Another ethical question (I suppose) --

We've been dealing for the past couple of days with a woman who's not in good shape. Half-conscious, unresponsive, feeding tube, not actually living a recognizably human life. Like the 94-year-old man I wrote about the other day, the family doesn't want to acknowledge what's happening, and is refusing to sign a DNR.

"She's the leader of the family, she's always been the one in charge, we don't feel comfortable making medical decisions for her, we just want her back the way she was, you have to do everything you can, no matter what."

They don't get that she's never going to be the way she was, she's never going to be the leader of the family again, she's not even opening her eyes. And if her heart stops, and we do a full code, the best they can hope for is that she gets to go to a nursing home and live in a state of semi-existence for just a little bit longer. So I spent half the day trying to convince the family that unless she's said this is what she would want in a situation like this, it's not what anyone would reasonably want, there's no coming back from this state, and they really need to consider signing the DNR.

But then I find out that as it turns out, it doesn't really matter whether they sign the DNR or not. Because if she codes, they'll follow legal protocol and call the code, and then before anyone shows up to actually try and get her heart started again, they'll cancel the code on account of "medical futility," and say there's no point in even trying.

End result-- we do nothing, whether she's DNR or not. Now, I think the end result is good-- I don't think we should be torturing this woman any more than we have to, and, really, it's absolutely medically futile to do anything. But, gosh, is this really how the system is supposed to work? The family ends up with a phantom choice-- sign the DNR (and feel like you're signing a death warrant, to some extent), or don't sign the DNR, but we're going to act like you did anyway except for a careful technicality to satisfy the law, where we call a code, cancel a code, and get around what I assume was the intention of the rule-- to let the family decide. Why are we giving them the power to decide if it's actually no power at all? And I'm certainly glad not to have to be the one who goes out and explains to the family that after all that-- after all the debate over the DNR, after a bunch of us have all tried unsuccessfully to convince you it was the right thing-- we went ahead and didn't do anything anyway. But we couldn't do anything-- "medical futility" !

So the "rapid response" alarm went off this morning-- my first time involved with this-- I'd just figured every alarm was a code situation, but apparently there's distinctions. They call rapid response when a patient falls, or faints, or needs some sort of immediate help but not CPR, basically. So the alarm went off during rounds, we asked the attending if we should go, and he said no, it's fine, someone else will deal with it. Five minutes later, we hear the code alarm over the loudspeaker, and so we all go running. Turns out it wasn't a code. It was just this patient who fell. The nurse rang the code alarm because no one responded to "rapid response."

I can't figure out which is the bigger problem: no one responds to "rapid response," because everyone assumes someone else will respond and since it isn't the highest-level emergency, no one feels terribly compelled to interrupt whatever they're doing-- or that the solution to this is to fake a code, so everyone does come running... but then feels duped. I mean, the scary thing is that the next time there's a code, there's going to be some doubt that maybe it's not a code, maybe they just want someone to come running. And maybe it's for something someone should come running for, but still. It's like The Boy Who Cried Code. You fake a code enough times and when there's a real code, no one's going to care and the patient's going to die.

But at the same time, I don't know if it's really fair to blame the nurses for faking the alarm-- the rapid response team should be responding when the alarm goes off. Or they should change the system to something that makes sense, whatever that might be. Hopefully something with more clarity than the terror alert color scheme. Because clearly if they have to fake codes, something's not working. The attending who told us not to go to the rapid response wasn't acting maliciously-- he didn't want anything bad to happen to the patient who needed help-- but he'd just seen too many "rapid responses" that didn't need a response at all, so he figured we didn't need to bother. But if that's what happens, then maybe it's the rapid response threshold that's the problem.

The fire alarm went off too, and everyone completely ignored it. "Not a code, don't worry," my resident said. But if it's a fire---- I guess everyone assumes it's not going to be a fire. Although there was a hospital fire in the news earlier this year, so it's not completely impossible. So we have the fire alarm and the rapid response alarm, both of which everyone ignores-- what if it's a patient that's on fire. Is that the fire alarm, or the rapid response alarm, and even if both of them go off, what if no one bothers to go find out what the problem is?

Thing is, codes are sexy, if that makes any sense. In a weird way, I've seen a lot of my colleagues get really excited when there's a code, they get to use the defibrillator, they get to potentially save a life. Picking someone up off the ground-- not sexy. So in a way I get why the code alarm has people running from across the hospital to get there and the rapid response alarm doesn't. But it doesn't actually make sense. There's lives at stake, and more than just theoretically.

It's much too easy to see why no one goes into general practice. General practice is the rapid (or not so rapid) response, as opposed to the specialties being the codes. The specialists get to solve the sexy problems, and general practitioners get to help people manage their diabetes. Not sexy.

Everyone had been saying working every 4th night overnight isn't so bad, but, man, I take back any complaints about staying late on the day shift. At least on the day shift you get to sleep in your bed at night. I'm still exhausted from the other night, and by the time my body re-adjusts, it's going to be Saturday and I'll be on call overnight again and screw my system right back up. I'm not someone who can thrive on 4 hours of sleep. I love sleep. I sleep well, and often. I don't have a lot in my life-- no girlfriend, not enough friends, no hobbies to speak of, this blog I suppose, a few too many video games, a basically-empty refrigerator-- sleep is one of my few highlights. And I hate that they're taking it away from me. I hate it.

My body feels very confused about what time it is.

I had my first overnight call last night, was at the hospital until around 10AM, got home, ate a Pop Tart, and collapsed into bed. Just woke up. With about 11 hours until I have to be back at the hospital for a 12 hour shift. So do I force myself back to sleep in a few hours and try to get back onto a normal schedule? Or do I stay awake, and then crash right after tomorrow's shift? Does it even make a difference, since four days from now I'm back overnight again?

It's taken as a given that a bunch of us have to be there overnight, and of course I understand why-- anything can happen to a patient at any time, plus you never know when there's going to be a flood of new admits and doctors needed to see them. But from everything I've heard, and from what I experienced last night, usually it's pretty slow. Usually there's not a lot to do, usually the patients make it through the night okay... so why can't they at least give us a real bed to sleep in and maybe even a shower? Heck, convert a patient's room-- we'd have a TV, a phone.... Instead, there's a closet they call the on-call room, with a cot, right next to the nurse's station, so we hear the noise from there all night long... no one can possibly sleep in there. I went in there at about midnight, tried to fall asleep, but couldn't. Maybe I fell asleep for five minutes at about 2, but then the phone rang, a nurse wanted me to take a look at something. And then I was pretty much awake for the rest of the night. It wouldn't be so bad if they spent, I don't know, the cost of one diagnostic test on a patient, to make it just comfortable enough that being on call all night wouldn't feel like torture. I'm totally willing to order a couple needless MRIs just to fund this thing. A nice pillow, some white noise, maybe even a working air conditioner....

It's like it has to be unpleasant or it's not really the intern experience. It's like they have to keep us there for 27 hours straight or it's not really the intern experience. I get it. I get that it's all a hazing ritual. I get that everyone in past generations has gone through it-- and gone through it worse, before the work hour limitations became law-- and so we have to do it too. But who's it serving? Not the patients. Not the hospital, since if I'm tired and I screw something up, they're the ones getting sued too. Not the interns. Not the residents and attending who have to work with tired and cranky interns. No one. It serves no one. It's a relic from the past. We don't use leeches anymore, we shouldn't make people stay all night in closets on cots that wouldn't even pass muster in a homeless shelter.

I realize I'm not a victim. I signed up for this. Everyone else goes through it. And I don't have it anywhere near as bad as the patients. I'm healthy, I'll survive some missed nights of sleep, I'll survive a vending machine dinner. The patients are the ones suffering. I'm just mildly inconvenienced. But even recognizing all that, it doesn't make it okay. Just because they're suffering more doesn't mean we should have to suffer just for the heck of it, without any real reason behind it. It doesn't make me a better doctor, I promise. It doesn't make me a better person. It definitely doesn't make me a better colleague, or a better friend to whatever friends I might have left even though I haven't even had time to send someone an e-mail longer than two sentences in the past month. It makes me annoyed at the system, and annoyed that there's very little energy that ever goes toward trying to make systems like this any better.

I'll watch some baseball, maybe Top Chef, and then I'll force myself back to sleep. I'd rather have too much than too little. I'd rather build up some extra reserves than be a zombie by lunchtime tomorrow. I'd rather know at least I'm trying my best to give it my all, even if that means I literally do nothing else but work and sleep. Maybe that's just what everyone does, no matter what they do. We're spoiled as students, but real life is just 40 years of work and sleep. Can't wait.

Had rounds yesterday morning, and one of the patients was not doing well. Trouble breathing, couldn't open his eyes... I said to the attending, maybe we should get a palliative care consult, ease his pain a little bit?

"Palliative care?" he laughed.

"It's waaaay too late to be thinking about palliative care. This guy's got 90 minutes, maybe two hours left."

"Oh."

And sure enough, just about an hour and a half later, the guy died. I guess when you've been doing this long enough you can just tell the difference between suffering and actual close-to-death dying. It's a skill I hope I don't acquire too quickly.

The attending told me to "do the death certificate" which involved figuring out where one gets a death certificate, and then calling up the hospital registrar, who couldn't hear me.

"I need a death certificate.... No, death. No, someone DIED. I need a DEATH certificate. A certificate. Of death. Yes, he just died. No, I've never done this before. Yes, we need the certificate. Oh, that guy's at lunch? Okay, I'll call back later."

I'm pretty sure every patient on the floor heard me screaming the word DEATH into the phone. Half of them probably thought I was talking about them.

Okay, as I'm writing this I feel like I'm particularly jaded this morning about all of this, and not in a great place. I'm tired. I'm seeing myself getting used to people dying, which is uncomfortable and scary and not the way I want to feel. But how can I avoid it? Death, in a hospital setting, is unfortunately routine. I don't want it to be, but already it's feeling like in a lot of cases, it's not even such a bad thing. For the patients who've lived long lives and have terminal illnesses, no quality of life, then is it so terrible? Is it so terrible if instead of months on a ventilator not being able to open your eyes, you die? Is it so terrible if instead of intense pain that keeps you bed-bound, drugged-up, and incoherent, you die? I don't know.

There's a 94-year-old man in the unit whose family won't sign a DNR. They say they want full code if something happens, they want us to bring him back, do whatever we can. He's in the last stages of Alzheimer's, he doesn't know who any of them are, he's on oxygen, his heart is failing, his kidneys are shutting down. If he codes and we bring him back, he's going to be a vegetable. His body is saying this is the end. His family still wants to fight it. They shouldn't. If this was a 55-year-old man with his mental faculties intact, of course we want to do whatever we can, preserve whatever chance of recovery there might be. But for a 94-year-old who has no hope for any sort of quality of life at all, why not just let him go when his body goes? What are they gaining otherwise? He's not coming back to them, the way he used to be. Unfortunately. No matter how hard they try.

A patient coded last night and died.

Wasn't on my service, but everyone runs when we hear the alarm. It was late Sunday, no attendings around, and only a fraction of the residents (I was on late call), so there were only a few of us. One of the other residents immediately started CPR, but it was too late-- the patient was dead before we got there. His son had been there, had alerted the nurse as his father started slurring his words and then suddenly lost consciousness. But there was nothing we could do. Didn't have a long time left in any case-- body riddled with disease, treatments not working. But it seemed like no one had told the son what the state of his father's condition really was-- he started screaming in the halls, yelling at us for stopping CPR, for causing him to die, for killing him. Understandably inconsolable, but not entirely fair.

I feel like a terrible person to write this, but, honestly, it wasn't that sad. The patient was lucky to go instantly and probably painlessly. The alternative for him was going to be maybe six more weeks, eight more weeks-- six or eight more painful weeks, in varying states of alertness, stuck in a hospital bed, without any quality of life at all. What's the point? His son, and I guess whoever else he has in his life, sitting by the bed hoping for recovery that wasn't going to happen, putting their own lives on hold, dragging out death and making it harder and harder once the inevitable happened. It's not as if a healthy person died.

Still traumatic, of course. Besides my med school cadaver-- who was long deceased-- I'd never been that close to a dead body. It's still a shock to me that there isn't more of an indication-- more of a signpost-- more of a difference between "dead" and "looks like he's sleeping, but we can't wake him up." I don't know what I expect-- black crows flying in the window? a guy in a black robe coming to take him away? But whatever I expect, it isn't there. It's just a sleeping body that won't wake up. There's nothing dramatic about it, nothing final about it.... It just is.

When I was about nineteen years old, I took my grandfather to an appointment at the eye doctor-- he wasn't driving anymore, and I'd offered to take him. He'd been in the hospital recently, but had seemed back to himself. As we were sitting in the waiting room, he started to drift off a little bit, lose consciousness, and kind of collapsed. I went over to get the nurse and she called the doctor into the waiting room-- where he completely freaked out. This was an MD, gone to medical school, did a residency, everything-- but after years as an ophthalmologist, was clearly of no use as a "real" doctor. He ran into the hall-- the building had a bunch of medical offices-- and screamed for a cardiologist. Doctors didn't roam the halls, so no one came. He called 911. Put my grandfather on the ground, told me to watch over him-- he was conscious again and talking at that point-- and then went back to see his eye-exam patient. As he walked back into the exam room, my grandfather on the ground, and me, a nineteen-year-old kid, completely panicked, the doctor said to the waiting room-- and I'll never forget this-- "No one bring any more dying patients in here."

The ambulance came, took him to the hospital-- it turned out to just be a fainting spell, probably from a medication he was taking-- and he was okay.

I didn't go back to that doctor. Obviously. Good grief. Of all the potential doctor role models I could have in my head....

I'm reminded of that because I can look back at yesterday and even though the patient didn't survive the code-- and, frankly, even though I didn't do much to contribute but watch my fellow resident do CPR-- at least I didn't panic. At least I can say I was a competent professional who, in the face of death, didn't do anything to embarrass the profession or harm the patient. The rest of it will come-- I'll save people, eventually. I'll be of positive service. But even if I can just stand up and honestly say I did no harm-- well, there are some doctors who can't meet that standard, so I'm ahead of the game at least compared to them.

Last day today of my first rotation. And, unbelievably, I'm actually looking forward to my next month, in the critical care unit, because it won't be as depressing. Yes, bad things happen in critical care. But good things also happen! We fix people! They get better! They leave! They don't come back! For the past month, all I've delivered is bad news, and all I've seen is patients get worse. There is virtually no good news to deliver in hospital-based cancer care. In an outpatient setting, sure. People go into remission, people have often years and years and years of quality living. But at the point you're coming to the hospital, and staying here, it's never good news. And most of the time the patients don't realize that until we're in there telling them. It's "yeah, I know you weren't feeling any pain and thought you just had a cold, but actually your kidneys are shutting down and you have seventeen hours to live." Or "no, it's actually growing really fast, and there's nothing left for us to do." Or "yeah, that pain you're feeling, it's only going to get worse, and you're going to suffer for the next eight months until you die." It's young people, old people, everyone. With something we can't really fix and can only stave off for a little while, and maybe, if we're lucky, get you a year. Maybe. A painful year, filled mostly with doctor's appointments and toxic chemicals swimming through your system. It makes me thank my lucky stars that I'm healthy, and wonder how anyone can really be healthy.

My big internship lesson so far-- I don't want to practice medicine in a setting where no one gets better. I don't want to be the doctor they only see when they're dying. I don't want my entire day to be spent delivering bad news and running tests that can't possibly have good results. I want to feel like I'm helping people, not torturing them. I want to feel like I'm adding to their quality of life, not hastening their demise. Frankly, once they're dying, I want to pass them off to someone else. That's why I'm doing internal medicine, that's why I want to work in an outpatient setting, where often enough my patients can walk out without crying. I want to be their partners in health, I want to tell them how they can live well, I want to get them on the right medication, I want to figure out what's making them feel bad and try to fix it. I want to know them when their lives aren't just about staving off pain and lying in a hospital bed. I want to know them when they're not crying.

Maybe it's crazy for a doctor to say he can't take death. But isn't it worse if a doctor says he's comfortable with it? Don't we want doctors who want to do whatever they can to avoid dealing with death? Who won't just give up and decide there's nothing more they can do, and throw their patients into hospice? We become doctors because we want to help people, not because we want to watch them suffer and die. Yet all too much of medicine is about watching people die, about throwing up our hands and telling a patient there's nothing more to be done.

Once again, I wish I had the grades for ophthalmology. Or dermatology. Or the inclination to be a psychiatrist. Or the talent to play for the Dodgers. I wish I was a shortstop. That would be a happier career.

Her sodium goes up, her potassium goes down, her calcium goes up, her glucose spikes... this is the first time I've ever had to chase someone's electrolytes. Every test means another lab result gone wild, and another correction to whatever we're doing. It's not entirely our fault-- she's going downhill quickly regardless, at worst we're merely hastening her decline by a couple of days-- but it's hard not to feel like you're killing someone. The attending saw the last set of labs yesterday afternoon and started yelling that she's dehydrated and why didn't any of us realize it. But I asked my resident how much fluid to give her, and I gave her what he said... I can't be expected to know the answer to this on my own, and to know enough to second-guess the resident. But the resident doesn't know all that much more than I do. And the attending is hands-off to the extent that it ends up in our hands to decide what to do. I'm sure the patient's family thinks of all this in a very different way-- "they're doing what they can, look at all the medicine they're giving her, her body must really be failing." But the truth is that a lot of the corrections and course changes are because we're screwing up to begin with and can't figure out how to get her blood chemistry stable.

Today's my last weekday on this first rotation-- I'm off tomorrow and then I work a half-day (hopefully) on Sunday... and then I start somewhere else on Monday. It's definitely different now three weeks in than it was when I started. I'm definitely a more confident, better doctor. I'm definitely seeing how there might be a light at the end of the tunnel, how there might be nights I can have dinner with friends, there might be days that don't feel like the end of the world, there might be a way to survive this. But I'm nowhere near confident enough to trust myself to know what to do. I'm nowhere near confident enough that I'd ever recommend someone turn to me as their doctor. I don't know when that all starts to change-- is it a month? a year? three years? or never? Has every doctor I've ever seen had those doubts, wondered if maybe they were killing me even though they were trying to help, worried they were missing something, worried that someone would discover their secret-- that they really don't know a whole lot about anything, and it's all just guesswork and hoping that the body happens to heal itself. We're charlatans in a lot of ways. We take credit for things we're not responsible for-- infections healing, treatments working-- and try to offload the blame when things don't come out well-- it's not our fault, everyone reacts differently, there were no symptoms, etc. It's how baseball players must feel when they get a hit-- maybe I did something good, but maybe the ball just went where the fielders weren't and I got lucky. We get lucky. Or sometimes we don't.

Can't wait for the weekend.

What do you say to a woman whose 26-year-old son is dying?

I'll tell you what you don't say:

"I'm sorry to interrupt while you're all gathered around his bedside praying-- but our discharge manager wanted me to let you know that since we've done everything we possibly can as far as treatment, and there's nothing left, medically, that we can try, the insurance company isn't going to pay for you to use the hospital as a hospice, and after he dies, you're going to get a pretty substantial bill. So you might want to have him transferred out of here, even though he probably won't survive the move."

Here's something else you don't say:

"I know you want to try more treatment, but his body's too weak, and if we do anything else I expect it will just finish him off."

And one more thing you don't say:

"I need you to stop what you're doing and before you say another word, you need to fill out his menu for tomorrow, otherwise he's not going to get any food."

I wish I had the grades for ophthalmology.

A question about medical ethics:

We have an 81-year-old patient with a fairly aggressive cancer. She came in yesterday, her son immediately asks to speak to us in the hall. The family is worried she wouldn't deal well knowing she has cancer, and her primary doctor agreed not to tell her and to instead call it an "infection" when talking to her. Giving her appropriate treatment, but hiding the actual diagnosis from her.

The patient has no signs of dementia, seems mentally competent.

The attending agreed to do what the son was asking. So now we're all calling this thing an "infection" and telling her the chemotherapy drugs are "antibiotics".

I find this appalling.

Her son doesn't have medical power of attorney over his mother. I don't know how we can say that she's giving her consent to treatment when she's being lied to about what she's being treated for. I don't know what the son plans to do if the mother finds out what she has, and finds out we've all been in cahoots with her son to lie to her. I don't know what anyone expects we're supposed to do if the "antibiotics" don't work, and she needs some sort of surgical intervention, or more powerful treatment, or how you talk to someone about advance directives when they aren't aware of the gravity of their condition. I don't know how to even really look her in the eye when I talk to her, knowing we're lying about what's going on. I don't know how her son keeps this secret. And I'm pretty sure one of us is bound to slip up and accidentally say something within earshot... and then what? If she gets a roommate, it's going to be awfully confusing if the roommate starts asking what she has, because this isn't the "infection" floor and she's not being seen by the "infection" doctors.

Not to be silly about it, but if this is okay, ethically speaking, then where's the line? What if she really did have just an infection, but her son was worried she wouldn't take that seriously enough, and that in order to scare her into cooperating with treatment, we should tell her she has cancer. Would that be okay? Surely not. At least I assume not! But what's the difference, really?

A mentally competent patient, who's being robbed of her ability to make her own choices about her treatment and her life, and being lied to about her medical condition, just because her family assumes they know what's best. But we're the ones charged with knowing what's best, not her son. At least not without a court order.

But what do I know, I'm just an intern.

Seriously, am I wrong here? Is this standard practice? Is it ethical practice? Is it even legal practice??

One of my patients has been heading steadily downhill, and now has only brief moments of lucidity. It seems like she's choosing to use those brief moments of lucidity to berate the nurses. She'll be fast asleep, and then suddenly a nurse will walk in, go over to check the IV, and suddenly the patient will wake up and be like, "Carol, go and get me more ice already!" And then she's back asleep for the next three hours.

Dealing with the patients I've had for the past few weeks has sort of reinforced how much more there is to being a doctor than just the medicine, despite what we learn in medical school. The questions the patients and their families ask-- perfectly legitimate questions-- about what they should be eating, whether there's any useful exercises they can be doing, tips for getting better sleep, how to deal with the psychological issues brought on by their illness-- I don't have very good answers. Elderly patient losing weight-- eat more? Eat ice cream? Drink milkshakes? I'm just pulling this stuff out of the "generally intelligent human being" bucket, not my medical education. I don't know how to counsel a depressed patient-- who's got every reason to be depressed, because she's dying. I don't know what to tell a patient who can't sleep, besides that we can give her more pain medication. But I'm sure that's not the only (nor the best) answer, at least not all the time. I don't know what exercises strengthen the back. I don't know if it's normal to feel tingling on the bottoms of one patient's feet, given the medications she's on. I don't know how our 51-year-old patient can start the conversation with her 82-year-old mother, to tell her she's dying.

Yet these are the questions we're asked, and the questions it feels like we should have answers to. I barely have answers to the purely-medical questions, let alone these. And it's frustrating when I can't help more, when I can't provide the solution. We're looked at as if we have such power, and yet we're really just people.

I watched an episode of TV before going to bed last night, a lawyer show called Raising The Bar, on TNT. One of the lawyers had a client who couldn't afford to pay the $75 fine he'd incurred for jumping the subway turnstile, and he was being put in jail for 30 days, which meant he was going to lose his job and (I think) custody of his kids. So the lawyer ended up paying the fine for him. And got in trouble for it. Made me think lawyers have much the same problem as doctors here, but in a lot of ways they're even more powerless-- I mean, I'm at least able to do whatever I can do to help-- it's an issue of frustration the medicine can't do more, or that someone isn't responding, more than an issue of my own hands being tied (although maybe that changes in private practice, with insurance issues coming into play). But this lawyer was limited by what he was even allowed to do, even though he was able to help and could keep his client out of jail.

Maybe there's no analogy here and I'm just seeing everything through a medical lens because I'm in the hospital 80 hours a week. I don't know. I dream about work. I dream about inputting orders into the computer, which is no more fascinating in dream-land than in real life.

Worked Saturday, was off on Sunday. Went to a museum. Was afraid all day that I would encounter someone having a medical emergency and would have to work on my only day off. The fear will pass. I think I was just tired.

On Saturday, I was talking to one of my patients, giving his family an update on his condition, and they asked a question about a certain experimental drug. I told them I would ask his attending and get back to them. They looked at me funny.

"So is the difference between you and [the attending] just that he's older, so he doesn't have to work weekends anymore?"

"No, he's an attending, and I'm an intern, which means I graduated from medical school but am still in training."

"Oh, you seem just like a regular doctor."

"Thanks."

Nice to be confused for an attending, instead of confused for a nurse or a medical student, which is what usually happens.

This patient's attending is particularly unpleasant, so I think the family may have just been relieved to be dealing with someone who seemed like he had more than fifteen seconds to spend in the room, and wasn't trying to leave at the first possible exit from the conversation. But still, nice to feel like I'm able to fool the patients and their families into thinking I know stuff.

I mean, I do know stuff. I just don't know that much. Yet.

I did the math-- I'm 2% done with residency. It doesn't sound like much, but yet it does-- because it does really feel like it just started. And if I'm already a real percentage done. Well, I could do this length of time 49 more times, I think. That's not a thousand, or even a hundred. Forty-nine more three-week stints and I'll officially be finished. I think I can handle that.

I say that now, a week before my first overnight call... we'll see if I'm still saying it then.

Yesterday was my attending's last day on the service-- we have another week and a half to go, but the attendings switch every two weeks. As we were finishing up rounds, he asked if we all wanted to grab a beer, since it's his last day. Immediately, just about everyone gave an excuse-- dinner plans, had to see her husband, needed to get home, friend's birthday party. I said I'd go-- nothing else to do on a Friday night, and have already learned not to make plans with friends on a day I'm working because there's been a pretty good chance that even if I think I'm getting out at 6:30, I'm usually there until at least 8, if not later. I was in fact the only one who said I'd go. And the attending looked at me, shrugged his shoulders, and said, "I guess everyone's busy. Another time then." Which makes me officially the loneliest person in the world, if the attending who suggested grabbing a drink, when faced with grabbing a drink just with me, says no thanks, forget about it.

Hey, I understand why most people are going to be busy (or say they're busy even if they aren't). I don't know how people can keep up relationships on this schedule unless they use absolutely every moment of their free time to be with their partner-- or don't sleep. If I didn't sleep, I could probably have a life. You don't realize how bad getting out of work at 8:00 is until you remember you have to be back there at 6:30 the next morning. It's 15 minutes door to door for me, which is about as close as I can reasonably expect to be without living right next door to the hospital, given where we are. So if I get home at 8:15, and have to leave the next morning at 6:15... that means I'm waking up at 5:30... that means I want to go to bed by 10 so I have at least 7 hours and change... that means I have a little less than two hours at night to make dinner, eat dinner, catch up on any e-mail, watch a little TV, check my fantasy baseball team, and maybe call a friend, or maybe just decompress from the day. That hour and 45 minutes doesn't feel like much, especially when I haven't had any time to myself all day, any time to even see what the stock market did, or whether anyone famous died.

And the nights I'm on late call, it's of course even worse. I get home around 10. Which means I shovel food into my mouth and collapse in the bed and don't have any time at all.

So I have my one weekend day. Where the last thing I really want to do is get in the car and go somewhere, or do anything that takes any energy at all.

What kind of life is that? I may as well be a patient in the hospital instead of the doctor. At least they make you dinner (not that it's edible). At least you can watch TV during the day, or make a phone call, or go to the bathroom on your own schedule. At least you have visitors (sometimes).

I thought I was counting down the 4 years of medical school until finally residency-- a "job"-- a "life"-- but now I'm counting down the 3 years of residency until... until what? Until a job that's probably going to end up looking a lot like residency, and a life that looks like... what exactly?

I got yelled at yesterday morning by the night-float intern when I got there to sign in.

Apparently I forgot to tell her to run a extra set of labs on one of my patients overnight. We've been closely monitoring her to make sure a new drug isn't causing any dangerous side effects, all the numbers looked good in her last set before I left, and even though I'd written in the chart that we needed to monitor her, I didn't say anything specifically when I was signing out... so the night float intern, who didn't have time to read the charts and was just going on what we'd told her, didn't know to do it, and by the morning the patient's lab values were way off the chart and we needed to stop the new drug... and even though nothing happened...

I apologized to the intern, right away.

"I should have told you, it was my mistake, I'm sorry."

And she starts yelling back. "You needed to tell me, everyone else tells me if someone needs something tested overnight, I can't read your mind, I can't be expected to read every chart, you could have been the reason a patient died and I would have been blamed because it would have been on my watch..."

"I said I made a mistake. It won't happen again."

"Well, you can't make mistakes like that."

"Oh, come on, you're an intern too. We've both been here two weeks. You don't know any better than I do. We're both making mistakes."

"I'm not making mistakes."

"That's not true." The other day she told me a patient was doing fine, and I went into her room and found that she was practically unresponsive, due to a medication issue. It was lucky we checked on her when we did, or she would have been dead. But we caught it, she's getting better, and it's not as if I blamed the other intern-- I know we can't be everywhere at once, I know most of us are just doing our best.

"Yes, it is. We can't make mistakes. You can't make mistakes. I already told the chief what happened."

"Fine. How's the patient?"

"She's doing okay."

"That's the important thing, isn't it?"

"No, not really."

And I walked away. Fine, I should have flagged that we had to run an extra set of labs. But she should have read the chart, and she definitely should have been just a little less insane about blaming me for nothing happening. We're both new, neither of us knows what we're doing, and she doesn't deserve to put herself on some moral high ground. Luckily the patient is okay, that's what's important... and I feel bad enough for what happened that I don't need another intern's judgment.

This is one of the things that makes it so hard here. You'd think, medicine of all things, there'd be a culture of cooperation and teamwork. That we'd all try to be focused on the same page, of treating the patients as best as we can. Instead, it's a culture of "not my fault." Everyone wants to do just enough to not be blamed, and wants to do everything they can to find someone else to point the finger at. You didn't do this, you didn't do that. Not, we should do this now, because it's in the patient's best interest.

It makes it extra frightening to feel like no one has your back, that they're waiting for you to do something wrong. Instead of trying to help you do something right.

And the patients suffer for it.

My first patient died yesterday.

It's really sad. It's really sad even though we knew she was going to die, and her family knew she was going to die, and I didn't even really know her. I was disappointed but not surprised at how little we're supposed to acknowledge the sadness of it. The attending stopped by her room in the morning, told her family she could go at any time, and that if she didn't die by Monday, we were going to have to move her to a long-term facility because there wasn't space here. I thought that was a particularly unfortunate way to pitch what he was trying to say: she better die soon, because she can't stay here if she doesn't. What was the husband supposed to do? Apologize that it was taking his wife too long to die? I guess that's exactly what he was supposed to do. And I guess maybe she overheard the conversation, because an hour later she died. The resident told me to go in and pronounce her dead. I did a double-take-- what? He said to go in, make sure she isn't breathing, and tell the family she's dead. So I did, as gently as I could. And they cried, and I tried not to, and then the family in the room next door pulls me aside and asks if their person is going to die today too, and I sort of snapped at them-- it's not contagious, and, no, their person is not dying, at least not today. Every day they've been asking if they should call the relatives, get everyone gathered-- and, yes, they should, but they should do it because, at least for now, their person is alert enough to appreciate it and get something from it. And if they wait until she's on death's door, what's the point? Everyone will come to see a corpse instead of a person.

There is a coldness to this profession that I don't like but don't know how it can be avoided. What's the right reaction to a patient's death, especially in a place where death happens all the time? I feel like as doctors we're torn between being permitted to actually react to the death and being "professionals" about it and moving on to the patients who we're able to help. It's a frustrating feeling.

It's also frustrating to know that this woman would not have died as quickly as she did if she did not come to the hospital. She was over-medicated (which zonked her basically into a coma), she was incorrectly medicated, she was given really poor treatment, and at home the attending said he expected she would have had another couple of months to live. That's not a great feeling either.

No, mom, I do not know a good gynecologist to recommend.

I feel like even though my parents go to doctors, they still have no idea what it is a doctor does, and what residency is, and what I learned and didn't learn in medical school, no matter how many times I try to explain. My mom called me last night telling me (in graphic detail) about the gynecological problems of one of her friends, and asked me (a) if I think her doctor is giving her the right treatment, and (b) if I could recommend a better gynecologist for her to see.

I'm not going into gynecology, and my only exposure was a three-week rotation during medical school when I spent most of the time playing with babies and as little time as possible investigating the insides of patients. Nevertheless, my mom expects I'm an expert-- and in fact such an expert that I should be able to diagnose and treat without even seeing the patient or hearing first-hand what her problems are. No, I don't know if that's the right drug, and what the side effects are, and whether she should take it with food.

My mom wanted to know if I'm working with any good doctors now who might be able to see her, even if their specialty isn't gynecology. "A good doctor should be able to do everything," she says. Well, no, that's not any more correct than saying a good athlete should be able to play every sport. And yet it doesn't sink in.

I did what I could do-- which is the same as what her friend could do. I googled her doctor, saw that he went to medical school in Mexico and did his residency in a hospital I'd never heard of, and told my mom to tell her there are probably better-trained doctors out there but given that her problem is pretty minor, she's probably okay sticking with this guy if she likes him. I googled the drug, it seems appropriate for her condition, I guess, but I don't know any more than anyone off the street would.

This is the rest of my life, right? People assuming that because I'm a "doctor," I can solve all of their medical problems, without examining them, and whether or not I have any familiarity at all in the field. If they need surgery, I'm supposed to be able to do it. If they need to deliver a baby, I'm supposed to be able to do it. If they "just don't feel right," I'm supposed to be able to divine what the problem is, over the phone. For free. Right? That's what I've signed up for? What I really want to know is whether there's a billing code for this. Whether "googled someone else's doctor to reassure them he has a license" is something insurance will one day reimburse me for. Then I'd be glad to help.

"Having a good day, even though my patients are dying."

It's strange to realize that for just about everyone else, death is only something they see rarely, and it's a traumatic experience each and every time. No one in most other lines of work could ever claim to be having a good day when surrounded by death. And certainly no one in most other lines of work could ever admit to it. In fact, I'm not even sure I should feel okay admitting to it.

But I don't know how else to put it. I'm getting more and more comfortable doing this, the attending is getting to know me and I don't feel like he thinks I'm completely incompetent. I'm getting to know some of the residents and we have a good relationship. The days are still long, but there's a little more camaraderie, there's a little more of a team feeling, there's a little less fear I'm going to do something terrible and have no one to turn to. My pre-rounding goes faster, it takes less time to know what's going on with the patients, and I've had some patients for the whole time I've been here, so I've gotten to know them and feel more and more comfortable around them.

Yet even as I feel like I'm settling in, I can't deny the reality that my day may very well be going okay, but my patients are dying. And that's always going to be the case, at least in a hospital setting. I can't prevent it, I can't make them well, I can't do a whole lot but try not to make things worse. And I don't know how much sympathy is the right amount. How sad am I supposed to be, or at least to seem? Every one of these people has no quality of life remaining and pretty close to no quantity of life remaining. It's horribly sad, and sometimes it seems thoroughly unfathomable that this is what the end of life looks like all too often. And that we will all die, in some way or another, and everyone we love will die, and life is very, very short even if it's a hundred years long.

Am I allowed to call it a good day if a patient dies? If a patient gets sicker? If a patient is in pain? If not, what are the good days, especially in a hospital setting?

We don't do much. Maybe lawyers feel like this too, maybe teachers, maybe everyone. That to the outside it certainly seems like we're helping someone, like we're adding some great value to the world. But in most cases, we're just not doing much. We're following recommended drug protocols and we're hoping the patient responds. We're monitoring their test results. We're trying to ease their pain. But a lot of times there's just not much we can do, and not much difference we're making. Frustrating. Maybe. Or just the nature of the job.

I wouldn't want to be an inpatient here.

It's interesting how hospitals get their reputations off the purported quality of their attendings, but the attendings aren't the ones actually doing the moment-to-moment patient care. One of the patients on my floor coded while I was on call yesterday and as soon as the bells sounded, the second-year resident goes running-- "I'm supposed to run the code," he said. "Good luck," whispered the attending, just when the resident was out of earshot. This is a guy who two weeks ago was an intern, just like me. I don't want him running my code if I'm the one in the bed.

But it's not just that. It's that you could have world-class attendings, specialists in their fields, but they're not internists, they haven't practiced general medicine in twenty years. So when an incidental problem comes up-- not necessarily incidental to the patient but I just mean something that doesn't have to do directly with that world-class treatment they're getting for Big Fancy Disease that Big Fancy Attending specializes in. Say, elevated blood sugar. Or pain. Or delirium. Or sleeplessness. Problems sick people have. There's no expert in general medicine around to order the right treatment. We've got interns like me, who don't have a clue. And we've got specialist attending (if the problem happens to come up between 9 and 12 or 4 and 6, when he's here doing rounds), who only has a clue in his very small specialty bubble. And so no one knows that the 93-year-old who's suffering from some nighttime confusion probably shouldn't get drugged up with Haldol as a first-line treatment. Especially not the night float intern. So when someone like me rolls in at 7AM and finds his patient hallucinating and practically comatose, it's a little too late.

In more than a couple of cases, I feel like my patients' biggest mistakes have been coming to the hospital at all. We've taken one sick but relatively stable patient and drugged her to the brink of death. We've taken another sick but relatively stable patient and given her a battery of unnecessary tests-- I say unnecessary because even if they all came back positive, she's likely not going to live long enough from Big Fancy Disease for Little Thing We Biopsied to ever make an impact-- and caused a pretty painful Something-Itis in the process (oops!) that seems like it's very quickly hastening her demise. Are any of these actual malpractice, as in standard-of-negligence, court-finds-the-doctor guilty malpractice? Probably not. Are they unfortunate complications that could have been avoided if we at least had some hospitalists or some general medicine attendings roaming around? Absolutely.

What's completely bizarre to me is that no one trains us. We're dropped in on day one expected to be able to apply our med school knowledge to patient care, but the chain of command is such that the only people we're able to ask for help aren't much more knowledgeable than we are, and the only people they're able to ask for help are people they're afraid to talk to. So even if I remember that Drug X is first-line hypertension, I don't know if there's a better drug to use in this case, or whether my textbook was outdated, or whether there's going to be interactions between Drug X and everything else going on with the patient. And even if I try my best to find out, I don't have the clinical experience to be confident about my decision. And the attending doesn't necessarily have the wherewithal to realize he has to be triple-checking, or to assume we know as little as we do, and so he signs off without giving it due diligence, and patient ends up suffering for it.

Has anyone on my service died? No, not yet. Have any of these mistakes been mine? No, not yet. But I can see how easy it would be for something bad to happen-- how few checks and balances are in the system, how much people like me are being relied on, far beyond our experience and capabilities at this stage-- and it terrifies me every time I write an order. It terrifies me. Because I know, without question, that I would not want to be one of those patients. And, maybe just as bad, I know that not everyone is as terrified as I am, and that's the scariest part-- because there are no consequences, short of something truly, truly egregious happening. But hastening a sick person's death doesn't seem to rise to that level. And that's crazy.

In other words, if I am your doctor... run away.

I spent 45 minutes today trying to convince a patient not to eat a peanut butter and jelly sandwich. The nurse chases me down around lunchtime: "Mrs. Whoever says she wants a benadryl, can you write the order?" "Why does she want a benadryl?" "She says she wants to eat a peanut butter sandwich but she's allergic to nuts and if she takes a benadryl it'll be okay." "Why does she want to eat peanut butter if she's allergic to nuts?" "I don't know." So I go into Mrs. Whoever's room, and she's about to take a bite of this sandwich and I stop her. "Why are you eating that?" "I'm hungry." "I can have the nurse get you something you're not allergic to." "No, it'll be fine, I can just take a benadryl. I'm already in the hospital, what's the difference?" "The difference is that I'd rather you didn't go into anaphylactic shock while I'm in charge of you." "But if I take a benadryl--" "Benadryl's a fine drug, but it's not a miracle. You never know what can happen with an allergic reaction, and it could exacerbate your other conditions in any case." "But I really want to eat this." "We'll get you something else to eat." "What?" "I don't know. I'll have the nurse get you today's menu." "I didn't like anything on the menu." "Well, you're not eating something you're allergic to. Sorry."

I don't know how some people manage to live to adulthood.

Lesson learned from an attending today: how not to deliver bad news. How about when the patient's not even yours, but you're the attending and you've just seen the latest scans, and you're on rounds so there's a dozen people in the room, and you've just introduced yourself to the patient for the first time. "So, Mrs. So-and-so, we got the results back and they're not good. Blah-blah-blah details, blah-blah-blah treatment options, any questions? Quickly, because we're running late and have a lot of other patients to get to this morning." I don't know, if I were a patient I don't think I'd want bad news delivered to me in a room packed with residents, med students, nurse practitioners, and the janitor. If possible, it would be great if it were actually my own doctor telling me this stuff too. And if not, maybe one-on-one, or two-on-one. Maybe when you actually have time to sit and talk about it, to explain stuff slowly, to hold my hand. Good grief. And it's not like anyone can say to the attending, "hey, how about you just circle back to this one at the end and not drag us all in there to tell her she's gonna die," or "hey, I know it's convenient for you to do this now, but maybe it's not that considerate for the patient."

I'm not really sure why I decided to start a blog about residency. Already I'm worried it's bound to become a broken record. The hours are long, we're locked in the hospital like prisoners, it's completely impossible to have any semblance of a life.... Repeat daily. I thought today, finally, we would get out at a reasonable time. We're allowed to sign out at 5:00 when we're not on late call to do the handoff to the night team. And you'd think if I could get all my notes done and push myself to finish up, there'd be at least one day this week I could get out at 5. Or 5:30. Or 6. But it doesn't work that way. We're at the mercy of whenever the attending happens to decide he wants to come back for afternoon rounds, and if he shows up at 5:15, well, then I'm here until 7:30 again. I know it's not fair to feel this way, and that of course the attending has patients he's seeing during the day and isn't showing up late for rounds simply to keep the interns there for an extra two hours, but it's the lack of any interest in moving things along that starts to get frustrating after twelve hours in the hospital. He gets there in the morning at 9:30, bright and well-rested, while we've already been there for two and a half hours. Then he goes home, takes a nap perhaps, sees a few patients in his office, and waltzes back in at 5:15 as if it's morning again and it's fine to drag us through two and a half more hours of rounds, stopping to instruct on the finer points of how to help the patients aim the TV at a better angle to the bed and other such thrilling, vital information. Fine if it's 11AM and we have to be there anyway. But when it's 7:15 and I could be eating dinner, or on the couch, or somehow having a semblance of a life.... I wanted to go to the gym once this week, that's all. Once. If I was getting out at 6, I could go. But at 7:45, I'm starving, and once I get home and eat I just want to go to sleep. I'm not going go to the gym at 9:00 when I need to be up before 6 the next morning. Just once. Not every night, not even every other night, but once. One day, let me out. One day, let me feel like a normal person with a normal job. One day.

I was originally inspired to start this blog because of the other medical blogs I'd been finding myself drawn to during medical school. Panda Bear, MD, who somehow has the energy to form actual smart opinions about health care and the broader issues of being a doctor while still slogging through this life. Kevin, MD, who's probably a better source for medical news and commentary than pretty much anything else out there. GruntDoc, and all sorts of others I don't have the energy to look in my Google Reader to remember.

Doing this every day is making me realize how hard this is-- a lot of days as a doctor are just not that interesting. I never thought that would be the case-- I wanted to be a doctor in part because every day is different-- but especially this first month, where I'm on a very specific service, all the patients have pretty much the same problems and are getting pretty much the same treatment, and to do this for any real amount of time seems like torture. That's part of why I'm drawn to primary care-- but at the same time, rationally I know that primary care's only marginally better in these terms. Most of my patients are going to have one of a very small set of complaints. And after not much time, I'm going to know exactly how to analyze those complaints and the treatment options. And while that's great for my patients, because I'll be less likely to miss things and make mistakes, selfishly it's not as good for the doctor, because it will get dull. But if being a doctor is dull... what hope is there for anyone, in any profession? Argh. I hate when I start thinking this way. I hate when I start wondering if anyone's job is really worth having, if there's any way to feel fulfilled in this world, if anybody's really happy or they're just deluding themselves, or too stupid to know better. I don't mean too stupid. I don't know what I mean. I knew this wasn't a guaranteed ticket to happiness. And I know I can't rely on the job to do it all for me, to solve all my issues. But at least I hoped it would help.

This is probably just the lack of sleep talking. I'm going to bed. 9:00, I'm going to bed. I have to. My body is telling me I have to.

Nothing ever changes. All throughout med school, you think it'll be different when you're finally an M.D. You think becoming an M.D. is the pot of gold at the end of the rainbow, and once you get there you'll finally feel like a professional, and maybe even be treated like one. But no, not yet. I got yelled at by the attending for going to the bathroom during rounds. We were in between patients, and I really had to go, so I raced off, went, and then caught up with the group as we were reaching the next room. The attending sees me sneak back in line, gives me a look, and asks me if I had somewhere more important to be. I said no, I had just quickly gone to use the restroom, and he makes an example out of me, says that I slowed down the rest of the group, that his time is valuable, and that I'm wasting it and should have the self-control to hold it in until we're done with rounds. Well, excuse me. Excuse me for drinking three cups of coffee just to stay awake, since we're working 14 hour shifts every day and I'm not getting enough sleep. Excuse me for staying late to make sure my charts are up to date, every night. Excuse me for wasting perhaps three seconds of the "valuable" time you're desperately wishing you could be using to go play golf. Yeah, I heard you talking about it as we finished up. "Only call if it's urgent," I heard you tell the chief resident. "I'll be golfing until 2." Awesome.

Even with the degree, even with the letters at the end of my name, I'm still just an indentured servant until residency is over. If the patients knew that decisions about their care were being made by people who apparently can't even be trusted to know when it's okay to use the bathroom, they'd question the whole system. It's hard not to question the system. It's hard to accept that patients are the guinea pigs while the second- and third-years test out their abilities to determine correct medication dosages rather than feeling comfortable enough to call the attending and ask, just to be sure. It's hard to accept that the system thinks exhausted students making decisions are better than rested ones. It's hard to accept that the system thinks there's some benefit to us working so many hours that we can't possibly have a life.

I'm never going to see my friends, for the next three years. I'm never going to see my family. I'm going to miss weddings, and birthdays. And for what? So at the end of three years I have no friends left and I'm entering a profession that it seems like everyone already in it wants to leave. "We're not clinicians, we're business people," is what you hear from everyone. From the editorial in yesterday's NY Times that I barely had a chance to read. A cardiologist, Sandeep Jauhar, moonlighting at a clinic in Queens. Why is he moonlighting? He's a cardiologist. How much money does he want? Maybe he's moonlighting because he doesn't know how to spend time with his family, he's been gone so much. Maybe it's a business to him because he just wants to maximize profits. I don't want or need to maximize profits. I went to medical school to help people and feel like I have a safety net-- to feel like I'm employable no matter what, and I have a real profession. But I don't need or want it to be the only thing in my life. I want to have friends, and hobbies, and time to just space out in front of the television. But we certainly don't get that in residency, and maybe not even afterwards. Being an intern sucks, being an adult sucks. Life sucks, sometimes.

There's a second-year resident who sits in the nurse's station all day with her iPod on, absolutely fast asleep. She's not my resident, so I shouldn't really care, but it still seems ridiculous. I mean, a week ago she was an intern, so I guess now she feels like she can take it easy. But her intern is constantly trying to ask her questions, and she just shoos him away. If a patient gets harmed... whose fault is it going to be?

It's very quickly clear that the hierarchy at a place like this is clear and never compromised. Interns don't go directly to chief residents, residents take pains to avoid needing to call attendings, second-years deal with first-years, third-years deal with second years... everyone's at some level on the chain of command and there's no way to shortcut around it to just deal with the people you think are competent, or at least decent human beings. I don't think the strict hierarchy makes sense if best-quality patient care is the goal. Not that I have anything useful to say (yet), but at some point, if I see someone making a mistake, I shouldn't have to worry that I can't tell the chief resident he's about to harm the patient, just because I'm not supposed to be talking directly to him. I shouldn't have to hold my tongue and not ask the attending a question about the right meds for the patient just because my second-year thinks I should always go through him. Second-years don't know everything, third-years don't know everything, attendings don't even know everything. But we get thrown into this environment where the expectation is that whoever is one level above you knows everything you do plus everything you will ever need to know, and everyone's afraid to question that authority and think for themselves. I've already seen minor mistakes-- a patient discharged with the wrong prescription, and we had to call her and tell her not to fill it; a missed chemotherapy dosage because the handoff to the night float team was rushed; a patient discharged to clear a bed before everyone was really sure she was fit to leave. Nothing (hopefully) that led to any negative outcome for anyone, but it's still clear that mistakes happen-- and if I've seen these in less than a week, surely there are more happening over time, and throughout the system. There is unquestionably a lot of documentation-- and unquestionably almost everyone I've met has absolutely the best intentions, and frankly a pretty superb base of knowledge-- but we should be encouraged to speak when we see something going wrong, or else it's the patients who suffer.

I haven't talked to anyone outside the hospital for four days, except my parents. I get out too late to call most of my friends on the phone, and haven't been communicative enough on e-mail that I've had any substantive talks with anyone about what my life has been like since this started. I actually haven't yet figured out how anyone makes friends intern year. Every few weeks we're moved around to work with different people, and during the day it's too hectic to ever really have a conversation that isn't about ordering these labs or that scrip. Maybe once we start having some lectures, or some social activities, or clinic, it will be more apparent how to get to know people, but for now it feels like I've signed up for three very lonely years, going from home to the hospital back home to sleep and up again the next day. If I had a wife, she'd be feeling a little neglected at this point, I fear. Maybe not, maybe she would know I'm trying my best and there just aren't any options-- the day ends when they let me go, and it's not my fault if a new patient comes in right when I'm in line to sign out-- but I'd still feel bad. As is, I feel bad I'm wasting money on a cell phone plan, because I'm never going to use my minutes.

Didn't blog yesterday, because I didn't work yesterday. I figured a day off from the hospital should mean a day off from the blog. I spent my day off mostly sleeping. Sat down on the couch to watch the fireworks on TV, but I didn't even make it to the first commercial break before I was out. Woke up this morning to trek back to the hospital at 7AM. Oddly enough, I actually think I like working on the weekends better. Things are quieter. Fewer people around, fewer things to do, more time to actually spend with the patients.

We have a couple of patients who would be doing a lot better if their primary care physicians had diagnosed them properly and gotten them into the hospital sooner to start treatment for their conditions. I asked the attending-- is it typical for the primary care docs to miss stuff like this? He laughed. They miss this stuff all the time. They miss all sorts of things, all the time, until something is bad enough that no one can miss it. It's sad-- for these patients, and for everyone else. It makes me feel lucky that I know enough that (hopefully) I'll catch things in myself before they progress too far, that I won't ignore symptoms and be happy to take a doctor's first opinion that it's nothing. But then I worry that I'm going to fall into the same habits as everyone else-- assume standard symptoms lead to standard diagnosis, forget to rule things out, hope for the best. We miss a diagnosis, we potentially cost someone his life.

The sad story from today was a young man who has something particularly undesirable going on. He was in for the first of a series of treatments, which make him not terribly equipped to drive home. I felt bad for him-- he had no one to take him home, he had to call a taxi. And I start talking to him, telling him he should maybe find a friend to bring him next time, or someone else in his life-- and he said, oh, his wife might be able to come next time. But she's gonna miss treatments 3 and 4 for sure because she's going to Europe with her sister. Crazy. Your husband is probably going to die, and you're going on vacation? You can't even pick him up from his treatments? What's the point of being married? What's the point of having someone if they're not even going to be there for you? "In sickness" is part of the vow. Pathetic. I hate this woman and I haven't even met her. Awful. Inexcusable.

The bad part about working on Sunday is that it's one extra day of work until the weekend. I'm on 7 days in a row-- not off again until next Sunday. I have energy now, but I'm sure it will be gone soon enough.

It feels like it's been a lot more than three days of intern year. I'm ready for tomorrow's day off. We started a patient on a new drug intravenously and all of a sudden she started shaking and coughing the most frightening coughs I've ever heard. Her family started screaming-- I was definitely thinking I was about to watch a patient die right before my eyes. And the nurse looks at me-- "what do we do, doc?" I nearly threw up hearing the question-- how do I know what to do? I'd never seen anything like this. And I'm supposed to know? I'm supposed to be in charge? I called the attending. He laughed-- laughed!-- and said this happens sometimes with a patient's first exposure to this particular drug, just give her a bit of this other thing and keep a close watch. Well, fine, maybe it's normal after you've seen it a few times, but in that moment I just wanted to run out of the hospital and never come back. I'm not ready to be the one in charge.

And all throughout the day the nurses are asking me what to give this patient for that, and that patient for this, and how much-- and I don't know dosages, or what you're supposed to give for nausea or a headache or anything else in combination with the drugs they're already taking. In medical school we learn the mechanism of disease-- how it progresses over time, what it's doing in the body-- but we don't learn how to act in the moment, what the best course of action is when a patient feels one way or another. The nurses seem to know from experience, but they look to me like I have something to add. I don't. At least not yet.

Speaking of nurses: it's pretty crazy how they just accept being treated as second-class citizens. I've been introducing myself to them-- which itself gets a reaction like it's unusual-- by my first name, instead of Doctor ______. They're the same age as me, it's not like I feel more important, if I'm going to call them Frank or Ginger, it seems bizarre for them to call me Doctor _____. I certainly don't feel like "Doctor" yet anyway. At the end of the day one of the nurses thanked me for being so helpful. I wasn't helpful-- I didn't have an answer to anything she asked all day. But I was polite, and I think that was what she wasn't used to. I hear the attendings-- and even the more senior residents-- yelling at them, cursing even, and I can't believe that's really the acceptable and normal behavior. The whole thing makes for an uncomfortable workplace. I don't want to feel like everyone's looking for reasons to yell at each other. I want to feel supported and like we're all part of a team. In surgery maybe I'd expect it, but in medicine?

It's been a long three days and I'm already sleep-deprived. I don't eat lunch, I don't go to the bathroom, I can't predict when it's going to be slow for an hour or when a patient is going to crash and I'm going to have to rush over and pretend to know what to do. It's funny, we can't leave until a certain time, in case someone needs us-- but what could someone possibly need me for? I know nothing. I have no answers, and barely even know the questions. Surely that will change, but today, having gotten through this first half-week, I'm not sure I can remember why I even want to be a doctor. That's the sleep-deprivation talking, but, gosh, I don't know if I care enough. By the end of the day I just wanted to go home. I felt bad for my patients, but I didn't want to answer any more questions, and I didn't really care how they were feeling as long as it wasn't going to keep me there any longer. That's a terrible way to feel on day three, and I know it is-- but, man, I just wanted to leave and go to sleep.

Second day, better than the first. I had my notes organized, I was ready to go, I was on fire. And then we got to the first patient's bedside. "Did you start her on a PCA pump yet?" the attending asked. Well, no, I didn't-- I didn't know I was supposed to. I'm supposed to do things on my own, before the attending gives the orders? No one told me that-- I'm not supposed to be actually making decisions, am I? If I'm the patient, I certainly don't want my second-day-as-a-doctor-ever intern deciding anything without talking to a real doctor first. "Uh, no, not yet. But we will." He rolled his eyes. Why am I getting an eye-roll? I'm trying my best.

Doctors suck. That's the confusing part of all of this. So many doctors are bad human beings. You would think anyone who would choose to be a doctor-- at least a doctor who has to deal with patients who probably aren't getting any better, at least most of them-- would have some compassion. That no one would go into this if they didn't have feelings. But, no, it doesn't make a difference. I guess it's only natural, but it seems like it doesn't take much time at all for some doctors to forget that for their patients, this stuff is scary and it's not routine at all. Having a terminal illness is not something a normal patient is going to be glib about. So they ask questions. And they cry. And they want help. It's only normal. Yet I've now heard pretty much every patient here mocked behind their backs. "She's sooooo needy!" Well, I'd be needy too if I just found out I'm going to die. These are people with comorbidities, with multiple problems all piled up, with no chance of ever having a normal life again. So excuse them if they're a little moody.

"I just wanted to ask a couple of questions," my frail 67-year-old said to the attending.

"We talked about all of this yesterday. I don't have time."

"My daughter wrote out this list of--"

"We talked about it yesterday. I can't explain it to every family member individually."

"I know you're busy, but--"

"That's right. I am. Have a good day."

The patient had so much more patience than I would have. I would have punched the doctor. I would have absolutely punched him. This woman is going to die. I can't even imagine how she's feeling. And he has no compassion, not even a drop. We leave the room and he says "she's a nut." No, she's not. She's scared. For her life. Answer her fucking questions.

I'm not a saint. But come on, these are human beings. At least fake it. At least fake that you care.

First day of intern year is over! Only 364 to go. You would think it wouldn't be much of a transition from medical student to intern, but I have to admit it's a lot more different than I realized. For the first time, you're actually on the hook for knowing things. You're the one who has to be the expert on the patient-- you're not just the observer. And when the attending says the patient needs this test or that test, this medication, that dosage-- you're the one who's going to have to implement it. So I ended up with eight pages of scrawled notes at the end, everything the doctor said, and then I spent my afternoon deciphering it. It used to be so easy-- you just listen and nod, and if you tuned out for a second, it didn't matter. Now I'm actually the one who has to do this stuff. It's stressful. More than I thought it would be.

At the same time, it's so weird that now when I'm introducing myself as a doctor, the patients really do sit up and listen. Twice they asked how to spell my name, so they could write it down-- so they could refer to me later. As in, "Doctor so-and-so said I should take that pill." As if I know anything! My first patient asked me about a research study the attending wanted her to sign up for. She asked me if she should do it. And it's not like I can say, "oh, wow, it's my first day as a doctor-- ever! And not only have I never heard of that study, I've never met that doctor, and I've never even learned anything about how to treat the disease you have! In fact, right after this, I'm going to go on the Internet and google what you have, just so I make sure I know what it is-- and then I'm going to look back at my textbooks from medical school and see if it's in there, so I have some clue about it and don't sound like an idiot! But, yes, I think the study is great, and, yes, even though this hospital is supposed to be the best place you can go for the thing you have, you're still stuck with people like me who have absolutely no idea what they're talking about."

If patients knew how little I know... if they knew how little most of us know.... It's really scary how much faith people put in doctors. It's scary how much they assume we know everything and we're going to fix them. Truth is, most of the time, even the best doctor is faking it to some extent, and doesn't know a whole lot. We can look things up, and see what the accepted course of treatment is... but if you have something complicated, we have no idea how your body is really going to respond, and why one person heals and one person doesn't, why one person lives and one person dies. We're trying our best (most of us), but we just don't know a lot.

I looked up the research study after I left the patient's room. I couldn't find anything. I have no idea what to tell her. The only thing I know I can do-- and maybe this isn't nothing-- is listen, hold her hand, and tell her we're doing our best. I'm trying, I really am. But it's an awesome responsibility, and at least on day number one, I'm just not ready for it.