I became curious enough on the workings of the doorman world that I decided to ask José, a doorman whom I’ve known for 6 years now. He staffs a 31-floor residential building (that I don’t live in) 4 days week. I befriended him when he allowed me to park my car on the sidewalk of the building when I was moving some furniture. I usually chat with José about once a month, whenever I pass by campus. We usually speak about general world matters, and I was always impressed that José never failed to educate me in politics. Last week we chatted about medicine, and I became sidetracked (from asking him about doorman life) when I commented on his esotropia (ET).

It turns out (no pun intended) that José developed a squint when he about about one year old. He was living in Cuba (!) at the time. His mother had pushed the doctors to straighten his eyes every week for 3 years, without success. Apparently there was a huge deficiency in physicians in Cuba, and the waiting list was infinite. He finally had surgery after 3 years, only to have his ET regress after months. He waited in line for surgery for almost another year before being approved by the government. The day of his surgery, he found out that his ophthalmologist had fled to Spain by means of a fishing boat earlier that morning!

Several years later, José emigrated to Madrid with his mother and brother.  However, ophthalmologists in Madrid determined that it was too late for his amblyopia to improve with surgery, and he fell off the waiting list for surgery to straighten his eyes (non-emergent). He never got around to getting repeat surgery. The interesting part of his journey was that he decided to emigrate again, this time to the US.

“Unemployment is just too high in Spain,” remarked José, “I wanted to come to the U.S.”

Why did he become a doorman?

“I have one bad eye. It’s not safe to drive a cab.”

Too bad taxi drivers with half of José’s vision don’t have the insight to find a different job…

Take language, for example. Aside from the broken Spanish I acquire from my Hispanic patients, I rarely invoke English dictum beyond the eighth grade. Our vocabulary in the office is limited to a defined collection of complex medical terms strung together with linking verbs and qualifiers describing outcomes (hemorrhage, blindness, infection, inflammation). Outside of  the office, I’ve struggled to identify common objects like “spoon” and “basket” without using hand gestures.

Is this shift simply a result of natural selection (adaptation on steroids!)? French naturalist Jean Lamarck coined terms like “use” and “disuse” for adaptation spanning generations. Are professionals contributing to their own extinction by being good at their job?

It would be interesting to measure cortical function throughout the course of medical school. This could be followed with serial PET scans to localize metabolic activity in the brain. Areas that fail to sustain signal can be used to correlate with mapped cortical regions. Indeed, a spatial correlation in such an experiment would be damming to future physicians-to-be…

I spoke with Drew Mays, an ophthalmologist at UAB, about the stresses of residency and a career. Drew won the Van Cliburn Amateur piano competition a few years ago while being program director of the UAB residency. He is tangible evidence that you can allocate time for your hobbies. To those of you who are unfamiliar with this venue, it consists of a gathering of would-be classical pianists who decided to pursue a career outside of music. Drew assured me that there will be a time after my training where I will find sufficient time to pursue my hobbies. He tells me that during residency, we have to prioritize our options to create the maximal ‘amount’ of happiness.

Not too profound advice, but it is indeed a fact that we lose sight of (no pun intended). The next time you feel lost in the midst of your training, think about Drew’s reassurance. It can help get you through the day.

Today a patient came into emergency triage stating that she had lost vision suddenly in one eye a month ago, but only decided to come to the clinic today. She also denied ever being here in the clinic. To no surprise, we did not have any records of their encounters in the clinic either.

I spent the next hour toiling around to find an egregious cause for her vision loss, only to find non-specific drusen in her fundus. When my attending, who was fluent in Spanish, questioned the patient again, the story was relayed in a different manner than I gathered. She had GRADUAL vision loss over a month, and she also “lost” her glasses 20 days ago. Her chart also magically appeared underneath my progress note–I suppose one of the techs found it 4 hours later–and a workup of AMD  was suggested in her plan.

Lesson learned: you can’t win.

However, apparently you cannot ship wine (or parcels in wine packaging) through UPS without a license. Doh! Fortunately the guy at the UPS Store was kind enough to repack my boxes in a discrete cardboard box for a nominal fee.

In retrospect, the cost differential isn’t as significant as I initially thought; the salaries are usually somewhat proportional to cost of living. One of my friends training in Boston ended up with similar funds as I did, simply because he had a higher salary and did not have a car to maintain. He’s now moving to Los Angeles, which is a sprawling freeway wasteland with traditionally crappy resident salaries.

I gave the salary issue a more quantitative analysis, and indeed it holds true to a certain extent. Take, for instance, the medicine residency program at St. Luke’s-Roosevelt Medical Center in NYC. For 2009, the PGY-2 salary is $58,463.  A subsidized studio runs about $1,600/month near the hospital. Wilmer Eye Institute in Baltimore pays its PGY-2 residents $44,192. An apartment in Baltimore away from the ghetto will cost at least $1,000 a month. The nearly $14,000 annual salary difference in NYC ought to cover the extra housing costs and hefty city taxes. In addition, you’d have to maintain a car in Baltimore.

But wait, you’re comparing a Yugo to a Rolls-Royce! Indeed, higher profile academic centers will still draw residents despite being in a seedy location and offering a lousy benefits package. It actually depends on the city.  MEEI offers a PGY-2 salary of approximately $52,000. Doheny offers a PGY-2 salary of $48,000, but a PGY-3 receives an extra $5,000 annually.

Ultimately, the end result is negligible. Instead, you should ask yourself whether you can tolerate living in a cramped apartment instead of a suburban home with a yard. Can you handle living in Utah if you typically spend your Friday nights at the bar? Or can you handle waiting in line for hours in Central Park to play tennis (don’t forget to buy a public tennis pass, or you’ll be fined!)?

Today I parted with the mug. It was too much to carry with me in my move. I wonder if I’ll ever find a mug as cool as this.

I could hear the siren of an ambulance wailing off in the distance. I wondered if the driver was dead, but I supposed the ambulance would have kept kept its siren off if the patient were definitively dead.

While I don’t who is at fault, this is yet another reason why you shouldn’t drive 80mph in foggy, rainy weather with 50ft visibility ahead.