The Advice That Every New Medical Grad Needs to Hear? Get Out Now (while you still can)!

Get out, get out while you can! It won’t be easy, it requires a lot of practice and preparation. Which is why I am talking to you now, this is something that you need to start planning soon, before it’s too late. . . like it is for me.  

The key to happiness in clinical medicine is to not practice it, but rather to tell other doctors how to practice it.

So I am imparting to you this wisdom of the hairless; the key to happiness in clinical medicine is to not practice it, but rather to tell other doctors how to practice it. To accomplish this you must get through your training and then begin the process of positioning yourself as non-essential staff, or as we call it in the parlance, Physician Executive Leadership.

Earnings? Don’t be so short-sighted. What you give up in earnings will be repaid  in nights, weekends, and holidays of blissful nothingness. As non-essential staff you will not find yourself up at 4:30 am on a freezing and moonless night to dig your car out from the snowbank it got stuck in on your way home from work just a few hours earlier. (See figure 1).


It may seem like I have something against Physician Leadership in hospitals, but that could not be further from the the truth. My physician executive colleagues meet with me quite often, some would say suspiciously often. They share with me important information like how to improve my revenue and satisfaction metrics.  They created a committee for physician burnout and were kind enough to supply me with a free yoga mat. It came in handy last week when I had to sleep in the hospital.   They even say things like “Bye, have a nice weekend, we really value you!” every Friday at 4:30 pm.

Clearly, these guys have figured things out, which is what I want for you. All it takes is a few hours online and a few weekend courses and you too can have your executive MBA.

Why am I not I doing this? Well, really it’s too late for me. I could probably make the time,  but between maintaining 4 boards, 2 kids, 1 marriage, and an acre of untended yard, I don’t have the juice for more continuing education. I’m already on the career treadmill, the speed is too high for me to do anything but keep running.  Eventually I won’t be able to keep up, and I’ll be flung off into the abyss, the oblivion, or whatever it is they call locum tenens these days.

I’ve done locums for a bit a few years ago. The docs I was subbing for were always SO excited to see me. Like a dog with a bursting bladder who’s master just came home. I must have that same look on my face when my locums guys comes in; I can finally go out and pee!

Oh, and I’m sure you’re wondering who’s going to take care of patients if you don’t go into clinical practice. Don’t worry, nurses will. Oh you didn’t hear? They’re all becoming doctors now. Look up the search history of any computer in the hospital and the most googled term is probably “online nurse practitioner course”. You should probably be aware of this, because as a physician executive you will be conducting numerous nurse practitioner interviews as you phase out your expensive physician workforce. So remember not to ask that degree holder from Arizona State University if they’ll miss the warm weather, that’s a beginner move, really.

I hope that this information has been useful to you, and you take this advice to heart. As for me I’ve got to get back to it, my treadmill awaits!


as the condensation from you breath kisses cold icicles on your brow. (See figure 1)

African Americans Are Less Accepting of Hospice and Palliative Care at End of Life; What Can ICU Doctors Do?

I grew up in a small town in the gently rolling hills of Connecticut. Previously unheard of, but now infamous, my hometown, Newtown, was a sleepy small New England town of mostly white people for whom my lone brown face served as diversity. I went to college at a mostly white college in said state, and went on to an Indian Medical School with predominantly other brown people. So you might imagine that July 1st, 2001 proved to be quite a shock. That was the day when I started my residency in Detroit, Michigan. Only I didn’t think there would be much culture shock, after all I was great guy who gets along with everybody. I was smart too, so naturally all patients would bow to my obvious mastery of medicine. It’s true that I had never really spent much time around African Americans, however I was an avid fan of both the Cosby show AND Fresh Prince of Bel Air. So really, what could go wrong?

Over the past 2 decades I’ve learned alot about how African Americans view health care and physicians. This is particularly important for anyone in the field of critical care where clinicians   often need to discuss end of life care decisions with patients and their families. Many of these conversations revolve around changing the goals of care from cure to comfort. These conversations are difficult, emotionally charged, and put tremendous strain on patients and their families. They also put a strain on medical teams–it becomes demoralizing to continue to care for someone who is obviously suffering and has no real chance of getting better. These conversations can be even more frustrating with African American patients and families.

As someone who provides care to the African American community I can certainly endorse what the literature shows; African Americans are more likely to choose life sustaining therapies over palliative or hospice approaches. The literature also suggests that African Americans have less awareness of hospice and advance care planning, and are less likely to enroll in hospice.  They are also more likely to withdraw from hospice to seek further life sustaining medical care. This is problematic as African Americans often have a greater illness burden at baseline, often have less access to medical care, and thus may have a greater need for palliative care services.

Why are African Americans less likely to accept palliative care and hospice enrollment? There may be several reasons, but there are 2 central reasons among them, at least when it comes to end of life conversations: faith and trust.

A common refrain among African American patients and their families is the power of healing,  that God can heal all ills, that miracles happen, and that God alone determines life and death. As a health care provider who often deals with hopeless end of life situations, to have my logical and reasoned conclusions that a person had no reasonable chance of recovery swept aside in order to “pray for a miracle” was incredibly frustrating.  These rebukes of my recommendations for hospice seemed at first to me as affronts to science and medicine. More than that, I took them personally as a total disregard for all the training and education I had gone through to take care of their loved one.

For many years I viewed this obstinance, incorrectly, as a sort of stubbornness- an incorrect viewpoint stemming from ignorance of science, and a lack respect for medical institutions. As my experience with African American patients has grown, I better understand that it was perhaps my own view that was incorrect.  

African Americans often see end of life situations through the lens of spiritual belief. A severe illness is a trial; a test of faith that must be endured. If God alone can create miracles, then faith alone can provide them. To belittle these cultural beliefs can itself be an affront to patients and their families and may lessen any chance of meaningful communications.

There are also issues with trust. The African American community has met with disparity, bias and past injustices, and hence has a distrust of many institutions, including medicine. It is thus important to remember that as I don my white coat, I am now the speaking personification of that institution, and this fact may reduce my credibility in the eyes of some. It is therefore important for providers not to carry a chip on their shoulder, to enter discussions as equals rather than from a position of authority. To engage with family and community members including a patient’s pastor who may help bridge communication gaps.

Both greater understanding and greater empathy can help bridge the gap of understanding between health care providers and African American patients and their families. But we need more that that. I’ve said before that the ICU is the last and worst place to talk about end of life care– there’s simply too much stress, emotional strain and physical fatigue for people and their families to think objectively. We need to have these conversations much sooner. Dr. Kimberly Johnson, a researcher at Duke University, has started to engage with African American pastors to educate parishioners about advance care planning and dispel myths about hospice. Ultimately, we need more of this boots on the ground-type engagement in order to spare our African American patients from unnecessary end of life interventions.

Deep Ramachandran, M.D. is a Pulmonary, Critical Care, Sleep Medicine physician, and CHEST Journal Social Media Editor. He blogs at Caduceusblog and the CHEST Thought Leaders Blog. He is on twitter @Caduceusblogger.

Not Dead but Not Alive; The terminally unhealed languish in America’s hospitals.

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May lay in a hospital bed, her wrinkled and mottled skin covered with leads, and sensors that monitored her every breath and heartbeat. A camera that was mounted on the wall allowed a doctor to zoom in closely enough to count her tattered eyelashes. Her husband  sat at her bedside, gently stroking her withering gray hair  as her chest moved slowly up and down accompanied by the soft whoosh-whoosh of the ventilator that breathed for her. He stared expectantly at her face as if at any moment she would rise and free herself from the myriad tubes that sustained her.  Her adult daughters sat and stared blankly at the floor, waiting for something, anything. The streams of data transmitted from her body were monitored closely both by a team in a remote electronic-ICU bunker 50 miles away and her ICU nurse 15 feet away. Yet what May could not have realized was that despite her family’s presence at her bedside and the twenty-four hour care she received, she had been abandoned. She was alone. 

Several weeks earlier, May came to the hospital from her nursing home, “yet another pneumonia”, the note in her chart said.  “She seems to get one of these every few months” said her husband “can’t we give her something for that?”. The Emergency Room physician explained that she had aspiration, essentially choking on her own food and spit. She would continue to get pneumonia, until she eventually passed away. This wasn’t the first time he had heard this. “They told me before to let her die, but I didn’t listen to them, I told them to treat her anyway, and she made it through. I didn’t give up on her then and I’m not going to now”, adding “she’s a fighter”. Her husband Daniels countenance was such that the Emergency physician admitting May to the hospital didn’t bother asking whether his wife should be resuscitated in the event her heart  or lungs stopped working and she needed to be put on life support. May was admitted to the general medical ward, and was started  on antibiotics, but she eventually got worse. Sometime in the middle of the night a nurse found her ashen and struggling to breathe, and called a “code blue”. May’s breathing had gotten so bad that she needed life support, she had a tube put down her trachea and was taken to the ICU where she was put on a ventilator.

Doctors worked on her for more than a week,  treating her pneumonia with powerful antibiotics. But even as her pneumonia cleared, her body withered. Her skin hung from her bones as her muscles wasted away, her eyes hollowed, and the skin of her arms filled with bruises as nurses struggled to find a place from which to draw blood. On the second Sunday of her ICU stay, the doctors tried a “trial extubation”. As the family understood it, her lungs had improved to the point that she might be able to be taken off the ventilator, but her body was now so weak, they did not know whether she would actually be able to breathe on her own. If she had to be put back on the ventilator, the doctors told them, she would require a tracheostomy that would allow her to live on the ventilator long term.  The social worker would then seek placement in a long term facility for patients on long term ventilators, essentially a hybrid hospital, rehab, and nursing home in one. Her breathing failed within minutes of being taken off the ventilator, and she was immediately put back on life support.

It was the following day, Monday morning, that I met with May’s family to discuss what had happened the day before, it was the beginning of my ICU week. For May and her family it was the beginning of their third week in the ICU, and it showed. Her husband, Daniel looked unkept, his thick shock of gray hair was whirled and tangled, his flannel shirt partly tucked into ripped and stained jeans. He gave the impression of someone who had not been taking care of himself, let alone someone who could take care of his chronically ill wife. His visage upon seeing me betrayed both surprise and regret as he recognized me from four months earlier.  I was the doctor who told him that May was going to die. Continue reading “Not Dead but Not Alive; The terminally unhealed languish in America’s hospitals.”

Devastation in Puerto Rico leads to hospital shortages in U.S.

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Hospitals run short of critical medications after loss of production in Puerto Rico facilities. 

“Doc, you mind switching that to an oral preparation?”, our clinical pharmacist inquired during multi-disciplinary rounds as intravenous infusion devices beeped annoyingly in the background.  Taking care of ICU patients can be extraordinarily complicated, so doing it as part of a team helps make sure that all bases are covered. ICU’s like ours have a BEEP BEEP BEEP. Excuse me, for a moment,  Staci, can you get that thing to stop, please? BEEP, BEEP, BEE– Thanks, Staci!. As I was saying, like many hospitals, ours uses a multidisciplinary model which makes rounds on all patients in the ICU.  An ICU nurse, clinical pharmacist, dietitian,  social worker, pastoral care, respiratory therapist, each provides important insight and perspective that guides patient care in the right direction.

As a pulmonary, critical care doc, I’m lucky to have a great team, so my ears perked up when I heard the suggestion. This was now the third patient he had made a suggestion to switch a medication to the oral route from the intravenous route. “What gives, Scott?” Over the past few years, we’ve been experiencing alot of spot medication shortages either because of inadequate supply, or because of precipitous price increases;  we can usually change to an alternative. But today was different. Today we were switching a number of different medications, all of which were intravenous to oral formulations of the same or similar medicines.

“It’s not the medicines,” he replied, “It’s the bags they’re in”. Continue reading “Devastation in Puerto Rico leads to hospital shortages in U.S.”

Top 5 Ways That Television is Ruining Your Sleep.

As a sleep physician, I spend a lot of time educating patients about what sleep is and how it works. Sleep, as I often explain, is not simply the lack of being awake; anymore than landing a plane is simply the lack of flying. It’s becoming increasingly understood that sleep is an actively generated state, created by a series of neuro-hormonal changes which work in concert to nudge the brain into the sleep state. To stretch the plane analogy further, if being asleep were like the plane being on the ground, then falling asleep is like the act of landing the plane. And just like when you land a plane, there are a lot of variables that are involved. There are numerous events that must happen in succession, each affecting and triggering other events which ultimately induce the brain to sleep. A recent study demonstrates just how watching too much television can wreak havoc in this delicate process. Here’s just a few of the ways that television can ruin your sleep.

     5. Watching television makes you go to bed later.

Television watching has steadily increased in our society, and its migration into our bedrooms marked a time when it began to disrupt our collective sleep and sleep habits. The most obvious effect that this might have is the most simple; we stay up later watching a program that has our attention. This few minutes a night may seem innocent enough. But our brains have a pre-determined amount of sleep they need to function well. When we miss that sleep we build up a “sleep debt” that can make us tired all of the time. Even if we catch up on a bit of sleep the next day, unless that sleep debt is paid back, the brain will still be fatigued.

     4. Watching television alters your brain’s bedtime habits. Continue reading “Top 5 Ways That Television is Ruining Your Sleep.”

The Shocking Truth Behind “Shocking” Healthcare Social Media Statistics

As a regular follower of social media, I am keenly aware of changes in the healthcare landscape as it relates to social media. While there’s much talk about the impact of social media in healthcare, most of the action sits on the consumer side of the equation. Much of the medical world has to yet to tap into its potential. For most healthcare providers social media engagement amounts to little more than watching as others dip their feet, testing  the waters. A few watch as they anticipate their own entry into the arena. Still many others watch with the expectation that the water would soon become bloody.

So its with a burlap full  of salt that I read various healthcare social media stats promulgated in various infographics, twitter feeds, and blog posts celebrating Medicine 2.0 powered by social media. Collectively they hash and rehash a series of surprising statistics that aren’t exactly bogus, but aren’t exactly completely factual either.

A recent one caught my eye with the claim was that “53% of physicians practices have a facebook page”. This was curious to me, because as I read this in the physician lounge and  took my own poll, the results was much closer to 5% than 50%. Continue reading “The Shocking Truth Behind “Shocking” Healthcare Social Media Statistics”

Top 5 CPAP Travel Tips from a Sleep Doctor and CPAP User.

Sleep Apnea is a condition that aflicts millions of people.  There are 2 types of sleep apnea, central, and obstructive. Obstructive is by far the most common, and is usually what is referred to when people talk about “sleep apnea”. Obstructive sleep apnea occurs when, during sleep, the airway passages in the throat close and block the movement of air. Common symptoms are snoring, gasping during sleep, sleepiness during the day, and the overall feeling that your sleep was not restful. While we all may have a laugh recalling that uncle or grandpa that was “sawing logs” all night when they slept over, the truth is that sleep apnea can have profound negative effects on overall health. Sleep apnea has been linked with stroke, cardiovascular disease, hypertension, and is an important contributor to deaths and injuries due to traffic accidents. The most common and effective treatment for sleep apnea is the use of a CPAP (Continuous Positive Airway Pressure) device. As a sleep physician, and a CPAP user myself I know the importance of using your CPAP whenever you sleep, that includes during travel.

Whether I’m travelling across a state line or an equatorial line, whether the destination is medical education, or a mediterranean beach, my CPAP is along for the ride. Because of this, I’ve also run into pretty  much every complication, problem, pitfall, morass, and quagmire that you can have when travelling with your CPAP. Thus I present to you, gleaned from both my experiences and those of my patients, my Top 5 tips for travelling with your CPAP.

  1. Bring Your CPAP With You!

This would seem obvious, but it’s not. Alot of people see their CPAP as an assistive  device which they only need to use when they need it. But they really need to look at it for what it is: therapy. You take your hypertension and diabetes medicines with you when you travel, think of your CPAP the same way. Besides, if you’re travelling for business, you need to be sharp and focused. If you’re travelling for pleasure, well who wants to spend their hard earned vacation being tired and irritable? CPAP will help you get the most out your travels! Continue reading “Top 5 CPAP Travel Tips from a Sleep Doctor and CPAP User.”