31 July 2011

Licensed to

In James Bond terms, it’s a license to kill.

In philosophical terms, it’s a license to heal or to help live.

In pragmatic terms, it’s a DEA number and a way to bill and get reimbursed by insurance.

In French, license means bachelor's degree, and permis means license. Unspoken, assumed permission. Allowed.

A medical license – just a general one – requires five full days of testing, over 3-4 years.
A lot of time is spent studying – during school, after hours from the hospital. A lot of money goes into each part of the exam, from the question banks to the tests themselves, with the requisite nothing-but-the-ID-check-in and checks inside of your sleeves .
Eventually, 5 years after starting medical school, many more years after starting the process of getting into and moving toward medical school, you have a license.

On the most basic level, this allows you to prescribe – that’s helpful for your patients, your attending (who no longer have to cosign your scripts), and potentially for your friends and other loved ones. All it takes is your name and license number – the person you’re prescribing for’s name, birthday, and allergy-to-medications status, and any pharmacy will transcribe it over the phone .

But a medical license – and the steps to obtaining one – implies more than this sort of power (and responsibility).

Doctors can pronounce death – we learn to know when someone is dead, or alive, and to say it officially. Saying it makes it true.
Doctors can teach other doctors. There’s no teaching certificate required, here, but the way medical students, in the clinical years, and residents and fellows learn is by teaching each other. On down the food chain. The main source of information, actually, is the teaching on the wards. There’s no training in that.
Doctors can run businesses – what else do you call a medical practice? No business acumen or training required (technically, not optimally).
Doctors can work in public health without an MPH.
Doctors can get a loan for a house – even med students can, sometimes – while 100s of thousands in debt. “Future earnings potential” they call it, not taking into account whether your career choice within doctor-dom actually has much of that.
Doctors can run labs without having PhDs.
Doctors are more likely to get published as op-eds or letters to the editor – “MD” looks pretty  official and officious, tagged onto whatever-name.

And doctors can tell patients to focus on self-care, sleep, the importance of healthy eating and exercise. Well, we do get exercise on a service that runs up and down the floors of the hospital. Even on one floor, you’re constantly dashing between rooms.

I don’t have a medical license. I have ½ or 2/3, depending on how you count it.

And I hurt people on a daily basis.
With license.

I hurt people, by which I mean I cause pain.”Discomfort.”
I don’t lie to patients. “Will it hurt?”
“Well, it’s not fun. It shouldn’t hurt, but it’s not comfortable. It’s different for everyone – you know, I had a patient the other week who was talking on the phone the whole time.” (Now I can count that as two . And I’m not even counting the texter).
I don’t lie to patients. The one who, somewhat suspiciously, asked “how old are you?” I told her. She’s three years older. And she decided to trust me – I can say I’ve done this (dozens) of times before, that I’ve only been in this clinic a few weeks, but before that, I was working other places (…in other areas, not doing this particular job, but I can hand-wave a little about that).
“How much longer do you have in school?”
In truth? Six months of coursework.

I like procedures. I like working with my hands, having those physical skills. And on this rotation, I did just a few procedures but many, many times. You can get good that way – or, closer to good. Pretty good. To the point that, at least, I can carry on a conversation the entire time, smoothly, while doing what I need to do.
One Filipina patient – her entire family lives on the same street (in the US). Everytime someone leaves, they buy up another house.
Another patient is a horse trainer and travels around to county fairs.
Another works as a security guard.
Another is majoring in environmental studies.
Another’s kids are at Disneyland.
The list continues. And this is what we talk about.
For some, it doesn’t help so much – but others are so distracted that they have no idea what I’m doing, and they’re surprised when I tell them I’m done.
We’re done. “Great job!” I say.

I say.

I tell them about books I’ve read, if they bring that up. If it’s a commonality, what I majored in, in college. If I lived where they do now, know the area. If my friend is moving there. That one of my patients lives on the same street as her entire family. For a Procedure, there’s a whole other set of shtick. “I swear, I think I spend half my day fighting with this lamp…” (it was actually somewhat true, but it made patients laugh). “Hopefully, this will be the longest part!” I say similar things about computers. Math, etc. The light self-deprecating humor works pretty well.
(My doctor self is really, really good at small talk).

“Do you like your job? Do you like doing this?”
“Yes, I do. But the part I don’t like is when it causes people pain.”


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