I passed one of my patients in the hall. He was on a stretcher, and his wife was wheeling him down the corridor. Alone. I did a double-take. "What's going on?"

"He had an MRI," the wife said.

"Yeah, I know. But where is he going, and why isn't there anyone with you?"

"Oh, they said the transport people were busy and asked if I could just take him to his room myself."

"Maybe I should go with you."

"Okay, that's good, because I'm not sure I know how to get all the way back."

This probably shouldn't happen. I'm no expert in the hospital rules and regulations, but I'm pretty sure it's a bad idea to have family members wheeling patients down the hall. You know, just in case something bad happens.

It's hard enough for me to wheel patients down the hall, because I still don't know where everything is, and I have this terrible fear that a patient's going to go into cardiac arrest and I'm not going to be able to find a phone or another doctor, or I won't be able to accurately explain to someone where I am-- and I'm going to inadvertently be responsible for someone dying on a stretcher in the hall.

But if I'm worried about my own ability to do this-- certainly I'm more competent to transport a patient than his wife is.

Part of me wants to call the MRI folks and follow up-- to ask, hey, did you really tell my patient's wife to take him back, alone. But part of me doesn't really want to know the answer.

"Sir, you have to wear your oxygen"

"Just my oxygen?" says the 61-year-old man, and gives me a wink.

Uh, excuse me?

How about not being creepy to the person who's trying to help you?

I don't understand why some patients think it's fine to scream at us, to insult us, to ignore us, to act like they're the high-status person in this relationship. They're not. Without us, they're not getting better. We're the ones with the knowledge and training to help them. We're not their servants. I don't just mean the doctors-- it's even more ridiculous when it comes to how some of these people treat the nurses. Yes, you're sick, but that doesn't absolve you from the obligation to act like a civilized human being, and not to try and get the nurse to touch your penis when she's checking your hernia wound (that happened last night too-- with three other people in the room, the patient grabs the nurse's hand and is like, "no, feel a little bit to the left." Gross.).

1AM: Nurse calls, says patient is having chest pains. EKG looks fine. I go see him.

"Have you ever had this kind of pain before?"
"Yes. All the time."
"All the time?"
"Yes. Whenever I have to go to the bathroom. Then it goes away."
"Have you tried going to the bathroom?"
"No."
"Maybe you should try that."

2AM: Nurse calls, says same patient is complaining of nausea.

"Describe the feeling."
"I want to throw up."
"On a scale of 1 to 10, how strong is the feeling?"
"About a 2."
"I'll give you an antacid. Try getting some sleep."

3AM: Nurse calls, says same patient is complaining of shortness of breath.

"Describe the feeling."
"I'm having trouble breathing."
"You seem okay to me. The monitors are all indicating your breathing is okay."
"When I get annoyed, I have trouble breathing."
"What is making you annoyed?"
"You keep coming in here and waking me up."
"Sir, you keep telling the nurse you're not feeling well, and then I have to come see you."
"I don't like my nurse. Can I get a different one?"
"No."
"Can you leave me alone?"
"I would be delighted to leave you alone."

4AM: Nurse calls, says same patient is complaining of a cramp in his foot.

Some patients are just complainers.
The problem with night float is that I don't know these patients well enough to know right away who's a reliable reporter of his own problems and who's just wasting my time. So I have to visit everyone to make sure, and I end up spending an hour with crazy people like this guy, who have nothing acute wrong with them and just like to complain.
Argh.

"I toldja so" is a bittersweet feeling when it's about correctly diagnosing a terminal illness.

One of the patients had some vague complaints last night, that no one was taking particularly seriously-- elderly woman, likes to complain, no one likes her but I'm new to this rotation so I hadn't been poisoned against her yet. As I checked the chart, and matched up these new complaints with what she's already being treated for, something clicked and I had an idea that we might have misdiagnosed and it might actually be something a lot more serious than we'd been thinking.

Mentioned it to the attending, he told me to order a couple tests to rule it out-- and told me it was a nice catch, which made me think maybe I was onto something. Third-year resident said no way, fellow said no way, my co-intern thought I was crazy for questioning a diagnosis, but, hey, it wasn't like I was trying to show anyone up, I was polite about it, I just wanted to make sure we weren't missing something.

I get back tonight for my shift, check in on the patient-- sure enough, tests came back and I was basically right (not entirely, but close enough). Yay me. Boo patient never going home.

So I'm supposed to be happy, right? I caught something. I made a diagnosis others missed.

But you know what? If I were the patient, I'd probably wish the intern had kept his mouth shut, because if I'm going to die anyway, why not have a couple more weeks blissfully(?) unaware, until more symptoms pop up? Why ruin some fraction of the limited time left? What's the point?

In medical school it's all about hypotheticals-- of course you want to make the right diagnosis, because that's the whole point-- of course you want to do everything you can for every patient, because that's the whole point. But my biggest lesson so far this year is that we really do too much, try too hard, for too long. Why are we bringing terminal patients back from the dead? Why are we wasting (limited) resources on people who don't have any hope for any sort of quality of life? I'm not talking about adding productive and healthy years to people's lives-- of course we should do that, no matter whether they're in their 50s or their 90s. I'm all for organ transplants to 80-year-olds if we can buy them another decade and they're otherwise healthy enough. But there becomes a point where it's futile, wasteful, and sad. Death is sad. But everyone dies of something. There are some miracles we can't perform. Two weeks of painful half-comatose death versus six weeks of painful half-comatose death, what's the difference? Bring you back tonight so you can die tomorrow? What's the point?

And again the post turns into this horribly depressing thing, even when I start with something that should be good news-- not for the patient, but at least for me. Yay, I feel like a doctor. A depressed, jaded, lonely doctor. Awesome.

Just got home after my first night of Night Float, the rotation I'll be on for the next two weeks. I get in at 7PM, accept the sign-outs from the day teams, and stay until 8AM. Having just done the 28-hour overnight shifts in the cardiac care unit, I figured 13 hours would be a breeze. Nothing much happened in the CCU at night-- would it really be any different on the regular patient floors? Maybe I'd even get some sleep.

Nope.

Two deaths, three codes, and a missing pair of dentures.

Got a phone call at 2AM from the nurse's station, about this woman I'd checked in on a few hours earlier. She wasn't doing great, but she didn't seem hours away from the end-- "she has no pulse," the nurse said. "Call a rapid response!" I yelled. Why is she calling me, two floors down, and two months out of medical school? What am I supposed to do when it's going to take me two full minutes to get there anyway?

So she called a rapid response, and I got there as quickly as I could run up the stairs-- but she was long gone. Not sure if she just her heart just stopped while she was sleeping, or what the deal was-- I'll find out tonight, I'm sure.

An hour later, I get a call that a guy fell out of bed. I race up there and they were in the middle of CPR-- the nurse neglected to say he fell out of bed and wasn't breathing, but luckily she called a code while I was on my way. Dead too.

One other code-- successful. And 25 minutes spent in one guy's room searching under his bed, in the closet, in the bathroom, and (successfully-- finally) in his laundry bag for his dentures. Just in time to eat his oatmeal-- yeah, you need teeth for that?-- for breakfast.

Now, since my body is completely confused about whether it's day or night, I'll try to get some sleep and do this all again tonight.... I'll warn you again-- people die in hospitals-- stay away if you can.

I think I went on a date last night, with another intern. I'm not sure it was a date. We'd met during orientation and had a very brief conversation. Then I ran into her as I was leaving the hospital yesterday. It seemed like we were both just going home to eat dinner alone, so I asked her if she wanted to grab a bite. And so we did.

And all we talked about was the hospital.

Her patients, my patients, how tired we both are, how intern year sucks.

Is this really all I'm able to talk about anymore?

I guess we had an okay time, but I really hate doctors. They're too intense. I need someone less intense. I need someone who has something else going on in her life. Of course, when am I ever going to meet that person? The only people I'm going to meet are doctors.

And patients.

One of the wedding announcements in the New York Times yesterday (my mom reads these things and e-mails them to me) was about a doctor marrying the granddaughter of a patient.

"The couple first spoke in May, 2007, on an elevator at Beth Israel, where Ms. Feldinger’s paternal grandmother was hospitalized. Dr. Geller was very kind, Ms. Feldinger said, and offered to occasionally check on her grandmother."

But here's where it got odd:

"Dr. Geller soon asked Ms. Feldinger for a date, and she promptly sought counsel from her grandmother, who nodded yes. But the death of Ms. Feldinger’s grandmother set back plans for a first date."

Maybe I'm reading too much into this, but if the grandmother had said she should go out with him, they wouldn't have just said she "nodded yes." I think the Times had to phrase it this way because I don't think this grandmother-- on the brink of death, it seems-- could do anything more than nod her head.

So I'm not sure how much counsel she was able to give her granddaughter, or whether she was even lucid at this point. And maybe she had bigger things to worry about than the weird doctor asking her granddaughter on a date.

Then again, maybe I ought to be doing the same thing, scouting out patients' families looking for people I should ask out. We could go on our first date in the hospital cafeteria. Of course, if I were a patient, I'd probably be more interested in the attendings than the residents. They make actual money.

Some people are terrible.

A patient died today after a week in the hospital. For the past four days, we'd been calling his wife, telling her she needs to come in, her husband isn't doing well, not much time left, she should really be with him....

And every day, she's made some excuse. "I'm very busy, I can't come in today. Maybe tomorrow...." And maybe she's just been afraid of death, doesn't like hospitals, couldn't bear to see her husband this way-- but sometimes you have to just suck it up. It sounds harsh, but if she really loved him, how could she let him die alone like that, with no one?

So I had to be the one to call her today, after he died, and tell her. And she starts yelling at me-- "How could this happen? Why didn't anyone tell me this was going to happen?" Uh, we did. For the past four days we did.

Still it took her five hours to get to the hospital-- she lives twenty minutes away-- and of course we'd already moved the body to the morgue. She comes in screaming-- where is the body, I have to see the body.

She's saying we killed him, it's all our fault, that he came in fine and we killed him. He came in dying. We made him comfortable. We didn't do anything, we told her he was dying, she didn't even say goodbye. She left him for a week, visiting him once. She left him to die alone.

HE thanked us. The night before he died, in a lucid moment, he thanked us for taking care of him. She didn't deserve him. She doesn't deserve anyone.

Big news. I am now authorized to sign death certificates. That should make me an even more popular party guest.

It was all part of an exciting day, processing the death of a woman with no family, and no visitors except for a strange male friend she didn't seem to recognize who was very interested in getting the keys to her house.

When I got to the Office of Decedent Affairs (how's that for making Death Department sound as civilized as possible?), the death certificate had already been filled out by the clerk. "Pneumonia," he'd written. "It might not have been pneumonia," I said. "She probably had a cardiopulmonary arrest." "Let's just leave it as pneumonia," the clerk said. "I don't want to have to start a new one."

And then I checked the box officially transferring the patient from the CCU to "Deceased" and added a three-paragraph note to the file that no one will ever read. I placed my thumb on the pad-- death certificates are signed by fingerprint, to avoid possible fraud-- and clicked the button, and she was officially dead.

The nurse packed her rectum with cotton to avoid leakage, clamped off the catheter, and sent her to the morgue. At some point, if no family comes forward, she will be marked unclaimed and placed in a common grave.

At least they found her teeth. Her entire stay at the hospital, she didn't have her dentures, and no one knew where they were. I don't know who found them, and how they got in her mouth, but there they were. Finally. Now she could eat. I mean, if she were alive.

I told the attending that the patient had died. "That's good," he said. "She needed to die."

I saw a cockroach in the call room.

I swear it was like 4 inches long.

In a hospital.

It's bad enough that whenever I'm on overnight call it seems like the resident in charge decides to amp up her caffeine intake and want to stay up all night checking and re-checking test results that we can't act on until the morning anyway because the rest of the hospital staff is home sleeping.

But, in the two hours I can actually sleep-- to now discover the call room has roaches-- disgusting.

I'm worried they're going to crawl into my backpack and I'm going to inadvertently take them home with me.

I'm worried they're going to crawl on me during the night.

And, frankly, I'm completely repulsed that in a HOSPITAL, this is okay.

Hospitals should be clean.

If I were a patient, and saw a cockroach, and was in any condition to change hospitals, I would.

If I were a real doctor, sending my patients to a hospital, I wouldn't send them to the place with cockroaches.

Enjoy your hospital food, patients. Because if there are bugs in the call room, where there is and has never been any food, I can't imagine what the kitchen looks like.

I wish the health department would shut the hospital down and let me go home and sleep.

How much am I supposed to care about a 52-year-old who's drinking himself to death? He's in liver failure, and he's still drinking. Why is he worth staying the extra ten minutes after 27 hours in the hospital? Why should I care more than he does about his health? Why should I care more than I care about finally getting to go to sleep?

There's nothing rewarding about dropping in on these patients' lives for a couple of weeks. Nothing I'm doing-- nothing any resident is doing-- even has the potential to make a difference. We're executing orders, mostly we're just watching patients die, there are very, very few moments that feel even slightly uplifting, even slightly fulfilling.

Not that there's anything we can do in the vast majority of these cases, not that there's anything left in the medical arsenal that's going to keep some of these patients from continuing to fade-- but it's awfully hard to get used to failing so often.

We go through college and med school never failing. We can't fail, or we won't get to this point. We're used to succeeding, we're used to everything working out, we're used to feeling accomplished. And then we become doctors, and it becomes all about failure. At least in a hospital setting like this. It's about staving off failure for another three days, it's about feeling helpless and tired and cranky. There is no positive feedback. Even when someone gets better, someone new takes his place and doesn't get better. There is no end to sick people. You're no longer working toward a degree, you no longer have something different to look forward to. Sick people are your life. And you can't save all of them, or most of them, or some of them. Failure is your life.

I'm good at being a student. I'm good at studying, I'm good at taking tests, I'm good at learning. I like learning. I don't really like doing. I don't like not sleeping. I don't like worrying. I don't like feeling responsible for things I have no control over. I want a normal schedule, and a normal life. I want to be able to take a breath. I want to be able to relax. I want to care. I want to run offense instead of defense. I don't want every night to be catching up on sleep, I want to be ahead of sleep, I want to feel like there's a balance. I want to have friends. I want to like the people I work with. I want the patients to know who I am and appreciate me. I want the attendings to know who I am and treat me like a person instead of a slave. I want to feel useful instead of feeling like all we do is babysit. All we do is babysit people who don't even care about their own health. We babysit alcoholics and drug addicts. Awesome. What a fucking accomplishment. What a fucking way to spend a day.

I want to know my neighbors. I want to have a life that's about more than just the hospital, about more than just sick people, about more than failing. But no one here does. Everyone's miserable, or just deluded. No one has that balance, at least not to my eyes. I think I used to be happy. I'm not sure, but I feel like once upon a time, I was happy. I'm not. No one seems to be. And if I weren't a doctor, what else? Is anyone else happier? What makes someone happy?

Because this doesn't. Then again, no one ever said intern year was fun.

Sleep.

It's probably wrong to say, but I find myself pretty excited when patients decide to leave AMA (against medical advice). I should be warning them it's a bad idea, they should really stay, they need monitoring, they're going to regret the decision... but instead it's like, one less patient, awesome, maybe I'll get out twenty minutes earlier.

By working us this many hours, I'm afraid they're making us forget why we wanted to be doctors in the first place. I think I still want to help people. Deep down, I think I still want to help people. But when all I can think about is going to sleep, it's hard to remember what the point was to begin with. And so it becomes a battle to get things done as quickly as possible and get as many patients off the to-do list as I can, so that maybe my resident will let me go home.

The day before we're on overnight call we're supposed to get out early (so we stay under the maximum hour limits-- not because anyone's trying to be considerate), and for the most part I have been-- but it depends on the resident in charge, and what are we supposed to say when a resident just doesn't want to let us leave? I'd finished with all of my patients, I had no work left to do, and I'm just waiting for an emergency, basically-- but you can wait all day. There were other people there, who were supposed to be there-- but if I start complaining about wanting to go home and sleep, so I can spend my 27 consecutive hours in the hospital today and tomorrow, then I'm branded the lazy one, the annoying one, the bad one. I just wanted to leave. I just wanted to sleep.

I miss sleep.

Another ethical issue, sort of.

I never really thought about before actually spending time in a hospital, but doctors are human, just like everyone else, and if you're nice to your doctor, he's going to be willing to spend more time dealing with you than if you're difficult, he's going to want to help you, he's going to think about you more. As opposed to just wanting to do the minimum he needs to do and get rid of you.

This obviously affects overall care. People who we don't want to deal with don't get as much attention, the nurses and doctors don't check in on them as frequently, subtle problems don't get noticed, and, if someone did a big study on this, I bet they'd find there's a real difference in overall outcomes between people who are pleasant to the hospital staff and people who are unpleasant.

It seems unfair, I guess. Some people in a hospital are surely unpleasant in large part because they're ill, and feel terrible, or because they're frustrated, or in some cases because they have dementia and don't even understand what's going on. And it's not like the big stuff gets ignored-- you crash, we're obviously going to call a code, we're not just going to let you die because we find you irritating. But yesterday on rounds we noticed, after a fair amount of extra time dealing with one of our more pleasant patients, that one arm looked a little bigger than the other, very subtle, but there was definitely some swelling. And, sure enough, we did a sonogram, and there's a blood clot in his arm. Almost certainly not something we would have picked up on if we were rushing to get out of his room, and it's a big deal. Had we not noticed it, absolutely could lead to a bad outcome, and we would have chalked it up to unavoidable complication, nothing we could have done. Except there was something we could have done-- we could have noticed it, like we did in this case.

The lesson-- you want us paying attention. You want to make it easy for us to care and notice things and spend time thinking about you. Otherwise we will miss things. oops.

"Don't touch me. I want the doctor."

"I am the doctor."

"No, you're not."

"Yes, I am."

"You're a liar."

"Look at my ID badge. It says M.D. I'm the doctor."

"You're a liar. I hate liars. Get out of here."

"Sir, I'm the doctor. I just need to examine you."

"No, you're lying. You're not the doctor. You're a liar."

And so it went, for ten minutes, until I was finally able to get the patient to let me examine him. Just another day....

I have a patient who knows too much. Or at least he thinks he does. Every time any of us walk into his room, he's like, "No resident. Just attending." He thinks that means better care. He thinks we're incompetent. The first time I took it personally. But once I saw he says it to everyone, I don't really care anymore. Now we mostly try to keep the attending away from him so he's forced to deal with residents as much as possible. We sent a med student to take his blood yesterday, to practice on him, just because we wanted to see his reaction. Maybe we shouldn't have done that, but, really, don't go into a teaching hospital and complain about seeing residents. 90% of the time, you're going to be dealing with residents. We're the ones scheduling your tests and making sure you're getting the right care. It's probably better to be polite.

A nurse I'd never seen before came in and calmly said: "I was talking to the new patient in room 18, and she suddenly stopped responding."

I was the only one on the floor and started to freak out. "Call a code," I said, and I raced to the room.

Where there was a mannequin neatly tucked into the bed.

The fellow passed the room and started laughing.

It was a fake-out, for training purposes, but, running on limited sleep, it sort of seemed like hazing.

Like there aren't enough real emergencies that they need to fake some for practice?

Like you really want us to be thinking, each time there's a code, in the back of our minds, what if it's a fake?

I understand the pedagogical intention, but, really, it doesn't make a lot of sense. We're trained in CPR, we're already responsible for patients, what is this supposed to teach us? There's a code, we run. We run and we start chest compressions and we do everything we're supposed to do. It's not like if we fail on the mannequin there are any consequences-- we're still doctors, we're still residents, all it can possibly do is make us doubt ourselves.

The mannequin died. My chest compressions weren't hard enough. I need to push more, break a couple ribs. Except real people feel different from fake people, and I don't know that killing the mannequin means I would kill a patient. And practicing on a mannequin doesn't really tell me how hard I have to press on a real person. And now I'm all nervous about the next time-- and for what? Because the mannequin told me I failed? This isn't teaching. This is stupid.

Everyone ends up wearing scrubs when we're there overnight-- easier to sleep in, easier to shuffle down the hall in when there's an emergency (or just an overcaffeinated resident-- see my previous post) at 2AM.

Here's a reason not to.

Was at a gas station on my way home from my shift, still wearing scrubs. Am pumping gas, and the guy at the next pump yells to me: "you a doctor?"

"Yeah," I make the mistake of answering.

He comes over, shows me a cut on his arm. "I got this thing on my arm, you think it's infected?"

"I don't know, you should get a doctor to take a look."

"That's what I'm doing!"

"No, not at a gas station. If you're worried about it, go see your doctor."

"That's all I get? You can't examine it or something?"

"I'm sorry, you should go see your doctor."

And then he walks away, annoyed at me.

That's what I get for wearing my scrubs.

A nurse runs into the call room at 4AM: "Doctor, doctor, look at this EKG." I open my eyes and slowly adjust to the light-- it was the first time I'd had a chance to get any asleep all night. I can barely read an EKG when I'm awake, so I certainly can't do much with it at 4AM.

"Which patient is this? What's going on?"

The EKG looked a little abnormal, but I couldn't tell if it was something to be alarmed about or not. "We should call [the second-year resident], he's upstairs," I said.

"No, no," the nurse said. "Not a patient. It's [another nurse]. He has chest pains for thirty minutes. We hook him up to EKG, this is what we get."

I told them to get him to the emergency room! Why are the nurses hooking each other up to the EKG at 4 in the morning??

..........My second-year resident didn't let me sleep last night. This whole overnight thing depends so much on the resident in charge. This guy must be on drugs or something, because he just did not get tired. At 2AM, he pulls me out of bed to check the labs on a patient, said he felt like it would be a "teaching opportunity," and that he wanted to show me something about something I can't even remember. I finally get back into bed by 3 and at 3:30 he grabs me "to go over the patients for 7AM rounds, just so we're on the same page." At 3:30 in the morning?? Then the nurse with the EKG at 4, and a patient wandering out of bed and pulling out his tubes at 4:30, that the nurse felt compelled to wake me up to tell me. And I couldn't get to sleep after that, wrote my morning notes, then stumbled through rounds before finally getting to leave a couple of minutes ago.

I am SO tired. I will never get used to these overnights. Some people seem equipped to deal with the lack of sleep, but I just can't. Who can read an EKG half-asleep at 4 in the morning? Why do we have to prepare for rounds at 3AM? Why can't the labs be read in the morning when there's nothing we can do in the middle of the night anyway? It's not my job to check on then patients every hour, that's not what overnight call is supposed to be about. It's for emergencies and situations where you really do need a doctor. I'm supposed to get to sleep, at least a little bit. Not that anyone can sleep on the plastic mattress in the tiny room, but in theory--

I can't wait for outpatient month.

My med students think I'm important.

It's really a mistake.

I have no power.

I don't even evaluate them.

Not that it would matter much even if I did.

But they don't get it. They think when I ask them what the differential diagnosis is on a particular patient, they think it's a quiz. They think I know the right answer. They think I'm testing them. I'm not! I want to know what they think! Because I HAVE NO IDEA.

When they ask me if they can leave, and I say I don't care if they leave, that's not an invitation to leave. Because I'm not their boss. They don't have to explain to me that they've been sitting around for three hours without anything to do, and they really need to study for the boards. I sympathize, but I have no power. I'm waiting for someone to tell me I can leave, too.

I scrolled through the posts I've been writing lately. This blog's not a very good advertisement for medical school. Maybe it's just because I (finally) got a full night's sleep last night, after working just 4 hours yesterday morning and then a day off today, but things are feeling just a little bit better. Although maybe I'm just deluding myself in the other direction.

What's the goal, in the end? I don't just mean about being a doctor, I mean about life, about happiness, about fulfillment? Not very long ago, I thought, okay, once medical school is over and I'm getting paid, I'm not a student anymore, then it'll be good, then it'll feel like I'm a real doctor and I'll be happy. And very quickly that's become, okay, once intern year is over, and my schedule isn't so terrible, it'll be good, like I'm a real doctor. And I'm pretty sure once I'm a second-year I'll think if only I was an attending... and then once I'm an attending, then if only I were in private practice... and then once I'm in private practice, then if only I could retire... and then once I retire, then if only I could... I don't know. But that can't be it.

I got a message on Facebook the other day from a friend I'm not in good enough touch with, who lives in a different city. He said he has a friend who works in business, not too far from me, that he knows we both work too much and complain about not having enough friends nearby, so he thinks we should meet up and maybe we'd be friends. It's like he's matchmaking, but for a platonic friendship. Which is nice of my friend to try and do-- I appreciate it, really. But it's been two weeks now and neither of us have any time to meet each other. I'm free at weird hours, he's free at no hours-- he works until 11 every night, never knows if he'll be out early... and even when I'm out early, I'm sleeping well before 11. But if I don't even have time to make a new friend, what is this life I have? And not that I want someone else's life-- no one I know seems to enjoy their work, and if they enjoy their work a little bit there's something else wrong-- it doesn't pay, or their personal life is a mess.

I meant for this to be an upbeat post, although I seem to have wandered back into the abyss. What was my point? Oh, okay, I remember-- things don't suck simply because I'm an intern. I can't blame residency. I wouldn't necessarily be any happier or any more satisfied doing something else. Everyone has problems, everyone struggles with how to find balance and reward in their lives. It's not the hospital's fault, it's not even necessarily my fault, it just is. And there are things I can be doing to make it better, but I'm not. I can force myself to make plans, even if I'm tired, I can turn off the TV, I can call my family more, I can call my friends more, I can live in less of a bubble. I can find things I like about my fellow residents, I can try harder to be friendly and not hate people two minutes after I meet them. I can try not to let my patients' quick marches toward death get me down so much (acknowledging that having less empathy is an odd goal). It can be better.

And that's my goal for this week. It can be better. I can try and find balance where balance might be hiding.

And I can focus on the good parts of the job. On the fact that I do help people, families are thankful, patients are thankful. I am making a difference, however small, in some lives. Not everyone can say that. Hardly anyone can say that.

I don't blame medical school. I don't regret my decision to become a doctor. At least not today.

My parents think I work in an environment that looks like the TV show ER.

I tell them it's not really like that, it's much quieter, there's a lot less drama-- but they don't really believe me.

So let me spell it out. We sit in a narrow little room with some phones and old computers, typing in orders and checking lab results. Every so often the phone rings, we pick it up, a nurse tells us the patient in room 816, his blood pressure is over 180. I get up, I go check on him, I tell the nurse to keep monitoring him. I go back to the little room and ask the resident what we should do, he says monitor him. We wait. I check my e-mail. I go to the bathroom. The phone rings, I pick it up, a nurse tells me another patient is having trouble breathing. I get up, I go check on her.

It's quiet, if that makes any sense. It's lazy, almost. Which sucks. Because it makes it feel really unimportant. Of course it's not unimportant for the patients, but in the scheme of things-- being a doctor is supposed to feel important, it's supposed to feel like it matters. And maybe it's a function of this particular service in this particular hospital, but, man, it doesn't feel important at all. It feels like medical babysitting. I don't get to know these patients, they're in and out. Our job is to get them out of the CCU -- whether that's by getting them moved to a regular floor, getting them discharged, or watching them die, our job is to keep as few bed filled as possible. So I meet someone, they stabilize, they leave. I'm not part of their care, I'm not really helping them get better, I'm not really a part of their team, they will never remember me. And I will never remember them. And there's no one here. You can hear a syringe drop.

This is the lack of sleep talking, but-- it's not fair. It's supposed to feel like it matters. If I didn't want a job that felt important, I would have skipped the past 4 years of school and become an accountant. Then I could work in a quiet office doing paperwork, ostensibly helping people but really not so much. That's what this feels like. I'm providing a service, sure. It's just not a very interesting one, and even the parts that are based on the knowledge I have aren't that interesting. We look things up in books. My lawyer friends do the same thing except at least the halls are busy, at least people yell at them. I wish I was on ER. Maybe it's the adrenaline rush that I want-- but I don't think that's quite it. Because I can imagine being happy in private practice-- or at least I thought I could-- where it might be a little slow but at least there's some personal connection, at least I know the people I'm working with and the patients I'm seeing, at least I feel useful. I don't feel useful here. I feel like a babysitter.

And I feel tired.

I'm sorry this blog is so depressing. I should have better stories. I should have more interesting patients and medical dilemmas and problems to solve. I should have more behind-the-scenes excitement I can share. Except there is no behind the scenes excitement, at least not this week. There's just a little, narrow office with a couple of computers, and me, waiting for a nurse to tell me someone's vomiting. At least I'm not a nurse. One of them pulled me aside yesterday, as if she was telling me a secret. "No clean-up staff here," she said, in broken English. "If patient make a doody, I clean up." Thanks. Seriously, thanks, because otherwise I'd be cleaning it up. But, gosh, being a nurse-- and being a doctor-- should be about more than patient doodies.

What I'd really like to say when patients say stupid things.

Patient: "You look too young to be a doctor!"
Me: "You look too old to be alive."

Patient: "Do I really have to take all these pills?"
Me: "No. Just pick your favorite two."

Patient: "When can I leave?"

...okay, this post sucks. Because not even at my most frustrated, not even at my most jaded can I even pretend that my problems come anywhere to close to the problems of the patients I'm dealing with. Or that I wouldn't be tempted to ask exactly the same questions they are. But if we stop to really put ourselves in our patients' position-- if we stop and really think about what they're asking us, think about how scared they are, and the good reasons they have to be scared-- then how can we get through the day without losing it? We walk by family members crying in the hall, and if we really let ourselves think about it from their perspective, how can we not break down too? A patient asks, "When can I leave?" and the only honest answer I would be able to give is a horrifying, awful, terrible answer. "There's a good chance you're not leaving here alive." But then is the right answer to lie? Is it bland reassurances-- "we're doing everything we can, and hopefully you'll be stable enough that you can go home soon."

I mean, I don't know, these first two rotations I've had have started to make me forget that people get better. That regular patients on regular hospital floors come in, we fix them, they leave. They smile. They live. Instead, I've been dealing with end-stage everything, and I can't do it. I don't know how anyone does it. I don't know how anyone can be an oncologist, I don't know how anyone can adjust their point of view so that good news has such a low threshold-- so that "you're still alive today" is good news, let alone "you're healthy, go and live your life."

In the outpatient setting, as a med student in clinic, I liked getting to know the patients a little bit, asking them what they did, finding out about their lives. I miss that part of it-- making that connection. Because you can't do it here. Not just that we don't have time to spend talking to the patients, because we have too many to cover and too many tests to order and follow up on-- but because no one here has lives that are ever going to be normal again. None of these patients are in any condition to have a conversation even if they wanted to-- most of them aren't even able to feed themselves. Their lives are their illnesses-- which means their lives aren't much of anything. But this is what doctors do. This is what I signed up for. This is what I'm going to be doing for the next 40 years.

And that means at some point I'm going to get used to it. And death won't faze me. And disease will seem normal. And illness will seem ordinary and not so bad. Great. That's a great recipe for happiness. What a great way to see the world-- as a landscape filled with death and disease.

I need a rotation with good news. Where people get better. Where people can smile.

Patient: "You look too young to be a doctor!"
Me: "Well, I feel too young to be a doctor, too."

People are delusional.

We have a 3-pack-a-day smoker who's telling me she just started drinking a glass of red wine every night because she read that it's good for her.

We have a 400-pound guy who told me he gives himself a colonic every three months to keep his system clean.

We have a cocaine addict who asked if we could refer him to a nutritionist, since he's worried about his heart.

Maybe it's not their fault. Maybe the media just does a horrible job of helping us understand the relative risks and benefits of assorted activities. Someone forwarded me an article from yesterday New York Times with breaking news that the spleen is a useful organ. Did the reporter just open a medical textbook and decide that was news? Also news, the brain's an important organ too! It's impossible to get patients to understand what's meaningful and what isn't. If you're going to smoke three packs a day, that glass of red wine isn't doing anything for you. If you're snorting coke, the rest of your diet is not particularly important to your overall health. There's such an ignorance on the part of so many patients, that it's hard to even know how to explain anything to them.

And that's just the patients themselves. Then we have family members who read about studies that-- apparently there's a study about everything. No one accepts they have an illness that isn't going to be cured. No one accepts that at some point there is no turning back. If we have to cut off your leg, it will never grow back.

And if you're a cocaine addict, stop worrying about fatty foods. The cocaine will stop your heart faster than the french fries will, I promise.

A patient left against medical advice early this morning. And died three hours later.

See, sometimes you should listen to your doctors.

Except I'm not sure that's really the lesson here. For the past week, every doctor who's seen this patient has had a different message. One attending talked to her husband about discharging her last week. The next attending said no, she wasn't stable. The next attending said sure, we're not really doing anything for her, she's just as good at home. She packed her bags... and then some blood work came back and, oh, no, she's staying. Leaving, staying, leaving, staying. The family got fed up. Every day we're changing our minds, what can we possibly know? We lost credibility. We waffled, and stopped seeming like experts. They started asking more and more questions, and we didn't have answers. Not that there are always answers-- we don't know how disease is going to progress, we don't know how much time someone has left with any great accuracy. She had a year, maybe. At best. Kept in a bubble. At home, apparently she had three hours. Stopped breathing, husband called 911, but it was too late, she was gone.

Now the husband surely blames himself for pulling her out of the hospital, and to some degree I guess he should, but, really, what was the alternative? She had no quality of life no matter whether she was here or at home, and at least at home she could eat real food and sleep in a real bed. She was dying, no matter what. We weren't doing a lot for her, except that we were here to react to an emergency. But the price of that was he couldn't have a life and neither could she. If you're never going to leave the hospital, what's the point? If we're keeping you alive for the sake of keeping you alive, what's the point? Never gonna recover, you're in this state of limbo between life and death... I understand why they wanted to leave... and I understand why they thought it would be okay to leave, since we didn't seem to feel all that strongly either way.

And of course the response here is relief the patient left against our advice, because otherwise would we be sued? Of all the things doctors could and should be sued for, hopefully telling terminal patients they can go home to die if they'd rather do it there than in the hospital isn't high on the list of malpractice infractions anyway. I'm sure there's a forceps stuck in someone's chest cavity that's better worth a lawyer's time.

Potential patients -- you should probably try to avoid getting sick at night or on the weekend.

I don't know why they think it's fine to have an intern, alone, taking care of an entire floor of patients, just because it's Sunday. Illness doesn't know it's the weekend! Something happens to you, and I'm the one in charge? Okay, so there's a second-year resident asleep two floors up, who I'm supposed to be able to ask-- but how much more does she know than I do? It's not that they expressly tell us not to page the attendings on the weekend, but that's what the culture seems to be. You do as much as you can handle, on your own, before you ask for help. Sure, that might be great for learning-- if I kill someone, I'm pretty sure I won't make the same mistake again!-- but it's terrible for patient care!

I guess it's not as if there's a lot I can do anyway in the middle of the night. No specialists, no diagnostic tests-- we can't run a CT scan outside of business hours-- it's a glorified babysitting service costing insurance companies thousands of dollars a day. Someone comes in on Friday night having a heart attack, he's not getting to the cath lab until Monday at the earliest. That's more than 48 hours he's just resting in the bed, with me in charge, asking him if he's sleeping okay. I had a patient last night kick me out of his room because he wanted to get some rest-- I was glad to go! It was midnight! I wanted to get some rest too! But I didn't want to be yelled at for not being thorough enough with my patient history.

A hospital in the middle of the night is an expensive waiting room, especially in the middle of the night on a Sunday. The nurses were reading books. Novels. Long novels. And I don't blame them-- no attending comes in, there's no hospitalist, there's nobody. If they call a code, it's me and I pray the second-year resident wakes up and brings some friends. And this is thought of as good medical care!

We had a smart-aleck elderly patient last night ask me how long I've been a doctor. I told him I'm a first-year resident. He said his grandson is a doctor so he "knows the deal." "So I'm like your first patient, right?" "Well, no, it's been more than a month since I started." "Oh, more than a month! Well then, I know I must be in great hands." Look, make me feel like a moron, that's fine-- but if you think it's better anywhere else, you're kidding yourself. Residents start the same time everywhere, and if it isn't me, it'll just be someone else exactly like me, who knows just as little. You want to forget about a teaching hospital and go to a community hospital instead? Fine with me-- instead of doctors, you'll be seeing newly-minted PAs and nurse practitioners, and your attending probably went to medical school in the West Indies. You can't win, sir. It's a Sunday night in August. Me and my month of practice-- I'm as good as it gets.

I can't even watch movies like a normal person anymore. I used my day off yesterday to go see the new Adam Sandler movie, Funny People. In the movie, Adam Sandler's character is diagnosed with AML (acute myelogenous leukemia) but somehow never seems sick. I spent most of the movie annoyed that they take the time to think of a real disease to afflict him with, but then they don't actually bother giving him any symptoms. He's supposed to be past the point of treatment-- too far gone for radiation or chemotherapy-- but they give him some "experimental treatment" and then magically (after one day he's shown sleeping late and feeling grouchy) he's all better. Healthy people seem sicker than he did. And what's this magical experiment if it's not radiation or chemotherapy? They gave him some pills. Great. Magic. And they had such detailed stats to back it up-- "8% of patients get better on this experimental regimen. 92% don't." What kind of study was this? I kept thinking he should get a second opinion (his doctor didn't seem particularly awesome), or, I don't know, maybe ask a couple questions about what the heck they're giving him. I know the point of the movie was not a realistic treatment of Adam Sandler's battle with AML, but come on, it was lazy.

Kind of ruined the film for me. Partly because even if they were accurate in the portrayal, what am I doing spending my day off thinking about sick people-- even fictional sick people? Why did I go to this stupid movie when I could have been doing something else-- anything else-- that didn't involve illness and death? I get enough illness and death the other six days of the week. And then I'm on overnight tonight and going to probably be sleepy enough at some point that I'm going to get reality and fiction mixed up and start looking for Adam Sandler in the CCU to see how his experimental treatment is going.

I didn't even have anyone to go to the movie with, because I couldn't see a movie at a normal time, because I had to go to sleep to get to the hospital at 7 AM on Sunday morning. So I saw a 5:00 movie, with fifteen elderly people in the theater who will probably be my patients this week anyway. I can't even see a movie at a normal time, or like a normal human being who doesn't spend the whole time wishing Adam Sandler would seem like an actual sick person. They needed a medical consultant. All that money to make this thing and they couldn't hire a doctor to tell them that people with terminal illnesses usually seem kind of sick. At least this was better the The Bucket List, where they gave Morgan Freeman and Jack Nicholson vague diagnoses of "imminent death" and then they went skydiving and on a safari in Africa, as if it's easy to go enjoy a vacation when your organ systems are shutting down.

I guess no one wants illness played real. No one wants to watch death on a movie screen, no one wants to see actual decline, actual suffering. No, we're too sensitive for that. Let's leave that to the doctors, they can take it. Hide it from everyone else, pretend illness doesn't exist. We want it packaged in a palatable way so we don't have to come to terms with the truth that we will all die, and many of us will die in very unpleasant, painful, drawn-out, terrible ways. It's like chicken nuggets-- we turn chicken into chicken nuggets, bearing no resemblance to the actual animal killed for the food, so that we can pretend it wasn't an animal at all. Let's dress death up to look like Adam Sandler performing stand-up comedy but taking a vitamin pill afterwards to make it all better, and then we can ignore the reality. Okay, maybe this analogy sucks. Maybe I'm exhausted and grumpy and not even thinking like a normal person anymore. Maybe I'm losing my mind.

But this is what the system is making me into. This is what overnight call followed by a new shift at 7AM the next morning does to someone. Irregular sleep schedule, irregular meals, vending machine garbage for dinner because we're not allowed to leave the hospital and I don't have time to buy ingredients to make myself something to bring, not that there's a refrigerator I'm allowed to keep it in. And we're expected to be empathetic, patient, caring physicians too. A patient complained the other day and said he only got 3 hours of sleep. Well, so did I. I told him. And he looked at me like I'd just said something out of line. What, you're the only one allowed to complain? I'm a person too, just the same. We're doing the best we can, we're trying to heal him, we're employing the best of modern medicine-- but we're not robots.