April 18, 2020

And back to the accidental plague diaries I go. We’re up to about 730,000 cases in the US, 4,300 in the state of Alabama and greater Birmingham is leveling off between 1000-1200 due to our early adoption of shut downs and social distancing. Unfortunately, a certain class of corporate masters seem to have decided that an increased mortality rate is worth it as long as their next quarter profit margins increase and they are getting their minions to agitate for opening things up prematurely. All that’s going to do is cause some flare ups. Fortunately, Alabama is not yet among the states where a Trump rally sans Trump is happening on the steps of the state house. I see pictures of those people rushing and roaring at buildings or at Alex Jones who seems to have been strapped in a barcalounger on top of an SUV, and all I can think of is the zombie hordes in The Walking Dead.

I hadn’t really thought that my job as a physician was going to turn into part call center employee and part tech support. We’re trying to transfer visits to video conferencing software as much as we can. You haven’t lived until you’ve tried to get a ninety year old to download and connect over a video app when neither their cognition nor hearing is what it once was. “I’m sorry you’re having trouble hearing me. Let me use my opera voice”. “No, you need the app store”. “No, don’t open the app, it will run in the background. I’m going to send you a text”. “No, you don’t text me back. You see that link in the text? Just select it”. “No, we can’t do this through Facebook” “Is your daughter there?” “Could you give her the phone? Maybe she can help you.” “Can you turn the camera around? The breakfast table doesn’t help me.” “Yes, I’ll look at your legs but lets not point the camera up your dress.” And on it goes. Every time I successfully complete a video visit, I feel like I’ve won a small victory.

I was somewhat constructive today. I went down to the storage space and retrieved all of the remaining wigs that I could find and put them in the studio so everything would be together when Red Mountain Theater Company comes to pack it all up and take it away this next week. I’m furnishing out the wig room in their new theater complex for them and they’re going to name it after Tommy. Once the studio is empty, I’ll have a staging area for my dejunking of the house. I’m hiring Holly McClendon, Tommy’s wig assistant to be my move coordinator and help make this all go well. As a military wife, she’s moved her family multiple times and knows how to make it all work. I also met the contractor at the new condo and went over all of the minor repairs that need to be done prior to moving and he’s going to get started on them this next week. We both agreed that the bathrooms ultimately will need some updating but that’s a problem for another day. They’re perfectly functional for now. I’m starting to think about colors for the paint job. I keep changing my mind about them. One of my friends has volunteered to come over with her decorator daughter and kibitz next week.

Someone brought up in a comment on a previous plague diary entry that most of the doctors of his acquaintance were quite conservative in their politics and I am not and wondering why that was. First of all, I’m not that far left. I’m a bit left of center for the Pacific Coast. This, of course, makes me somewhere to the left of Vladimir Lenin in the state of Alabama. Second, not all doctors are the same. We’re as varied as any other profession. How the education works is as follows. In order to get into medical school in this country, there are a number of requirements in terms of college level science classes plus the MCAT entry exam. This tends to push most premedical students into majors like biology or chemistry. (I actually majored in both – more fool I). In the 60s and 70s, top grades in science and high scores were all that was necessary and the system churned out great clinicians who were not terribly well rounded people and often had problems with the humanistic aspects of medicine. There was a shift in the 80s (when I was a med student) to trying to admit people who had something else going for them making them a more well rounded person in addition to just grades and test scores. For me, it was my technical theater background. My medical school class included a professional kayaker, a modern dance major,and a table dancer from one of the more notorious bars in Fairbanks. Of course, the education hadn’t changed and most of us round pegs were being pounded into the same danged square holes and were pretty miserable. Everyone gets pretty much exactly the same education over four years.

In your fourth year of medical school, you apply for a residency position. This will determine your specialty. They range from three years for most primary care specialties such as family practice and internal medicine up to six or seven years for the more technical surgical specialties such as cardiac surgery or plastic surgery. Your education will be very different and the demands on you will vary widely depending on what you select. The number of residency slots per specialty is fixed at each institution and the choice of which one to apply for is up to the student so for certain specialties with limited slots and the possibility of a very lucrative career on the far side, there is enormous competition (dermatology, ophthalmology) while others go begging due to lots of slots and low prestige and reimbursement (family practice). I chose internal medicine because I didn’t know what I wanted to be when I grew up. The same process happens again after residency for fellowship (subspecialty training) anything from another additional one to four years depending on what you’re learning. For me, it was two years of geriatric medicine. It’s the second least popular specialty in the country. The least popular is geriatric psychiatry.

Why is that? Because everything about medical training is about diagnosis and cure. In geriatrics, we don’t worry so much about that as we do about how people function and feel. That’s antithetical to the medical mind and makes a lot of doctors very uncomfortable. All of this is a long way of saying that medical trainees start early in their careers to sort themselves depending on interest, drives, and personality types. Surgeons tend to be technicians. They’re good with their hands and they want easily identified problems with cut and dried solutions. Medical subspecialists are problem solvers. They like the puzzle of diagnosis. Primary care docs are nurturers. They want to know their patients as people and recognize that 90% of the issues that bring patients into a primary care office are things that doctors don’t have answers for but the good ones develop strategies that help people anyway. The closer a doc is to the lives his or her patients live, especially if the patients belong to marginalized communities, the more likely they are to understand the downside of what actually goes on in our society and the more likely he or she will advocate for policies or programs that will help the people who entrust their lives to him or her, which in American politics, mean they move left. The technicians, being very removed from the life of their patients and only really encountering them in the artificial world of the hospital, tend to look at the world through the lens of business and personal pocketbook issues.

There’s one huge trend that is pushing these dynamics more and more and that is the influence of women in medicine. Women in this country did not start to go to medical school in any number until the 1970s. There were a few who went earlier (my grandmother graduated from medical school in 1926 – the only woman in her class). One thing I noticed about these pioneers when I started to meet them in the 1980s, fifteen or twenty years into their careers, was that they had to degender themselves to succeed. The feminine had to give way to the asexual. By the time my generation came along, their were enough women in medicine that this was no longer true but there were still some interesting trends. Women were self segregating, for the most part in primary care disciplines. I guess they speak to their nurturing instincts. They are also more flexible in regards to such issues as job sharing and time off which is important when dealing with childbirth and family life. To this day, the surgical specialties still remain heavily masculine but it is changing slowly. A few years ago the scales tipped and there are now more women than men in medical education in this country. I can easily see the entire profession becoming female dominated over the next fifty years and that just might be a good thing.

Enough for tonight. Be well. Be safe. And wash your hands. Holmes and Semmelweis were right.