ER轮转

这个月我在急诊室轮转。第一天上班的时候，带我的医生就跟我说，我们的工作跟你们内科工作不同，我们首要任务是辨别这个病是不是危及生命，最重要的是抓住最重的疾病开始治疗，而不是像内科一样把所有相关的病史家族史问个遍。

我一开始不太习惯，总是忍不住要问一下其他的东西，然后汇报CASE的时候，带教医生就会微笑地看着我说，focus, focus，我不好意思地把病史一缩再缩，浓缩成几句话。当我最后能够把所有的病史变成一句长长的带着定语，状语，表语的陈述句，我的带教医生终于鼓掌说，that's what i need!

在急诊室虽然才上了一个星期的班，却看到了美国社会的另一面。如果不是做住院医生，也许生活圈子狭窄的我永远也看不到这些。眼睛被丈夫殴打致瞎的家庭妇女，吸毒后行暴的年轻人，被前男友入室强奸的女孩子。我学到很重要的一点，是不要judge，不要让自己的好恶是非影响到治疗。我的带教医生是一个五十多岁的伯伯，慈祥得很，今天一个监狱女犯来做妇科检查，我差点没熏过去，老伯伯却仔仔细细问她的病史，有没有过孩子，是否被暴力侵犯过之类的问题，那个女犯吵着要喝咖啡，吃饼干，老伯伯就去休息室里给她倒了咖啡，拿了饼干。然后继续检查。我们结束问诊以后，老伯伯握着女犯的手说，你去教堂吗？女犯说我很久没去了，因为我不敢去，怕上帝惩罚我。老伯伯拍拍她的肩膀和蔼地说，you know, church is for sinners, not for saints.

下午无线电说有一个心脏卒停的病人在路上，另一个急诊科医生拍拍我的肩膀说，show time! 我们还有三个护士一起等在医院紧急通道门口，我的心不由得狂跳，感觉自己就像在电视剧ER里的那些医生了。病人到达的时候没有自主心跳和呼吸，明显紫绀，经过抢救，心跳和呼吸恢复了，血压也上来了。但是没有恢复意识，三十分钟的心跳停止，大脑可能已经有了不可逆转的损伤。但是家属明确表示不愿意放弃，我们只能把病人送去了ICU（重症监护病房）。另一个急诊医生叹口气说，后面的路，对病人和家属，都是很艰难的。有时候抢救成功，并不是一件皆大欢喜的事情。

我挺喜欢ER的工作，干脆利落，而且跟不同的人打交道，我的带教医生老伯伯经常点拨我一些观察病人的技巧，通过观察他们的言谈举止，往往能够初步判断他们藏在病情后面的一些隐情，从而对进一步的诊断作出帮助。挺有意思的。

[Dalaoshu]

老伯伯拍拍她的肩膀和蔼地说，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]

谢谢。我现在看那些program看到一头雾水，都不知道从何着手。我的最大问题是要H1，所以也限制了很多。我的email是：[e-mail]. 如果有空，能否给我发个email指导一下我这个师妹吗？谢谢

[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]

落花飘零:你的好几篇文章都提到了父母，非常令人感动，好几次硬是将已出来的眼泪再逼回去。哎，女人终究是女人。这几天在办公室里，有空就看你的文字，非常耽误工作呀 ：-) 不过，多谢你提供的精神食粮。现在可看的东西不多因为我比较“挑食”，从大学起，就不再看非纪实的东西了。

[落花飘零]

bali，油墩子都是冬天才有卖的阿，我回去的时候是春天，没看见有。甜大饼是长的，我同意！我也很喜欢太阳的味道，说到这个，记得在宿舍的时候，因为看书到很晚，每天都是深夜洗衣服，我就开玩笑跟同学说，你们的衣服是阳光的味道，我的衣服都是月亮星星的味道，呵呵。

LUCKYAL，这个说来话长了，等我有时间，慢慢写个系列：）

[Bali]

落花飘零: 我看了“几张生活气息浓浓的照片”。晒衣服那张太有意思了，很亲切。我妈妈现在定居于阳光灿烂的城市，还是经常“抢”阳光晒被子衣服。家里的烘干机从来不用。还好有自家花园，不影响市容。不过，阳光晒出来的被子味道真好。我真是非常喜欢阳光的味道。另外，想说，甜大饼是长的圆大饼是咸的。但我小时候吃的大饼买相比较实，不象照片上那样松松的。你在上海腐败了那么久，怎么没有吃油墩子？

[luckyal]

很喜欢你的博客，也很喜欢你的行医的经历。
不过没否给你match申请program的经验？谢谢

[落花飘零]

bali，你留在以前文章里的留言，一般我是不会看到的，我以前文章太多，文学城留言的安排好象是根据文章的顺序安排的，所以如果是很以前的文章留言，我是看不到的，除非你特别告诉我是哪篇。

[落花飘零]

holy moly, 你们说得都好高深阿，我没有在美国读医学院，没有巨额的贷款，所以收入多少对我来说不是很敏感，只要能够让我衣食无忧，也不指望发财。大多数医生是没时间享受生活的，我现在工作的ER，那些医生都是几年甚至十几年没有vacation过了。我不想过这样的生活，情愿少点钱，但是要好好过日子。
谢谢各位的深刻发言，我就不敢多评论了，呵呵。

[纵然平行]

Hi, 上二医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.

[上二医ROCK]

现在就有病人不远万里去印度做手术呢.由美国毕业的医生主刀.住院什么的都配套,价格只是a fraction.

[上二医ROCK]

你说那些看片子的医生将来会不会都被计算或印度医生取代?

[上二医ROCK]

从美国医生收入的结构来看二，三十年后医生还是好职业么？

在美国社会里，医生是一个传统的好职业，社会地位又高，金钱收入也不错。这种名利双收的情形是由美国医生的职业特点所决定的。一方面医生作为DOCTOR，一种知识性职业性都很强的工作，自然受到病人的尊重。另一方面，传统上美国的医生其实都是小业主，这种SMALL BUSINESS OWNER的身份决定了医生的收入比较可观。

但是近年间由于HMO和超级医学中心的发展，医生越来越难维持小业主的地位，越来越多的医生变成了雇员。医生的收入也明显减少。

美国的医生收入的一个大头是MEDICARE。MEDICARE FEE SCHEDULE 实际上也是各个保险公司决定REIMBURSEMENT 的BENCHMARK。所以医生的收入是和MEDICARE REIMBURSEMENT 息息相关的。

从里根时代起，美国MEDICARE的付款总额就几乎是被冻结了。在MEDICARE里，不同专业的医生又按照不同的服务分成七千多个BILLING CODE。不同的CODE收到的钱是按照这个CODE的相对价值所决定的。所以美国的医生可以说是大家共同分享一张大小固定的大饼。

最近几年因为新技术的发展使得一些专科医生的收入得到不少提高，这就给人们留下了医生收入增加的假象。实际上专科医生是少数。占美国医生中大多数的PRIMARY CARE PHYSICIAN的收入几乎没有增加，甚至降低了。专科医生收入的增加可以说间接上是以PRIMARY CARE PHYSICIANS 收入相对降低而换取的。即使收入持平，随着医学的发展，医生同样的收入付出的单位劳动却要多很多。

随着美国老龄化的趋势，婴儿潮世代的逐步退休，以及越来越高的财政赤字。美国医疗费用的总大饼是不可能持续高额增长的。医疗费用中付给医生劳动的这部分很可能要相对下降。

我个人的感觉是，美国的医生会经历一个开始用增加工作量来保持收入的时期，然后是降低工作量的反弹。最终医生会变成一个类似警察，教师的雇员阶层，收入相对于现在会低下来，工作量相对于现在也会降下来。

恐怕将来会有一个时期，医生的报酬无法JUSTIFY 医学院的昂贵学费和住院医生的惊人工作量。最终当然看不见的手会在两者之间重新找到平衡。但是在这一阶段中，会有不少人陷入高投资第回报的艰难处境。

[落花飘零]

谢谢各位，我会加油的！

[纵然平行]

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]

呵呵，看到这儿，我必须出来冒个泡了。每天都回来看你的文章，觉得你写得真实，朴实，展现了医生世界里不被了解的一面，我很喜欢。希望你继续努力，并将一直关注着。很喜欢你的小说，知道你最近忙，所以一直没有下文，恩，在救人治病的时候，也要注意自己的身体。

[glxf]

加油!

[红叶情]

RE对你应该不陌生吧,你一定是干的最好的了。再加油！

[happyljx]

ER 果然刺激啊。
哈哈。 加油哦。