MD Envy

      Here's a question for my paramedic brethren: Did anyone ever have to remind you that you're not a doctor? Your partner, perhaps? Your boss? A judge?

   A Korean War corpsman nearing retirement delivered that message to me during my first year of practice. I had just delayed our departure from the local ER by reciting obscure differentials, scavenged from memories of multiple-choice exams, to my patient's bemused physician.

   "You know," my partner said, "you ought to change that 'EMT-P' after your name to 'AAD.'"

   "What's AAD?" I asked.

   "Almost a doctor."

   Got it.

   My colleague had correctly diagnosed me with MD envy, a humiliating but treatable condition presenting with any of the following signs:

• You carry more prehospital meds in your car than the neighborhood pharmacy stocks.
• You favor physician oversight—for other medics.
• Your diagnoses correlate to last week's House reruns.
• You think the only difference between you and a doctor is $150K a year.
• You spend hours on the Internet searching for paramedic-to-physician bridge programs.

   I'm not sure why we sometimes think we're smarter than doctors. Maybe we confuse skills with knowledge. Sure, we might have more recent experience inserting airways and IVs than, say, the dermatologist who just cut that mole off your back, but that doesn't mean our curriculum approaches the depth and detail of a physician's. Perhaps it's unrealistic to expect us to grasp the exponential differences in training and accountability between our two disciplines.

   I remember a lunchtime discussion with an ED attending and several EMS coworkers about a paramedic who had attempted a prehospital C-section, ostensibly to save the fetus of a mortally injured mother. The sentiment around the table was mostly supportive of the medic's actions. Only the physician dissented. His point was, "You'd have to be a doctor to know why you'd have to be a doctor" to safely perform such an advanced procedure. I agree that it's difficult to make good decisions with only superficial knowledge of pros and cons.

   Even interventions within our scope of practice can be risky without recent experience. For example, I worked in a system with a prehospital protocol specifying repeated intubation and extubation to suction aspirated meconium. If I count the neonatal intubations I've done in the field, add them to the number of meconium births I've witnessed, then multiply by two just to impress you, I still get zero. Sometimes we have to stretch our comfort zone, but it's dangerous to substitute willingness for competence.

   I think much of our self-image as AADs is wishful thinking, spurred by our earliest prehospital successes. Favorable short-term outcomes after treating manageable but incurable conditions like diabetes and asthma can distort our perception of EMS' limitations and leave us feeling omnipotent. With enough positive reinforcement from patients and peers, some of us begin to view higher education as an option, rather than as a prerequisite for entry into the gated community of professional healers.

   Another cause of MD envy is Hollywood's progressive portrayal of physicians as more vulnerable and less stoic than their predecessors (think Mark Greene vs. Ben Casey). It's easier for us to identify with doctors who are sleep-deprived and fallible than with the imperturbable white-coated icons of my youth. The danger is allowing collegiality to inflate our sense of our own capabilities. Instead of thinking, I've done easier procedures; therefore, I can do harder ones, our oath to do no harm should discourage experimentation with risky treatment modalities suggested not by sound medicine, but by ambition.

   Patients can potentiate pangs of MD envy, too. As a semi-unretired paramedic in the entertainment business, I treat many people who don't want to waste even an hour of their recreational time at a medical facility. I'd like to help them by reading x-rays and writing prescriptions, but I'm about seven years short on training. Consequently, there are sore throats, upset stomachs, swollen ankles and twisted knees that never get definitive care. The best I can do is spot emergent issues, treat what I can, then lobby for transport to an ED. When my patients hear me say, "I'm a paramedic, not a doctor," as I try to avoid yet another refusal, some think it's just a posterior-protecting ploy. Mostly it's an acknowledgment that my expertise is limited, and I don't always know what I don't know.

   For those of you whose MD envy is refractory to my innocuous but well-intentioned guidance, there is a solution: Become a doctor. Or a nurse practitioner or a physician's assistant. (The latter two didn't even exist when I was a kid.) Each of the above occupations gives dedicated caregivers a chance to practice at a much higher level than the most gifted paramedic.

   On the other hand, there's no shame in not being a doctor. If it were easy, I would have done it three decades ago, just to pursue a childhood fascination with all things medical. Instead I've adapted to my limitations and cultivated pride in EMS. I'd like to think there are plenty of people out there who envy us.

Mike Rubin, BS, NREMT-P, is a paramedic in Nashville, TN, and a member of EMS World’s editorial advisory board. Contact him at mgr22@prodigy.net.