Para-rabbis and PAs
"Totem pole": descriptive, not prescriptive.
MEDICINE MENSCH: What Little I Know About Medicine
By Zackary Sholem Berger
November 11, 2005
I thought I would title this month's column "What I Don't Know About Medicine," but my editors want 800 words, not an encyclopedia. What I do know about medicine should fit nicely into the space allotted.
The rotation I'm starting this week is known in hospital jargon as the sub-internship; the registrar's office calls it "advanced medicine." In this rotation the medical student plays the role of an intern, a first-year resident. He can write orders on the computer, decide on a course of treatment and prescribe medications — all with the co-signature of a supervisor, of course. The main thing is that the student manages his own list of patients. In other words, I won't be following a resident around anymore; I will be a resident.
More precisely, I'll be pretending to be a resident. That's the catch of this rotation — it's the adolescence of medical education, in which one is something more than a senior student but something less than an intern. How much like an intern will I be? If one reasons by similarity of activity (lack of sleep; independent decision-making on behalf of actual patients), I could very well call myself the intern. Could I walk into my patient's room and say, "I'm Dr. Berger, and I'll be taking care of you during your stay in the hospital?" The second half of this statement is definitely true, but the first part (with "Dr.") isn't quite. I won't have my medical degree until my graduation in May 2006, and I won't have a license to practice medicine until I finish my boards, which stretch from now (while I'm still a medical student) until the end of my residency.
On this rotation, I don't plan to introduce myself as "Doctor" (that would be quite a stretch), but I understand why some of my colleagues would. While many patients don't understand the difference between senior medical students, interns, residents, fellows and attending physicians, they come to appreciate something of the hierarchy during their hospital stay. One thing soon becomes clear to them: Medical students are at the bottom of the totem pole of health care providers. (Or almost at the bottom —more on that subject, below.) If a sub-intern walks into a patient's room and starts out by saying, "My name's Joseph Brighteyes, I'm a medical student, and I'm here to take care of you," the patient is likely to respond, "That's great, Joe, but who's going to be my doctor?"
Is qualification defined more by knowledge or by capability? This larger question comes up when talking about the thousands of people whose elbow grease makes a big hospital run as smoothly as it can. Even lower on the pole than the medical student is the physician assistant. P.A.s train for fewer years than medical students, so they often get less respect from folks in medical academia. But in every rotation where, as a medical student, I've worked together with P.A.s or P.A. students, they have seemed more on the ball than the medical students — not as over-theoretically concerned with fascinating disease entities and more knowledgeable about what might immediately help the patient. Part of the reason is that the P.A. student spends more time in her early training (most P.A.s I've met are women) familiarizing herself with the way things actually are in the uncompromisingly practical universe of the hospital or clinic. Perhaps P.A.s can't name 12 different kinds of small-vessel disease. (I'm making up that number; I certainly can't name them, either — not off the top of my head.) But such encyclopedic knowledge is sometimes transcended, or rendered irrelevant, by practical considerations. On the other hand, you don't want to miss the rare diseases when they do pop up. So both kinds of training (practical and theoretical encyclopedic) are essential, even complementary. The trick is to appreciate both kinds of thinking at the same time, even though most people find one of them more congenial than the other.
A similar divide is evident in the Jewish tradition, especially with regard to Torah study. In previous generations — and even today in some circles — memorizing vast tracts of the Talmud is a prized skill. On the other hand, if you've dipped into any of the Talmud, you know that it takes considerable exegetical ingenuity to derive laws applicable to everyday life from the rich stew of magic, folklore, intellectual speculation, casual yeshiva talk and campfire tales about the destroyed Temple. (Even the strict constructionists, those who actually bury their fingernail clippings according to the magical practice of the rabbis, still have to exercise creativity in deriving everyday religious practice from Babylonian-Jewish digression.) The two skills — encyclopedic knowledge of the Talmud and the ability to apply the Talmud to everyday religious life — are complementary, but rarely are found in the same person. Many of the greatest talmudic scholars have famously refused to adjudicate Jewish law, protesting that they could see all sides of any issue.
Today's Jewish communities rely very much on what some people call "para-rabbis" — people who aren't religious scholars but are reliable, even expert, in the details of daily practice. You might have met some of them: the guy who knows everything about building a sukkah; the woman who is obsessed with reading Torah; the member of the local synagogue who knows exactly how to help a recently bereaved family.
In other words, Jews (at least religious Jews) depend on "rabbis' assistants." In the same way, a hospital must cobble together a vast number of people who have different abilities. Some sit in offices and absorb themselves in the study of disorders affecting 10 people in the entire world, while others, down amid the gore in the E.R., can contradict those same scholars with absolute certainty if they see in front of them a practical problem they know how to solve quickly and effectively.
Bit by bit, I hope to amass both kinds of knowledge till I can be considered a doctor (a learned person, according to the word's historical meaning) in at least one of these categories. But no matter what, there always will be plenty of material for my upcoming masterwork, "What Zack Berger Doesn't Know." I look forward to doing the research.
Zackary Sholem Berger is becoming a doctor, hour by sleepless hour. Feel free to write him about it at doctor@forward.com.
Showing posts with label nurses. Show all posts
Showing posts with label nurses. Show all posts
11/13/05
1/12/05
Nurses: the importance of the (relatively) powerless
In response to the first installment of Medicine Mensch, I've received two e-mails from doctors aggrieved at what they see is a slight upon nurses. Owing to their misreading of the article or the unclarity of my prose, they mistook the term "hierarchy" for a ranking of importance. According to such a reading, I would hold that medical students are more important [sic!] than nurses, who in turn are more important than cafeteria workers, transporters, and the like.
Of course, nothing could be further than the truth. The hierarchy in the article was meant to be (and, in fact, my impression is that most readers understood it as) an informal characterization of the power and control each profession is vouchsafed within the hospital's many labyrinths. My iimportance to patients' medical care is approximately nil compared to the hospital's lifeblood which flows through the veins of every nurse. But who's going to get paid more in the future, and who has more access, even at this early stage in his career, to the decision-making apparatus of the medical center? Me. There are fair and unfair aspects of this sociological fact, but representing a state of affairs in prose should not be taken as an endorsement.
To any nurses who might have read the article: if you did take offense, feel free to assume that I know absolutely nothing about medicine and am a snotnose short white coat bumbling along the wards. After all, that was the point.
Next article, a month from now: all about psychiatry. In a thousand words or less.
In response to the first installment of Medicine Mensch, I've received two e-mails from doctors aggrieved at what they see is a slight upon nurses. Owing to their misreading of the article or the unclarity of my prose, they mistook the term "hierarchy" for a ranking of importance. According to such a reading, I would hold that medical students are more important [sic!] than nurses, who in turn are more important than cafeteria workers, transporters, and the like.
Of course, nothing could be further than the truth. The hierarchy in the article was meant to be (and, in fact, my impression is that most readers understood it as) an informal characterization of the power and control each profession is vouchsafed within the hospital's many labyrinths. My iimportance to patients' medical care is approximately nil compared to the hospital's lifeblood which flows through the veins of every nurse. But who's going to get paid more in the future, and who has more access, even at this early stage in his career, to the decision-making apparatus of the medical center? Me. There are fair and unfair aspects of this sociological fact, but representing a state of affairs in prose should not be taken as an endorsement.
To any nurses who might have read the article: if you did take offense, feel free to assume that I know absolutely nothing about medicine and am a snotnose short white coat bumbling along the wards. After all, that was the point.
Next article, a month from now: all about psychiatry. In a thousand words or less.
1/7/05
Medicine Mensch
This new series of articles in the Forward follows me through my medical training and, I hope, out the other side. I hope to talk about Jewish and medical topics which are sometimes broad, sometimes narrow, and often interrelated with each other. The first installment is here.
Here it is below, as well:
MEDICINE MENSCH: Today I Am a Short White Coat
By Zackary Sholem Berger
January 7, 2005
My first day as a medical underling.
Today I am a short, white coat.
Until last week, I was locked up in the ivory tower to finish my doctorate in epidemiology. But now it's finally time to learn how to be a medical student. I'm going on the wards, where I'll learn all manner of things: how to put in an I.V., how to build a rapport with annoying patients and how to avoid rampaging gurneys. To understand a hospital, you need to understand its hierarchy: when it's followed, when it's hallowed and when it's violated. I'll try to explain it all, but forgive me if we get lost. It's my first day.
The dilemma of the medical student with the short white coat — am I wearing it, or is it wearing me? — is as important to the person as it is to her wardrobe. On the first day of a new job, or in a new school, it's hard to know where to fit. All the more so in the topsy-turvy hospital hierarchy, where the most important person, the patient, has none of the economic or directive influence that powers the huge institution.
Starting from the very bottom, we first have the janitors, the cafeteria ladies, the orderlies, the "transporters" (gurney pushers) — anyone who makes sure that the huge hospital organism can fulfill its basic needs. Those of you who watch the television show "Scrubs" are familiar with the show's wisecracking, joke-playing janitor. He's completely in control, and jerks around J.D. (the medical resident who's the show's main character) to his heart's content. But if you've ever been inside a real hospital, you've never met a janitor like that. Sure, the janitors are friendly; sure, there's a modicum of genial give-and-take between upper (doctor) and lower (custodian). But at the same time, there's the uneasy reality that one is Over and one is Under, and never the twain shall meet. There is no magical moment of cross-understanding that one finds in Hasidic stories, when the rebbe realizes that the coachman greasing his wheels is just as spiritually attuned as he is. They are janitors, and that's that; no enlightenment is expected from them.
There are two kinds of uniforms in the hospital: medical and nonmedical. Janitors wear the second variety. Orderlies often wear scrubs of a laughably loud color, to point out just how removed they are from the medical hierarchy — the same reason that clowns wear the getup they do, to signal their freedom from normal rules.
Moving up a step, we find one of the most necessary groups of people in the hospital, aside from the administrators and money wranglers (who are sometimes known, unsurprisingly, as "the suits"). These are the nurses. It used to be the custom for them to wear white, but as uniforms everywhere become more and more casual, they've chosen the minimum amount of white to look a little bit like angels: white coats, white pants, perhaps a pair of white sneakers. The sneakers make them look like they're always on the way to or from Kol Nidre, which makes sense: If you'd like to build a community that's compassionate and practical, you could do worse than to convince the nurses to join you. It's smart to be nice to nurses in the same way that it's advisable to be on good terms with God.
One step above nurses is the medical student. That's me over here, not waving but drowning, trying to find in this rambling hospital the bathrooms, the library, the cafeteria and, most important, the stairs (the elevators are crowded and slow). While a long white coat looks dignified, flowing and somewhat old fashioned — a kind of medical kittel — a short white coat makes anyone look like a barber or an ice-cream scooper. Whether to counteract or exacerbate this effect, every medical student fills the pockets of her coat with a bewildering array of slips of paper, handbooks, equipment, tongue depressors, alcohol pads, pens, pencils, Palm Pilots and the odd bit of snack food. The rationale here is, I guess, "If I don't know anything, at least the pockets of my coat can be stuffed with facts."
On top, of course, is the physician himself. (I would write "herself," but it would be unrepresentative. The top rungs of the hierarchy are mostly male, even at this late date.) Their coats are long, with pockets that don't have to be filled with anything (the clinical experience and diagnostic certitude are all kept in the head at this stage, not on PDAs or in quick-reference books). Some doctors don't even wear coats — their rank is obvious.
The above hierarchy is just an approximation. There are enough exceptions and exceptions-to-the-exceptions to impress any devotee of the Talmud. For instance, at my medical school, at least until recently, surgeons wore scrubs and no one else did. Then, in a heroic mass movement, medical students decided that scrubs were comfy. They wanted to wear them, too! Now everyone can have his own pair. For some reason, though, only a surgeon wearing scrubs looks like a surgeon wearing scrubs. Anyone else looks like an escaped convict or someone whose last set of sweats is in the laundry.
The sick person wears no coat at all — aside from the robes that open in the back, like misappropriated evening gowns — and can feel as ashamed as Adam and Eve, the first naked couple. The rabbis of the Talmud said that the prototypical act of loving-kindness was God's providing loincloths to cover their nakedness. Even if I don't know anything about medicine yet, maybe I still can help patients feel better, no matter how short and overloaded my coat is.
Zackary Sholem Berger finished his doctorate in epidemiology from New York University this month, and will complete medical school in 2006. This is the first column in a series tracing his transformation into that mythical figure: The Jewish Doctor. Comments and questions encouraged at doctor@forward.com. No medical advice given!
This new series of articles in the Forward follows me through my medical training and, I hope, out the other side. I hope to talk about Jewish and medical topics which are sometimes broad, sometimes narrow, and often interrelated with each other. The first installment is here.
Here it is below, as well:
MEDICINE MENSCH: Today I Am a Short White Coat
By Zackary Sholem Berger
January 7, 2005
My first day as a medical underling.
Today I am a short, white coat.
Until last week, I was locked up in the ivory tower to finish my doctorate in epidemiology. But now it's finally time to learn how to be a medical student. I'm going on the wards, where I'll learn all manner of things: how to put in an I.V., how to build a rapport with annoying patients and how to avoid rampaging gurneys. To understand a hospital, you need to understand its hierarchy: when it's followed, when it's hallowed and when it's violated. I'll try to explain it all, but forgive me if we get lost. It's my first day.
The dilemma of the medical student with the short white coat — am I wearing it, or is it wearing me? — is as important to the person as it is to her wardrobe. On the first day of a new job, or in a new school, it's hard to know where to fit. All the more so in the topsy-turvy hospital hierarchy, where the most important person, the patient, has none of the economic or directive influence that powers the huge institution.
Starting from the very bottom, we first have the janitors, the cafeteria ladies, the orderlies, the "transporters" (gurney pushers) — anyone who makes sure that the huge hospital organism can fulfill its basic needs. Those of you who watch the television show "Scrubs" are familiar with the show's wisecracking, joke-playing janitor. He's completely in control, and jerks around J.D. (the medical resident who's the show's main character) to his heart's content. But if you've ever been inside a real hospital, you've never met a janitor like that. Sure, the janitors are friendly; sure, there's a modicum of genial give-and-take between upper (doctor) and lower (custodian). But at the same time, there's the uneasy reality that one is Over and one is Under, and never the twain shall meet. There is no magical moment of cross-understanding that one finds in Hasidic stories, when the rebbe realizes that the coachman greasing his wheels is just as spiritually attuned as he is. They are janitors, and that's that; no enlightenment is expected from them.
There are two kinds of uniforms in the hospital: medical and nonmedical. Janitors wear the second variety. Orderlies often wear scrubs of a laughably loud color, to point out just how removed they are from the medical hierarchy — the same reason that clowns wear the getup they do, to signal their freedom from normal rules.
Moving up a step, we find one of the most necessary groups of people in the hospital, aside from the administrators and money wranglers (who are sometimes known, unsurprisingly, as "the suits"). These are the nurses. It used to be the custom for them to wear white, but as uniforms everywhere become more and more casual, they've chosen the minimum amount of white to look a little bit like angels: white coats, white pants, perhaps a pair of white sneakers. The sneakers make them look like they're always on the way to or from Kol Nidre, which makes sense: If you'd like to build a community that's compassionate and practical, you could do worse than to convince the nurses to join you. It's smart to be nice to nurses in the same way that it's advisable to be on good terms with God.
One step above nurses is the medical student. That's me over here, not waving but drowning, trying to find in this rambling hospital the bathrooms, the library, the cafeteria and, most important, the stairs (the elevators are crowded and slow). While a long white coat looks dignified, flowing and somewhat old fashioned — a kind of medical kittel — a short white coat makes anyone look like a barber or an ice-cream scooper. Whether to counteract or exacerbate this effect, every medical student fills the pockets of her coat with a bewildering array of slips of paper, handbooks, equipment, tongue depressors, alcohol pads, pens, pencils, Palm Pilots and the odd bit of snack food. The rationale here is, I guess, "If I don't know anything, at least the pockets of my coat can be stuffed with facts."
On top, of course, is the physician himself. (I would write "herself," but it would be unrepresentative. The top rungs of the hierarchy are mostly male, even at this late date.) Their coats are long, with pockets that don't have to be filled with anything (the clinical experience and diagnostic certitude are all kept in the head at this stage, not on PDAs or in quick-reference books). Some doctors don't even wear coats — their rank is obvious.
The above hierarchy is just an approximation. There are enough exceptions and exceptions-to-the-exceptions to impress any devotee of the Talmud. For instance, at my medical school, at least until recently, surgeons wore scrubs and no one else did. Then, in a heroic mass movement, medical students decided that scrubs were comfy. They wanted to wear them, too! Now everyone can have his own pair. For some reason, though, only a surgeon wearing scrubs looks like a surgeon wearing scrubs. Anyone else looks like an escaped convict or someone whose last set of sweats is in the laundry.
The sick person wears no coat at all — aside from the robes that open in the back, like misappropriated evening gowns — and can feel as ashamed as Adam and Eve, the first naked couple. The rabbis of the Talmud said that the prototypical act of loving-kindness was God's providing loincloths to cover their nakedness. Even if I don't know anything about medicine yet, maybe I still can help patients feel better, no matter how short and overloaded my coat is.
Zackary Sholem Berger finished his doctorate in epidemiology from New York University this month, and will complete medical school in 2006. This is the first column in a series tracing his transformation into that mythical figure: The Jewish Doctor. Comments and questions encouraged at doctor@forward.com. No medical advice given!
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