There's an intern, married, who keeps saying she wants to set me up but hasn't found the right person yet. No kidding. I haven't found the right person either. I don't know why married people think that because they met the one person for them, it means they're an expert on relationships. We wouldn't accept that on the professional side of their careers-- if you diagnose one case of pancreatic cancer, it doesn't make you an authority. It just makes you lucky.

So much more luck goes into this job than I expected coming in. Luck as far as who your residents are, who your patients are, what happens to your patients under your watch versus what happens when you're not on call, which patients get assigned to you, which files are on top of the stack in the morning. Already there are interns who have a reputation for being terrible. The program director warns us that our reputations matter. You get one chance to make an impression, and if it's the wrong impression, then you're the lousy intern who's never going to be trusted to make decisions, who's not going to get good evaluations, who's not going to get fellowship interviews, who's going to be stuck in an ultimately unsatisfying medical career. Most of the people who write our evaluations don't spend enough time with us to make judgments of their own. The attendings admit that. They ask around, see what everyone else thinks of us, and that's what they write. But the interns with the bad reputations-- it's not always their fault. You have one complicated case and a patient has a bad outcome-- and suddenly you're known as the one who killed that patient. You accidentally piss off a family and they go complain to the attending about you and you're the "difficult personality" who needs to be monitored. You forget to follow up on one lab result and you're the scatterbrained moron who can't be trusted to do his work. There is no margin for error. It just takes one bad outcome. Other jobs, people can fail. As doctors, we can't. And even though the cost of failure is often absolutely incredibly high, still, it's a standard no one can meet.

I had a full day of clinic today, saw eight patients. Had to refer one of them to gynecology-- she didn't know she was pregnant. Three months along, and she had no idea. No clue. At least I got to give her (arguably) good news. We don't get to give good news very often.

Just to address the comments on the last post -- my friend and the nurse -- he asked her out, she politely declined, he thinks it's crazy awkward now even though it really isn't, so he acts weird around her, regrets ever taking a chance, and she seems to feel pretty bad about it.

I had a patient yesterday, young girl but not that young, mid-20s-- we were talking, and in the middle of the visit, all of a sudden she asks if she can have a female doctor instead. I didn't think I'd done anything wrong-- turns out I hadn't-- but I sheepishly went and told the attending who was supervising, and she went in to talk to the patient. Fifteen minutes later she comes back out and tells me she hopes I wasn't beating myself about anything-- the patient is about to get married, and had some questions about how the baby-making process works-- where it grows, how it happens, what it feels like, what to do to help make sure it's a boy (??)-- and felt more comfortable asking a woman. After my post earlier this week about the lack of health literacy among patients... I feel like this went even deeper than that-- this patient literally did not know where a baby comes out. Shouldn't this come up at some point before people turn 25? Did she not see Knocked Up?

The e-mail lists have been passing around an article this week (here's a link) about a guy in medical school who posted a picture on Facebook posing with his anatomy lab cadaver, smiling and holding two thumbs up (his, not the cadaver's). The reaction is of course the right one-- it's beyond unprofessional to take a picture with your anatomy lab cadaver, it's disrespectful to the deceased and his family, to say it's in poor taste is a huge understatement-- but anyone who thinks it's an isolated incident is fooling himself. By necessity, after the first couple of days of anatomy lab, first year of medical school, you have to sort of block out the fact that you're in a room filled with dead people. We're forced to cut into the bodies, dissect them, examine them-- they cease to be people. They're lab specimens. And we were there three hours a day. So of course people end up letting their guard down, people make jokes-- not always tasteful jokes. Obviously there's a line, and certainly taking a picture, with you smiling and standing over the cadaver, and posting it on Facebook-- well, that seems to unambiguously cross the line-- but it's not as if everyone else is behaving in a way that the families of the deceased would be thrilled about.

What I think is amusing about the article is part of the school's intended response:

"The medical school will also develop a social media policy, a set of guidelines that will lay out for students what is appropriate and not appropriate to post on social networking sites."

Something goes wrong? Develop a policy. Of course. Because that will fix everything.

All high school students should be forced to take a basic health care class-- not just the sex ed classes most kids get, but something that teaches everyone a little bit about medical tests and medication and what cancer is and what MRIs can show and what constitutes good nutrition. The lack of knowledge among so many of my patients is astounding-- but when I think about it, it's not like my family knows any more than this. Educated people, uneducated people, it doesn't matter all that much. No one knows anything.

I had a patient today who didn't know what a stethoscope was.

I had another patient who came in the other day with a tumor the size of an eggplant. It's metastatic cancer, growing quickly, he probably has a couple of months left. But this must have been noticeable for at least the past six months, if not longer. And yet no doctor visit until now. When one side of your body has something growing that makes it twice the size it used to be and it's turning purple and it's lumpy-- go to a doctor! I see how people can ignore something that seems like a cold, I see how people can ignore a general feeling of malaise for a little while-- they shouldn't, but I can see how it happens. Big lumpy growths, I don't understand. Not normal. Go seek medical attention.

People convince themselves nothing can possibly be wrong with them. Or they just don't know. I asked one woman, in her 70s, when her last mammogram was. "Oh, I never had any problems," she said. Yeah, but when was your last mammogram? "Oh, I never went, I never had any problems." Sure, you don't have any problems, until you do. I've had patients who tell me they've never been to a dentist-- let alone had a colonoscopy when they're supposed to. We need some basic preventative care education-- what you need to do to best help yourself, what you can do to make some real impact in your chance of staying alive a little longer. You find things early, we can sometimes fix them. You wait until blood is pouring out of your ears, it's probably too late!

We had a team dinner last night after work that I wish I had something to say about. See, it's not that the program doesn't try to forge social connections and give us all the chance to be friends-- we had orientation activities that were social, there are weekly happy hours, we're divided into "teams" that have occasional dinners like this one, there's going to be an overnight retreat in a few months-- but it's hard to force these things especially when the workplace itself is not that friendly day-to-day just because of the nature of the work. We all have different patients, we all spend most of our day either with those patients or in front of a computer entering orders and writing notes. The interaction with other interns is minimal-- sometimes there are two interns to a resident, in which case you're in the same call room as the other intern most of the day, but you're each working on your own things, and basically competing for your resident's attention (or competing to avoid your resident's attention, depending on the resident...), not really hanging out and getting to know each other. And it's tough to become too close to a resident, because he or she is your boss-- and that goes quadruple for an attending. We don't really have direct colleagues-- and even if you become friendly with someone on one cycle, two or four weeks later, you're both onto a different unit in the schedule and won't see each other for six months. The people I've found I become friendliest with during each schedule chunk are the ones I sign out to or sign in from-- the night float folks, when I'm on days, or the day team, when I was on nights. Because you're chatting for 10 minutes, twice a day, about the patients, and it's actually like a conversation. Then you go the rest of the day staring into patient charts and feeling stressed and on your own.

Anyway, the other piece of it-- which isn't the program's fault at all-- is that so many of us are at completely different life stages. It was sort of nice that of the ten people at this team dinner, five of us are single, and so we were there alone and had the chance to talk and get to know each other a little better. But even so, two of the five of us are more than a decade older than the rest, medicine is a second career, and they're single and 40-- which is a different place than single and 27. And of the other five, three are married and brought their spouses (none are doctors-- we hear about doctors marrying other doctors, and of course it happens, but what really seems to happen is doctors date other doctors, or doctors marry and divorce other doctors, because the number of actual doctor-doctor marriages in the hospital, at least among the resident and fellow population, is much smaller than it first seems-- although maybe a lot of them meet down the road as attendings or in private practice, because there do seem to be a fair number of attending-attending marriages), one brought her boyfriend (a resident on another team), and one was on like a first date-- she (rightly) claimed she has no time to date, so when a thing like this came about, she figured she'd invite a guy she'd been e-mailing on Match.com for weeks to come along. Which of course was awkward and weird-- the rest of us know each other or at least know the spouse we came with, and then there's this guy who doesn't even know his own date, and we're in someone's house having dinner, and the host (an attending) is worried this guy is going to steal things, and the joke was that he was some psych patient she picked up on the ward-- which maybe he was.

The spouses didn't have jobs that sounded more interesting than this one, they all seemed to wish they were doctors (they shouldn't), but, hey, I guess the grass is always greener on the other side. Am doing nothing with my two-day weekend-- it's so soon after my lazy vacation that I almost don't feel entitled to be lazy again, but what else can I do. I'm invited to an intern's place to watch some Pro Bowl football thing-- I don't like football but I'll probably go anyway.

"Oh, don't worry about making mistakes," said the attending. "It's not like any of the clinic patients would ever be savvy enough to figure it out. You think someone who's here illegally and doesn't even speak English is going to find a lawyer and sue us?"

Ah, yes. The reason it's okay to make mistakes is because the clinic patients probably won't sue us. Unquestionably the right way to think about our job. Patients who can afford lawyers? Be careful. Patients who can't? Eh, what's the difference, who cares if you get the diagnosis right, maybe we should let the surgeons experiment on them too, while we're at it.

I seriously think I'm going to tell my friends to pretend they're lawyers whenever they go to the doctor. You tell a doctor you're a lawyer, and maybe they won't just pick the sterile instrument off the floor if they accidentally drop it. Maybe they'll get a new one, a clean one, one that won't cause an infection. Maybe they'll double-check the prescription. Maybe they'll order the right tests. Maybe they won't. But at least they'll think twice.

I had a patient come in to clinic today complaining of depression. I think. She brought her boyfriend to be her translator. But that makes it difficult to be sure the boyfriend isn't a contributing factor. How do you ask "does your boyfriend abuse you?" when the boyfriend is the translator? I asked him to leave the room, and called the translator phone instead. He seemed insulted. He probably had a right to be. She gave no indication he's abusing her. I had no reason to suspect. But why have the doubt? The translator today was not putting 100% into the job. She was probably watching TV or something while translating. Even my terrible Spanish was enough to know she wasn't quite right. I don't know where they find the translators, who these people are. It's a work-from-home job, I'm sure it doesn't pay that well, I feel like these people have two or three phone lines and switch off between whatever rings. They do some translating, and then when we're done, they're also the phone psychics and on the sex hotlines. Same people, no doubt. Medical translation and phone sex. Heck, there's probably about the same amount of talk about genitalia on each of those lines. Although we may get a little more graphic.

One day back from vacation and I get a clinic patient with a butt rash. It's the exception that proves the rule: I've written before that whenever it's a young guy coming to the clinic, it's because there's something wrong with his penis. There is no other reason an uninsured guy under the age of 50 goes to a free clinic to see a doctor. Except, apparently, for a rash on his butt.

At first I thought he was a test patient-- they've said that they will sprinkle test patients into clinic throughout the year, so our progress can be evaluated. The test patients are prepped with answers to all of our possible questions, and armed with a checklist to mark us against ("did the doctor do a complete and thorough physical examination?" / "did the doctor wash his hands?" / "did the doctor explain the possible side effects of the medication?"). It's sort of fun to know that somewhere along the line, we'll get a couple of fake patients. It's like trying to figure out which section on the SAT is the experimental one, which won't count. Anyway, this guy just seemed so textbook-- he was too quick with all of his answers, and much too excited to be sharing. "I just got out of a relationship, and I'm concerned my girlfriend may have been cheating on me, and could have given me a sexually transmitted disease. I had gonorrhea a few years ago, but it was effectively treated with medication." Thanks. And he was just a little too clinical with a couple of answers. "We use protection approximately 75% of the time." Are you keeping a log?

So when I went to talk to the supervisor before going back to examine the patient, I told him I thought this might be a test patient, and handed him the file. He laughed. "Trust me, you will never have a test patient with a butt rash." Oh. Well, I guess that makes sense.

Went back in, examined his rash, and sent him off with some cream that will hopefully clear it up. I understand why outpatient medicine gets looked down upon by the specialists-- it doesn't take a genius to deal with butt rashes-- but, hey, I helped him, I don't have to worry that he's going to die overnight, and I got to leave the office before 5. Is it worth looking at butt rashes to get out in time for dinner? I don't know, but it might be.

I'm sorry for the break in posting.

I stayed at my parents' house longer than I expected I would, and just got back. Getting ready to go back to work tomorrow. And since my parents still live in the past, Internet access was spotty. I don't know why I spent a week with them. It's too long. Even though I didn't get to see them over the holidays. It's still too long. But given the choice of being alone in my apartment or tagging along on their pointless days, I chose them. You'd think they'd be happy that I'm a doctor. You'd think any parents would be satisfied that their kid is a doctor. All throughout high school and college that's all they wanted for me, that's all they kept pushing-- do something with your life, become a professional, make sure you have a career. And now that I've done it, they're still not happy. "You need a wife, you need a family...." Well, it's not like I'm not trying, and it's not like you need to remind me. And, frankly, it's not like becoming a doctor isn't what has made the other piece of it so difficult. I asked someone out right before vacation, someone else in the hospital. She said she doesn't want to date another resident because she knows what the schedule is like. So if I can't even get someone at the hospital to understand, how in the world can I have a chance with someone in the real world? The schedule is crazy, there's no way someone with a normal job wants to deal with this. It's one thing if you're already in a relationship, but to start something when you're working 80 hours a week? I'm exhausted most of the time, I'm irritable, I'm not myself. Although if I'm always feeling like I'm not myself maybe I just don't know who "myself" is anymore. Maybe I'm becoming this person I don't want to be. This person who's going to end up alone and miserable. I kept snapping at my parents. I don't know why they even tolerated me being around for a week. I was obnoxious. I was mean. I don't want to be like that, but it's the knee-jerk reaction. I'm trying to be an adult, I'm trying to figure out what an adult life ought to look like. But it's hard. And all I can really do is keep getting up and going to work and hope it figures itself out eventually.

In the morning I start two months of outpatient service, which should be considerably less stressful than the past few months have been. I might actually have free weekends. Which would be great if I had something to do, but since I hardly even know my friends anymore and the only people I talk to are other residents, I don't know why I even need the days off. Maybe I'll do research so I can get a good fellowship. That's the smart thing to do, right? Spend my days off in the library just to fill the hours, pretending I'm doing it for the right reasons?

Going to sleep early tonight, to bank a few extra hours just in case. Awesome.

Vacation is going well. I am sleeping a lot. Catching up on the backlog of TV shows on my DVR. Explaining to friends that even though I have officially been a doctor for six months, I still can't write them prescriptions until I pass Step 3 of the boards, and even then, I'm going to require an actual doctor's visit.

It's kind of nice to go a week without being called "doctor," without having to ask anyone if they moved their bowels today, without having to find a vein, and without having to check lab results. So much of what we do is tedious, dull, mindless work. Interrupted only occasionally by moments of excitement or reward. I guess that's any job though.

I don't think I've talked about this before, but the doctor/nurse divide is weird. One of my intern friends called me the other night and said there's a nurse he likes, and in theory wants to ask her out, but doesn't think he should. It would be awkward, he's like her superior... he doesn't feel comfortable doing anything. And maybe he's right. But the whole dynamic is weird. They call us doctor, and we call them by their names-- and sometimes not even. At one of the hospitals, there's this strange custom where the nurses all go by Miss or Mister and their first names. So I'm Dr. Lastname and they're Miss Jenny or Mister Steve. It's bizarre. Miss Jenny sounds like a kindergarten teacher. Maybe. And some of the residents use these names when they talk about the nurses to each other, like-- "did you give the order to Miss Amber?" "did you tell Miss Jeanette?" Are we children? I feel like we're colleagues, and we should all just call each other by our first names. Like colleagues do. Patients can call us Dr. Whatever, but I don't feel like I need the nurses to treat me like a superior, and I also don't want to treat them like they're my nursery school teacher.

Back to my DVR.

After today's shift is finished, I will be on vacation for my assigned two week block. It's great to have vacation right after everyone I know who isn't a doctor has already taken vacation for the holidays and is back at work without any time to hang out.

I have big plans to sleep, visit my family, and read at least a couple of books that aren't about diagnosing and treating medical conditions. I will also clean my apartment and buy more ketchup, which I've been trying to find time to do for the past three weeks but instead I end up taking tomato paste and mixing it with maple syrup to get a sort of ketchup-like slurry that approximates the taste pretty well.

The past couple of weeks haven't been too bad. I like the people on my team, which I'm starting to realize makes all the difference. It's like any other job-- you like the people you're working with, it makes the days a lot easier. Sort of.

More later.

I walked into a patient's room today, and with the curtain wide open, no blanket over him, no clothing over him-- he was cleaning his penis.

His roommate was watching, riveted.

This is why you don't want to be in a hospital. Ever.

I asked him if he wanted a minute to cover himself up before we talked.

He said no, not necessary.

I asked him if he could please cover himself up.

He said he was just cleaning himself.

I said that's fine, but I wanted his full attention while we talked.

He didn't look up.

I got my resident to deal with him instead. :)

I got home a couple of hours ago, and just got a call from the resident on night float. They hardly ever call-- and it never means something good. Some piece of information is either lost or confusing, or something terrible is happening with a patient and they need to know if there was anything relevant that happened during the day.

This call wasn't a good one.

One of my patients died. Unexpectedly, I guess. If the death of a 90-year-old with multiple cancers, a feeding tube, and a blood infection can be called unexpected. It's just that we didn't expect him to die today. He looked better today. His family went home. He talked about getting out of the hospital.

We should have sent him home as soon as he came in. We should have called hospice and let him die at home. We shouldn't have poked and prodded and given him more pain than he already had. Instead, we tortured him for a week and then he died, in the hospital, alone. Instead of in his own bed, surrounded by people who loved him.

They come, we treat. That's the default. They come, we treat. To send someone home because there's hardly anything we can do isn't how it usually works. As long as hardly anything means maybe something, we do it. If they ask for treatment, we treat. Even if we know it's probably not going to make anything better. So maybe we gave him an extra day. Maybe. Maybe we cost him a week. I don't know. He wasn't going to make it another two months, for sure. And he was in pain. But he was alert, and talking... he was alive. Until he wasn't.

I tell people I don't want to spend my life dealing with death and they ask me why the heck I went to medical school. I want to deal with life. Living patients. People who get better. People who leave the hospital, and not just in a bag. People with years ahead of them, not days. Death is depressing. To be surrounded by it is unceasingly sad.

The resident called the family. The family thanked the resident for his help, said they were relieved that at least his suffering was over. But what were they really thanking us for? We did nothing. There was nothing for us to do. Too often, there's nothing for us to do, and yet we find something to keep the patient there, in the hospital, just one more day. One day too many. One day too many.

I went into a patient's room yesterday to check on him, I pull back the curtain--

And his girlfriend is in the hospital bed with him, naked from the waist up. I immediately closed the curtain, apologized for interrupting, and told him to let me know when they're ready for me. I hear some rustling, he yells out "okay" and I open the curtain back up--

And the girlfriend is pulling up her pants, over leopard-skin underwear.

The patient seems to be feeling better. :)

Happy New Year.

I celebrated by going to sleep at 10:00. Which means I just woke up, 6 and a half hours later, and I think trying to get that last 90 minutes of sleep is going to be a futile effort.

I've been trying to come up with some New Years resolutions, but they're not ready yet. I'm hoping for something more than "do a better job at this doctor thing" and "do a better job at this life thing". We'll see what happens.

My patients finished off the year by simultaneously going downhill all at once. We have one who seems to have acquired a nickname. "The Cadaver." As in, "how's the cadaver looking today?" His blood pressure spiked, so we called a cardiology consult. The doctor came to see him when none of us were in the room, so he went to the nurse's station to make sure this was the right patient, and this was his baseline status-- he said he was worried something had happened to him between the call and when he got there, because he couldn't imagine we were calling a consult on someone who looked like he was already dead. We were like, no, that's what he looks like, and he's looked like this for a week and he's still here. The cardiologist had no recommendations, and said next time if we could refer him the living instead, he would appreciate it.

Which brings me to a weird practice that goes on in the private hospital-- specialist consults.

The way it seems to work is that whichever resident or attending wants the patient to see a specialist just calls whichever specialist they want, there's no system, there's no process-- so if you're a smart gastroenterologist, you just need to befriend all of the residents, make sure you get your contact info in their phones, and you'll get all the referrals and make money. See, the specialists aren't on salary-- they get paid per patient, they get paid per consult. And the way they get new patients, at least at the beginning, is to get hospital referrals-- they see the patient in the hospital and then the patient comes back as an outpatient. If all the residents know cardiologist X, and haven't met cardiologist Y, cardiologist X will get every referral, because it's like cardiologist Y doesn't exist. He has an office down the hall, he would love to see patients-- but it's not about availability, or competence, or a particular sub-specialty, it's just about who the resident likes and wants to send business to.

It's kind of absurd. You could have two neurologists, one who's awesome with stroke patients and one who's awesome with movement disorders, but unless the resident knows that, knows both of them, and doesn't have anything against one of them, one of them might get all of the business. It puts pressure on the specialists to be oddly and extraordinarily polite to us-- they are economically incentivized to be friendly-- they need us to send them business.

But it shouldn't work this way. The specialist you get should be the one who can get there fastest, or the one who will best serve you, not the one who's friendliest with your resident.

It's like you have to be a schmoozer and a salesman besides just being a good doctor. And the potential for corruption is enormous-- if I'm a specialist, what if I tell the residents that I'll give them a kickback for every patient they send me, under the table. Because what's the difference to them, they just need the consult-- and this way they get the consult and I get the business. I'm sure there's a rule against this. There must be. But if no one enforces it, the potential for abuse is obvious.

I guess that's enough on my soapbox for this morning. Maybe 2010 will bring an end to illness and accidents, and then I can sleep more.

Despite the lack of updates over the weekend, I was still at work. I have two weeks of vacation coming up starting a week from Friday, but it's straight through until then-- New Years Eve, New Years Day, etc. Being in the private hospital for the past few weeks instead of the public hospital has caused a few observations:

1. People with insurance feel entitled to make unreasonable demands. I've had a number of patients' families demand the patient be discharged at a certain time of day because it's most convenient for them. It's one thing if that time of day is "before 5" or "in the afternoon" -- it's quite another to be told that there's a one-hour window from 3-4 when they will be "able to accept him." Or one who demanded the patient be discharged before 7AM so she can get to work. We're not a concierge service. There are tests that need to be run, discharge summaries to write, doctors who need to sign off on things. The process takes time. Just because you have insurance doesn't mean you can dictate my schedule.

2. Similarly, two patients have threatened to "write letters" to the hospital CEO complaining about their care. One was complaining that the food wasn't any good, and the other was complaining there was nothing good on the television. Again, we are a hospital, not a hotel. If you are well enough to complain about the food or the cable, you should leave. Also, they should know that the CEO really won't care about their letters.

3. At the public hospital, patients are very deferential -- I'm always called doctor, and even the drug addicts and alcoholics seem to respect that we're professionals, even if they're belligerent and don't want to listen. At the private hospital, I've repeatedly been called by my first name, asked by families to "clean the bathroom better," and told that I don't know what I'm talking about because of something they read on the Internet.

As I write this post, I'm realizing-- it actually hasn't been the patients doing any of this, almost entirely. It's the families. The families of people with insurance think this is a hotel, not a hospital. And it makes the job much more difficult, because I have to deal with them.

No more complaining in 2010-- that's the resolution-- so I need to get it all out now.

Not a surprise: it is sad to work on Christmas.

It's hard to feel too sorry for yourself when surrounded by sick people, but the entire hospital today was filled with doctors and nurses who didn't want to be there, and it was really hard not to get drawn in to the self-pity. "First time I haven't spent Christmas with my family," "I'm going to have Christmas dinner all alone," etc. I'm a huge downer about almost everything-- and the neverending crush of six days a week, 12+ hours a day is terrible, absolutely-- but it is what it is. For the next three years, we work holidays. Someone has to. People still get sick.

Although not that many people.

It's hard not to start questioning how necessary most hospital visits are when on Christmas Day we got about a fifth of the usual headcount. If 80% of the people usually coming to the hospital don't come if it's Christmas, why are they coming when it isn't Christmas? I don't think there are fewer people getting sick today, or fewer people having accidents. So most of them are just choosing not to come. Why can't they choose not to come every day? And then I could get home at a normal hour.

We had a stupid ethical dilemma today-- for some reason, the orders got mixed up, and a patient ended up getting a doppler of her leg when there was no reason to do it. And the scan showed she has a clot. She also has a history of bleeding, so treating a clot has potential complications, and may also interfere with our treatment of what she's actually in the hospital for.

So the resident's first inclination was to pretend we didn't see the scan. The scan was never ordered, it shouldn't have been done, there was no medical reason to do it, and if it hadn't been done, we would have never known about the clot. .....

Except of course that's not really in the best interests of the patient (even though it's easier) and we can't put the genie back in the bottle. We know she has a clot, we have to figure out a way to treat it, and balance all of the patient's issues as best as we can.

The resident realized we couldn't just ignore it, called the attending, and even though it took an extra hour, we figured out what to do.

If the clot was going to cause a pulmonary embolism, then this accidental scan very well could have saved the patient's life. This should scare you, as a potential patient. A life possibly saved, by a scan that no one ordered, that just happened to accidentally get done. Perhaps appropriate on Christmas-- perhaps this patient's Christmas miracle.

Not to get too caught up in fate and a higher power. But, really, it's almost enough to be okay with having to work on Christmas.

Sometimes the family members provide even better stories than the patients.

My attending told us a story. He goes into one patient's room to tell his wife that visiting hours are over and unfortunately she needs to leave for the night. They're very old-- they've both got some degree of dementia, neither one is in very good shape. She's sitting at the bedside, stroking the patient's leg.

"I don't want to leave," she says. "My husband needs me, he gets very anxious when I'm not here, I need to calm him down, won't you please let me stay?" as she continues to stroke his leg.

"Ma'am," says the attending, "your husband is in the other bed."

Oops.

Merry Christmas.

I just got alerted to a new admission, I go onto the computer, click to see what the issue is-- the computer tells me reason for admission: Patient deceased.

I call up the ICU to ask what's going on with this patient-- did someone put in the wrong code, why am I getting a patient who the computer says is already dead?

"Oh, it must be a mistake," the ICU tells me-- we'll check what happened and fix it. Ten minutes later I get paged again-- yeah, cancel that admission, the computer was right. Oops.

During rounds this morning, we were dealing with a patient with a grossly enlarged testicle, and the attending puts his stethoscope right on the thing, no sterile cover or anything. Next room, elderly woman, he puts the stethoscope right on her chest. Didn't clean it in between or anything.

I wanted to say something. Something like, "doctor, did you wipe that down?" but it's so hard to question anyone. It's different for something major-- I was reading one of the notes that an attending wrote on my patient, and noticed he didn't mention the potassium level, which had come back crazy high in the lab work. So I called him to make sure he saw that, and it turned out he hadn't, and we had to add a couple more pills into the mix. But in real-time, in person, it's hard to question an attending, especially when it's "just" about cleanliness and not about medication levels or something that you know is definitely going to mess up the patient.

But it gnawed at me for a couple of minutes, so I said something afterwards, phrased it like a question I didn't already know the answer to-- like, "I notice some docs are super-vigilant about the stethoscope, but it varies-- is it overkill to be cleaning it between each patient, or should we try and remember to do that, every time?" And he said, yeah, we should probably do that every time, but he forgets sometimes, and it's bad form. And he cleaned it before the next one. And then forgot before the one after that.

Even though it's been almost six months of this, it's still hard to wrap my head around how thin the line is between 'patient gets good treatment' and 'something goes wrong'. The rotation I'm on right now, there's a systems problem-- it's all private attendings, they see the patients, they write their notes, but there's no central coordination of anything. It's up to me and my resident to keep track of the notes, and to keep track of the overall patient management, but we don't actually make any decisions, and we don't always know who has seen the patient, if they don't write the note right away. We have a guy who's being seen by a couple of different specialists, and they keep entering conflicting orders-- give drug X, says one of them. Stop drug X, says the next. Next day, same thing-- give drug X, stop drug X. They don't talk to each other, and when we call to resolve the conflict, they're both happy to defer to the other one-- but we haven't yet resolved it. We gave it one day, we didn't give it the next, we don't know which doctor is right and neither do they.

I'm talking to a patient in his room when his cell phone rings. He puts his hand up for me to stop talking and takes the call. "Hello?" he says. "Yeah, yeah, what do you want? I'm talking to the male nurse." He has a thirty-second conversation and then hangs up.

"Sir, I'm actually a doctor, not a nurse."

"I thought the other guy was the doctor."

"Yeah, we're both doctors."

"It seems like you do all the nurse stuff."

Four years of medical school, for this? I'm wearing a white coat. I have a stethoscope. What more can I do to look like the doctor?

My attending got a little annoyed at me today. A patient's brother asked why we'd stopped doing a certain treatment on the patient, and I said the attending decided it wasn't necessary. The brother wanted to know why, and saw the attending standing right outside the door-- so he went over and asked him.

The attending pulls me aside afterwards-- "why did you send that family member after me?"

"I didn't-- he was just asking--"

"Don't tell these people any more than you have to. They don't need to know our decision-making process. All they need to know is we're doing everything we can for the patient. I don't want anyone questioning what we're doing--"

"He asked specifically about that treatment--"

"And you tell him it's no longer the right treatment and you leave it at that. You don't say I decided something, or anyone decided anything. It's no longer the treatment. That's it. No questions. It's not our job to explain ourselves."

I mean, this guy is a good attending, and I think he's sort of right-- we don't want to explain every decision to every family member-- but when asked a real question I think they're entitled to a real answer, and to know what's going on. Even if it takes thirty seconds out of our day.

But I'm sure I will soon be jaded and sick of talking to family members and want to do everything I can to brush them off, like a real doctor.

We have a patient who, somehow, in the hospital, lost his dentures.

"I heard you lost your teeth," I asked. "How'd that happen?"

"Oh, one at a time, over the years."

"I'm sorry, I didn't mean your real teeth. I meant your dentures."

[He feels his gums with his tongue.]

"Oh, I guess you're right. I have no idea."

Another patient, showed up to clinic. I look at his chart and see that last time he came in because he was bleeding from his penis whenever he ejaculated, which made me very excited to find out what was bringing him back here.

"I have a stuffed nose, doc."

"That's it?"

"Yep."

"Okay, great. How long has it been feeling stuffed?"

"Four or five years."

"Do you think it might be allergies."

"Oh, I was on allergy medication for a while, but I stopped it recently, and my nose became stuffed again. So I don't think it's that."

"I'm sorry, run your logic by me again?"

"I took the allergy medication, but when I stopped taking it, my nose became stuffed again. So it didn't fix anything-- it must not be allergies."

"No, the medication doesn't cure allergies, it just treats them. So when you stop taking it, the allergies come back."

"Then what's the point of the medication if it doesn't do anything?"

"It takes the allergy symptoms away, as long as you take the medication. It works as long as you continue taking it."

"So I have to take it forever?"

"As long as you want the symptoms to go away, I'm afraid you do."

"That's ridiculous."

"I'm sorry, sir. That's how the medication works."

"You mean that's how it doesn't work."

"If you want to think of it that way, I'm not going to argue with you."

"Oh, and also, there's another problem with my penis--"

I'm getting sick. Which sucks for me, and sucks for my patients, since I'm not sick enough that anyone's going to actually want me to stay home, but I'm totally sick enough that I feel like I'm sleepwalking through the day. I don't think it's anything real-- right now I'm just a little sniffly and there's a little scratchiness in my throat-- but it's still hard to be "on" for 12 hours in a row when all I want to do is lie down and take a nap.

Today was my first day of the new rotation, which is a relief because if I had to spend one more day where I was, I think I was going to jump out the window. On Friday I was at the hospital until midnight, and it wasn't much better on Saturday. We had one patient who came out of surgery and started acting psychotic. We didn't know what was going on, ran a whole battery of tests, called in the attending, thought he was having a reaction to something, that maybe something serious was going on... and then he had a moment of lucidity and told us he forgot to mention he was on a couple of medications that we didn't know about and hadn't given him... and so this was just withdrawal from those. Awesome. When you're in the hospital, please tell your doctors all the medicine you take and not just some of it. Otherwise we think we've done something wrong when really you're just a moron.

The new rotation seems better. Different hospital-- private instead of public; my first time doing a rotation at this one. There's a big difference as far as the nursing staff. It's really quite crazy. I didn't realize there would be such a difference, but these nurses actually know things, and actually do things. One of them entered the patients' overnight lab results before I got in-- I was floored. They know what lab results are? They know how to use the computer system? Incredible. Not to disparage the nurses at the other hospital, because, hey, they've probably just never been told to do any of this stuff, and are short-staffed and some of them work hard, but it's night and day. They actually hire enough nurses here, with enough training and education, that they seem truly helpful. Maybe I'll be able to go a whole month without having to collect any urine samples on my own. I can dream, can't I?