ER輪轉

這個月我在急診室輪轉。第一天上班的時候，帶我的醫生就跟我說，我們的工作跟你們內科工作不同，我們首要任務是辨別這個病是不是危及生命，最重要的是抓住最重的疾病開始治療，而不是像內科一樣把所有相關的病史家族史問個遍。

我一開始不太習慣，總是忍不住要問一下其他的東西，然後匯報CASE的時候，帶教醫生就會微笑地看著我說，focus, focus，我不好意思地把病史一縮再縮，濃縮成幾句話。當我最後能夠把所有的病史變成一句長長的帶著定語，狀語，表語的陳述句，我的帶教醫生終於鼓掌說，that's what i need!

在急診室雖然才上了一個星期的班，卻看到了美國社會的另一麵。如果不是做住院醫生，也許生活圈子狹窄的我永遠也看不到這些。眼睛被丈夫毆打致瞎的家庭婦女，吸毒後行暴的年輕人，被前男友入室強奸的女孩子。我學到很重要的一點，是不要judge，不要讓自己的好惡是非影響到治療。我的帶教醫生是一個五十多歲的伯伯，慈祥得很，今天一個監獄女犯來做婦科檢查，我差點沒熏過去，老伯伯卻仔仔細細問她的病史，有沒有過孩子，是否被暴力侵犯過之類的問題，那個女犯吵著要喝咖啡，吃餅幹，老伯伯就去休息室裏給她倒了咖啡，拿了餅幹。然後繼續檢查。我們結束問診以後，老伯伯握著女犯的手說，你去教堂嗎？女犯說我很久沒去了，因為我不敢去，怕上帝懲罰我。老伯伯拍拍她的肩膀和藹地說，you know, church is for sinners, not for saints.

下午無線電說有一個心髒卒停的病人在路上，另一個急診科醫生拍拍我的肩膀說，show time! 我們還有三個護士一起等在醫院緊急通道門口，我的心不由得狂跳，感覺自己就像在電視劇ER裏的那些醫生了。病人到達的時候沒有自主心跳和呼吸，明顯紫紺，經過搶救，心跳和呼吸恢複了，血壓也上來了。但是沒有恢複意識，三十分鍾的心跳停止，大腦可能已經有了不可逆轉的損傷。但是家屬明確表示不願意放棄，我們隻能把病人送去了ICU（重症監護病房）。另一個急診醫生歎口氣說，後麵的路，對病人和家屬，都是很艱難的。有時候搶救成功，並不是一件皆大歡喜的事情。

我挺喜歡ER的工作，幹脆利落，而且跟不同的人打交道，我的帶教醫生老伯伯經常點撥我一些觀察病人的技巧，通過觀察他們的言談舉止，往往能夠初步判斷他們藏在病情後麵的一些隱情，從而對進一步的診斷作出幫助。挺有意思的。

[Dalaoshu]

老伯伯拍拍她的肩膀和藹地說，you know, church is for sinners, not for saints.

I d't know why your story make me tear every time.
I guess everyone is moved. or, it is me who is vulnerable at critical times. I am preparing for the usmle.
It is a luxury to read your blog. Though I felt guilty sometimes when I had binged on your stories for a long time, I know it is time spent wisely. It is kind of spiritual benefit.
Thank you.
May God bless you.

[luckyal]

謝謝。我現在看那些program看到一頭霧水，都不知道從何著手。我的最大問題是要H1，所以也限製了很多。我的email是：[e-mail]. 如果有空，能否給我發個email指導一下我這個師妹嗎？謝謝

[wuximm]

Luohua, It is unbelievable that ER physicians in your hospital haven't take vacation over yrs. Those are called workaholic. As a physician, you set up your schedules and decide how much you want to work. Despite of the headaches from managed care companies and pay cuts from medicare, physicians still have a plenty of autonomies. You decide if you want to work part-time or full time, regular hrs or after hrs, inpt or outpts, etc. You have absolute job securities, you get letters from recruiters daily with lucrative offers even if you are not looking for a job. etc. I don't agree that physicians will be comparable with policemen and teaches one day. Society can't afford to have poor doctors-from Mark Twin.
I think it is hopeful that you will be able to afford a luxury car for your beloved father as a gift in the near future if you moonlight a little bit when you get to 2nd yr.

[Bali]

落花飄零:你的好幾篇文章都提到了父母，非常令人感動，好幾次硬是將已出來的眼淚再逼回去。哎，女人終究是女人。這幾天在辦公室裏，有空就看你的文字，非常耽誤工作呀 ：-) 不過，多謝你提供的精神食糧。現在可看的東西不多因為我比較“挑食”，從大學起，就不再看非紀實的東西了。

[落花飄零]

bali，油墩子都是冬天才有賣的阿，我回去的時候是春天，沒看見有。甜大餅是長的，我同意！我也很喜歡太陽的味道，說到這個，記得在宿舍的時候，因為看書到很晚，每天都是深夜洗衣服，我就開玩笑跟同學說，你們的衣服是陽光的味道，我的衣服都是月亮星星的味道，嗬嗬。

LUCKYAL，這個說來話長了，等我有時間，慢慢寫個係列：）

[Bali]

落花飄零: 我看了“幾張生活氣息濃濃的照片”。曬衣服那張太有意思了，很親切。我媽媽現在定居於陽光燦爛的城市，還是經常“搶”陽光曬被子衣服。家裏的烘幹機從來不用。還好有自家花園，不影響市容。不過，陽光曬出來的被子味道真好。我真是非常喜歡陽光的味道。另外，想說，甜大餅是長的圓大餅是鹹的。但我小時候吃的大餅買相比較實，不象照片上那樣鬆鬆的。你在上海腐敗了那麽久，怎麽沒有吃油墩子？

[luckyal]

很喜歡你的博客，也很喜歡你的行醫的經曆。
不過沒否給你match申請program的經驗？謝謝

[落花飄零]

bali，你留在以前文章裏的留言，一般我是不會看到的，我以前文章太多，文學城留言的安排好象是根據文章的順序安排的，所以如果是很以前的文章留言，我是看不到的，除非你特別告訴我是哪篇。

[落花飄零]

holy moly, 你們說得都好高深阿，我沒有在美國讀醫學院，沒有巨額的貸款，所以收入多少對我來說不是很敏感，隻要能夠讓我衣食無憂，也不指望發財。大多數醫生是沒時間享受生活的，我現在工作的ER，那些醫生都是幾年甚至十幾年沒有vacation過了。我不想過這樣的生活，情願少點錢，但是要好好過日子。
謝謝各位的深刻發言，我就不敢多評論了，嗬嗬。

[縱然平行]

Hi, 上二醫ROCK:

Your assessments probably are right in regarding to most physicians’ meager incomes at current time. However, there are few things in your analysis I’d disagree with you respectfully so that I’d like to bring them to discuss.

First of all, what have made a physician income to stagnate for recent years ? I think, the major culprit is not MEDICARE system rather HMO. In prevailing arrangement HMOs are the middle men who constantly squeeze physicians for their own profits; they run system as business enterprises and seek profits at each and every available opportunity. Having said that I mean HMOs would take care of their stock’s PE ratio, gross margin, net profit margin, MPQ, TTM … the same way as GE or IBM does. In other words, HMOs beget every effort to make their stocks to be attractive to investors. It is HMOs’ CEO Job to ensure stock prices to be up and to convince financial analysts on the conference calls its Quarterly Earning will be on track. There is no free lunch for the growth. As the results physicians become the “expendable” item on the cost cutting list. So who are the winners ? corporate executives who have the stock options plus performance bonus which together could make the Queen of England to be jealous and Wall Street investment bankers are certainly on the short list.. Unfortunately, the losers are doctors and patients, in so many cases the doctors could not order the best treatments for their patients because they know they can not win the fights when coming to deal with HMOs. The fact is that HMOs always have the upper hands because for physician to survive and make a living they have to have patient source which are controlled by HMOs. For instance, the contracts doctors’ signed with HMOs expire every one or two years. In these contracts HMOs can put the restriction such as HMOs can de-list doctors from network as a HMO thinks to be necessary. For example, if a doctor treat at their patients “too expensively. Anther headache that physicians’ can not avoid is the ever-growing insurance premium. This is America, one can get rich by having litigation against someone, doctors can be the easy targets. By protect themselves doctors have to thin the wallet to buy those expensive insurance policies.

Second, it is my belief that physicians may not become the same level occupation as policeman or teacher. The reason is that physicians are professionals who are ready entrepreneurs working for themselves to the large extents. They may also have the option to establish a clinic with initial capital investment and hire other doctors and nurses to work for them. On the other hand It would be more difficulty for policemen or teachers to do same thing as Doctors do.

Third, nobility and prestige of being a physician are these soft, yet season-prove,values that rarely other professions may match, plus with some conditions being made doctors may not have to worry about the possible layoff most of American do. Therefore, I think Physicians would still hold the top notch spot on most admired careers for years to come.

In short, right now the journey, costs, and pay-off to become a doctor and stay here as one would not be for the faint hearts, that is for sure. But I think that the tide may turn other direction in near future as patients and doctors are being pushed too far in current situation.

I wrote my comments with limited time and information on the top of my head during the lunch. Certainly, I could be wrong for my points. In that case, thanks for your tolerance in advance.

[Bali]

LHPL, I read your article for the first time yesterday. Today, I read about your holiday in Shanghai...really good stuff and bring back a lot of memories. I like the way you keep your writing low key and relaxed, and you maintain your innocence and conscience. I left a message on one of our old articles. Not that it's important but just wonder whether you read or are able to read the messages left on the old articles.

[上二醫ROCK]

現在就有病人不遠萬裏去印度做手術呢.由美國畢業的醫生主刀.住院什麽的都配套,價格隻是a fraction.

[上二醫ROCK]

你說那些看片子的醫生將來會不會都被計算或印度醫生取代?

[上二醫ROCK]

從美國醫生收入的結構來看二，三十年後醫生還是好職業麽？

在美國社會裏，醫生是一個傳統的好職業，社會地位又高，金錢收入也不錯。這種名利雙收的情形是由美國醫生的職業特點所決定的。一方麵醫生作為DOCTOR，一種知識性職業性都很強的工作，自然受到病人的尊重。另一方麵，傳統上美國的醫生其實都是小業主，這種SMALL BUSINESS OWNER的身份決定了醫生的收入比較可觀。

但是近年間由於HMO和超級醫學中心的發展，醫生越來越難維持小業主的地位，越來越多的醫生變成了雇員。醫生的收入也明顯減少。

美國的醫生收入的一個大頭是MEDICARE。MEDICARE FEE SCHEDULE 實際上也是各個保險公司決定REIMBURSEMENT 的BENCHMARK。所以醫生的收入是和MEDICARE REIMBURSEMENT 息息相關的。

從裏根時代起，美國MEDICARE的付款總額就幾乎是被凍結了。在MEDICARE裏，不同專業的醫生又按照不同的服務分成七千多個BILLING CODE。不同的CODE收到的錢是按照這個CODE的相對價值所決定的。所以美國的醫生可以說是大家共同分享一張大小固定的大餅。

最近幾年因為新技術的發展使得一些專科醫生的收入得到不少提高，這就給人們留下了醫生收入增加的假象。實際上專科醫生是少數。占美國醫生中大多數的PRIMARY CARE PHYSICIAN的收入幾乎沒有增加，甚至降低了。專科醫生收入的增加可以說間接上是以PRIMARY CARE PHYSICIANS 收入相對降低而換取的。即使收入持平，隨著醫學的發展，醫生同樣的收入付出的單位勞動卻要多很多。

隨著美國老齡化的趨勢，嬰兒潮世代的逐步退休，以及越來越高的財政赤字。美國醫療費用的總大餅是不可能持續高額增長的。醫療費用中付給醫生勞動的這部分很可能要相對下降。

我個人的感覺是，美國的醫生會經曆一個開始用增加工作量來保持收入的時期，然後是降低工作量的反彈。最終醫生會變成一個類似警察，教師的雇員階層，收入相對於現在會低下來，工作量相對於現在也會降下來。

恐怕將來會有一個時期，醫生的報酬無法JUSTIFY 醫學院的昂貴學費和住院醫生的驚人工作量。最終當然看不見的手會在兩者之間重新找到平衡。但是在這一階段中，會有不少人陷入高投資第回報的艱難處境。

[落花飄零]

謝謝各位，我會加油的！

[縱然平行]

I’d concur with you for your tendency of not rushing to the judgment for those less fortunate people in ER. You may have demonstrated a kind heart which not only give medical attentions but also seed the hope and care to these who need them most.

[xiaonizixq]

嗬嗬，看到這兒，我必須出來冒個泡了。每天都回來看你的文章，覺得你寫得真實，樸實，展現了醫生世界裏不被了解的一麵，我很喜歡。希望你繼續努力，並將一直關注著。很喜歡你的小說，知道你最近忙，所以一直沒有下文，恩，在救人治病的時候，也要注意自己的身體。

[glxf]

加油!

[紅葉情]

RE對你應該不陌生吧,你一定是幹的最好的了。再加油！

[happyljx]

ER 果然刺激啊。
哈哈。 加油哦。