physician – Weary Wretch

Live by the word, die by the word

A colleague and I were talking at work the other day. The secretary came up to us and addressed my colleague in a hushed voice, “Did you happen to drop the “F” word in room x?”

Blushing, he replied, “I don’t think I did, but I guess it could have happened.”

The secretary then stated that she was on Facebook and the patient was ranting that a Doctor had just dropped the “F-bomb” in front of him and his family. Her sister was a friend of this patient which is why she happened to notice the Facebook post.

It’s going to happen. If you use obscene or offensive language of any kind, sooner or later you will say the wrong word at the wrong time. Sure, use of language will, by definition, contain some words that are offensive to somebody, somewhere eventually.

But we are talking the commonly known 4 letter, English-words that are generally considered “offensive” in general public, the ones that would get you thrown in jail, if said to a police officer.

Yet, these words are also heard, occasionally, on children’s networks and in lesser rated (pg-13) movies. Huh, society?

Continuing with my story, my colleague and I talked some more. He is relatively new to private practice and I thought I would lend my advice. Yes, it is tried and true advice, deep from the well of experience.

I suggested he humbly return to the room and express his apologies in as sincere a fashion he could muster. If the patient rants and lambasts him mercilessly, take it like a dog with his tail between his legs. At the next opportunity during working hours, inform the department head of what happened and how it was handled.

He did.

When he came out of the patient’s room, he told me that it went well.

I asked, “Oh, how was that?”

Colleague, “After I apologized, they said there was no need to and that they thought it was cool. They said they were sick of Docs that pussy-footed around and wouldn’t come to the point!”

Still, I recommend following the above advice if you want to keep your job.

Your Grumpy Uncle Dave.

Weary

The Recommendation Letter

For almost any professional school, fellowship or job, an applicant will be asked to provide references. Choose the individual(s) that you are going to ask with some thought. There are things that you might overlook as obvious or irrelevant. Consider the following.

Look for experience in both the field of concern and in writing recommendation letters for applicants.

Look for authority. For instance, if you have a fellow in training versus a Nobel Prize recipient that are otherwise equal in consideration, choose the Nobel Prize recipient.

Know that your choice is respectful of you as an individual, your career choice and your choice of institution to which you are applying.

The individual should be knowledgeable of you, your talents, skills, character and any other trait that will indicate that they truly know you and are not using a boilerplate form for “just another” referral request.

When you approach the individual do not just ask for a recommendation. What you really want to know is whether or not the individual will give you a good recommendation. You do not want to find out, after the fact, that they gave you something less. I speak from experience that there are people that would do so and smile in your face and never let you know that they planned to trash you from the very beginning. Sure, they might still do that, but at least, you will have done due diligence to see that they are honest.

A few years ago, I was applying for a new job and asked a coworker to write a recommendation letter. I had worked with her for several years and thought she would write a good one. Traditionally, recommendations are kept private and the applicant is not allowed to know what is being said about them. In this situation, I found out that the recommendation was not a good one and was able to avoid using that individual in the future.

Despite the temptation, it is not appropriate to ask the person writing the recommendation to share it with you. They can if they want but you should not ask them to.

Be prepared for the individual to ask you to write your own recommendation. Be thoughtful and intellectually honest. Put your best assets out there and forget your worst. Or, at least, play them down to oblivion. If you are asked to write your own recommendation, ask for advice.

Basically, you will want your recommendation letter to communicate to the institution what your best traits are that make you more desirable to them than any other candidate. A recent online recommendation letter I filled out asked for ratings from Excellent to Poor in the following categories; Adaptability, Conflict Resolution, Empathy, Intellectual ability, Interpersonal Relations, Oral Communication, Reaction to criticism, Reliability, Self Awareness, Team Skills, Written Communication and Overall Evaluation. Almost without fail the submitter will be asked to and should fill out a written letter. This is in the form of prose as opposed to a table or graph. You don’t want to be too sterile, include traits on the human side of things, such as hobbies, family and other interests. You could (and should) prepare your own recommendation or a cheat sheet for whoever you plan to ask for a recommendation. A cheat sheet should include, at least, your name, what position you are applying for, how long you’ve known or worked with the person being asked, the circumstances of the acquaintance, all attributes that you feel you project into the relationship and some personality traits in case the recommendation writer doesn’t know any. Then, when the individual asks you to write your own recommendation, you could tell them that you have prepared one already and present it. If they don’t, you can tell them you have a demographic sheet for their use as background information.

From your Uncle Dave.

Death Panels

I received a 7 page double sided letter from CMT. Care Management Technologies, which sounds real official. It is part of Missouri Department of Social Services that monitors drug claims, diagnoses and ER visits. It is also part of Missouri Medicaid Audit and Compliance Unit (MMAC, read Death Panel). Probably a whole lot more, but I’ll come back to that.

The purpose of the letter was to bring to my attention that a patient I saw and gave narcotic medication (opioid narcotic, gasp) to who had also received narcotic prescriptions from 5 other doctors. Of course 2 of the others were hospitalists that had taken care of the patient while he was in the hospital.

I had given the patient one hydrocodone tablet while we were waiting for lab results in the ED. No other medication was given by me and no scripts were given by me.

In contrast, he received 334 tablets from the 4 other physicians over a 3 month time frame. That sounds like a lot, but it is 25% less than the maximum recommended dose over 98 days.

And, the pain the patient was being treated for was metastatic prostate cancer. Prostate cancer metastasizes to bone and is the most excruciating cancer pain known. There is no cure and treatment options include estrogen hormone supplement and castration to lessen testosterone which stimulates the prostate cancer to grow. Otherwise the only thing modern medicine has to offer is relief of pain.

So, you must be wondering why I am going on about all this trivial and complex issue. If you remember, we have suffered a few years of Obama Care and the rationing of health care that was predicted to result. Here is evidence that the pundits were right to predict that the “Death Panels” were coming. And, they are here. Actually, they’ve been here for a lot longer, they are just more functional since Obama.

And last week, President Trump signed the “Omnibus Budget Act” leaving Obama Care intact. And, President Trump vowed to stop all the opioid abuse, like my giving this patient one pain pill in the emergency department.

I have been writing about the pending doom of this opioid hysteria for a couple of years. Again will I stress;

There is no opioid crisis, there is only opioid hysteria.

There is a crisis of poor law enforcement, poor government regulations, poor prescribing habits and poor management of psychiatric health issues in America.

There is no opioid crisis.

Venting from your grumpy Uncle/Brother Dave.

Weary

The Interview

The old adage that there is no wrong answer couldn’t be more wrong.

Different Medical schools use different systems for the applicant interview. Some are very structured, using interviewers that have been “trained” and that are only allowed to use selected questions. Other institutions use random interviewers, including current medical students, guest interviewers and random questions.

Because of that, one may run into a variety of questions that may or may not seem appropriate. You need to be able to turn an inappropriate question into an appropriate response. For example, consider the following.

Question: There is a Christian, a Jew and a Muslim on the list for a liver transplant. Which one should get it?

Answer: There is insufficient information provided to make a decision as to which patient should receive the transplant. Obviously it cannot be made on the basis of religious preference and no medical criteria are provided.

My example is kind of obvious, but has been used. Odd ball questions may be very subtle.

Find every opportunity to practice interviewing. Colleges and Universities often have Job Fairs that can serve as practice for an interview. The practice doesn’t have to be in your field, just the experience of talking to strangers that are evaluating you will help. Unfamiliar situations are stressful, more so to some than others. The more you are in those situations, the less stressed you will feel and therefore the easier your responses will come. An answer delivered in a halting, stuttering, “uh” infested, or shaky-voiced manner will be viewed less favorably than one delivered with confidence, firmly and quickly.

Avoid personal opinions about sex, politics and religion from the stand point that the purpose of your interview is to get into medical school (or wherever), not to proselytize. You are not trying to convert the interviewer to your position; you are trying to provide insight into your ability to think on the fly, present your views in a less than abrasive manner and support your views from a position of logic, reason and fact.

Avoid telling jokes. You never know what the interviewer’s sensitivities are.

Make and maintain eye contact. Dress conservatively. Flip flops, board shorts and a tank top are not appropriate unless you are interviewing in Granada. No gum allowed. Leave your cell phone off or at home. If you have tattoos or piercings, minimize them. They look cool, are very much in vogue and you may be proud of them but this isn’t Facebook, Snapchat or a stage for you to display them. Like jokes, you don’t know what your interviewer’s opinions are and the intent of the interview is to have a positive outcome, not show off.

If something distracting happens, like a bomb goes off, the fire sprinklers go off or something, acknowledge it and refocus the conversation on the interviewer or the answer, whichever is appropriate. Use respectful language. At the very least use please, thank you and your welcome. Avoid marginal slang, words like duh, like, suck, shit, damn, effing or fricking. You may not intend your slang to be offensive, but the interviewer may be offended. Give complete and thorough answers, but avoid verbal diarrhea. Be cognizant of the interviewer’s attention span and don’t exceed it.

Try to remember the name of the interviewer sitting in front of you. It is OK to refer to an itinerary or note to refer to previous interviewers if you’ve forgotten their names.

The following are examples of questions you might be asked, but that you might not have thought about. At the time of the last revision of this document, I used current events in the topics of culture, medicine and public health. If this does not seem current, research it on your own. If you are a scribe, tech, nurse or otherwise work in health care, use your fellow employees and supervisors (especially physicians you work with/around) as sounding boards and sources of information. Don’t necessarily parrot what they say or think, because you would never be able to defend their position. Think about their responses and come up with your own thoughts and ways to express them.

Who are you?

What are your strong points, your strengths? What are your weaknesses or weak points?

What do you have to offer your patients or medicine?

In what areas do you feel you could improve?

In what areas do you think your training to this point could be improved?

What areas of medicine or science could be improved, and how?

What criticism of medicine or health care do you have?

What weaknesses do you see in health care in the US, in the World?

What do you think about the opioid crisis, gender issues, cloning, free healthcare, abortion, genetic manipulation or genetically modified organisms (GMOs)?

What do you think about Obama care, or Trump care?

What do you think about socialized medicine, single payer healthcare, health insurance or access to healthcare?

Society is going to fund your training to the tune of several million dollars. How do you justify that social expense?

Who or what has been most influential in your decision to study/practice medicine?

What is the most influential discovery in healthcare in the last 10 years, 100 years, ever?

How do you feel about taking money from people to heal them? Or not healing them? What if they can’t pay?

Where have you applied to Medical school? Why did you choose that/those choice(s)?

Why do you want to come to this institution?

Almost every interview will end with something like, “Do you have any questions for me?”

You betcha, or you should. Expect to interview with 2-3 people, so have at least 3-4 questions ready to be asked. Don’t use the same question more than once. The interviewers meet later and compare notes. If the question is institution or interviewer specific, so much the better. Don’t be surprised if the question is turned back on you, so be prepared to respond from your perspective what you just asked the interviewer. If you have already used all 4 of your questions or if they were answered in previous discussions, say so. Explain what the questions were and how they were answered.

A different type of interview process has been adopted by a few facilities. The Multiple mini-interview (MMI).

UMKC has apparently adopted the multiple mini-interview concept, at least for the anesthesia assistant program. This is an 8 am to 4 pm day. The interview portion may last 2 hours, more or less, with up to 11 interviews. It is frequently described as being like “speed dating.”

An example of the “mini” portion of this is that you may be given 2 minutes to read the interview question, 2 minutes to process your response, and 6-8 minutes to answer the interview question and any follow up questions the interviewer may add. It is up to the interviewee to pace one’s self to allow time for all of the questions. Follow up questions are an attempt on the interviewer’s part to nudge you to provide information in your answer that you did not give in the spontaneous response. There is some indication that the interviewers were given outlines of points that should be covered in the answer of the questions.

There were several ethical questions and several standard questions.

There appears to be a variation in the degree of stress intentionally induced by the interviewers. This probably reflects the different personalities of the interviewers.

While the “official” recommendation is to not try to prepare for the MMI, most of the applicants I have debriefed disagree. I would venture that not all applicants are versed in ethics. In addition, many ethical situations have cultural, religious and legal components. Therefore, I think it wise to prepare for those types of questions.

Some resources that may be helpful in preparing for the MMI.

This book is filled with many good examples of “ethical” questions and an overall good explanation of MMI:

Multiple Mini Interview (MMI), Winning strategies from Admissions Faculty, Samir, P. Desai, M.D., MD2B, Houston, Texas, POB 300988, Houston, Texas, 77230, 0988, 2016.

A YouTube play list of practice scenarios:

https://m.youtube.com/playlist?list=PLltsQb0J9n8vJ69Rlvqyu6chREtdObu8V –

American Association of medical Colleges post on MMI:

https://students-residents.aamc.org/applying-medical-school/article/what-its-participate-multiple-mini-interviews-mmis/

Your Uncle Dave’s opinion.

Weary

The idea for this post and all of the subsequent posts was initiated by conversations with my scribe, Morgan. She was instrumental in my posting the Uncle Dave’s Guides and I want to thank her for that.

The Government is Out to Get Me

The Attorney General, Jeff Sessions, is out to get me. Well, maybe not me specifically, but anybody and everybody that is complying with the law in regards to drug prescribing and distribution. What I just said is not paranoid hyperbole.

Sessions has designated 12 federal prosecutors to go to cities that have a high impact from the “opiod epidemic”. These prosecutors are to seek and destroy anyone deemed to be prescribing opiod narcotics, and profiting from the process. Their targets include doctors and other health care practitioners, pharmacists, hospitals, clinics and just about anybody or anything that is legally involved in the drug trade.

In his own words in a speech to the Columbus Police Academy in Ohio, he stated, “If you are a doctor illegally prescribing opioid drugs for profit or a pharmacist letting these pills walk out the door… we are coming after you,” Sessions declared. The Opioid Fraud and Abuse Detection Unit, as Sessions referred to the 12 attorneys, will … work in conjunction with the FBI, Drug Enforcement Administration and Health and Human Services to identify and arrest the violators.(2)

Now, why is that? There have been drug crises ongoing in this country and most of the developed world in one form or another, forever. Why would the government decide that the opioid epidemic is worthy of it’s attention, as opposed to, say, methamphetamine, peyote, heroine or marijuana?

Because of the Willie Sutton Syndrome. The bank robber that replied that he robbed banks because that was where the money was.

You see, all of the aforementioned entities are regulated, licensed and insured out the wazoo. Which means that they can be further regulated with licenses, permits, fines and the like. To a point that money may actually be collected.

So, do you think the War on Drugs has produced anything of substance, yet? No. In fact, the only thing the War on Drugs has produced has been a dependent culture and extreme expense to the taxpayers for detention and incarceration, rehabilitation (failed and otherwise), dependent support, medical expenses and on and on.

But, are these legal entities actually responsible for the “opioid epidemic”? Even the liberal New York Times doesn’t think so. “… opioid addiction, now made more deadly by an influx of illicitly manufactured fentanyl and similar drugs.” (1) Overwhelmingly, these drugs are obtained illegally. They may be stolen, purchased on the street from nefarious sources or obtained by malingering (presenting false symptoms for the express purpose of obtaining these drugs).

It doesn’t matter, the government has finally realized that they are more likely to collect their fines from someone making a 6 figure income and dependent on said government for the “right ” to practice their vocation than someone that is on welfare.

One drug dealer’s opinion from your grumpy-drug-dealing Uncle/Brother Dave.

1. https://www.nytimes.com/interactive/2017/06/05/upshot/opioid-epidemic-drug-overdose-deaths-are-rising-faster-than-ever.html

2. http://www.rollingstone.com/culture/news/jeff-sessions-targeting-doctors-profiting-off-opioid-epidemic-w495603