In clinic yesterday--

Tiny Female Med Student, talking to patient: "You have an infection in your scrotum."

Patient: "My what?"

Tiny Female Med Student: "An infection in your scrotum"

Patient: "What is a scroat-um?"

Tiny Female Med Student: "You have an infection in your ball sac, sir."

Patient: "Oh. Well why didn't you say so?"

I got evaluated for the first time yesterday. Theoretically, each attending and resident I work with is supposed to file an evaluation, but very few people actually do. Everyone works with so many residents and attendings, and the form is so long, that actually filling them out for everyone would take all day. Which certainly means the system is broken, because we ought to get evaluated more than we do. But I can't fix the system, all I can do is check it three times a week to see if anyone said anything about me. And, finally, someone did.

My attending from the last rotation evaluated me, and I did okay. It's not a verbose evaluation. "[name] showed competence with patient care." "[name] wrote competent notes." "[name] performed his tasks competently." Competence is apparently this attending's favorite adjective. On a scale from one to seven (I don't know why that's the scale), I got mostly 4s and 5s. A couple of 6s, and one 3. I got a 3 in "demonstrates proficiency in assimilating material from research studies into patient care." The attending had asked me two separate times about any studies that backed up some treatment plan I was recommending, and I didn't have an answer each time. I guess he remembered. I can live with that.

I got a 6 on "displays sensitivity and respect to the needs of the patients" and also on "is aware of own limitations, takes advice gracefully, and uses this information for growth and education." I think that's a backhanded compliment. I know I don't know stuff. Great.

I asked another intern if she got any evaluations yet, and she said she got one and it was mostly 4s and 5s. So I guess I'm doing okay.

My resident on the current rotation is constantly talking about "hazing" the interns. Yesterday, he prank called one of my colleagues, disguising his voice and pretending to be from the nurse's station. "Ah, yes, doctor, one of your patients is not breathing." And then he started to laugh. He sent another intern on a wild goose chase for test results that didn't exist. He hid another intern's stethoscope in a closet for two hours.

Maybe it's just me, a little stressed about the work, and a little worried that one of these days I'm going to screw up and accidentally kill someone-- but, really, is this appropriate hospital behavior? Shouldn't the goal be to help each other help the patients and not distract us from getting our work done and have us on edge about whether a problem is serious or it's just a joke that the resident is playing on us?

It's hard enough to deal with the fake patients they sprinkle into the clinic and the fake codes they call-- rehearsals for the real thing, training exercises. But at least those are pedagogical. At least the way to deal with those is simply to do our job and assume everyone is real-- and so when we stumble into a training exercise it's no big deal, we just treat it like everything else.

But there's something different between a training exercise and a practical joke, or a prank. I don't want to be worried that my resident is trying to confuse me, or even sabotage me. I don't want to be looking for my stethoscope when I need it, or getting freaked out about a patient falling out of bed when everything's fine and he's just trying to make his own life more interesting.

I also don't want to be the kind of intern who goes to the chief and tells her this guy is "hazing" us and I wish he wouldn't. I don't want to be the tattletale or the crybaby, I don't want to turn something into a big deal if it isn't, I don't want to make enemies. But I also hope he gets the swine flu and can't come to work for two weeks.

I have a patient whose family has abandoned him.

He's dying. Soon. There was apparently a meeting with the family last week, and they said they wanted him to stay in the hospital until he died, but the hospital said he can't, he has to go to another facility, a nursing home or somewhere that can handle hospice care, there's no more treatment, he's just taking up a bed, it's sad but he can't stay...

And so the family disappeared. They haven't been in to visit him since, they don't answer the phone, they ignored a registered letter, no one can reach them. They've left him to die, and now the hospital has to figure out what to do with him.

I don't know how some people live with themselves, I really don't.

On a brighter note, I learned about a new medical procedure today. We have a patient with an infection that's not healing, the patient is colonized with the infectious bacteria and needs the normal gut flora-- so they're thinking about doing a stool transplant. They said this on rounds and I did a double-take. A what? You're going to do what?

They're going to take a relative's stool, and transplant it.

How?

Oh, via the throat.

They're going to put someone's stool down this guy's throat.

Seriously. This is an actual medical procedure.

We did not learn about this in medical school.

And this was right before lunch, which, of course, made lunch extremely enjoyable.

Today was my last day of this rotation-- on Monday I switch hospitals, though the work will be much the same. Standard patient floors, six days a week. I was hoping I'd get out early today since it was my last day (so no new admissions), but I had to write my final notes for the next intern to know what's going on.

So many transitions from doctor to doctor, so many handoffs, so much potential for disaster.

One of my med students sent me a text thanking me for helping him out and being a good role model. I thought that was nice.

A couple of months ago, I thought, oh, it'll be great not to be the intern, it'll be great to be the second-year or the third-year, so I can delegate all the scut work to the intern. Now I'm realizing that even though we have to do a lot of the scut work, we also get to leave when we're done and don't have to stick around to supervise. There hasn't been a single day this month that I've left after my resident. My hours have been bad, but hers have been terrible. And she has the responsibility of not making mistakes, too. At least I have someone to check with. She has no one. It's all on her. Something goes wrong, it's on her. I don't want to be the resident, I really don't.

There was a piece in the New York Times yesterday about primary care, and how no one wants to go into it, the pay is low, the respect is low, the rewards are low.... I thought the piece sold primary care kinda short. In private practice, it's not as if the hours have to be any different from specialists-- you're setting office hours-- and if you think you're dealing with the same problems over and over again in primary care, well, how many problems is a dermatologist really dealing with? How many different problems is a cardiologist dealing with? Yes, the pay is lower-- hopefully reforms will change that-- but there's also the reward of getting to know your patients over time and being the person they think of as "doctor." I can't imagine being an anesthesiologist, never knowing your patients, sitting alone in the corner of the room manipulating machines, and only having anything to do when something has gone terribly wrong. I'll take primary care over that, I really will.

For the past three days I've had a patient I've been trying to communicate with in my barely-existent Spanish. Tiene dolor? Dolor en la cabeza? I think I'm doing the patient a service-- my Spanish is poor enough it makes her laugh. Laughing is good. But it has made it hard to understand what is going on with the patient, and hard to be sure what is wrong with her and what we need to do. I tried to bring a translator in, and she said no, we were fine, I should keep talking.

Yesterday I go into her room to check on her, and she's talking to a nurse. In English. In perfect damn English. Three days she's making me speak my terrible Spanish, making me think this is the only way we can possibly communicate with each other. And all along, she speaks English. She speaks English. I asked her-- was this some sort of joke? Yep, she said. Thought it would be fun.

Would have been less fun if somehow we'd misunderstood each other and we'd started treating her for something she didn't have, or didn't treat her for something she did have. Gosh, she was risking her health and I was too naive to do anything about it.

It's hard enough to do some of this stuff when the patient isn't trying to deliberately trick the doctor. "Patient actually does speak English after all" is the most embarrassing patient note I've been forced to write so far.

One of my patients-- drug addict, alcoholic, smoker-- wanted to know if he could see a nutritionist. "Sure, but a balanced diet is the least of your problems, sir." "I'm not worried about that other stuff." "Well, you should be."

I've been trying very hard each morning not to be the last one there to let the night floats sign my patients back out to me. I know from my night float experience, it sucks to be waiting on someone at 7:10, 7:15, 7:20. I've been doing well at getting there at 7. Okay, 7:03. 7:05 this morning, but that was a toaster-related exception. I forgot to turn it on to make my Pop Tart. I know they're not healthy, but I like Pop Tarts. Not every day, but sometimes.

I had my clinic today. One of the patients came back to see me for a second time. Apparently asked for me by name when making her appointment. So that was nice. Unfortunately her issue was that she had a rash on her genitals, so it wasn't a very enjoyable visit.

We have another patient, hardly talking, been in bed for weeks, and my resident and I had to do a breast exam on her. So we basically molested a comatose woman in her bed. She moaned, sort of. It was creepy. Very uncomfortable.

I felt like a bad doctor today, or at least a lazy one. On weekend days when we're not on late call, we're allowed to leave whenever we're done, and in theory that can be as early as lunchtime. So I raced to get my work done this morning, hoping nothing would come up, hoping I could leave at noon and have the rest of the day off, hoping I wouldn't get any new patients assigned to me....

And then I got one patient's blood work back, and his hemoglobin was a little low. My reaction should have been, "oh, his hemoglobin is low, I should figure out why." Instead, my reaction was, "oh no, this is going to keep me here, it's probably nothing, maybe I can just ignore it." And I stood there for 90 seconds weighing what to do. A good doctor, or at least a conscientious doctor, shouldn't weigh what to do. A good doctor should just suck it up and deal with it and make sure there isn't a problem. Which is what I realized after the 90 seconds, and I went to see the patient, made sure nothing was wrong, checked in with the resident, and, okay, no one would have been harmed if I had done nothing, because he was fine, but obviously I would have felt terrible if I'd ignored it and it turned out to be something important.

So I'm about to sign out-- and then I get paged that one of my patients needed to be moved to the ICU. A good doctor would have stopped everything, gone over to deal with the patient, and wait for transport to come with the appropriate monitors to attach to him for transport. A bad doctor would have left and told the intern on late call to deal with it. And in between was me, who went to check the patient, realized the transport team was hours away from getting there and attaching all the monitors-- and so I just wheeled him to the ICU myself, hoped nothing bad would happen along the way, and then I could sign out and go.

On a normal day, at 1:00 everything is fine, you do what you have to do, you know you're there until at least 5:00 anyway, and usually later than that. But today I wanted my afternoon, I didn't want to wait two hours for transport, I wanted to leave. So I did what I had to do, and left. Should I have been more diligent, should I have double-checked everything? Probably. But there's always more you can do, there's always another patient to check on, there's always tests to order, test results to read, things you can do. We can't do everything. And sometimes you just need to decide this is a day when I'm going to do what I have to do and then leave. I was the first one on the team to leave. It's my pre-call day (I'm on late call tomorrow), so that's how it's supposed to work. And I didn't do anything wrong. I did my job. I still can't help but worry that a good doctor wouldn't be in such a rush to leave. A good doctor would want to stay. A good doctor would care more. Maybe.

I wonder what a paper clip tastes like.

Maybe one of my patients can tell me.

We have a guy with a swallowing problem. He swallows things. Or so he says. Metal clips, plastic cutlery (apparently he breaks them in half), bottle caps. But last week he was faking seizures, so who knows. The x-ray didn't show anything, so we're not sure what to think. So we are trying to prevent any of the things he may or may not have swallowed from perforating his intestines, until we can figure out if he's actually swallowing things, or he's just making up a story so he can get attention. Psych ward, or medical ward? These are the burning questions.

The good news is I think another one of my patients might be his perfect match. She says she can't walk. Except she can. She hadn't left her apartment in weeks before her son called 911 to bring her to the hospital. Why did she need to come to the hospital? Can't walk. Except she can. When we make her walk, she walks fine. Then she goes back into the bed and says she can't walk. Called a psych consult, they said she's okay. She's not okay. She's crazy.

So much crazy in the hospital. Hard to avoid. And when the patients aren't crazy, the families are crazy. At least I have half a weekend!

My 22-year-old patient died today. He came in with what he thought was the flu-- high fever, nausea, headache. We suspected possible meningitis, ran some tests.... One morning we noticed he was talking a little funny, having a little trouble moving one side of his body. It was subtle but definitely there. Seemed like a stroke. Ran more tests. Didn't know quite what was going on. And what we found sucked. Cancer riddled throughout his body, unsure where the primary tumor was. Ran more tests, but, really, we didn't know what we were attacking, how long it had been there, how quickly it was spreading, what was going on. A week of increasing symptoms. More tests, less consciousness. Overnight the attending got some results and they decided it was lymphoma. This morning, he died.

And I complain about my hours? Jeez, it could be so much worse. I feel like we grow up thinking if you do everything right, things will be okay. And yet for so many people, it isn't. I have no idea of this patient's history-- if he was a good person, if he was a bad person, if he treated his body well or badly, although at age 22 how much can any of that matter anyway? And if I were to walk down the stairs to pediatrics it would be even worse, what did any of those kids do to deserve any of what they have? It's sad. It's crushingly sad. Which is why we're supposed to get used to it and see it as routine and move past it. But virtually every patient comes in with a family, comes in with people who care about them. For them it's not routine, it's not ordinary, and it's not something to move past. It matters. It matters more than anything.

And then the next day the families are supposed to go back to work, go about their lives, move on. Is life just about alternating between looking forward to the high points and getting past the low ones? When do you just get to *be*, without looking forward or looking back? We spend all of residency with an eye on what's next, very few people come in thinking they're here for the long haul, it doesn't feel like "adulthood," it just feels like another stage along the way-- college, med school, residency-- but maybe life is just that way, nothing ever feels permanent, you're never finished having to think about the future and having to make sure you're doing the right things to get there.

Somehow I've jumped from my patient to me, and onto an entirely different subject. I'm tired of feeling like everything in my life is temporary. This job, this city, this hospital. But at the same time, I'd be scared if I didn't think of it as temporary. If I thought I would be here forever, from intern to resident to attending, here, for the rest of my life, stuck, in this hospital, doing this day after day after day. Not that this is worse than what a lot of people do. But day to day it's kind of the same. You round, you do orders, you write notes, you respond... and then back again. There's a reason hospital shows on TV are only on once a week, for an hour. That's about the amount of time it's exciting. An hour a week. More than that, and it's a job. An endless job where there are always new problems and you can never finish. You're never really finished. There's always something else to check, and if there isn't, there's always someone new coming through the door.

Sometimes I just want to take a nap.

We had our semi-regular breakfast lecture this morning-- one of the residents gives a talk to all of the interns about a recent patient issue, things we should keep in mind when a patient presents with a certain set of symptoms.... It's pretty standard stuff, sometimes the talks are interesting, sometimes they're less interesting, and either way we get free bagels.

My point isn't about the talk though. I get there and sit down, and sitting next to me is an intern I've gotten to know a little bit, he's on night float this cycle, so he's working overnight six nights a week... but I remembered talking to him the other day, and he said he was off Tuesday night into Wednesday. Which means he didn't need to be in the hospital this morning. Which means he didn't need to be at this lecture (they're useful enough, but it's not like they're some important thing-- we're not expected to show up if we're off, and a lot of people skip them even when they're not).

"What are you doing here?" I asked. "I thought you had the night off."

"I did. But I figured I'd come in anyway, free breakfast and everything."

"You're here six nights a week-- and the one day you're off, you come in just for fun?"

"I was awake anyway."

"And this is what you felt like doing?"

"I guess."

See, this is why I'm never going to be the perfect intern, and I'm never going to be the perfect doctor. I know I've complained before that I don't have nearly enough going on in my life, and don't always have a lot lined up on my days off-- but there's no way I would ever be choosing to come into the hospital if I don't have to be here. There's no way I would spend my day off at morning lecture. I would rather be in my apartment staring at the wall than in the hospital on my day off. I would rather go take a drive aimlessly around a random suburb, mindlessly killing time, than come into the hospital on my day off and go to a lecture. And if I did somehow find myself here on a day off, due to some pathetic circumstance where I desperately needed a free breakfast and all the stores in the world were closed and I had no ingredients at home with which to make anything at all-- then there's no way I would admit that I was here on my day off. I'd at least make up a story about switching days off, or getting called in for an emergency, or needing to meet with someone about something, or working on research, or leaving my beeper in my locker, or ANYTHING to avoid having to admit that I have so little going on in my life that I would choose to voluntarily come in on the one day off I have in a week, to eat a stale bagel and listen to a resident talk about thrush.

It's not even like this is a social activity. I can see maybe coming in if this was something where you get to talk to other people, where you can pretend you have friends and have some social interaction. But it's a lecture. The minute at the beginning when you sit down and the minute at the end before everyone runs back to their patients is all you get. This is not a fun event. It's not torture, but it's not something anyone should choose to attend if they don't have to.

Except maybe everyone else thinks it's fun. Maybe everyone else gets something out of this that I don't. Maybe everyone else is more interested, more committed, better at this than I am. I'm doing my job, I'm doing okay at it. But it's a job, it's not a passion, it's not a calling. Maybe medicine in the general sense is-- I haven't totally lost what drove me here to begin with-- but intern year, working on the hospital floors, doing the scut-work, writing patient notes, supervising med students-- this is a job, no more and no less. And on my day off, I don't want to be here.

We have a homeless patient, a crack addict who's either faking chest pain to get pain meds or has chest pain because of all the crack she's smoking, and she's refusing to talk to med students, residents, or fellows. "Get me a real doctor," she insists. "An attending."

Somehow, at some point on her journey toward crack-addicted homelessness, she became informed about the medical education process in this country and decided she would only deal with attendings. If my parents were in the hospital, they wouldn't know the difference between an intern and an attending, between a med student and the chief of surgery-- but this woman, somewhere along the line, has decided she's going to check out everyone's name tag and ask them who they are and what their title is-- and she's not going to talk to you unless you're "real."

And this is MY problem?

She doesn't want my help, I'm happy to leave her alone. Except I can't, because it's my job not to. I thought we got rid of her yesterday. We decided she wasn't getting any pain meds, and we discharged her. She walked out of the hospital-- or so we thought. No, instead she walked right from her room back to the ER and started complaining of chest pain. They put her at the back of the line, she slept in the ER all night, and this morning, when they finally took a look at her, she was still insisting chest pain, so they sent her right back up to us.

At first I thought, gosh, how unlucky my team is to get this woman again-- but it's not about luck. If you're discharged and then you come back within the same rotation cycle, the team you were on gets you back-- we're "familiar with her case." Uh, yeah, we're familiar with her crazy. I wish you could do a CT scan and it would show the crazy. It would light up, you could point to it and be like, yep, there it is, this scan proves it, this patient is a lunatic, let's move her over to psych. But, no, it's not that easy. Scans don't show the crazy, we just have to find it ourselves.

My Halloween dragon guy from the other day finally got discharged this afternoon. He wanted to leave this morning, started complaining to me. There's paperwork, I said. "I don't have time for paperwork, you're trapping me in here," he said. Hey, we didn't come kidnap you and drag you here-- you came to the hospital for us to help you. You can wait another two hours. "It's boring in here." Yeah, well, I'm stuck here too, and I don't even get to complain.

It gets so frustrating sometimes that none of the patients seem to recognize that we're trying to help them, none of them realize we're working long hours for their benefit, that we're the ones making them better. It's not that I even want them to thank us-- but at least they can be civil and a little polite. But, no, instead they threaten to sue (one patient today-- insisting she's getting a lawyer) or they grumble about everything, confuse the doctor with a chef whose job it is to get them a gourmet lunch, and just generally make things more difficult than they have to be. I don't want to make you have a lumbar puncture (spinal tap). I wish we didn't have to do it, it doesn't benefit me in any way, I am not doing it to punish you. But, alas, it doesn't matter, they think we're out to get them, they think we want them to suffer, they think we want them dead. For most of them, not true. Perhaps I do want some of them to leave-- but even in the worst cases I'd rather they leave through the front door than out the side exit in a body bag.

I guess it's been a frustrating day. It had been good for a few days, or at least okay. But things start to build. Need positive reinforcement sometimes. Just a little. Just to remind me why I'm doing this.

The aftermath of Halloween on Sunday morning: a new patient, in full costume. A dragon (complete with long green tail) who did not (as I first expected to hear when I was told we had a dragon in the ER) light himself on fire while trying to blow flames, but who passed out in the middle of the street, too drunk to get to the Halloween party he was on his way to.

His friends, as friends often do, scattered when the ambulance came, and apparently took his wallet with them, because he had no ID on him at all (maybe there just weren't any pockets in the dragon costume...). Based on that, we expected perhaps drugs in his system, and his friends didn't want to get caught and arrested. But, no, no drugs. Just a very intoxicated dragon, who hadn't eaten in twelve hours and passed out in the street.

It's like I'm back in high school.

I went to the local shopping mall yesterday to kill some time on my day off, figured I'd see some little kids in costume for Halloween, and even though it's a pathetic way to spend a day off, I was a little bored in my apartment.

And, funny enough, at the mall I ran into another intern, who I've sort of had a crush on, who had exactly the same idea.

And so we spent the afternoon together, and it was kind of nice. We definitely talked too much about our patients, and about the hospital, but it was nice to spend a few hours outside of the hospital with another human being. Not being paged. Not dealing with nurses and med students and attendings and patients and families and rapid responses and sickness and disease. But still someone who understands what we're going through and who I could talk about this stuff with and not feel like I'm boring them to death.

We had a nice dinner-- an early dinner, since we both had to be back at work at 6:30 this morning-- but it was going really well, almost like a really good first date, my first really good first date in a really long time...

And then she told me about her boyfriend who's an intern at a hospital halfway across the country and how they're really committed to making it work even though it's so hard for them to see each other, and he was working yesterday, otherwise he would have flown in even though it would have just been for 24 hours and how they've both been desperately trying to switch days off with people so that they can have some common time off and would I be willing to trade part of my next vacation because I overlap a week with his vacation and it would be so amazing if she could go there and visit him for more than 24 hours at a time and she misses him so much and--

Oh, wow, look at the time, I really should get going, we have to work at 6:30 tomorrow morning, and, yeah, I'll think about the vacation thing, but I've already sort of made plans to go see my family and... argh. How do you spend four hours with someone and wait until you're having dessert to mention that you have a boyfriend?

Yesterday I had to go down to the emergency room with my resident for an internal medicine consult. Chest pain. Or so we thought. Her daughter arrives, in a panic, looking for her mother... they talk in a foreign language for a few minutes... ankle pain. She has ankle pain, not chest pain. She stumbled through English well enough to convince the triage folks that a translator wasn't necessary, and somehow she ended up being understood as a chest pain patient. Oops. Chest pain? Admit. Ankle pain? You go home.

I am surprised at how much fun it is to have med students around, more confused than I am, making me feel like I'm a genius, or at least that I'm a doctor. Hey, after five months I know things! I know the abbreviations people use! I know what's probably serious and what's probably not! I know when to call a rapid response! I sent one of the med students an e-mail with a link to an article about a condition one of the patients has, I told him to read it and then he can tell the resident about it, impress her, make her think he knows something, since she's the one evaluating him. I think he appreciated it. I remember being a med student. I remember wishing someone would help me out like that. So I'm trying to be a good intern and help them feel not so lost. It helps that it's a slow week, not too many patients. Low stress level.

I can't actually tell if the lowered stress level is because of the actual work-- fewer patients, easier stuff going on with them, just by chance, could change any minute-- or it's because I'm actually starting to figure out what I'm doing and getting comfortable. It's probably some of each. And I think perhaps the third piece of it is that I'm getting to know some of the other interns and making friends. It's harder than I expected it would be to make friends. Not because of anything about the people, but just because there is no communal downtime. Everyone is on a different rotation, in a different part of the hospital or even a different hospital, and we never actually have a chance to get to know each other. In med school you have classes, you have lunch, you have extracurricular activities. At a "normal" job you have downtime, people chat, people get to know each other. But here it's so busy and you're often so isolated in the call room, just dealing with your resident, and maybe one other intern, that it's hard to actually have a conversation with someone.

Not to mention there isn't a lot of "not at work" time that people have in common and can make plans. My day off might not be your day off, my early night is probably your on-call night, you're on days and I'm on nights... so even if I wanted to make plans with someone, it's almost impossible. But bit by bit the five minute conversations add up. The guy on night float who I have to sign out my patients to, and then get them back in the morning-- we talk for a couple minutes, I know where he's from, what he wants to do, we chat about the patients... slowly, we're becoming friends. The other interns on the floor, we see each other when a patient is coding or during a rapid response-- you know, it's not the most opportune time to get to know someone, but little by little.... And so I can sort of see the light at the end of the tunnel. That after a year, after two, after three, I'll know some of these people pretty well, I'll have some friends, I won't be completely alone here, sad, frustrated, depressed. Or at least that's the hope.

Off Saturday, working Sunday. Hopefully out early enough tonight to feel like it's a full day off tomorrow and not just a break between two shifts. Hopefully.

A patient rose from the dead yesterday.

Okay, not quite. But almost. She had been basically catatonic-- unresponsive, a tremor in her leg but otherwise practically paralyzed, unable to speak, completely out of it-- for days, we thought maybe from her psych medications but even after we stopped the meds nothing changed. We ran tests, couldn't figure out what was going on.

Then yesterday her son runs into the hall-- "she woke up," he starts screaming. I go into her room, and sure enough, she's sitting up, talking, acting as if nothing had happened. "It feels like I had a stroke," she said. I asked what she meant, but she couldn't really verbalize. We've done an MRI-- there's no evidence she had a stroke. But everyone was talking miracle yesterday, we were telling her that she was in such bad shape, but what a miracle that she's better, we don't know what happened, we'll keep trying to figure it out....

I get in this morning... and she's back to how she was before. Unresponsive, like she's in a trance.

It's like she's possessed. For Halloween, perhaps. And we don't know what to do. And her son is even more distraught than before, since he had that glimmer of hope-- more than a glimmer, really-- for half a day she was back to some degree of normal.

People getting better, only to get worse. Very frustrating part of the job.

A new crop of third-year med students started today, doing their sub-internships. It's nice to feel smarter than they are. To know a little bit about what to do, to feel like I'm not the most useless one on the team. It's silly for me to feel that way-- it's silly for me to like feeling superior, and to actually think I'm superior-- I'm sure they know more than I did when I was a third-year med student. But still, it's nice to feel like after a few months of doing this, I know enough to teach someone something. I know enough to feel like I'm not completely lost all the time. I know enough to be able to distinguish real crisis from fake crisis. Sort of.

It's been a running joke with the girl night float that nothing ever happens to my patients. They're pretty boring. When I'm signing in every morning we joke about it, maybe we're flirting a little bit, I'm not sure. So today when she said, "Your patients! What a night!" I thought she was kidding, like she usually is. But no. One of my patients was discovered at 4:45AM unable to move the left side of his body. That's when these things are discovered, since the nurses mostly ignore the patients all night until they round just before 5. He had a massive stroke during the night. They didn't know how long he'd been that way, so there wasn't much treatment to do. It's unfortunate-- I mean, he wasn't in good shape beforehand, he probably only has a few weeks left, so even while I feel bad and it's a sad situation, it's less sad than if the same thing happened to someone healthy. So instead of the playful flirting with my co-intern, I had to go run and check on the patient and see what was going on. Another one of my patients fell out of bed just after midnight, but luckily didn't break anything. And another one threw a little fit in the middle of the night wanting to check himself out of the hospital. "They didn't call you," he told me in the morning. "I told them to call you and you would say it was okay for me to go home." Uh, no. I would have said you need to stay in the hospital, and I'm glad they didn't call me, because I was fast asleep. Patients don't really understand the work schedules. I'm glad they don't give out our cell phone numbers to the patients.

I didn't mean the last sentence of my previous post. The commenter is right. I apologize.

I can't sleep. I don't know why. Usually I have no difficulties. I don't think it's tied to anything from work, except maybe it is. Maybe it's the work itself, a week of it accumulating after two weeks of vacation.

I almost did a bad thing the other night. Okay, I did do a bad (negligent) thing, but luckily nothing bad happened. I accidentally left a patient off my sign-out list, to the guy on night float. Easy mistake to make, but shouldn't have happened. If something had happened to the guy during the night-- nothing did-- they would have paged the guy on night float, and he would have said he didn't know that patient, wasn't on his list, he would have had to pull up the file, he wouldn't have known what was going on. He would have figured it out, but it would have taken a few minutes, he would have been caught off-guard, and something could have happened to the patient. Teaches me to triple-check. I didn't realize until getting my patients back in the morning. Saw he wasn't on the list. Went to check on him. He was still there. He was okay. A bit of a relief. Wouldn't have been disastrous, in 99% of cases, but still, I should be better than that.

I saw someone pass out this afternoon. And it wasn't even a patient.

The things we see... and that we're totally unprepared for. I was in a patient's room with one of the medical students, we're talking to the patient about his medications, surgical history, allergies... and all of the sudden the med student makes this noise, kind of like a hiccup, and then crumples to the floor.

I froze. The patient's wife screamed. I ran into the hall and grabbed a nurse, told her to call a rapid response. Went back in, made sure the student was breathing, and by then he'd regained consciousness. The code team arrived, made sure the student was okay, and took him out of the room to rest in the nurse's station. I had to calm the patient and his wife, assure them that this was atypical and not indicative of any sort of illness in the hospital or anything they needed to be worried about. Swine flu? Random death disease? In their minds, it could have been anything.

I was pretty shaken up. It was crazy. I'm a little scared how shaken up I felt -- I'm a doctor, I should be able to handle these things better, shouldn't I? But a med student passing out? It's scary.

In med school someone passed out while watching a surgery-- something bloody and stomach-turning, but he said something when he started feeling faint, and one of the doctors watching with us was able to grab him before he fell and make sure he was okay. This time, it was just in the course of normal business, and he went down to the ground.

We're not quite sure what happened. I thought they should have admitted him, just to make sure it wasn't something more than dehydration (the student's excuse), but they decided not to. He said it's happened before (!!) and he's always been okay... I'm not sure I'm completely on board with that, but it's not like it's my call.

The patient was justifiably freaked out. Most of the patients seem to get freaked out about things they shouldn't be freaked out about-- taking medication, getting their blood pressure checked-- so at least this one had a real reason. Gosh. I don't want to work with that med student anymore.

A good doctor would never actually leave. There's always more to do, there's always labs to check on, there's always tests to run, there's always follow-up. When I look at my watch and see it's time to sign out to the night float, I'm genuinely excited to leave. I race to finish up what needs to finish up, and I leave. And then as I walk to my car I remember eight more things I should have done, calls to make, results to check on. And I feel like I'm not giving my patients enough, that if I was a good doctor, I'd still be there.

That's the problem with this profession. The problems are never all solved. There's always another patient, there's always another illness. Everyone will die of something, no matter what we do. We will never reach the end of the stack. It's like being a public defender, I guess. There are always more criminals. So what's the point? I mean, of course there's a point. There are the ones you can help, the ones you can save. But there are so many more. My work doesn't make a dent. Even for these specific patients I'm not sure my work makes a dent. But in the overall scheme of things it certainly doesn't.

The solution, if there is one? People say this stuff is why they're drawn to research. They want to be involved in the bigger questions, they want to make an impact. Well, okay... but then you look at the research actually being done, and the vast majority of it is pointless. Maybe not pointless, but at least very specific. Even in the best journals-- I went to the JAMA website. We've got "Implications of Hypertrophic Cardiomyopathy Transmitted by Sperm Donation," "Laser Photocoagulation and Intravitreal Injection of Triamcinolone for Retinal Vein Occlusions," "Computed Tomographic Colonography for Detecting Advanced Neoplasia." These may well be important and useful studies, but they're relevant for such a tiny percentage of the population. And this is a *good* journal. There are all sorts of less-good journals. And unpublished papers. And research that finds nothing. This isn't a knock on research. We need good research. Research helps us. But doing research doesn't actually sound that interesting, especially not at the level I'm at. Helping a professor collect data, input data, sort data. Calling a list of folks who've broken a hip to ask them about the fall precautions they've taken in their homes. This is one step above telemarketing.

A good doctor would leave. A good doctor can't do everything. A good doctor shouldn't feel guilty for passing things off to night float. That's what night float is there for. That's the job. We can't care about everyone and everything. We can't get personally invested in every patient, in every test result. We couldn't do our jobs if we did. There aren't enough hours in the day. A good doctor should leave. A good doctor should sleep. A good doctor should leave.

Maybe.

Why do patients think that threatening to leave the hospital is going to motivate us to try and stop them? "I got the wrong lunch and I'm going to pack up and leave if you don't fix it," one of my patients said this afternoon. You want to leave because you got the wrong lunch? What do I care? It just means less work for me. You're not doing me any favors by being in the hospital. You should want to get better. You're not a child. I feel like half the patients in the hospital act like five year olds. "I'm not getting that test," another patient insisted. "Sir, we can't figure out what's wrong with you without the test." "Well I'm not getting it, and that's final." "That's your choice, but if you want to get better, you need to think about letting us do that test so that we can find out what's wrong and help you." "Well you need to find another way to figure that out." I don't gain anything by giving invasive tests. I don't even get paid for it. We're just trying to help. Why do the patients have to make it so difficult?

I have a schizophrenic patient who refuses to talk to doctors. At least he has an actual mental illness to excuse the behavior. He'll talk to nurses, physical therapists, the guy who cleans the floor... but not to doctors. I didn't know this at first, and went in with my white coat, introduced myself... and he said nothing. Wouldn't even look me in the eye. I thought perhaps he was deaf, or completely zonked out by some medication. Then a tech comes in and he's suddenly chatting away, friendly as can be. He let me relay my messages through her. "Can you ask the patient how he is feeling?" And she would ask him, and he would tell her, and she would tell me. I sent a med student in without her coat, told her to pretend to be a nursing student, and gave her the questions we needed him to answer. That worked, for now, but I'm not sure he'll keep buying the act.