smart people who realized that it just doen’t take this much to make a doctor.  You shouldn’t have to sell your soul for the honor and burden of taking care of sick people.

In the end, I approach graduation almost devoid of any elation at all.  Instead, I feel like I’m sitting in a field, blood and feces spilling into my lap from the mortal shotgun wound I’ve received to the gut, looking plaintively up at the shadow hovering over me – at my colleague and killer – and wondering aloud, “Look at this mess…look at what they make you give…”

Doctor Sells Insurance For His Own Procedures

**The following is another installment in an SW101 exclusive series entitled Medicine In America (MIA), covered by our crack journalist team scattered around the globe.**

TULSA, OK – “Just in case I screw something up,”  Dr. Jason Hines says, smiling, as he helps an elderly man sign a form and pay for his “procedure insurance.”

Dr. Hines, owner of New Day Family Medicine, a small group practice here, is one of a growing number of primary care doctors who are getting creative as they struggle to increase falling reimbursements.

“I got the idea from my very own Family Medicine Academy,”  Hines says excitedly, holding up a postcard with bold, red letters emblazoned across the top reading LAST CHANCE!  “They’ve been trying to get me to buy their life insurance policies for about 2 years.  This is the 14th ‘last chance’ notification I’ve gotten.

“Then it struck me!  Even the AAFP is getting in on insurance, why can’t I?  I mean, we can’t all be lawyers and dentists, right?  Gotta make the bucks somehow. ”

Dr. Hines’ fledgling business-within-a-business had a rough start.  “Nobody saw a need for it,”  he said.

Debbie Lawrence, one of the first patients to sign on, described her initial doubts.  “It seemed a little strange, you know?  I’ve already got insurance for my car, my house, for medical bills.  I even usually get that extra insurance for rented DVD’s.  But then, as the doctor described the procedure of removing a mole on my back, I saw this slight tremor…and then he read me the consent form!  Boy, it just seemed like the safest thing to do.”

“I had to figure out some way to promote things.”  Hines explained.  “The postcard idea was already taken by the AAFP, so I wanted to do something more creative.”

His solution was to enroll in an acting class at the local community college.

“Watch this!”  He said excitedly.  “I’ll just reach for this piece of paper, aaaaannd NOW, I’ll have this nearly-imperceptible tremor just before I pick it up.  See that?  We really worked on the subtle-but-obvious thing in class.”

Then he modified his legally-mandated consent form process.  “So, they make you blah, blah, blah about the risks and benefits of every procedure, right?  Well, I just figured I should capitalize on that.”

His consent form reads:

My signature is proof that I consent to the forthcoming procedure.  Procedures are dangerous.  Most are not proven to actually improve anyone’s health.  I understand that I risk serious pain, including but not limited to severe disfigurement such that my children and spouse might recognize me only by mannerisms.

Often, procedures of this kind result in lasting nerve damage, potentially to the genital area.  I understand and fully consent to an ambivalent and uninspired sex life from this point forward.

Bleeding is usually something that can be stopped.  If not, I am willing and happy to slowly dwindle into a shivering unconscious blackness from which I may never emerge.

I also agree to not underestimate the risk of infection.  I realize that flesh-eating bacteria exist everywhere, at all times, and are constantly attempting to gain access to my body.  I understand that should infection occur, I may wake up with parts of my body unexpectedly reduced to nothing more than exposed skeleton held together by rotting fascia.

“That’s the mellow one,”  Hines’ states matter-of-factly.  “I use it for wart removal and immunizations.”

After the slow start, business now is booming.  Dr. Hines calculated his acting class cost – “110 bucks a unit for a 3 unit class” – at $330, which he claimed on his income taxes as a business expense.  He sells insurance for any procedure in his office, usually at a cost of $25 to $350 per procedure.  “I’m thinking of adding waiting room insurance – you know, in case the roof collapses – but we haven’t worked that angle yet.”

What has been developed is the “Cabo” insurance package, which includes a special waiting room with palm fronds, seltzer water, a chaise lounge and soft music.  Aside from guaranteeing the procedure to be safe and “up to standards”, the patient also receives a massage at the conclusion.  “Sometimes, we’ll give their dog a massage also.” He said charitably.  “After signing my consent form, people are pretty keyed up.  I usually just throw the dog in for a reduced fee.”

The AAFP did not return calls for comment, but did release this statement,

The AAFP does not condone the practice of selling non-medical products within the environment of medicine.  We believe in assisting our doctors as they provide the best care possible for the entire family.  Just look at the success of primary care medicine in America over the past 30 years for evidence of our presence in Washington.

Although the insurance business does offer unbelievable profit margins and investment returns of nearly 50%, we strongly believe that individual doctors do not have the expertise to get into the business.  Individual family doctors should leave the big business and real financial gains to organizations that are qualified to actually make money.

Finally, although we typically keep information about doctors confidential, it should be mentioned that Dr. Hines appears appears to have let his board certification lapse.  He is soon to be rejected from our community as a “fellow” if he doesn’t pay his dues by cash, check or debit/credit.

“They can say whatever they want.”  Replies Hines.  “I got the idea from them.  The AAFP opened my eyes to the fact that there’s lots of ways to make money on the medical field, as long as you don’t waste much time actually practicing medicine.  I can’t believe it took me so long to figure it out.  I’m just glad I got in on the gig now, when the para-medical business is still in it’s Golden Age.”

Reader Q: My Med School

bgucloseI get lots of questions about my med school.  For those few not in The Know, I attended the Medical School for International Health.  The school is located in Israel, in the ancient town of Beer Sheva (you can find it in the Bible, dude…can you say something like THAT about Maple Acres, Kansas?).  The institution is Ben Gurion University.

The program focuses on providing medicine in an international context; particularly to the 3rd world.  The school is a collaboration project between BGU and Columbia University, so blokes like me have a reasonable shot of doing residencies in the U.S. after graduation (got my 1st choice in residency program).  

Anyway, emails come in from all over the world asking me about my experience there and soliciting my advice about going.  This latest query was so expansive and had such good questions, I figured that if I was going to go to the trouble of replying to it, I might as well post it as a blog so everyone could check it out:

My name is Bryan and I am an accepted MSIH student from Provo, UT headed to Israel in July.  Here are a few questions for you:  

What did your spouse and kids do while in Israel for the 3 years?  

They found all kinds of things to do.  Getting settled in Israel is quite a job compared to the U.S.  Everything is slower to accomplish, from records to mail to shopping, things just take lots of time.

That said, my wife and I had 2 children while in Israel, so that kept her busy in ways that older kids wouldn’t.  She also took a Hebrew class that provided lots of social interaction, friends and experiences in the culture.

Additionally, you will have WAAAY more time that you might expect.  The first year, you don’t even take an exam of any kind for 5 months.  Not one.  You just go to class.  Or don’t.  Depends on your learning style.  Then, when exam time does roll around, you are home studying most of the day.  I don’t know if that’s how it is at other med schools, but that’s the way we roll in the IS.

So, you won’t be gone as much as you probably envision.  And, the family will have more to do that you might think.

BGU from a distance:  Lots of dirt and dust...then, suddenly, CITY
BGU from a distance: Lots of dirt and dust...then, suddenly, CITY

Did your kids attend school at all?

Mine didn’t, but they easily could have.  I started the program with just one 2 year old girl, but we had 2 more by the time we left (like I said…you do have, *ahem* free time).  The oldest would have done fine in their preschools, called Gan (pronounced GONE, means garden).  

I would recommend it, especially if your kids want to learn Hebrew.  Like most European countries, education is a huge emphasis, so they’ll want your kid there EVERY day, all day.  Even preschool.  This was the hang-up for us.  Something M/W/F might have worked, but my wife wasn’t ready to ship our 3 year old off for full-time school, so we skipped it.

Did your kids and your spouse learn the language?

 

See comments above about wife.  Kids didn’t learn it (although for some reason, we ALL still regularly say ‘agvanot’, which means tomatoes).  I wish they had been a bit older, becuase then I would have insisted on school for them.

Did you have any Hebrew before MSIH, or did you buy a program like Rosetta Stone to get you started?

I had none, and sucked at it all the way through.  Figured out how to buy food pretty quick, though.  I bought a tape-series that supposedly was used by State Department people, but never even opened the box.  

The school provided a pretty good immersion class, but really you need to take the same Hebrew class that my wife took at night to actually learn the language.  The Israeli people (unlike many lame ethnocentric Americans like me) know English almost universally in addition to their native Hebrew.  So, they would rather work on their English with you than let you work on your Hebrew with them.  All of your classes are in English.  You actually don’t get as much exposure to the language as you might think.

Furthermore, on the wards, I’d say Hebrew is only spoken by about 60% of the patients.  Beer Sheva has to be one of the most nationally-diverse cities on the planet.  Walk down a typical medical ward, and you may hear anything from the Big Three:  Hebrew, Arabic and Russian, to many “lesser” languages of the area like English, Spanish, Bulgarian, Yiddish, Romanian, French and others.  Although Jewish in heritage, the people who immigrate to Israel come from nearly every country in the world.  Their primary language usually isn’t Hebrew.

If you truly want to learn the language – and the best reason to is so that you understand the ward doctors during your 3rd year – my recommendation is to go to Israel 2 months early and take a true immersion course.  This is how they do it for the new immigrants.  You live in a house with other immigrants and they DRILL the language into you.  You’ll have it forever after that.

Did you buy a car?

 

We did.  It was very expensive and a bad idea.  Getting all the paperwork for it took 3 solid days of sitting in offices all over the town of Beer Sheva.  Gas is spendy.  Insurance and licensing is more than in the states.  

We should have just used cabs instead.  They crawl all over the city all the time.  You never wait for them, and a trip anywhere in town is only 15 shekels, which is about 3 dollars. We calculated that we could take 60 one-way cab rides a month for the monthly cost of the car.  

Years out, I still talk to the guy on the left a few times a month.  He's starting a fellowship in pulmonary/critical care next month at Henry Ford in Detroit.
Years out, I still talk to the guy on the left a few times a month. He's starting a fellowship in pulmonary/critical care next month at Henry Ford in Detroit.

Right about that time, I got into a minor wreck;  we parked the car after that because we didn’t want to spend the money to fix it.  I watched with interest as teenagers slowly dismantled the thing on a semi-nightly basis over the ensuing months.  I ended up with a twisted metal creature that can only loosely be described as a “machine”.  They took everything.

“Oh well,”  my friend Brian consoled me one day.  “Just be happy that you probably made some high school kid’s senior year 10 times funnier as they systematically ripped your car apart every night.”

Do many students buy cars while there?

Nope.  Just the dumber ones.

How else can you get to the more remote sites like Masada, Dead Sea, Elat and the like? 

Rent cars.  Fairly easy.  Fairly cheap.  Pool with friends if you aren’t going with the fam.  We saw EVERYTHING in Israel in nice Skodas or Seats (see-aht) with power windows and A/C and no worries about breaking down.

You can also take the train, which is efficient and fun…except when its crowded and you’re crammed between 6 sweaty IDF soldiers with automatic rifles, some of which are pointed at you and your kids. 

Where did you do your residency and what specialty did you choose?

Olympia, WA.  Family medicine.  I felt then, and still feel, that my specialty is absolutely the best preparation for medical mission work.  

I have not once regretted my specialty choice or the residency program I chose.

Did you know of any MSIH grads applying to the handful of International Health Residency Programs?

None of my class applied, but this largely had to do with location, not competitiveness.  We wouldn’t have had a problem getting into those programs, in general.  U of Rochester had a good connection with our school and a few of our grads went there.  Their Intl Health cirriculum is fantastic (or was a few years ago when I was looking at them).

Is there any personal advice you think would be beneficial to me; advice that might not be included in the admissions packet?

Be flexible, don’t whine like an American.  Don’t expect anyone to care about you or your little worries.  Be a traveler.  Be observant and end your sentences with question marks rather that declarative periods at a ratio of at least 2:1.  

ipconflictRecognize that there is no answer to the Israel-Palestinian conflict.  Accept that you have no right to have any opinion on the issue until you can say honestly that you have deep friendships with BOTH an Israeli and a Palestinian.  Until then, try as hard as you can to shut up learn.

Travel, travel, travel as much as you possibly can.  Drive the country from end-to-end at least twice.  Stay at a Kibbutz or Moshav.  Swim in the waters of Gan Hashlosha and the Med.  Absolutely see the Golan Heights in the spring when curtains of flowing green grass are punctured by brilliant red Israeli poppies.  Try as many foods as you can and never turn down invitations to Shabbat, Passover, Rosh Hashanna or Succoth. 

Spend lots of time in Jerusalem – especially the Arab Quarter of the Old City – and try to hang out in the Armenian Tavern for dinner at least once.  See the Wall and the Dome on the same day.

The Golan
The Golan

Jump on chances to go to Europe, especially the eastern countries.  See Turkey, Jordan and at least the Sinai of Egypt.  Get certified in SCUBA in 3 days on the Gulf of Aquaba (look up a guy named Hamdi in Dahab if you are interested).  Consider your experience there a colossal failure if you miss out on many of these opportunities.

Pick up a cause that will build the school.  I started the literature and medicine class.  I think it’s a required class now, so if you hate it, you can thank me.  Pour part of your life into the school.  Put MSIH on the map in your own small (or big) way. 

Will every moment of your experience into the marrow of your soul; drink its precious nectar as if you never will again.  Because you won’t.

And pass your damn tests.