* * Anonymous Doc: 2009

Tuesday, December 29, 2009

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.

Friday, December 25, 2009

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.

Thursday, December 24, 2009

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."


Merry Christmas.

Tuesday, December 22, 2009

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.

Monday, December 21, 2009

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.

Friday, December 18, 2009

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.

Wednesday, December 16, 2009

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?"


"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--"

Monday, December 14, 2009

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?

Thursday, December 10, 2009

Another late night.

I don't know why the hours this month have been so much longer than previously. The job isn't any different. I think the whole team, on any particular rotation, is forced to operate however the resident operates. If he doesn't mind staying late, everything is going to happen later in the day and everyone's going to be stuck there. If he wants to leave early, he'll push everyone to get their work done, and everyone will get to leave. The problem is when there's a mismatch between how many hours the intern wants to work and how many hours the resident doesn't mind being there.

It makes me feel like I'm lazy. It makes me feel like this is the wrong career for me. Everyone else wants to be here, it seems. They check in from home. They think about the patients after they leave. They want to follow up. They're interested in what's going on. They genuinely don't mind spending every waking hour in the hospital.

I'm not like that, and I don't know why. It's not as if I have anything waiting for me at home, I just don't want to spend 15 hours at work. I'm not interested in the patients, honestly. Someone comes in and my first thought isn't about how I can make him better, it's about whether he's going to make me stay even later. Test results come back and I want them to be normal not because I want the patient to be okay but because I don't want to have to do anything. I want patients to leave. Someone tells me my patient died, I think, great, one less patient. I don't care. If it was a member of my family, I would care. If it was a friend, I would care. If it's someone who's dying anyway, I don't know that I care.

Okay, I'm a broken record this week. Something lighter. I had to extract a stool sample from a patient today. My co-intern came along to watch (!!). No, I don't know why she wanted to watch. She said to me, "you don't seem to like doing procedures." No, I don't! I don't want to get dirty. I don't want to use my hands. This is why I want to do primary care and not surgery. I don't want to extract stool. I don't want to see stool. I don't want to touch the insides of anyone.

...and that is why I'm going to make no money. Because insurance pays for procedures, and I don't want to do any. I just want to chat with my patients, get to know their life stories, and pass them along to a specialist who can extract their stool instead of me.

Tuesday, December 8, 2009

Yesterday was my latest night at the hospital since I've been on the day shift. I got there at 6:45 and didn't step out the door until 10:33 at night. (And back before 7 this morning.) I am so happy this rotation will be over this weekend. Not that there's any reason to think the next one will be any better-- and in fact I've heard it's worse-- but somehow the combination of this hospital and my patients and my team and these nurses has just made the whole thing so much harder than it should be.

What kept me so late was a patient with a fever, and an overworked nursing staff that is poorly synchronized with the doctor shifts. The nurses shouldn't have their shift handoffs an hour after the doctors do, it just shouldn't work that way. We're allowed to start handing patients over to the night team at 6, and the nurses change shifts at 7. In theory, I understand why this is supposed to work-- if the doctors are all ready to make their shift change at 6, then the night team is already set up with the patients by the time the nurses change, and there shouldn't be a lag. But, for the most part, the doctors are never really ready at 6. If nothing's going wrong, we're done at 6. But if anything's happening with any of our patients, we can't sign out, we have to do whatever we need to do to get the patient stable, run whatever tests, wait for whatever results, start whatever new medications.

So at 6:00, as I'm hoping to get to sign out, we realize my patient has a fever, and I need to order a urinalysis. I ask the nurse. She says she has other things she has to do before her shift is done, and she won't do it. I had an admission to deal with, so I figured I would just wait until 7 and grab the new nurse. By the time I find her at 7:15, she's already been given a list of half a dozen things to do, and says she'll get to the urinalysis when she can. At this point, I figured I'd just do it myself. Except we discovered the patient was incontinent and urinating all over herself. We needed to put in a catheter. I've never done this on my own. I waited for another intern to be free enough to help. We put in the catheter. I got the urine sample. It's 9:00 at this point. I bring it to the lab. And of course by 9:00 everything is working in slow-motion. I wait an hour for them to "rush" the results. And by the time I then do what I need to do and sign out, it's after 10.

I understand why we have to wait for test results, and can't just sign it over to the night team, I guess. I mean, I was on nights, I know what it's like to have 75 patients under your care and how annoying it is when a doctor leaves you someone who needs follow-up. It's enough that you have to deal with the emergencies that come up, but to have patients who you already know are going to take your attention, it makes it too much for the night person to have to deal with. But then there should be extra support at the transition period -- there should be an overlap so nurses can help get things done and help get the day doctors out at a normal time. Or the shift shouldn't end at that point, it should end two hours earlier, so the new nurses have time to get situated before the rush that needs to happen to get the day team out of there.

I don't know why I'm trying to explain this, and why I'm fixated on this systemic problem. I'm just grumpy that I had to be there so late, and I want to believe there's a way to fix it instead of being forced to admit that, hey, these are sick people and sometimes things happen, and for the next two and a half years there are going to be weeks like this, there are going to be nights I'm there for hours, trying to get someone's urine in a container so I can take it to the lab.

I ran into the attending from a previous rotation, and he told me one of my patients just died. Is it wrong that I don't feel too sad about it? This patient treated everyone poorly, treated his family poorly, and basically drank himself to death. Has this job made me so jaded that I feel nothing for him? That I'm not fazed in the least? I hope I'm still human. Gosh, this week sucks.

Friday, December 4, 2009

Whenever a male patient around my age comes into the clinic, my mind immediately jumps to one possibility, because that's all any guy my age ever goes to the clinic for.

"There's a problem with my penis."

Today, my fourth "problem with my penis" patient.

We tested him. I'm sure he has something.

"Have you had multiple partners?"

"No, only three or four."

"That's a yes, then."

"No, I've only had a few."

"Okay, that's fine. You should use protection."

"Oh, I try sometimes."

"Okay. You should try harder."

"Just fix my penis."

Wednesday, December 2, 2009

Better today. It's weird, in the moment I feel like there are all these ups and downs, but really there shouldn't be. Each day is more or less the same, and whether I leave at 6:45 or 7:15 shouldn't mean the difference between feeling good and feeling awful. I have bad days, the people around me have bad days, but all in all it's okay. My resident isn't so terrible, I like most of the people I'm working with, my patients are not suffering at my hands, the days are long but it's okay.

Deep breath.

I did my first procedure yesterday. Drained some fluid from a patient's abdomen. He said I did good. Nevermind that he didn't really know what was going on and what I was doing to him. Felt good to feel competent at a procedure. I can do things, sometimes. If I was alone in the hospital, if I had no one to ask, no one to teach me, I could at least muddle through some simple things and not kill my patients. That's a nice feeling, I guess. Makes me feel like one day I might be okay at this. In clinic, I saw 5 patients in an afternoon, which is the most I've gotten through so far. The attendings see 10 or 12 in an afternoon, but 5 isn't bad. Two patients asked for my card (as if I have one...), asked if I was new, asked if I can be their doctor next time they come. So that was nice.

And this morning, no new overnight admissions. Maybe it'll be a short day. Maybe it won't be. I don't know. No one knows. I treated myself to a $6.00 piece of pumpkin pie on the way home last night, from a bakery that's too expensive and not as it good as it thinks it is. Little things. Little moments. I'm trying.

Monday, November 30, 2009

I don't know what's wrong with me today. I don't know if it's working the past three days, when everyone else on the planet was home, eating leftovers and napping on the couch. I don't know if it's this slow, boring hospital where nothing is urgent and no one gets better and we're basically babysitting the demented. I don't know if it's my resident, who makes me feel like an idiot about fifty times a day.

I admit, I try to leave as early as I can leave. I try to do my work quickly, I try to push the lab to get me the results I'm waiting for, I try to move things along as much as I can so that once night float gets here, I'm not lingering for hours, finishing things up. We work 12 hour days. I get home and I have two hours before I have to go to sleep, to start again the next morning. I don't think it's so terrible that I don't want to be in the hospital any more time than I have to be. I don't think it's so terrible that I want to leave when I'm allowed to leave. Night float exists so the day team can go home. We're not supposed to be there twenty-four hours a day. We're supposed to get our work done, hand our patients off, and go home. For a couple of hours to eat dinner and watch half an episode of Law and Order and then get a full night's sleep so we can be functional the next day. I'm not missing things, I'm not leaving my patients in the lurch, I'm doing everything I need to do. I just happen to do it faster than some people, and so I leave earlier than some people. Some people just don't seem to mind if they're there until 10:00 and then back at work at 7 the next morning. I do. I don't want to be there at 10:00 if I don't have to.

So maybe it makes me want to scream when my resident pulls me aside this morning and says,

"Hey, you know, you have to expect that when you're on floors, you're going to be here late. You're gonna go over the hours limits. You're gonna pull 14, 15 hours days. That's just what you have to expect."

No. Why should I have to expect to be here every single one of my waking hours if nothing's going on? My patients are stable. Or they're dead. Stable or dead, I can't help them. And if something happens to them at midnight, hey, it's not my fault. I'm not supposed to be here. That's why there's a night team. If we don't make ourselves leave, we're never going to leave. There are always new patients, you can always check in one more time. But that's not the job. There's an hours limit for a reason. I can't function on 6 hours of sleep. I can't really function on 7 hours of sleep, but I do.

If there was something interesting going on, if I felt like I was part of something important, something that mattered-- then maybe. Maybe then I wouldn't feel so burdened to stay 16 hours a day. And maybe that's the problem-- maybe the fact that this place is where they throw the leftover patients, who we can't do anything for, who are just circling the drain-- maybe the fact that it feels like a morgue in here is why I don't want to be here longer than I have to. Maybe if I ever got to think without my resident standing over me. Maybe if I ever got to feel valued instead of tortured, it would be less of an ordeal to be here.

I go back and forth in my head-- does it depend on the team, and if you like everyone on the team, work can sort of be fun? Does it depend on the patients, and if you think you're actually helping, then work can sort of be rewarding? Does it depend on the hours, and no one can really be here, alert, for as long as we're expected to, for as many days in a row as we're expected to?

I don't know, I think it's a combination of all of that. But to be made to feel like my 12 hours aren't enough, like wanting to leave is a crime, like I'm a bad doctor because I get my work done and don't want to be here forever-- well, that sucks. That sucks and frankly makes me want to cry, because I'm trying really hard and I think I'm doing okay, and to be told that that isn't good enough and to feel like my resident thinks I'm lazy when I'm actually just trying my hardest to be efficient and not be here all night. Well, I don't know how to do two more weeks of this. At least it's two and not four, and then I'm on another team, in another hospital.

My resident is coming back from the bathroom. I hear her berating a nurse in the hall. If she yells at me one more time to check a result I've already checked--

Friday, November 27, 2009

In the hospital early this morning to round on my patients, hoping to get out of here by lunchtime-- was lucky enough to have Thanksgiving off, which means I'm working the next three days. I came back into the call room pretty pleased with myself after visiting my first patient, told my resident--

Me: "Mr. Smith just said he thinks I'm a terrific doctor."

Resident: "You do realize Mr. Smith is demented, right?"

Thanks. Thanks for killing my one moment of good feeling at six in the morning. Of course I know Mr. Smith is demented, but that doesn't mean he can't be right sometimes. So what if he thinks it's 1975 and Nixon is the President (...which he wasn't anymore in 1975, so besides having no idea what year it is, Mr. Smith also apparently didn't read the newspaper back in the '70s...), he can still think I'm a good doctor.

Wednesday, November 25, 2009

The hospital is a terrible place to be during a holiday week.

Nothing's getting done. Administrators are out, technicians are out, attendings are out. Sure, some people are here, and on call, and emergencies can get taken care of (slowly), but for the most part, everything is at half-speed. There were a tremendous number of discharges last Friday. There have been a lot fewer since. Illness doesn't know it's a holiday-- but you wouldn't realize that from walking the floors. You simply don't want to be in a hospital over Thanksgiving, if you have a choice. Which, of course, very few people do.

The hospital is also a terrible place to be during a non-holiday week.

I don't know, last month I felt like I had some interesting patients, some of the work was okay, I wasn't hating it so much. This month I'm in the bad hospital, where everyone's basically a nursing home patient taking up space for no legitimate medical reason, I don't have enough to do, and so I end up sitting in the call room for hours of the day, alone, surfing the Internet and intermittently checking on lab results. No one thinks of a doctor as having down time, as being bored, but a lot of the time that's what this is. You don't need a medical degree to do most of what I'm doing, you don't even need a high school degree. It's dull. But this is what a hospital-based attending does, a lot of the time, at least at a place like this where nothing cutting-edge is going on, where interesting cases are transferred away to somewhere better, or at least sent to a specialist. Maybe everyone is right. Maybe general internal medicine is just a dull profession. Not that I want to be dealing with the same organ all day as a specialist, and see two or three different problems 98% of the time. I don't know. I also don't want to work the hours of a surgeon. I have some friends who are jealous that at least I have a path, I have a future, I know what I'm doing with my life. But I'm jealous they still have choices, they still have a chance to end up doing something that feels more important than this. Yes, on good days being a doctor feels important. But today, in a half-empty hospital, twiddling my thumbs, it feels pretty pointless.

Monday, November 23, 2009

The rotation I'm on right now is a little too slow. I know, they're either too busy or too slow, there's never anything in between that's just right. I told the med student who's on my team to bring a book, there's just nothing to do. I have seven patients, but only two of them should even be in the hospital, the rest should be in a nursing home. I passed a patient lying on a gurney in the hall. He moaned, "am I on your list?" I said he wasn't. "People go to this place to die," he said, as I went to check his chart. No one had written a note on him in two days. I don't know whose patient he is or why they left him in the hall. I found his room, took him back, paged the resident who'd last seen him--

It's bizarre to go to the different hospitals in the system and realize the differences. Same doctors rotating through, but a different facility, different patient population, and different standards. If you need a scan here, it has to be a Monday or Thursday or it's not happening. Scans happen on Mondays and Thursdays. You need it on Tuesday, you're probably waiting until Thursday, emergency or not.

I went into one patient's room, I'm asking him about how he's doing-- and his roommate answers from behind the curtain. "I'm talking to Mr. [Patient], your doctor will be with you later." No matter, he just kept talking. I ask the guy how long he's been married. The roommate answers. I ask how his leg is feeling. The roommate answers. This would be merely annoying, except-- the patient has dementia and we haven't gotten a real answer from him since he came in. Somehow, he must have had a few moments of lucidity and had some sort of wide-ranging conversation with his roommate, where he told him about his family, about his medical problems, about his hobbies-- the roommate knew everything, we don't know anything, we've never been able to get a sensible answer out of this patient.

I have one patient, an African-American guy-- I feel bad for him-- he knows what year it is, he can count to ten, he knows the alphabet-- but he doesn't know who the President is, and when I say Obama, he just stares blankly, it doesn't ring a bell. He's probably been waiting 80 years for a black president, and now that we have one, he doesn't even know it. I know the mind doesn't work this way, but you'd hope something like that would have stuck. It's unfortunate.

Saturday, November 21, 2009

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?"

Thursday, November 19, 2009

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.

Wednesday, November 18, 2009

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.

Monday, November 16, 2009

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.


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.

Saturday, November 14, 2009

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.

Thursday, November 12, 2009

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.

Tuesday, November 10, 2009

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.

Sunday, November 8, 2009

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.

Friday, November 6, 2009

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!

Thursday, November 5, 2009

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.

Wednesday, November 4, 2009

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.

Tuesday, November 3, 2009

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.

Monday, November 2, 2009

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.

Sunday, November 1, 2009

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?

Friday, October 30, 2009

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.

Wednesday, October 28, 2009

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.

Monday, October 26, 2009

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.

Saturday, October 24, 2009

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.

Thursday, October 22, 2009

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.

Wednesday, October 21, 2009

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.


Tuesday, October 20, 2009

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.

Monday, October 19, 2009

I have a secret.

I can't read an EKG.

I've learned how to read an EKG. I've learned all about the P-waves and the T-waves, and the QRS complex, and the QT interval. I know about limb leads and precordial leads. I can answer multiple choice questions about which patient has an abnormal rhythm, at least well enough to pass a test, but if you hand me an EKG printout and tell me to tell you if it's normal...

I can't.

Not yet.

And I should be able to. I need to be able to.

Instead, I avoid. I ask someone else. I show a colleague. I show my resident. I ask the attending to "double check." No one expects me to be perfect. No one is perfect at this right away, not without practice. But I feel like I should be better than I am, and I feel like I'm hiding something. Like I need to keep it a secret.

First day back, I had a patient with a heart issue. Maybe. Who knows. I didn't. I should have. I'm looking at the EKG, the family is asking me what's going on. And I couldn't give them an answer. I got the resident to take a look, but by then the family was complaining to the attending that the only people they're seeing are med students and why can't they have a real doctor. They think I'm a med student. Of course, I would think I was a med student too. After two weeks away I'm rusty. Slow. I got out late, I was behind on the paperwork, and I still can't read an EKG. Tomorrow will be better. Tomorrow is 7 hours away. All that sleep I banked over the vacation-- am I going to lose it already? Am I already going to fall behind? Sleep. Now. Must. No TV. The Big Bang Theory can wait until tomorrow.

Sunday, October 18, 2009

Last precious hours of vacation.

I had a phone call this afternoon with the intern whose spot I'll be taking tomorrow, to find out who my patients are, get some background, and see what I'll have to do in the morning. I've got one projectile vomiter, one woman with a crazy family, and a guy who seems unlikely to last the week, unfortunately.

In a way, I'm excited to go back. My life just isn't that interesting on vacation. I don't know how people stand to be unemployed or underemployed or retired. Maybe they have hobbies. Maybe they have friends who don't work either. Maybe they have enough money to do things besides sit in their apartments, or walk around the block. I guess any of those things would help make life less dull. But me, I have the job, and at least for now, that's about all I have.

I was at a party over the weekend. Met a friend of a friend. He asked what I do, I said I'm a first-year resident. He asked if I've killed anyone. First question. This is polite conversation? I really wanted to say yes, just to get a reaction. Although thinking about it, what I should have said was "not yet, but I'm hoping to get a chance tonight." And then give him a look.

Thursday, October 15, 2009

I passed a homeless man on the street yesterday. He said he was hungry, asked for money. I happened to have a granola bar in my pocket. I offered it to him.

"No thanks, I'm diabetic," he said.

If I'd wanted to engage, which I didn't, I would have told him I'm a doctor, and starving to death on the street is going to kill him a lot faster than diabetes. More realistically, I expect he wasn't hungry at all, but just wanted the money for alcohol or drugs. Maybe wasn't even homeless.

Not that I was giving panhandlers money before, but my month of ICU rotation made me even more reluctant. Seemed like half the people we saw were homeless folks going through alcohol withdrawal.

"No thanks, I'm diabetic" ? Is he even checking his sugar? Is he seeing a doctor? Is he on medication? I'm skeptical of all of it, unfortunately.

Wednesday, October 14, 2009

I got a call from a co-intern last night, practically in tears. A patient yelled at her. She was giving the patient his test results-- he has a medium-serious condition, but not something that's going to kill him-- and was trying to offer sympathy by telling the patient about her mother, who has the same condition, and has lived with it for years and it's been okay. And apparently she got a little emotional talking about her mother, she let down her professional guard for a second-- and the patient got annoyed, said he didn't care about her or her mother, said he wasn't her therapist, he wasn't even her friend, and he wants a different doctor who can be more professional about it. (So she called in the senior resident, who took over dealing with the patient....)

It's weird-- it's such an imbalanced relationship we have with patients. We know all sorts of things about them. We know about their most personal issues, often we know secrets, or at least things they're not eager to shout from the rooftops. And yet they know very little about us, and it's "unprofessional" if we even make the attempt to form a more even bond. We heard a presentation a few weeks ago from an OB/GYN who's been dealing with her own fertility struggles for the better part of the last decade-- her talk was about the difficulty of keeping her personal life separate from the patients, of being able to be as enthusiastic about her patients' successes in this area of her life where she's had so much pain and difficulty.

In our careers, she said, we'll know some of our patients for years-- we'll know multiple generations of families, we'll experience the highs and lows in our patients' lives. And yet it's very rare that we'll be able to (or that it would be professional to) share as much from our end as we're supposed to take from our patients. The danger, she warned, is that it's easy to think our patients are our friends, especially since we know so much about them. But they aren't, or at least they shouldn't be.

I think this is a sad and frustrating point of view to have about the medical profession. I think we can be doctors as well as friends; I think we can be doctors as well as people, and that letting our patients know us doesn't have to be a bad thing. Even from the perspective of improving patient health, I expect that patients who feel closer to their doctors are willing to reveal more, and sometimes reveal things that would lead us closer to the right diagnosis, that they may not even know are relevant. Patients don't always know what the right things to tell us are, symptoms they don't even see as symptoms might be exactly what we need to know. And, besides, it seems a lot more rewarding for us as doctors if we feel like in our offices we can be people too, and not hide our humanity.

Then again, I see what the OB/GYN meant. I went to the dentist yesterday-- taking care of so many exciting things over my vacation-- and as she was looking at my x-rays, she said I shouldn't worry about an occasional cavity. "I'm a dentist," she said, "and even I get cavities. People look at my teeth and tell me how nice they are, but they don't see the back-- I have fillings all over the place. And my mother was a dentist! But it didn't matter. I still had terrible teeth growing up. I still do. I'll tell you a secret-- I don't always floss. I try, but I forget all the time."

This was too much. I just met the woman. I don't want to know all this. I don't know that I want to go to a dentist who doesn't floss.

Although, I'll tell you-- last night, I flossed twice. Just to be safe. So maybe it worked. If that was all a strategy. Which it probably wasn't.

Friday, October 9, 2009

I just got back from the doctor.

I haven't posted in a few days because I've been coughing and sneezing.

On my vacation, and I get sick.

It's interesting, though. After just a few months as an intern, I found myself with an entirely new perspective as a patient. Throughout outpatient month, I've tried to be really apologetic when I've had to keep patients waiting, thinking that was enough. It's not. It's still annoying to wait for 45 minutes even if the doctor apologizes.

I was a bad patient. I told the doctor what prescription to give me before she even looked at me. I kept asking what she was seeing when she looked in my nose and down my throat. I tried to peek at everything she was writing, to double-check. I reminded her to wash her hands. She probably hated me.

She definitely hated me. Doctors are bad patients.

Monday, October 5, 2009

It felt good not to set an alarm this morning.

Makes me realize one of the blessings of this job-- when you're not at work, you're free. I look at my friends in consulting or banking, at law firms, anywhere in business, and they're constantly on call. I think we work a lot harder than they do when we're in the hospital-- but at least I know my pager isn't going to go off if I'm on vacation. No one's going to send me an urgent e-mail, I'm not going to have to rush to the hospital to deal with an emergency, no one cares if I'm accessible or asleep.

Of course, the reality is that this is a residency-only situation.

Come three years from now, if I'm part of a private practice, sure, when I'm not in the office calls will go to an answering service and only one of some number of us will need to be on call at any given time-- but I'll have real patients, and those patients will expect me to be reachable, and available if something happens to them. Easier in the outpatient setting than for an OB/GYN or a surgeon-- if someone's calling me in the middle of the night, odds are I'm telling them to go to the hospital and then I can roll over and go back to sleep-- but it's not as if I'll be able to completely shut off when I'm away from the office (although that's one of the appeals of something like Emergency Medicine-- it's shift work, and when you're off, you're off).

Of course, the flexible time this weekend and so far today just serves to remind me how hard it's really been to keep in touch with people over these past three months and how quickly my life has gotten unfortunately small. I e-mail with friends-- the past month doing outpatient has let me do a lot more of that than the months in the hospital did-- but my calendar is really pretty empty. And after these two weeks, I'm back on hospital floors-- so it's not like I can really sign up for any sort of continuing activity that would take any time once that starts.

I'm fighting two impulses-- the desire to pack as much as I can into these two weeks, travel to see as many friends as I can, at least the ones within driving distance, and make sure I build up enough friendship goodwill to last through the months I'll be almost completely overwhelmed and inaccessible-- along with the desire to sit in my apartment and zone out, do nothing, watch TV, take walks, decompress.

Truth is, I'm not good at doing nothing. None of us are-- if we were, we wouldn't have gone to medical school. I don't know how to do nothing. I just get bored and depressed. I first wanted to be a doctor because it meant at least I'd get to be around people. I didn't realize at that point that so much of being a doctor ends up meaning you're just sitting in front of a computer alone in a hospital office inputting orders. It's not a social profession, for the most part. There's interaction, but there's not very much connection. I talk to the nurses in the course of the day but I don't actually talk to them. I don't know anything about most of the people I work with. There isn't time or the inclination for actual conversation except about the patients. Most of my colleagues talk exclusively about work, even at the weekly happy hours I've dragged myself to. They're boring. The happy hours I mean-- although I guess it applies to my fellow interns too. We're one-dimensional people. We've spent so much of these past four years just thinking about medicine that it's all we're left with.

I'm not obsessed with medicine. I don't want to talk about everyone else's patients, I don't read medical journals for fun, the academic part of it doesn't excite me. We've had some talks at grand rounds by doctors who seem genuinely into what they're researching-- genuinely passionate about it. They don't get bored. They don't need other things in their lives. I do. Or at least I worry that I do. I can't get by on just this.

But what does that mean? I don't know that medicine is that much different from anything else my peers end up doing, at least in this respect-- it's not like it's any more satisfying to be a lawyer dispassionate about the law than a doctor dispassionate about medicine. I don't know that I'm passionate about anything-- that's the problem, I guess. I don't know that I'm passionate about anything. I don't know that most people are passionate about anything.

But if you're not passionate about anything, how do you fill the empty space?

I have two weeks to solve that one... of course, even if I find an answer, then I have to go back into the abyss and won't have time to do anything but the job. Argh.

Saturday, October 3, 2009

Even after just a month of outpatient, already it's pretty clear-- from the things I've posted about and the things I haven't-- that the same kinds of problems pop up again and again. I've had more than a few people trying to get me to sign disability forms for them, I've had more than a few drug addicts who show up wanting to get clean but then don't follow through, I've seen more sexually transmitted diseases than I'd like, I've seen a bunch of patients with complaints of chronic problems that probably aren't actually problems at all, and I've actually seen a surprising number of patients come in for just a physical.

That's been the biggest surprise to me-- and it's a good surprise, as opposed to the usual downbeat stuff I post about-- the number of patients who are proactively coming to the clinic for a physical, even though no urgent problem is pressing on them to do so. And it's really hard for a lot of these patients to get here. A lot of them aren't able to take time off from work without consequences, a lot of them don't have reliable transportation or child care, a lot of them don't live especially close to the clinic, for a lot of them it's a real sacrifice to come see a doctor when nothing's broken, bleeding, or causing them pain. And yet they do. They come, and they tell me they haven't seen a doctor in a couple of years and just thought it would be smart to get themselves checked out. And I find they have high blood pressure, or diabetes, or sometimes nothing at all-- they're usually not the most interesting patients, but that's a good thing for them. To find this stuff before it kills them.

The bad surprise of outpatient care-- in terms of the doctor, it's just not always very interesting problems to deal with, and a lot of the same questions and same answers, day after day. And I knew that going in, but I'd say that especially compared to what I was dealing with during the inpatient months, there was much less variety than I expected, much less day-to-day learning and surprise. Which is disappointing. I guess.

But my biggest observation as far as the patients go-- I feel like I'm regularly surprised by how little the patients know about medicine and how the body works. "I think my eye drops are making my diabetes worse," "I get this pain in my hand every time I eat chicken," "How can I have a stomach virus when I shower every day." We need to teach health in grade school, and not just sexual health the way health class is now. Why shouldn't every child graduate from high school knowing some basic medicine, some basic sense of how the body works, what each organ does, what cancer means, why exercise is beneficial, what a heart attack is, what causes a stroke, etc. People don't know this stuff. At all. They should.

I start two weeks of vacation today-- we get four weeks of vacation a year, broken up into two two-week blocks that are assigned to us. I will keep posting, but I also have a strict schedule of sleeping and TV-watching that I will be trying to adhere to. :) Trying to put together some plans to visit friends, and I wish I'd been able to be more pro-active about planning this stuff before the vacation actually started, but we'll see what happens.

Thursday, October 1, 2009

Examining my first patient this morning:

"Have you had any unusual discharge from the penis, or any burning when you urinate?"

"I have a white discharge, but only when I'm excited."

Wednesday, September 30, 2009

I don't want to get old.

I did a patient home visit today, as part of a training workshop, tagging along with an attending to see a homebound elderly woman who can't leave her apartment to get to the doctor. She had a stroke a year ago, and broke her hip six months ago, so she's very limited as far as her mobility and in fact hasn't left her home in months.

A restaurant a few blocks away delivers her lunch and dinner every day, and she makes oatmeal for breakfast. She watches TV but can't really hear it well enough to entirely understand what's happening. She reads the newspaper. She looks out the window and watches cars passing on her street.

But that's about all she does. Her husband passed away a dozen years ago, they never had any kids, and her family is all overseas. Unclear if she has any friends. Unclear if she ever talks to anybody but the restaurant's deliveryman, and the doctor.

She was so excited to have us there. She even let us sit on her plastic-covered furniture-- she said it's her "special furniture" and she doesn't like to risk it getting dirty. She kept asking me if I think she'll ever be well enough to go outside again. The attending jumped in before I could say anything and told her she's too much of a fall risk, and for now it's probably better to stay in. She doesn't eat enough-- she's emaciated, she's going to starve to death if something doesn't get her before that.

I don't know what the point is, to be honest. It's gruesome to say, but I don't know what the point of this woman's life is. She has nobody and does nothing. She's waiting to die. And when she does, likely no one will even notice for days. I guess the restaurant deliveryman will. He'll ring the bell, she won't answer, and he'll call 911. And that's how it'll go. Her plastic-covered furniture, clean and untouched, will end up in the garbage, I imagine.

If nothing else is an argument for having kids, this woman is. Without a family, she has no one. The phone never rings, no one ever comes to visit, she has no one whose life she has a stake in. Look, I know having kids doesn't mean they're going to want to have anything to do with you once you're dying-- they may very well just put you in a nursing home and ignore you-- but if the alternative is to live this woman's life, alone, with a TV that she can barely understand and a deliveryman her only connection to the outside world-- I don't know if a nursing home is such a bad place.

What she needs is an adopt-a-grandparent program. I'm looking into it today and will hopefully be able to convince social work to pay her a visit. And I called my grandma tonight. Twice.

Tuesday, September 29, 2009

We had a lecture last week about two things we need to watch out for in the clinic: drug-seekers and malingerers. Today, my first malingerer. A 29-year-old guy who wanted me to sign his disability forms because he hurt his shoulder. "I can't lift it," he said. And then he lifted it. "It only hurts sometimes, but when it hurts it really hurts. I can't work at all." How do you spend your day, I asked. "I walk around a lot, helped a friend move the other day." You helped a friend move? "Yeah, yeah, I was feeling okay that day." Surely if you're able to do that, there's some job you could get, I said. "Not really."

I'm almost offended he didn't try a little harder to sell his story. At least make me wonder if you're telling the truth, at least put on a little show for me. But, no, his friends probably told him the doctors don't even care, they sign the forms, doesn't matter what you say. Problem is, even if I don't sign the forms, he'll just go to doctor after doctor until he finds one who will. The Internet says so. You google for information on this stuff and there's websites that say if your doctor doesn't believe you, "consider finding a more compassionate doctor."

This guy was a ridiculous example, but, honestly, I think if someone really wanted to fool someone like me, it wouldn't be that hard. I'm still questioning most of my own judgments, the last thing I want to do is accuse a patient of being a liar and not giving him the treatment he might need. I don't walk into the exam room assuming the patient is lying-- I don't think any of us do. We assume our patients come to see us because they're sick, and they need our help. We have to trust. So many conditions can present in so many different ways, and often enough the first guess is the wrong guess and we have to dig deeper. Patients with real symptoms sometimes have normal test results. We don't always know what we're doing. To add in a layer of suspicion-- to make us question the honesty of every patient-- I don't think it's something most of us do naturally.

I didn't sign the forms. I went to the resident in charge and she talked to him and agreed with me. He didn't even seem annoyed by it-- I'm guessing we weren't his first stop. And we won't be his last. And he'll find a doctor who'll either look the other way or he'll improve his story until he can fool someone. Of course, with the energy he's spending trying to get on disability, he could probably just get a job.