openmindedisgood wrote: . . . the VA system has become significantly better than when I finished training a decade ago. There is likely a spectrum of VA hospitals.
Although my personal experience is more than a decade old, my recent anecdote about the hapless hire who eventually eventually getting a VA job when no one else would hire, isn't. One certainly hopes the VA system has improved in caring for those who have sacrificed for our well being.
Biason wrote: don't let on just how efficient you are, and make sure to complain a lot and show mediocrity so you won't be singled out as being too efficient and then punished with more work.
This is the funniest backhanded compliment. On those hard days, I too have daydreamed of retiring to the VA after making enough money. Reading your posting not only made me LOL, but it reminded me about Michelle Rhee, Chancellor of the DC public schools efforts to clean out the listless, deadwood, school staff.
A lot of the problem is efficiency. Obviously I worked as a resident there for many months (close to 1 out of my 3 years) by choice. The VA was seen as a really, really hard rotation because you have NO SUPERVISION. This is different as attending,but the same political item applies.
Basically no one gives a turd of human excrement. This is actually a good thing. In our pill popping, "DO SOMETHING" society which is foaming at the mouth rabid to magically demand an immediate solution to today's problem that MUST be started yesterday or else (not an error, just showing how cuckoo most people's expectations are), the VA was a refreshing dose of mellow out don't give a shit.
80% of the work as a resident is either tracing down the patient's entire history. Thanks to VA computer, EVERYTHING, literally EVERY medicine prescription, stress test, consult or colonoscopy is in the same system. So instead of calling the pharmacy and getting in touch with umpteenth private attendsins, a VA admission, even for ICU patient was a joke. You'd just renew with ONE CLICK (literally) all the outpatient meds, quickly look through everything, and within 10-15 minutes know the patient as well as their primary care doc thanks to everything being accessible in the record.
*crude profanities removed
The VA was a sigh of relief from this as a resident. There is no threat of being sued. You get to care for the nation's heroes! I can't tell you how many Pearl Harbor, Phillipines, Normandy, bomber, battleship whatever heroes I met.
As a child I read and was told by my grandparents about these heroic, selfless people who saved our country from certain doom. If it wasn't for these heroes, certainly we would have to wake up every morning and wave a "heil hitler" to a nazi flag.
So yes,the VA was wonderful for residency. I can be a lot of work as a resident because you have very little supervision. But that is what I most loved about it! I was a good doctor. Sure, I had my faults, but I was being judged on tasks that had NOTHING to do with being a good doctor.
So much of my time was not involved with actually caring for patients, wasted, calling around gathering data that was impossibly hard to gather or kissing up to superiors so odious, so hateful, so unhappy in life they wre demeaning everything around them that breathed. In that sense, maybe the vets erred. Japan should have won WW2: that way I would order ritual Seppuku on a prescription pad for them, and without any "coup de grace" beheading from an assistant either!
The differece is this: most residents at the VA hated it. They had no appreciation for history. They didn't appreciate WHY most of these vets were so crazy that at night when covering the hospital, the hallways were full of screams, of crazies in the throes of withdrawal, of why these people were so nuts despite being on 5 psych meds. How soon our society forgets.
I managed to exploit the computer system. Instead of spening 80%of my work day calling pharmacies, kissing ass and tring to dodge bullets. IE, sometimes, as a resident, if you call cerain doctors to ask more history in the interest of taking better care of patient because you are in a confused, very combat like situation and need to get some fast answers, they will complain to your program you are a bad doctor because "your clinical judgement is bad".
Gone was this. I could look on the computer. I even constructed templates for pre-written progress notes. I didn't have to write anything new, just clicked on what I wanted, deleted what I didn't need. Do realize that medical documetation also takes a long time, as in 1 hour of documenting for every hour of patient care. That is pretty crazy, but thanks to macros I could just save in the computer and even order sets that could be saved (like pneumonia or alcohol withdrawal).
While with my regular hospital 12 patients would take me all day, at the VA even a full 12 patient (or sometimes more, as the VA is permissive ,they would violate the residency limits all the time) load was a joke. I had the feeling that I could be the ONLY internal medicine resident and manage all four teams of patients in an 8-10 hour work day. Attendings loved and trusted me, and vice versa.
Oh god, there were 2 attendings to whose houses I went with my intern to scarf down various foods, delights. They would take us out of the workday. One had so much art at his house, we would spend the whole day talking about European oil paintings or asian ceramics while eating exotic fish etc. The chief resident would "wonder" where our team wound up, and my attending would always vouch "teaching rounds". It was the bomb. I was free, and I got to talk all day with my patients about 'nam, battleships, B-17's. It was heaven.
The dark side was there though. I was actually offered a job at the local VA, but turned it down because of what I had heard and saw. I know that my personality type would not thrive there as an attending. I know with my restlessness and "urge", I could make 2-3x or more the same money (of course, at 2-3x the work) in pvt practive. I knew my enthusiasm would be punished. And yet I felt the "laziness" was a good thing.
I had a patient whose heart stopped and he died at 1am on telemetry. I never got a call, and I was on call that night. My intern found out the next morning that the patient had died because she checked the telemtry strip and found 6 hours of flatline! OF course, the patient was DNR/DNI, so even if I had been alerted the patient's heart had stopped (and I was expecting it), I couldn't been able to do anything.
Another time my intern rounded on a patient in rigor mortis . Rigor moris is what happens hours after you die: muscles for lack of energy become rigid after death, takes a few hours for this to happen, you have to be very "cold and blue". Strange, but your muscles actually need energy to RELAX! Your muscles will naturally contract, but most of the oxygen and energy is actually used to make them relax and cock like a revolver, ready to fire the next movement. So in essence, the movement is the downstream, easy and expected function. In other words, muscles act like capacitors, storing energy/charge. So when you die, your muscles stop dong this and after a while seize up, and the corpse will become stiff. It does take a few hours.
Now, on this occasion, my intern wandered in to round on this patient maybe 30 minutes after the nurse's aid had documented a blood pressure and pulse that were the same in the chart as had been measured for the last many days (alone, a questionable sign). Those vital signs were indeed documented as poisitive, in other words, a blood pressure and pulse were recorded at that time. But patient was in RIGOR MORTIS! He was stiff as a board and dead as a doornail. He would have to have been dead for longer than the time between the vitals were documented and my intern first saw the patient to get so stiff. What does this imply? Not measuring vitals and just copying the same number endlessly? perhaps.
Still, no harm no foul. The fact remains that both of these events were expected.
I think the "regular", lawyer dominated healthcare system does way more injustice to old people. Have you read my posts about my anger, my opposition to this "911 emegency" approach to trying to resuscitate 90 year olds, breaking their ribs. I still have nightmares and bawl like ababy about this. My wife has forbid any hospital conversation, the suffering, death and pain I have witnessed in that capacity is more than most men deserve to see in a thousand lifetimes. Dr. Mengele? Sure, I was he. I was forced to break ribs, mechanically ventilate old people that I thought deserved to die (in a good way, like "die nicely in their sleep"), but was ordered to disturb them from their eternal slumber. The guilt, the sickening texture of breaking ribs with my hands, seeing the whole corn kernels of their last meal watching them puke as I try to intubate them. I have repressed that. I don't remember the last time I cried about that, but I am pretty tearful sharing this tonight. And you need to know. People need to know. That was the VA difference. While there was that callous "government employees don't give a shit" attitude, IMHO a shit wasn't given about the things that don't deserve a shit to be given, see what I am saying? Because most institutions give a shit about those things because people have unreasonable, crazy expectations.
I practice with that sense of protection from my patients. I don't beat arond the bush. A handful of patients do get turned off by my very intense approach, but 98% appreciate my attempt to educate them, to illuminate them through life's journey. I feel like I get paid very fairly for it. I think I am doing better for me and for my patients than I could at VA. But I work very hard, very, very hard.
I still have a large number of vets. They like the "double dipping", having VA for free stuff and then seeing private doc for the boutique medicine 2nd opinion. I like that. They are some of my favorite patients.
So if you like VA, go ahead. Low pay, low work, but fabulous work environment. Can make more, do better in private practice, but from a risk/reward profile, a very "efficient" job. Take it from a veteran of that particular conflict.
Just make sure you thank your patients for what they have done. Give back.
We get to invest, to armchair talk about all this diehards baloney and have good jobs and not be slaves becaue of the vets' sacrifices. Thank a vet today, they will apreciate it.