I have read the recent postings by Nancy, Sara, and Tony and I will attempt to respond with some thoughts. I still have opportunity to teach interviewing skills to second year medical students at the School of Medicine of the Medical College of VA. This school prides itself on educating and producing clinicians as opposed to research oriented doctors. This school built on hills and certainly not barrier free in 1962 accepted me and I was fortuate to win a National Foundation Health Scholarship to pay my way. My MCV class had its 30th reunion last April and everyone present was involved in patient care, either primary care or speciality care. When I see the 2nd year students, they are usually likeable, caring, genuine, and somewhat niave (and yes, unspoiled). They come from diverse economic, ethic, and racial backgrounds. Currently, close to 40% are women. They seem motivated to enter a medical career for admirable and what I would call the right reasons. What happens to them during the next seven or eight years (completing medical school and a four to six year residency) can change many of them, sometimes unfortuately for the worse. There is only one word for it----PRESSURE.... that is hard to describe. There is the pressure simply to get into medical school somewhere, the pressure of essentially studying seven days a week year round for most of four years. One survives because as a class, one knows that one is not alone. One's peers in other fields are getting on with their lives and earning money and seem to be enjoying the good life. One finally graduates, yes---takes the Hippocratic Oath as a class and feels proud, only to discover that the whole grind starts over again when one starts the first year of residency (formerly called an internship) and one is at the bottom of the pyramid again. The advances in medical science that have occurred in the twentieth century (even the last twenty years) are awesome and to try to learn this volume of material is at times overwhelming. It is not that one has to be a genuius to learn, it really takes more steady perservering dedication to the task day to day as a priority over everything else. This is depicted fairly well on the TV show "ER". The toll in my opinion on the educated residency trained doctor is the development of some psychological defenses that are not always healthy (such as the loss of real empathy that may have been present as a 2nd year medical student), a fear of losing it all because of an unintentional mistake, the powers of outside forces such as boards of medicine, medicare and medicaide audits, continuing medical education pressures, the cost of malpractice insurance, having to battle HMOs and other managed care powers, and the business competition that has been created by the huge hospital corporations and insurance companies. To survive in practice one has to join them or sink financially. I really believe Albert Schweitzer would be appalled by modern medical practice and run happily back to the rain forests of Africa. Don't get me wrong. I know many doctors have abused insurance systems and probably still do, have done harm and should have their licenses revoked by medical boards, and there should be safeguards to protect us all. Many doctors have huge debts after finishing training and are too intent on making money. Also, many medical marriages fail because of the physical and emotionally absent medical member. "He or she is not the same is not the same person I married."
I was 35 years old when I passed my board certification examination because at that time, I had to have two years of clinical experience beyond residency before I would be eligible for the exam. My written exam was in Wash. D.C. and my oral exam was in New York the following year. My wife went with me and I carried my portable ventilator to survive. One of my oral exams was at Bellevue Hospital in N.Y. The cab ride to the exam created more anxiety than the exam, and had actually relaxed me because I was so thankful to get there in one piece. When I learned that I had passed that exam, I thought now I can relax. But no, now many specialities require recertification, with emphasis on facts and knowledge with little emphasis placed on experience in my opinion. I know that I would have difficulty passing a board exam now (not that I wouldn't try), but I know that I have immense experience now that can not be accurately measured on an exam.
To make matters worse, primary care physicians are in demand and with monetary rewards for doing less referring, I think many patients are being delayed in seeing the right specialist soon enough. There is no way that a primary care physician can know everything. I believe PPSers need to see a physical medicine and rehab specialist sooner than they usually do. These doctors usually know more about PPS.
The key to me as a doctor was to survive all this adversity over the educational and training years, and come out of it with my empathy intact. I think it was easy for me because I was educated and trained at MCV where I had been hospitalized with paralytic polio at age eleven, and I walked those same halls daily while in med school and psychiatric training. I have never forgotten how it felt to be a terrified, motionless child, totally dependent on the care of EMPATHIC doctors, nurses, P.T.s, aids, volunteers, and housekeeping and food service staff. Most of these people cared then and could bring a smile to my face.
There will always be disease and many diseases over the years do have recurrences such as malaria, TB, MS, Crohn's, and even untreated syphylis to name a few. Now, we, and I mean WE are learning more about the natural history of the the disease brought on by the wild polio virus before the discovery of Salk and Sabin. Our generation, if nothing else, should help solve this puzzle because there are many of us who have lived long enough after the original polio event that we will hopefully bear witness to the reality of PPS and maybe somebody will uncover what is really going on with us. Is it neurological, metabolic, sytemic in the CNS, biochemical, harmonal, etc? In my opinion, one thing that it is not....It is NOT in our heads (psychogenic), it is REAL day to day. As I think about it, many of us probably have similar defenses and personalities as the BAD doctors we complain about, except hopefully, we have retained our empathy for each other as is often revealed on this list service.
Even Sister Kenny concluded that the American doctor believes in the conservative scientific method (that brought Salk and Sabin), but is curious enough to listen and examine a new idea which usually keeps the American doctor ahead of the rest of the world. Remember, America was the only country that accepted her ideas at all. I hope we maintain the strict adherance to the scientific method but also keep our curiosity and sense of adventure.
I have said enough. If you have found a knowledgeable, listening, and empathic doctor, you are fortunate, and treat him or her as a friend. When I was in practice, I received the most thoughtful notes and holiday gifts from some of my more difficult and troublesome patients, but I somehow knew that they did not really enjoy their plight and they apparently perceived that.
I do not intend to create controversy, but I welcome thoughtful comments.
Henry Holland, Richmond., Virginia, USA. Henry4FDR@aol.com
28th January 1997
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