text:
Wherein a surgeon tells some stories, shares some thoughts, and occasionally shoots off his mouth. Like a surgeon.
Tuesday, August 07, 2007
One More Time
When I was "interviewed" for a website recently, one of the questions was if another blogger and I had stopped feuding. Not that I know of, was what I said. I'm not sure if there's been a feud, for one thing. For another, I feel teensy bad that many moons ago I did make some (possibly inappropriately) snide comments about his chosen field. The reason I bring it up now is that there've been a lot of articles lately that suggest that lots of people have no idea what it really means to be a doctor. Crazy stuff, some of it.
In the formative days of this blog, I wrote once about shortcomings I saw in family practice docs coming right out of training. (I find many of my older posts embarrassingly bad, so I'm not even going to look for and quote myself.) What I hope I said was along these lines: worse than a doctor who doesn't know stuff is a doctor who doesn't know s/he doesn't know stuff. Compared to specialty training -- in which it seems half the time is spent reminding (putting it nicely) trainees how little they know -- it was my impression that (at least at one time) the opposite seemed true of family practice. I probably didn't acknowledge that it's nearly an impossible task: teaching people a smattering of everything -- enough to know both what they're doing and to recognize when they don't. Still, the FPs I worked with who were freshly minted knew much less than they thought they did about the topics with which we dealt in common: breast lumps, breast cancer. Gallbladder problems, hernias, hemorrhoids. Colon things. Various stuff. (I put on some seminars, which helped.) And yet they happily (because, I assume, they weren't taught any differently) took on issues with no sense of discomfort or of a need for input. It may be intangible: but a doctor simply MUST know his/her limits. The shorter the training, the less intense (maybe, even, the kinder and gentler), the more poorly is that goal met. Now, in all specialties, that appears to be exactly where we're headed.
I think I also said -- and if I didn't, I should have -- that the FPs I knew who'd been around awhile were excellent docs. It just seemed to take a while to assimilate the sense of limits (not to mention to broaden the limits outward); and I think that's not as true of most specialty-trained docs. Acknowledging once more that many doctors share much in common with human beings, it's true that within any subset there are exceptions to the left, and to the right.
So why am I picking this scab again? Because of my recent post in response to an article in the NYT decrying doctors' incomes, and the comments thereon, as well as several related posts and comments in the recent medical blogosphere. Still more: I got an email from an excellent young medblogger asking my opinion about a post by some sort of health/fitness blogger in which he claimed that it should take way less time to train doctors; that you ought to be able to learn surgery in a couple of years. Procedures, he said, are often taught nowadays by reps from instrument companies, so how hard can it be?
Related is the concept bandied about by commenters here and elsewhere that all our health care money problems will be solved simply by cutting what doctors are paid and by cranking out way more docs. Perhaps the best of all was the prediction that any gaps in physician availability would be happily made up by women who want to be part-time docs and moms.
Still another connected issue is the on-going discussion among other bloggers regarding the 80-hour work week, and how us old farts who trained in the days of much longer hours simply haven't a clue about how clueless we are. These generally include tirades at how particularly egregious is surgical training and the arrogance of those within -- more the teachers than the teachees. But them, too.
And finally, my blog and those of others are rife with comments by people who've been treated egregiously by doctors. Truly. Egregiously. I'm embarrassed just to read some of the stuff; particularly as it reveals complete lack of communication skills, compassion, and empathy on the part of those doctors.
OK. I probably have neither the will nor the skill to do justice to bringing together all of these themes. Except to say this: there seems to be a very schizophrenic attitude about physicians. People want more knowledgeable doctors, ones that will listen better and explain more clearly. Docs that will fully enumerate and carefully explain all the issues and choices for any situation; who will be sensitive to their individual needs, who will both guide them but let them make all their own decisions. And, of course, doctors with comprehensively flawless knowledge and impeccably perfect skills. People criticize doctors -- surgeons especially -- for having a god-complex, but they want god-like perfection. To achieve it, they suggest flooding the market with doctors and spending less time training them. And, of course, after people flock to become these perfect doctors, to pay them less and less for their efforts. Highly qualified, well-motivated folks with altruism aplenty will fight their way to the front of the line.
Especially moms.
Talked to the tooth fairy lately?
36 comments:
- Unknown said...
Thank you for utterly depressing me. It's hard to know what physicians want and need to be. Honestly I think we should all attempt to (pardon me) cut the bullshit and talk about what's really going on. I see a lot of issues that are sensitive, and nobody is willing to bring them up. Why are doctors not fighting like hell to bring the profession to were it needs to be? Why are insurance companies holding us by the beans?
Medical schools want overly well-rounded people to be shoved into super-specialized boxes. It isn't going to work, and yet, nobody cares. . . - 8/07/2007 9:20 AM
- SeaSpray said...
Good post!
I also wonder why doctors aren't uniting, standing up for what's right? Or do they disagree? Are they just so busy working they don't have time? go read the Independent Urologist's post called Agonal Rhythms.
It scares me to think they would take short cuts in training surgeons. Dr S., you have discussed that you would do things differently to avoid burnout. Knowing everything you know now - what would you not change regarding surgical residencies and what are the welcomed improvements since you started? Specifically for the purpose of producing top notch surgeons?
Reading Panda Bear's recent post, your stuff and others - It seems to me that they are tough to weed out the weak because after all surgeons are responsible for their patient's lives and what they do can instantly make the difference between life and death. Just wondering.
It bothers me to see doctors get discouraged. - 8/07/2007 9:42 AM
Sid; Your Blog is one of my favorite and I read it daily.
Today's comments on understanding ones limitations, are not, in my opinion, limited to any one specialty. I agree with your observation that the weakest doc is one that does not understand his/her limitations. Nothing is more frustrating than to get a referral (Friday afternoons !!)for something that is now an urgent problem, because the referring doc has spent a week or so mucking about with what was initially something straightforward and easily dealt with. You now have to deal with a complication, not let the patient know that perhaps it could have been avoided, and say "thanks" for the referral!
In his book "Making of a Surgeon", Bill Nolen describes his experience as a new (only) residency trained General Surgeon establishing a practice in a community where GP's had historically been the Surgeons.
After many late night/weekend bailout referrals he finally said "enough is enough". Dr. X, your referral was complicated because of your efforts. I know this may cost me future referrals, but that is ok with me as I am not very appreciative of having to spend my time undoing things that could have been avoided. Call me earlier or do not call me.
Do we need more Bill Nolans? Possibly. Should our training programs be reevaluated-perhaps, but against what criteria?
A General Surgeon friend of mine, when in his mid 60's came to me with this observation and request; "I have greatly enjoyed my career, and it would make me sad, if my colleagues did not think enough of me to let me know when my work was less than what it should be". - 8/07/2007 9:47 AM
- Sid Schwab said...
anne: "by the beans." Good one.
seaspray: I guess I really should think about your questions, the answers to which might be self-enlightening.
tomp: I absolutely agree the "limits" thing applies everywhere. I think the training of "proceduralists" might be better at inculcating them, and I think it takes time. And, regarding your friend's insightful comment: I think part of my premature bailout was the sense that as I was getting more and more tired and overworked, I worried about making self-preservation decisions: it's safe to stay in bed and see the ER patient in the morning; that anastomosis looks good enough; etc. I don't think I ever did, but I began to worry about the possibility. - 8/07/2007 10:05 AM
- Mitch Keamy said...
re: Physician salaries - nice response from that hard-eyed economist at Princeton, Uwe Rinehart here: http://blog.hcfama.org/?p=1125
the physician income thing that Rinehart is addressing was most recently stirred up with an inane op-ed in the NYT about 9 days ago. If you can't find it, let me know, and I'll send you a link.
The problem with the blogospere is that every cock-a-mamie idea can be found and quoted, even mine. Yes, medicine has its issues, and yes, some of our colleagues are jerks. But that many more are inspiring...
I feel a little sorry for the youngsters; they don't know what they missed in medicine in the 70's. And I hope that what we leave them and what medicine inevitably evolves into inspires them as I have been...
That being said, it's hard work. I started as a chemical engineer. This is much tougher; external events set the tempo, not us... Surgeons have it especially hard; OR/call/clinic/referring docs. I often find myself feeling bad for my surgeons...
Mitch - 8/07/2007 10:39 AM
- Sid Schwab said...
Mitch: I assume that's the same NYT article to which I referred in this post and about which I wrote here.
I agree about the youngsters; although not knowing what was lost makes the experience easier. We old farts went through the change, as it were. For the new kids on the block, I'd assume a huge factor is not knowing what's coming and how it will all play out. I've always said that at its core, medicine will always be a rewarding and honorable career. But if that core is harder and harder to access, then who knows? - 8/07/2007 11:13 AM
- Jeffrey Parks MD FACS said...
Well spoken Doc.
Hey, I didn't say part-time mom-docs, I was talking about FULL-time docs -- but not double-time, either. Why can't a parent working 40-50 hours a week be a good doctor? Especially considering that parents of young children tend to be more acutely aware of their limitations -- unlike these young punks from Yale, perhaps, who think they already know everything they need to know.
When so much of the motivation for becoming a doctor is financial, seems like the people who end up as doctors are not the ones with the most aptitude for medicine. It's a truism that the C students are the ones making millions on Wall Street, while the A students are toiling away in grad student cubicles identifying insignificant (albeit novel) proteins. Right now, you get dermatologists who spend half an hour with the elective freckle-removal patient and five brusque minutes with the inexplicable rash. You get a glut of plastic surgeons and a dearth of rural GPs. I don't see as how we're getting particularly knowledgeable or god-like doctors this way (present company excepted, of course!) How do you restructure incentives so that the best and brightest, not just the ones who are bright enough and crave a certain status, will want to become doctors?
I don't necessarily want doctors to be paid less (per hour, anyway), and I'm not one of those advocating for a shorter medical education, but I do wish the field were more open to bright, insightful people with an aptitude for medicine who don't think it's healthy for them or their patients if they work 80-100 hour weeks. They aren't lazy, they've just prioritized a balanced life. Will such people make inadequate doctors? I can envision a tiered system, where the godlike, perfect, highly-paid and childless men become surgeons and the bright-but-balanced young parents become 9-to-5 GPs in Walnut Creek. I don't know, maybe that's how it shakes out already and we'd both be fully aware of this if we had larger sample sizes. - 8/07/2007 11:43 AM
- Bongi said...
i have seen the other side. i once replied to buckeye that south africa is layered. medical training too, but to a lesser extent. but more importantly, they are pushing whatever riffraff through to make up numbers. i have seen moe's ideal leaving to go home and leave some woman to bleed to death. i have seen the stupid missing the obvious and forcing people to take a journey to the brink of death. i have even worked with a doctor who bought his degree. he knew nothing at all about medicine. i don't think he knew where his head was.
a zimbabwean once told me that if you only sound the alarm when there is no bread on the shelves, you are too late. he left his country when he could no longer buy designer jeans. i don't think one should ignore people like sid just because he is old school. old school may just be right school.
i have always wondered who do they want to protect? the doctors or the patients. call me old school like sid, but i believe in protecting the patients, even at the expense of a bit of doctor comfort and spending a tad more time with the kids at home while some woman at work bleeds to death.
complain now. and don't get sick when you are old. - 8/07/2007 12:03 PM
- Mitch Keamy said...
yup-the op-ed was berenson, and the letter to which I linked is the first letter the NYT printed in response. I even commented on your original discussion of that op-ed; but it was so long ago (a week?) that I forgot you'd been there, done that.(sigh.)
I am in a public health program full of physicians who can't take it anymore. General practitioners who aren't making any money, can't deliver the care they want to give and still see enough patients a day to cover their overhead, and find that their patients' problems are in many cases far upstream of where the doctor comes in.
Maybe one of these dedicated but frustrated people will figure out the solution. - 8/07/2007 1:31 PM
- Lynn Price said...
"When so much of the motivation for becoming a doctor is financial, seems like the people who end up as doctors are not the ones with the most aptitude for medicine."
Maybe I'm missing something here, but out of all the docs I researched with , not one of them went into medicine for the money. There are far easier ways to make a buck.
I think the motivation you're seeing is that docs feel they deserve the lion's share since they're the ones doing the work. And isn't that the way of Man? Benevolence and feeling good don't pay the bills.
The insurance companies have become the new dictator, and they've taken it upon themselves to create an artificial playing field in which they're coach and quarterback. It's criminal when a doc has to face his staff and tell them they may not be able to afford to stay in business. And, yes, I've seen this.
Great post, as always, Sid. - 8/07/2007 3:52 PM
- rlbates said...
We may not have gone into medicine for the money, but we certainly never expected to need to declare bankruptcy due to the difference between overhead and reimbursement. I went into medicine because I loved science and wanted to do something good. I also thought it would be a decent living for all the work. My mom thought she might get a new house from me some day. That day is yet to arrive. - 8/07/2007 4:18 PM
- Sid Schwab said...
Moe: I appreciate your expansion on your previous post, and I see you are a thoughtful person. Like the others, I strongly disagree that doctors go into it for money. Believe it or not! (Sure there are some who are cynical, set up money-mills, milk and/or defraud the system. But truly, those are very exceptional.) But, as I've said before, the kind of people you'd like to be your doctor -- namely, those who are bright and hard-working and committed to their calling -- are, in general, also people who expect some sort of relation between effort and quality, and reward. To the extent that the system is moving away from that, those people will look elsewhere than medicine. I recognize that it's largely speculation: but we see the best doctors, the ones with the most experience, becoming disenchanted and dropping out (guilty as charged!) If the system changes as you propose, containing shift-workers that are happy working 40 hours for less pay, I think it's only human nature that the quality of care will suffer. At some point, if you're paid for forty hours, you'll quit working when the time's up. Everyone else does, don't they? The difference is that taking over the care of a human at 5 pm is not much like taking over a place on an assembly line. But who knows?
- Richard said...
In the end, we'd all like the best and the brightest to be our doctor. But then, the best and the brightest also recognize that:
1.) They'd like some semblance of family life, where they get to spend a meal with their family more than once a week.
2.) They could make far more money far more quickly and easily using their intellect in other fields. (12 years of medical training is a rather long financial head-start for someone in another field)
3.) They would have far more control over their own lives and lifestyle in other fields (rather than being subjected to the whims of medicine and the hospital).
These "best and brightest" usually end up in other fields, and those that do end up in medicine, for said reasons above (they're smart, right?), do so not for money or status, but instead out of altruism (the whole "helping people shindig).
There just aren't enough "godlike, perfect, highly-paid and childless men" to go around. - 8/08/2007 1:27 AM
- Eric, AKA The Pragmatic Caregiver said...
Color me naive; I interact with physicians from two of the Mayo outposts as a patient, a family member of a patient and as a casual research collaborator.
I have to assume that their doctors are highly paid - they attract awfully good people. I have to assume that they work fairly normal hours, at least in internal medicine, neurology, physical medicine and onoclogy - the departments I have the most interaction with - because I know when they're reachable and I know when they respond to email.
The environment of care is exceptional at their Arizona system - I can't speak for the other two. The "customer service" is fantastic - and the appointments, whether with specialists or internal medicine seem exceptionally lengthy and thorough.
So what the hell? How are they doing it? I've seen the bills. They're not markedly higher than other providers on a line-by-line basis.
Scott Fisher, MD, MPH, seems to think the answer is in "accountable care organizations" - systems that effectively manage the continuum of care across an integrated local delivery system. His benchmark organiations are interesting - Group Health Cooperative, Virginia Mason, Harvard Vanguard, Rochester IPA, Intermountain/LDS, and, yes, Mayo. His assertion is that if everyone in the country was treated at either Mayo or Intermountain, health care spending would be cut 30%, and I don't think *anyone* can argue with their quality of care. If we could take 30% off today's total costs and control the rate of escalation? Holy crap, it would be the health care finance equivalent of splitting the atom and finding some place to put the waste.
I *don't* see how solo/small practitioners can survive, quite frankly - the knowledge to support the financial and data management requirements of a professional enterprise, let alone one with such a mix of entities that pay for the service are, quite frankly, breathtaking. What's so wrong with an integrated model like Mayo's?
Eric - 8/08/2007 1:33 AM
- Jeffrey Parks MD FACS said...
I agree that most young people who opt to apply to medical school don't "do it for the money." But something happens along the way. The loans accumulate. You see your friends making boatloads of cash in non-medical fields and article after article decries the falling compensation of future physicians. The money does come into play for a lot of third and fourth year med students. Why else is it that the high achievers, the AOA students seem to gravitate toward the high earning, low work hour specialties like radiology and dermatology and anesthesiology?
- Sid Schwab said...
Eric: having practiced in a similar environment, I don't think there's much wrong with the Mayo model. Most multispecialty clinics go through reimbursement upheavals periodically, as one group feels more gored than another. But that's not too big a deal. In terms of efficiency, of being able to exert some group influence on behavior, of finding and promulgating ways of practice that are cost-effective, of standardizing and monitoring patient satisfaction issues -- all of those things are characteristics of a well-run group. And large, highly-reputed groups have at least some ability to influence insurance companies. So really, given the general environment, it seems the best approach in many ways. Groups aren't for everyone. You give up a certain independence; the overhead, at least for some specialties, is way higher than if one were in a single-group practice. And group or individual, the money that comes in is decided by those who pay, not those who do the work; so whereas people who work in large groups are insulated from the business work, they are still at the mercy of uncontrollable outside forces in terms of income, regulation, etc. But I stayed put for my whole career, even knowing I'd have made more money had I joined with the single-specialty group in town that made the offer more than once.
I've been a PA for almost thirty years. I've worked mostly in family practice, though with stints in the ED and some other places. I've working in training centers (some of the best) and in the community. The quality of doctors coming out of residency now seems to be dismal, especially in the primary care arena. I yearn for the docs of yore but, alas, they are all
either retired, retiring, or so burnt out that their advice can't be trusted. There are still some good ones about that have between 10-15 years of experience and trained under the "old" regime. I feel that the best preparation for general practice (and that's what it should be) is at least a surgical internship and a medical internship (two years) plus at least a couple of more years in various specialty rotations and a year's apprenticeship---which is the British system. And then, they do "just" ambulatory medicine, but they know what they don't know. Increase the payment for the generalists and good people will enter the field once again. Don't "de-skill" doctors by minimizing the rigor or length of their training. That's what we're for! - 8/08/2007 7:25 AM
- Sid Schwab said...
anonymous: very well said. You're singing my song. One thing I find interesting: the commenters and bloggers who are students give me some hope, based on what I perceive of their intelligence and commitment. On the other hand, virtually all of my friends in academic surgery express what you did: the decline in quality and commitment. So, sadly, it may be that the slice of the loaf that we see as bloggers doesn't represent reality across the (cutting) board.
- T. said...
What a GREAT final paragraph that really says it all.
I have had patients whose first words upon seeing me were, "So you're the one that's gonna kill me?"
After the suffering of medical training, the years of lost time, the insults and put-downs, and also the daily renewal of a commitment to rise above it all and treat each patient with genuine love and kindness, a greeting like this is deeply disappointing.
Somehow in our society it's not okay to disparage a particular racial group because an individual from that group happens to commit some wrong, but it's ok to denigrate ALL physicians because of some people's bad experiences.
I get the feeling people feel entitled not to the very best care that can be offered, but rather to PERFECT care. For free. I try my best, but there's no way on earth I can get it "perfect" every time, ever day, even if I can get it "really good." I guess I just gotta keep holding up my end of the commitment and effort and hope it makes a difference... - 8/08/2007 9:56 AM
Great post and wonderful discussion. I feel like I've re-invented my surgical career at least 3 times in the past 10 years since I've finished training. I've gone from single specialty groups where the business end wasn't up to snuff to solo practice to small group practice in a cash-based surgical practice to a solo practice in a mixed cash/insurance model. I won't be too obtuse the cash part is cosmetic surgery.
There are still innumerable problems in doing this and running a small business. Primary among them is the huge increase in overhead a cosmetic ("unnecessary") surgery practice has. At least most general surgeons don't have to actively seek out more patients to operate upon.
I think that the real solution in surgery and medicine in general is the multi-specialty group model. The only way we have to run a better business is to either increase our income or decrease our overhead. None of the insurance carriers or the government seems to be in a big hurry to increase our revenue.
Fundamentally, the public has no concept of doctors' income. Nor do I think they really care -- yet.
Upshot is I may be on to the next incarnation of my surgical career. - 8/08/2007 9:58 AM
The Mayo clinic is a poor example when trying to generalize care. They exist in a somewhat insulated environment with minimal numbers of unfunded or underfunded patients and serve as a super-teritary referral center rather the a nomal multi-specialty group.
Also note that they have (as I understand it) periodically opted out of Medicare and exist as an out of network provider in many instances, an option not available to almost any large groups.
The turnover of staff and disatisfaction with compensation in the Mayo system (and cleavland Clinic) is well known in surgical disciplines - 8/08/2007 12:40 PM
- Eric, AKA The Pragmatic Caregiver said...
I agree that part of Mayo operates in rarefied air; I'm wondering specifically about their community health systems in the surrounding area, the community internal medicine service in NE phoenix, etc.
There's also the option of ignoring Mayo as an outlier and considering LDS/Intermountain as closer to a typical workable model.
Anon 8/8 12:40:
I am interested in hearing more about your statement that turnover and dissatisfaction with compensation is well known in the Mayo and Cleveland Clinics.
A little background; I am a (prematurely) retired pathologist who now reads health care blogs in a vain attempt to understand where the system went wrong and how we docs might someday unite to correct it. I was beginning to form a preliminary opinion that the Mayo/Cleveland model might be the way to go. So what gives?
ps; I didn't retire due to burnout (well, maybe a little), but due to a new chief of our 6 person group whose sole focus was how in increase our already-abundant income - forget the quality assurance and report standardization programs I had been trying to install.... - 8/08/2007 2:33 PM
- Sebastian said...
Reading the responses, there seems to be a little FP bashing going on. I think all the specialties could do with a little longer training because there is SO much to know. I think it is easy to discriminate against the FP because, in many instances, they are held to the same standards as specialist. "The rash would have been treated in such and such a way by a dermatologist", or "the heart failure would have been better managed by the cardiologist". There will always be someone who knows more. The electrophysiologist will disparage the general cardiologist and the colorectal surgeon will disparage the general surgeon.
Looking nostalgically back at how great the GPs were goes against the argument of more training. Prior to 1969 family practice did not exist as a specialty nor did the residency. GP's were required only one year of internship (hospital) prior to hanging out their shingle.
We all have a hard job and are held to impossible standards by the public, each other, and ourselves. - 8/08/2007 2:34 PM
- Sid Schwab said...
Steven: appearances aside, it wasn't my intent to "bash" FPs; rather it was to use a prior perception of mine as a way into the essence of the discussion about public perception of all docs. I haven't been around newly trained FPs for a while. As I said, to the extent that I have misgivings, it's only about an aspect of their training; once out there a while, I think they seem to be fine. And I also acknowledged that none of us is close to perfect. Your points are well taken.
- Greg P said...
If my primary goal in life was to make money, I would not have gone into medicine. First of all, there are too many controls and limits on how much one can make.
More importantly, doctors have to do things to make money, time-consuming things, and there's only so much time in a day, and we don't even work like lawyers and charge by the clock -- there is a lot of our time that we have to use and are completely unreimbursed for.
Those who make a lot of money do not do things. They arrange for large sums of money to move from one place to another, charging a small percentage of those large sums of money for their services.
On balance, I am generally satisfied with this existence of doing things and thus limiting my income. That doesn't necessarily mean that I look forward to making less money so that a health insurance company executive has more money to shove around. - 8/08/2007 7:11 PM
- Michelle said...
You bring up some very good points. In my humble (read unprofessional) opinion - to get the kind of quality doctors and surgeons that people want is NOT going to be accomplished by paying them less and cranking out more of them. If anything it will have the opposite effect - making doctors more poorly trained, and less motivated to do a good job.
- mscriver said...
mI know these discussions are primarily for doctors, but I'm increasingly convinced that the things you name are not the problem of one profession but a problem of the whole society. I was a church minister for ten years and quit, in part, because of the steadily declining quality of colleague ministers all the while the expectations got higher. I taught high school at different periods and have found the quality of the superintendents sinking, all too quickly. The teachers are not so prepared as they used to be, but the students are smarter and tougher.
At first I thought it was just me, but now -- after talking to a lot of people and doing a lot of reading -- I'm inclined to think we're doing something as a society that nips idealism in the bud and doesn't support diligence.
Except in one category: the military. Why are fine people and strong leaders going to the military? Can't be the money. Can't be the hours. Can't be the reward of being home with family for dinner.
Is it some kind of evolution? Towards what? I'm not being facetious.
Prairie Mary - 8/08/2007 9:00 PM
- Sid Schwab said...
Mary: I love having comments from any and every one. Your observation about the military is interesting: the other side of the coin is that they've had to lower their standards in terms of education, criminal history, etc, to fill their quotas. That may not be true of the academies, however. One way in which the military differs from other fields is that there's a fairly clear path to success, to rising in the ranks, to getting recognition and respect. I'm arguing that at least in part that's becoming less true in medicine.
- Unknown said...
Welcome to my generation. We get through school with as many superficial accomplishments as possible to look good for future schooling and the job market - the result - we master nothing, and we are unhappy doing just one thing. Further, check out GRE scores for graduate students in education - they are only one notch above business majors (sorry).
Our educators are at the bottom of the barrel. I guess we've come back to the whole, "hire more, pay 'em less" plan. It doesn't work. We need more focus. - 8/09/2007 5:36 AM
- mscriver said...
Yes, I think it's the focus, the clarity. We are having a hard time sorting out the disciplines, much less trying to decide what a doctor is supposed to "profess." Doctors in this state have suddenly gone on a moral kick and will refuse to prescribe birth control pills or (gasp) viagra! On the other end, the state has jailed Doctor Kevorkian while trying to hire a doctor to make sure their capital punishment protocol is effective.
I'm told that only half the doctors in the country belong to the AMA now. Teachers consider the NEA to be only a labor union and when I heard their president interviewed on the radio he surely sounded more like a hod carrier than an educated college grad. His goals were strictly for teacher benefits. The NEA used to be focused on students.
We've lost confidence in what a "nation" is about and also what "medicine" is about. My diabetic friend (about the same level of diabetes 2 that I have) has begun going to a naturopath who is "reversing her polarities" and gave her a thing that looks like a refrigerator magnet to repel electromagnetic waves. She says at least he listens to her, which is more than the available doctors will do. When I stopped laughing, I had to admit that it's hard to get a doctor to listen to me, either.
Prairie Mary - 8/09/2007 8:38 AM
"Your" generation are not yet practicing, licensed doctors. You can argue plenty of things about Generation Y, but the people who are five years out of medical school are an average of 29-30 years old, which puts them squarely in Generation X. From what I've observed, that's (in general) a completely different set of values. Artifical inflation of accomplishments wasn't one of their specialties. - 8/09/2007 11:48 AM
- Beach Bum said...
It's an interesting question. I know that as a slightly older med student who came to medicine from a demanding and consuming career, I am working through these issues and trying to come to terms with my role. I also know that I want to do FP (although I'm willing to change my mind), but don't want to work 120 hours a week. I know that many in my generation have lost their enthusiasm, and have become cynical about work in general. We've seen our parents working dead-end jobs and end up miserable. We've been told that education is the key to our futures, so we've mortgaged our firstborns with student loans and end up being slightly more unemployable when we graduate from college than when we went in. We're even sold the dream of being a doctor, and find that when we get out into the trenches, it's pretty damn hard.
I think perhaps the most dangerous idea that we've bought is that life should be easy. So when it turns out to be really hard, whatever we end up doing, and whatever lifestyle we end up choosing, we feel cheated somehow.
Anyway, I'm off to the beach. - 8/10/2007 1:40 PM
- Sflwrgirl said...
Totally agree with what you've said. As a young physician in residency, I sometimes wish I had the experiences of older physicians, even if it meant working much harder, because it might mean that I actually got to make a difference in residency rather than waiting until I get out. And there are days that I wish I could go to the post office to mail a package (it took 9 days last time to find a day when my time away from work could coincide with open post office hours) or get my dishwasher fixed. I think the problems you describe hit young doctors-in-training where it hurts the most - their families. They also want doctors who are always available ("I can't believe -my- OBGYN had someone else deliver my baby!") but can't understand if you don't make it to your third-cousin's birthday; they want you to make a ton of money but get out of residency in 3 years, and what self-respecting spouse would iron their partner's shirts anymore? These things have also changed, and it makes a HUGE difference.
Moving this post to the head of the list, I present a recently expanded sampling of what this blog has been about. Occasional rant aside, i...
In no way is it false modesty to say that physicians are not healers. At best, what we do is to grease the way, to make conditions as favora...
Finally I'm getting around to writing about the gallbladder. Don't know what took me so long, seeing as how, next to hernias it'...
I finished the previous post with the sad story of my patient, illustrating diagnostic difficulties at the fringes of biliary disease. An...


text:
Stipend Tax Guide
Stipend Tax Made Easy
Reporting tax with a platform such as Stipend can seem daunting, but it doesn't have to be. Crypto Tax Calculator imports and categorises all the transactions from the wallet you used on Stipend, allowing you to generate tax reports quickly and easily. Crypto investors commonly use multiple wallets, exchanges and chains, which can lead to a convoluted transaction trail that can be hard to track at tax time. Crypto Tax Calculator integrates with all of your favourite exchanges, wallets and blockchains, allowing you to consolidate you data and track profits, losses, and income. This guide covers how to get started with your Stipend taxes so you can sort out your tax nightmare today.
Quick Start
Let's dive right into it! Here's a quick and easy breakdown of how to import your Stipend transaction history into Crypto Tax Calculator:
1. Stipend is available on
2. Locate and copy the wallet address/es you used to transact on Stipend.
This will be accessible via the wallet you used to connect to the Stipend originally (e.g. if you use Metamask, navigate to the wallet you used and you'll be able to copy your wallet address from there).
3. In Crypto Tax Calculator enter the associated blockchain you used when interacting with Stipend into the search field or scroll down.
For example, Kava.
4. Enter the wallet address into Crypto Tax Calculator, provide an optional nickname, and click **Add Wallet**. It is possible to add multiple wallet addresses after you add the first.
5. Your wallet/s will now sync and Crypto Tax Calculator will pull in all the transactions associated with your wallet on that chain, including any transactions on Stipend. If this wallet has interacted with other platforms, those will be imported as well.
Why are DeFi taxes so difficult?
Decentralized finance (DeFi) platforms, such as Stipend, offer people access innovative financial products in a decentralised and autonomous way. However, one crucial aspect that DeFi platforms can't currently provide is the ability to generate a user's tax forms.
The main reason for this is that DeFi platforms do not get the 'full story' of your transaction history. For example, Stipend only has the ability to calculate taxes on the transactions that happen on the platform. This leaves a gaping hole of information, such as where the crypto currency came from and how much it was purchased for, which is required to determine a cost basis. Without this, the tax calculations could be incorrect. DeFi platforms also typically lack the centralized structure and compliance mechanisms required to generate tax forms for users. Unlike centralized exchanges that collect and store user data in a centralized manner, DeFi platforms operate on a decentralized network that doesn't require users to provide personal information, such as their tax identification number. As a result, DeFi platforms lack the required user data to generate accurate tax forms for the individual.
Another issue is that the tax laws for cryptocurrencies and DeFi transactions are still largely undefined and constantly evolving. DeFi platforms often facilitate complex transactions involving multiple assets and protocols, which can make it difficult to determine the tax implications of each transaction.
Therefore, it is up to the individual user to keep track of their DeFi transactions and report them accurately on their tax forms. While this may seem daunting, but Crypto Tax Calculator can help you manage and stay on top of your DeFi taxes by automatically importing and categorizing transactions made with platforms like Stipend.
Can tax authorities find my DeFi transactions?
The decentralized and anonymous nature of DeFi leads some crypto investors to believe that they can fly under the radar and avoid tax reporting requirements. However, tax authorities are increasingly trying to catch those not playing by the rules and avoiding tax. Tax authorities around the world are adopting new techniques to identify and track crypto transactions, including those on DeFi platforms.
It is important to remember that decentralized blockchain data is publically available information. Tax authorities can identify DeFi transactions associated with an entity by analyzing public blockchain data and tracking the transaction trail left by a wallet or group of wallets. While users' identities are not immediately accessible on the blockchain, the public nature of blockchain data can still provide valuable information about the volume and nature of transactions.
In addition, tax authorities can assign identities to certain wallets through Know Your Customer (KYC) data collected on centralized exchanges. When users transfer funds from centralized exchanges to a wallet used to interact with DeFi platforms, they leave a trail that can be traced back to their identity through KYC data.
Furthermore, tax authorities can use other tracking data, such as IP addresses and browser cookies, to track user activity on DeFi platforms.
While tax authorities may be behind on the technical side of crypto, the immutable and public nature of blockchain data means that transactions made now can still be scrutinized by authorities in the future. This could lead to mass audits of blockchain data once the authorities catch up. Don't get caught out in the future, stay on top of your tax obligations and sleep easy at night by utilizing software such as Crypto Tax Calculator to sort out your DeFi taxes.
The information provided on this website is general in nature and is not tax, accounting or legal advice. It has been prepared without taking into account your objectives, financial situation or needs. Before acting on this information, you should consider the appropriateness of the information having regard to your own objectives, financial situation and needs and seek professional advice. Cryptotaxcalculator disclaims all and any guarantees, undertakings and warranties, expressed or implied, and is not liable for any loss or damage whatsoever (including human or computer error, negligent or otherwise, or incidental or Consequential Loss or damage) arising out of, or in connection with, any use or reliance on the information or advice in this website. The user must accept sole responsibility associated with the use of the material on this site, irrespective of the purpose for which such use or results are applied. The information in this website is no substitute for specialist advice.

subset: commoncrawl


text:
In a mother, there are two babies. One asked the other: "Do you believe in life after delivery?" The other replied, "Why, of course. There has to be something after delivery. Maybe we are here to prepare ourselves for what we will be later."
"Nonsense," said the first. "There is no life after delivery. What kind of life would that be?"
The second said, "I don't know, but there will be more light than here. Maybe we will walk with our legs and eat from our mouths. Maybe we will have other senses that we can't understand now."
The first replied, "That is absurd. Walking is impossible. And eating with our mouths? Ridiculous! The umbilical cord supplies nutrition and everything we need. But the umbilical cord is so short. Life after delivery is to be logically excluded."
The second insisted, "Well I think there is something and maybe it's different than it is here. Maybe we won't need this physical cord anymore."
The first replied, "Nonsense. And moreover, if there is life, then why has no one has ever come back from there? Delivery is the end of life, and in the after-delivery, there is nothing but darkness and silence and oblivion. It takes us nowhere."
"Well, I don't know," said the second, "but certainly we will meet Mother and she will take care of us."
The first replied "Mother? Do you actually believe in Mother? That's laughable. If Mother exists then where is She now?"
The second said, "She is all around us. We are surrounded by her. We are of Her. It is in Her that we live. Without Her, this world would not and could not exist."
Said the first: "Well I don't see Her, so it is only logical that She doesn't exist."
To which the second replied, "Sometimes, when you're in silence and you focus and you really listen, you can perceive Her presence, and you can hear Her loving voice, calling down from above."
Author BIO: Útmutató a Léleknek is a Hungarian writer whose writings inspire and challenge readers to see the unseen, imagine the unimaginable, and to think beyond what seems obvious in the world around us.


text:
Khalid Sheikh Mohammed's Secret Vacuum Cleaner: How The CIA Tries To Undo The Psychological Effects Of Its Interrogation Program
In this March 1, 2003, Khalid Sheikh Mohammed, the alleged Sept. 11 mastermind.
WASHINGTON — Confined to the basement of a CIA secret prison in Romania about a decade ago, Khalid Sheikh Mohammed, the admitted mastermind of the 9/11 terrorist attacks, asked his jailers whether he could embark on an unusual project: Would the spy agency allow Mohammed, who had earned his bachelor's in mechanical engineering, to design a vacuum cleaner?
The agency officer in charge of the prison called CIA headquarters and a manager approved the request, a former senior CIA official told The Associated Press.
Mohammed had endured the most brutal of the CIA's harsh interrogation methods and had confessed to a career of atrocities. But the agency had no long-term plan for him. Someday, he might prove useful. Perhaps, he'd even stand trial one day.
And for that, he'd need to be sane.
"We didn't want them to go nuts," the former senior CIA official said, one of several who spoke on condition of anonymity because they were not authorized to talk about the now-shuttered CIA prisons or Mohammed's interest in vacuums.
So, using schematics from the Internet as his guide, Mohammed began re-engineering one of the most mundane of household appliances.
That the CIA may be in possession of the world's most highly classified vacuum cleaner blueprints is but one peculiar, lasting byproduct of the controversial U.S. detention and interrogation program.
By the CIA's own account, the program's methods were "designed to psychologically `dislocate'" people. But once interrogations stopped, the agency had to try to undo the psychological damage inflicted on the detainees.
The CIA apparently succeeded in keeping Mohammed sane. He appears to be in good health, according to military records.
Others haven't fared as well. Accused al-Qaida terrorists Ramzi Binalshibh and Abd al-Nashiri, who were also locked up in Poland and Romania with Mohammed, have had mental issues. Al-Nashiri suffers from depression and post-traumatic stress disorder. Binalshibh is being treated for schizophrenia with a slew of anti-psychotic medications.
"Any type of prolonged isolation in custody – much less the settings described in the press – have been known to have a severe impact on the mental condition of the detainee," said Thomas Durkin, Binalshibh's former civilian lawyer. Durkin declined to discuss Binalshibh's case.
Mohammed was subjected to harsh interrogations in Poland. Agency officers and contractors forced him to stay awake for 180 hours, according to a CIA inspector general's report. He also underwent 183 instances of waterboarding, or simulated drowning.
After the CIA prison in Poland was closed in September 2003, Mohammed was moved to Bucharest, to a black site code-named "Britelite." Soon the CIA was trying to find ways to entertain Mohammed as his intelligence value diminished.
The prison had a debriefing room, where Mohammed, who saw himself as something of a professor, held "office hours," as he told CIA officers. While chained to the floor, Mohammed would lecture the CIA officers on his path to jihad, his childhood and family. Tea and cookies were served.
Along with the other five detainees at the prison in Bucharest, Mohammed was given assignments about his knowledge of al-Qaida, or "homework," as CIA officers called it. He was given Snickers candy bars as rewards for his studiousness.
In Romania, the prison provided books for detainees to read. Mohammed, former officials said, enjoyed the Harry Potter series. For the CIA officers at the prison, not so much. For security reasons, after a prisoner finished a book, they tediously checked every page to ensure detainees weren't passing messages. They once caught Mohammed trying to hide a message in a book warning his prison mates not to talk about Osama bin Laden's courier.
Mohammed graduated from North Carolina A&T State University with a degree in mechanical engineering in 1986. It's not clear whether Mohammed was interested in designing a better vacuum or had ulterior motives. He might have intended to use the plans to conceal secret information or trick his jailers.
In Graham Greene's spy thriller "Our Man in Havana," a vacuum salesman in Cuba agrees to work for MI6, the British spy service. He dupes the British into believing his vacuum designs are military installations. The AP was unable to determine whether Mohammed ever read the famous novel.
It remains a mystery how far Mohammed got with his designs or whether the plans still exist. The secret CIA prison in Romania was shuttered in early 2006 and Mohammed was transferred later that year to Guantanamo Bay Naval Base prison, where he remains. It's unlikely he was able to take his appliance plans to Cuba.
Mohammed's military lawyer, Jason Wright, said he was prohibited from discussing his client's interest in vacuums.
"It sounds ridiculous, but answering this question, or confirming or denying the very existence of a vacuum cleaner design, a Swiffer design, or even a design for a better hand towel would apparently expose the U.S. government and its citizens to exceptionally grave danger," Wright said.
But Wright added that he often discussed "modern technological innovations" and the "scientific wonders" of the Quran with Mohammed. He called Mohammed "exceptionally intelligent."
"If he had access to educational programs in Guantanamo Bay, such as distance learning programs, I am confident that in addition to furthering his Islamic studies, he could obtain a Ph.D. in mechanical engineering, and very likely patent inventions," Wright said.
The CIA won't discuss the Mohammed's vacuum plans, either. The AP asked the CIA for copies of the vacuum designs or any government records about them under the Freedom of Information Act.
The CIA responded in a letter to the AP that the records, "should they exist," would be considered operational files of the CIA – among its most highly classified category of government files – and therefore exempt from ever being released to the public.


text: Acer offers a full line of Hard Drives and Solid State Drives for all your computer needs. Know your computer is in good hands with our performance tested and quality assured. Each drive is simple to setup and easy to use. Strap one in today and equip your computer with the hard drives more and more businesses trust.


text:
Flooring from Bell Floor Covering in Philadelphia, PA
Browse 0 results (0 colors)
Oops! No results were found
We're sorry. It seems as though we were not able to locate exactly what you were looking for. Please try your search again or contact one of our knowledgeable customer service team.


text:
Neck pain is a relatively common ailment, which most of us will experience at least once in our lifetime. In most cases, neck pain will improve and disappear on its own, but if you frequently suffer from this problem, or find that conventional ways of relieving your pain are not working, you may want to consider chiropractic care.
The neck is a very important part of our body, containing the very top of the spine, called the cervical spine as well as many blood vessels and nerves that supply structures including our esophagus, larynx, trachea and thyroid gland. The neck is also home to major blood vessels including the carotid arteries and jugular veins.
When there is tension in the neck, it can have a significant impact on the flow of blood between the head and body, as well as cause compression of the nerves and potentially the spinal cord. When this happens, it can have an effect on other areas of the body, including the upper and lower limbs.
In many instances, the exact cause of neck pain may never be known, but some of the most common causes believed to be behind the majority of cases include:
Sleeping in an awkward position
Bad posture
Trapped nerve
An injury, such as from a vehicle collision or fall
The pain you experience may also differ. It may be a constant dull ache or a sharp pain that occurs when you place your head a certain way or perform a specific movement, such as turning your head from side to side.
In many cases, neck pain may be accompanied by other symptoms, including swelling or inflammation in the neck, pain that radiates into the shoulders or upper arms, or headaches.
Chiropractors specialize in treating problems with the musculoskeletal system which consists of the bones, ligaments, muscles, and tendons in your body that enable movement. This includes your cervical spine which is the top part of the spine located in your neck.
Chiropractic care involves several different elements, and the treatment you receive will depend on the extent and cause of your discomfort. It may involve a combination of spinal realignment using manual manipulation, chiropractic adjustments, or massage therapy. Your chiropractor will also be trained and experienced in giving advice regarding lifestyle changes that you may wish to make that may help to alleviate your condition further or prevent additional episodes from occurring. This can include guidance on nutrition, exercise, and recommendations for sleeping positions.
You don't have to continue to suffer from neck pain. Our trained and highly experienced chiropractor can help alleviate your discomfort. Please contact our offices today to arrange your consultation.