I don't want to get old.

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

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

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

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

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

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

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

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

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

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

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

How do you get an old person to be your friend?

I had a patient today, he's an 85 year old man, and he's lonely. His wife died about 9 months ago, and he's struggling. They were married for 60 years. He's retired, he doesn't have anything to do all day-- they spent their days together before she died, they played golf, they went to the movies, she cooked his meals. They never had any children, he doesn't have any other family nearby, and most of his friends have died. So now he goes to a local pizza place for most of his meals, putters around the house, watches TV.... He's tried joining some organizations, he's tried taking classes-- but he said he doesn't meet a lot of people his age, it's tiring to force himself to be active all the time, and he's lonely.

I spent an hour with him-- we're allowed to, our schedules are pretty loose in the outpatient clinic-- even though his medical problems were pretty minor. Honestly, I kind of wish there was a way to be his friend. I wish there was a sensible way for me to call him up and tell him I'll have dinner with him one of these nights, or we could go to the movies. I'm lonely, he's lonely-- and I just feel so bad for him. Married for 60 years and now she's gone-- and he's still in good enough health to enjoy his life, but he has nothing to live for.

I think part of it is I just want to help someone-- to actually help someone. For the past three months I've either been watching people die, or merely doing no harm.

Even the patients who get better-- it's not because of me. I'm ordering the same tests anyone else would, I'm making the same diagnoses anyone else can, anything difficult is being passed up the chain to the more senior residents or the attendings.

And maybe that's what being a doctor is really about, and we rarely get to actually make a difference or solve a problem no one else can (I guess surgeons get more of that). When I have my own patients hopefully I will develop relationships with them and that will be part of the reward, feeling like I'm part of their lives. But for now, I am a stranger passing through and, for the most part, I'm making no impact. I'm a medical robot.

But I felt a little bit of a connection to the guy today, I felt like I helped him-- even just by being someone he could talk to. I wish I could reach out and do more. Except if your doctor-- a third your age-- called you and said he wanted to be your friend, you'd probably hang up the phone. And you probably should.

Another patient yesterday, English wasn't his first language but he spoke it almost perfectly, didn't have to use the translator phone.

I'm taking the patient history, he's telling me why he's here, and I ask him if he's had any diarrhea. For the first time in the conversation, he pauses and gives me a look.

"I don't know that word."

"Diarrhea?"

"Yes. What is that?"

I'd never really thought about how you explain the concept of diarrhea to someone. But it's not that easy to do.

"Uh, it means loose stool, watery, comes out very quickly..."

"You mean out of the penis?"

"No."

I think I've blogged before about the translator phone, which we use when patients don't speak English-- we call a service, we get a translator, we put the translator on speaker phone-- which is awkward for the doctor and probably even more awkward for the patient, especially if the patient is trying to talk about a problem of a sensitive nature. It's awkward enough to have to look at someone's anus. Having a disembodied voice on the phone moderating the conversation makes it practically absurd.

So it was sort of nice that a patient today brought her own translator with her. She came into the office with a friend-- the patient had been here before and I guess she didn't like the translator phone, and was trying to avoid it.

"You don't need to phone the use," the friend said.

"Maybe I should call, just to be sure we get everything right?"

"No, I speak the English."

"Okay." I didn't want to offend her. And, frankly, it's easier and faster without the phone, so why use it if I don't absolutely have to?

This did not go well.

"What kind of work does she do?" I asked.

"No," the translator said.

"She does not work?"

"Every day."

"Okay. What kind of work?"

"Yes."

Eventually we figured that one out. We started talking about the reason the patient was here. She was having headaches. I asked if they were strong enough to wake her up from sleep. Standard brain tumor question.

"She sleep?" the translator said.

"No, do the headaches wake her up?"

"She sleep every night and then she wake up."

"Does she wake up from the headaches?"

"Yes, she sometimes wakes up with a headache."

"No, does the headache wake her up?"

"I do not understand what you are asking."

I tried acting it out. Closed my eyes, put my hands next to my head-- I'm asleep. Then hands on head, "ow!" Then wake up. This did not work. Playing charades with the patient who doesn't speak English does not work.

"I should use the translator phone."

"I am phone the better."

"I'm going to call the translator."

"I came here to help this."

"I know, and you've been very helpful. Thank you for being so helpful. I need to call the translator."

I called the translator. Turned out the patient didn't really have a headache. I mean, she had a headache, but she had a headache because she hit her head. She fell and hit her head. No brain tumor. You'd think the friend would have figured out this was relevant before we spent fifteen minutes chasing my brain tumor theory.

I don't hate the translator phone quite so much anymore.

And outpatient month was going so well.... I was asked to cover someone's overnight last night because of an illness, and I'm realizing-- so much of this really must be about sleep, and whether I'm getting enough of it to not sink into an abyss.

We had a patient overnight, the family decided to finally take her off life support, had finally decided that this was enough and she wasn't ever going to come off of it on her own. But they wanted the chaplain there when she died. I haven't dealt with the hospital chaplains much-- I see them around, but this was the first time I was actually asked to call one in. I try the office, but it was almost midnight already, there's no one there. The senior resident told me to call the guy at home-- so I called him, woke him up, and at first he didn't want to come in. Asked if the family would wait until the morning. Which they didn't want to. He apparently lives almost an hour away, was tired.... Anyway, he finally agrees to come in.

And so we stop the medication that's keeping up the blood pressure, expecting the patient to go very quickly... and she doesn't. She's breathing on her own, her blood pressure is stable.... After a few minutes, the chaplain pulls me aside and asks, "just how long is this going to take?"

The patient died a few hours later. The chaplain stayed with the family, comforted them....

I suppose just like it's easy for people to forget that doctors are just regular human beings, it's also easy for me to forget the chaplain is just a regular human being... but still....

And a companion to yesterday's post: Top ten lies doctors tell.

1. "No, we ask everyone to get tested for chlamydia."

2. "This is very common."

3. "I'll call you tomorrow with the results."

4. "Your insurance will probably cover that."

5. "You look great."

6. "I remember that from the last time you were here."

7. "The lab must have screwed that up."

8. "I'll be back in five minutes."

9. "I don't have an e-mail address."

10. "I think you'll be OK."

Okay, suitable for forwarding to your friends:

Anonymous Doc's Top Ten Useless Things Patients Say

1. "Family history? Well, my great-uncle had diabetes, and my second cousin just had an abortion."

2. "I take two pills every day, one is white and I think the name starts with a C, the other is green and I don't like the way it tastes. Oh, and I'm also supposed to take an orange pill but I don't. And I keep expired medication around just in case I need it later."

3. "I quit smoking... thirty years ago."

4. "I like you much better than the last doctor I saw. He thought I was crazy."

5. "I don't need an MRI-- I had one, ten years ago, before this problem started."

6. "I have a theory about why I'm having chest pain. It's because I have a brain tumor. Or because I'm constipated. Definitely one of the two."

7. "My friend weighs 50 pounds more than I do and her doctor didn't tell her to lose any weight-- so I don't know why you keep bringing it up."

8. "My stool? Here, I brought you a sample... in my pocket."

9. "No, I always take my medicine-- in fact, if I forget my pills one day I make sure to double up the next."

10. "I don't believe in doctors. My mother did everything her doctor said, and she still died."

Patient comes in for a checkup, I'm finishing up and he says, "oh, there's one more thing." Which is always the thing they actually came in for and should have said first.

"I've been using drugs for about a year, and I want to stop."

"That's great that you want to stop. What drug?"

"Oh, a lot of them."

"Which ones?"

"I'd rather not say. I also want to quit smoking."

"Well, that's terrific."

And we talk for the next fifteen minutes about approaches to quitting, and some outpatient programs I can get him involved with, and a schedule of follow-up appointments so we can keep track of his progress and he can feel like we're in this with him... and I'm going to the computer to print out a couple of prescriptions, so I tell him to sit tight for just a minute and I'll be right back. I get up, go to the computer, am back within three minutes... and he's gone.

I don't know if the idea of treatment scared him and he ran, I don't know if he just needed to talk to someone, if he wasn't really ready to quit, I don't know. So we'll send the information to the address on file, and hope he comes back... but, wow, I was really surprised he took off like that.

I mean, I thought I was doing good. I thought I was helping him, I thought I was making a difference. Finally, a problem we can sort of solve. A problem that doesn't end with me saying there's nothing more we can do and sending someone home to die. And he leaves. Argh.

Patient yesterday afternoon:

"I didn't tell anyone this the last time I came in, but I trust you--"

"Okay..."

"For the past ten years-- wait, do you have a pen and paper, I'll draw you a picture--"

"Um, sure." (I hand him a pen and paper)

"For the past ten years, I go to the bathroom and the pieces are very small." (He draws some circles on the paper) "They're less than a centimeter. I've measured."

"I'm not sure this is really--"

"They're brown, but not always exactly the kind of brown you expect they should be, you know what I mean?"

"I'm not--"

"And I go like three, four, five times a day. Almost every day. Is this normal?"

"Everyone's system works a little differently. You might want to--"

"And I'm very itchy down there."

"Okay..."

"No, for ten years, very itchy. All the time."

"Have you been checked for hemorrhoids? You might want to try some Preparation H."

"Oh, I tried that. Believe me, I tried that."

This went on for a few more minutes, before I was able to convince him that if it's been this way for ten years, and this is the first time he's told a doctor, he's probably okay.

It's interesting-- patients seem to all think that the longer they've had a problem-- whatever problem-- the worse it must be. And we're trained to think exactly the opposite-- if something's been going on for years, it hasn't gotten worse, you've never felt compelled to seek treatment-- well, maybe you're fine. I had a patient tell me his wrist hurts "twice a week, for three years." On a schedule? This is not a complaint I can bring to an attending, this is a magic crazy person complaint. "This started this morning and is getting worse" is something I'm going to look at. "This started a generation ago and most of the time I don't notice it" is not.

The corollary-- patients convinced one thing is causing something else, when it makes no medical sense. "I think the antibiotic is causing pain in my left thumb," one patient told me. Pain in one thumb? This is not from the antibiotic. "It sort of feels like something is twisted inside of me," one man said. "Could I have accidentally knocked my kidney out of place?" No. You didn't. "When I brush my teeth, my nose itches." I have no idea how to help you.

So do I save this guy's drawing in his file? Do I throw it out? I put it in the file. I didn't know what else to do with it. The next doctor who sees him in the clinic is going to see this picture of his poo, and probably ask him about it. And then they can be punished too.

There's a rule in the clinic: if the patient is half an hour late, we're not supposed to see them. In theory, this prevents patients from being late. In practice, it creates angry patients who argue until finally someone relents and agrees to see them.

I suppose the "right" position I should take is that the half-hour rule is a good one, it keeps us from running too far behind, it keeps us from punishing the patients who are on time just because one patient is late, it creates a strong incentive to be on time...

Except most of these people are taking public transportation, or they work at a low-wage job where it's hard to leave, or they have three kids they're shuttling around... plus they're sick, or at least there's some reason why they're coming in to see a doctor. A lot of them have decent-enough reasons for being late, and it feels terrible to turn them away and then watch them fight just to see us. If they don't see us, it's not like they're going to go to another doctor. They're not going to go to a doctor, they're not going to come back here... and so they're just going to get sicker, and end up in the emergency room at some point. We should be rewarding people who decide to come to the clinic and get treated instead of waiting until it's an emergency room problem.

And so I think we shouldn't necessarily see them right when they get here, an hour and a half late, but we should just do our best to accommodate. And not yell at them like they're children, tell them we won't see them, and send them back on the street to get sicker.

I think in a lot of cases there isn't enough paternalism in medicine-- I think we give patients too much choice when it comes to treatment-- because it's uninformed choice, for the most part, and people end up making decisions without accurate information or accurate explanations that they can understand to make the right choices. But when it comes to showing up on time for an appointment-- at a clinic for the uninsured, not at a plastic surgeon where you're paying out of pocket, not for a population that has options and advantages and lots of ways to get decent medical care-- I think it's ridiculous to try and teach these adults a lesson about promptness. We should be treating them like people who need our help, not treating them like children.

And we end up seeing them anyway, after they throw a fit, and then they hate us, we hate them, everyone in the waiting room hates them and hates us for giving in-- and we end up throwing off the whole schedule anyway.

Besides-- nothing bad happens to us when we're running two hours late-- we have excuses, often legitimate ones. Why can't we assume our patients might have legitimate excuses for being late as well?

It would be easier to argue the other side-- our time is valuable, how can they expect us to wait for them, we're trying to do the most good for the most people and that can't happen if we have late patients-- but I just can't shake the feeling most of these people aren't trying to be late, and their lives are a lot more complicated and difficult than mine is.

A rare show of sympathy in the blog, I know. :)

I never really thought about this, but, in the outpatient setting, people with insurance don't see residents. You have insurance, you make an appointment with a doctor, you go to his office, he sees you. You don't have insurance, you go to a clinic, and you're seen by someone like me. Or at least that's what I've seen so far. There are a couple of different outpatient settings I've been rotating through over the past couple of weeks. When I'm at the public hospital, I'm the only doctor the patient sees. I go in, I take a history, I do an exam, and then I consult with a more senior resident, or an attending-- but that all happens behind the scenes. As far as the patient is concerned, I'm the doctor. The only doctor. And yet I'm three months out of medical school. At the private clinic, I shadow an attending, he sees the patients, and I watch. I look but don't touch.

Is the care any different? Probably not-- in the public hospital, I'm consulting with other residents, there's an attending there overseeing everything, and all decisions have to be explained and justified. Even if I were to make a mistake, in this setting it probably gets caught and corrected (I wouldn't say the same thing about the inpatient rotations, at least not all the time). If anything, the care is probably better in the public clinic, because everything is being looked at multiple times and talked about. In the private clinic, if the doctor says something, I have to be pretty convinced he's wrong to feel bold enough to question it. And even if I question it, there's no reason he would listen. So there's not the same process of review. I mean, an attending who deals with these same problems every day for years is probably not making a ton of mistakes--

I guess the continuity of care is different-- in the private clinic you have your own doctor, he sees you every time, but in the public clinic you're just getting whichever resident is working that day and picks up your file. So you're constantly having to explain your situation to someone new, you're having to trust the resident has read the file and knows what's going on.... So that's a difference....

I don't know if there's a point here. I don't actually think the public clinic is providing worse care than the private clinic. It's just interesting that the customer-facing end of it is probably the biggest difference-- you see a doctor versus you see a resident-- as an outpatient, someone with insurance is never, ever going to see a resident. Perhaps that's obvious, and I just never thought about it before. The bigger question, I guess, is whether this is the smartest allocation of doctor resources, but I'm not sure I've thought about it enough to have an answer.

Outpatient clinic feels like med school, for better or worse. The pace is slow, the stress is low, and it's a lot more about learning than doing.

There's four of us interns, two more senior residents, and an attending, so it's a lot of one-on-one with the residents talking about the patients, a lot of consultation with the attending, and there's a lot of emphasis on taking our time to get to know the patients, take a careful history, be thorough, don't rush through-- which is all so radically different from life in the hospital, and especially from life in the ICU or in the middle of a code.

These aren't particularly sick patients-- I diagnosed an ear infection yesterday, we had a woman with some standard follow-up, a guy who's basically just depressed, and a woman with a cold.

In a lot of ways, it's great-- everything I was reacting negatively to over the past three months isn't an issue here. The hours are fine, there are people to talk to, I can get to know my patients, I can feel like I'm helping them (sort of).

It's what I've said I want to be doing all along-- treating patients in an outpatient setting, getting to deal with people who aren't inches from death, who we can actually make better.

And yet-- I hate to admit it-- I'm bored.

This is what I've said I want to be doing-- but it's boring. Especially after two months of high drama, of adrenaline, of feeling at the edge of sanity and deprived of sleep and thrown into situations I have no business handling.

This is slow medicine. This is "take a Tylenol and come back in six weeks." Anyone can do this.

Look, I think it doesn't help that these patients, for the most part, don't speak any English and so I can't really talk to them and feel like I'm getting to know them. It doesn't help that the appointments are so spread out that we have hours of downtime throughout the day. It doesn't help that one of my co-interns keeps stealing my lunch. But, gosh, forty years of this? This is what I went to medical school for? To prescribe Zithromax and take blood pressure? I may not be capable enough to run the ICU, but surely I'm more capable than this.

But what's the middle ground, if there is one? Either you're shepherding people to their death in the cancer ward of the hospital, or you're spending your day listening to healthy people cough.

I've never doubted my choice to do internal medicine. I've always pictured this perfect suburban life, a wife and kids, heading into the office every day, seeing some patients, getting to know their families, feeling like I'm a part of the community, and having time to enjoy my life and my family, time and the means to take vacations, to have friends over for dinner, to walk the dog.

But the family piece isn't there and I don't see how I'm going to get it. I'm not meeting anyone, I'm not doing anything outside of work-- and without that piece, I'm worried this life couldn't possibly be enough. Head into the office every day... and then what? Go home and eat a microwave dinner and fall asleep in front of the TV only to start it over again the next morning? Be the pathetic single doctor who doesn't have a life outside the office? I had all weekend free, but I was bored. I slept, I read a book, I went to the movies by myself... I called a couple of friends, but when you've spent the past two months never having a free minute, you can't expect people to drop everything and work their schedule around your newfound freedom.

I know why people go into surgery, I know why people become ER docs and moonlight and take extra shifts-- it's something to do. There's excitement and purpose that you don't get sitting on the couch watching ESPN. I don't want that life-- where work is everything-- but if it's a choice between having nothing and at least having the work, I don't know if it's so terrible.

I write this and it makes me realize-- the problem isn't work, at least not on the outpatient side. Maybe the problem has been work for the past two months. But the problem now is me. I need to meet people, I need to do things, I need to not sit here and feel sorry for myself. If I want someone to feel sorry for, I have sick patients I can transfer those feelings to. Being a doctor-- sadly-- isn't going to be my magic bullet. It can't take care of the rest of my life.

It's just frustrating to realize that and then hard to fix it.

Another good thing about the outpatient service: for the first time since this whole thing started, I had the whole weekend off. Yesterday, I slept 14 hours. Today, I slept only 11. Not for lack of trying to sleep more.

This may sound stupid, but I'm surprised that the patients who don't speak English really don't speak any English at all. Like, they don't even seem to know the word English, or what I'm talking about when I ask them if they speak English. At least we do have the translator phone-- but for most of the things these people have to do, how does someone get around without speaking a single word of the language of the country they're living in? It makes me worried that if we end up giving them a prescription, at worst they're going to have trouble getting it filled and at best they're at risk of misunderstanding the directions on the bottle.

The patients we deal with at the clinic often don't have permanent addresses, or any way for us to contact them. I told a patient to call a particular specialist for a follow-up appointment but found out afterward that in fact the doctor has to call and get the patient the appointment. So I called and got the patient a slot, but I have no way of reaching the patient to tell her when this appointment is. I have to hope she'll call the office and they'll realize there's an appointment on the books and they'll tell her about it. There's nothing else I can do.

There's another patient who we had sent from the clinic to the hospital-- he was having chest pains and we suspected a heart attack. A couple of hours later we got a call that unfortunately the patient died. We had a phone number on file, we called the phone number-- but we didn't get an answer, and there was no machine. The hospital hopefully has procedures to make every attempt to locate and notify next of kin-- but it's hard to know what can be done.

The problem is that a lot of these patients are invisible-- they're here illegally, they don't have insurance, they don't have social security numbers, they're not in any system. We have the information they give us, but it's not like they're in the phone book, it's not like we can find them through government records, and they're (probably) not on Facebook. Maybe some of them are on Facebook, who knows.

No, honestly, it's very sad. It's sad that they have to live their lives in the shadows, and it's sad that even when we're trying to help, and trying to provide care, there's a limit to what we can do.

I will get less sleep tonight than the past two nights, but hopefully I have enough stored up to last me through the week....

Well, the week-long "Medical Spanish" workshop I took during med school was clearly not enough.

My mistake is pretending, because then for eight seconds the patient thinks I actually speak Spanish and starts talking to me, and all I can do is shrug and nod. I can say hello, I can say goodbye, and I can say doctor. I can say I don't speak Spanish, which is helpful.

I find it amusing that the one procedure that transcends the language barrier is in fact the pelvic exam, because all of those words are pretty much the same in English as in Spanish. The face, nothing is the same-- la cabeza, la cara, la garganta, la boca, el cuello-- if you don't know these words, you can't really figure it out except by pointing. But la pelvis, el utero, los ovarios, el cervix, la vagina -- that's all pretty straightforward. (Similarly on the men's side-- la prostata, los testiculos, el pene.)

So someone starts telling me about pain in las costillas, I'm pretty clueless, a problem with la vejiga, I need a translator. But if his penis hurts, well, now we can do business, I'm totally on board.

The problem with the medical spanish class is that you end up with a script-- breathe deeply, squeeze my fingers, stick out your tongue, does it hurt-- and even if you memorize all of that, you're still not going to understand the responses. Patients don't talk back from a script. They say all kinds of things, some of which are important, and unless you're actually fluent, you're not going to catch everything-- and then to add tone of voice to the equation, it's impossible to learn this stuff from flash cards. At least in the outpatient setting, a good number of patients aren't just sitting down and telling you what the problem is. They may think they know what the problem is, but it isn't until you get a bit of the patient history and start asking the right questions that you really know the whole story. I had a patient yesterday who came in with a particular issue, and as he started talking I noticed he had a tremor in one of his limbs, and so I started asking questions about that-- questions he didn't really care about, because in his mind they were irrelevant, he was there for something unrelated, so why did I keep asking about this other thing-- and eventually we figured out there's all sorts of medication interactions going on and his real issue is a different one than what he came in thinking he was supposed to talk about.

It's hard enough to find the source of some of these problems when you and the patient are both speaking the same language. But when neither of you understands the other, it's impossible. We have translator phones-- you call a number, someone gets on and translates back and forth-- but it's not an ideal situation, and the translator isn't in the room, can't really engage with the patient, can't always make sense of what the patient is really talking about-- and the translator doesn't always have the medical knowledge to help make things clearer, of course. It's better than nothing-- but even better would be if I spoke the same language as the patient.

I don't know that there's much of a solution-- you can't expect doctors to know how to speak every language a hypothetical patient might speak, and it's unrealistic and unfair to expect every patient to be able to speak fluent English-- so we muddle through.

And at least in the case of pelvic exams, hey, it all works out just fine.

First day in outpatient is certainly a change from the night shift. Normal hours! Different problems! A patient came in, and it turned out she needed a pelvic exam. I've done one of these before, in med school, during my OB/GYN rotation, on a fake patient who they hire to let the med students practice (what a terrible job, no matter how well they pay). There's a safety net when it's a fake patient-- she's done it before, she knows what to expect, she knows we don't know what we're doing, and she's trained to guide our hands and tell us what we're touching and make it all a little bit removed from reality (again, what a terrible, terrible, terrible job, no matter how well they pay).

But when it's a real patient-- and especially a real patient who may in fact have some sort of issue down there-- it's a very different situation. The saving grace was that the woman said she had never had one of these before-- hence, she had no idea what to expect. Otherwise, if she actually had a point of comparison, I feel like she would have gotten up and left, or at least demanded a different doctor. I mean, surely she had some sense of what was happening, since my resident was standing over me trying to instruct: "I think you need to go deeper" ; "You're not quite all the way in" ; "Yes, that's what it's supposed to feel like." The resident did the exam after I did, just to double-check -- fortunately no real issues going on for the patient -- but, gosh, I'm really glad that I never have to be on the patient end of this, and I'm hoping that whatever practice I end up having as a real doctor, I don't have to do these very often.

I don't know how people go into gynecology or urology, and have to do this stuff all day, every day. Dealing with a patient's private parts in a clinical setting is really not appealing. It's weird to write this or think this, but it's like, I don't know, it takes some of the mystery away, it makes it all seem a little less magical, a little less special. And that's even putting aside the possibility of dealing with actual infection (or infestation, or wound, or other such problem) down there. It's just not something I want to spend a lot of my workday doing.

I'm around people all day, and yet it's very lonely to be an intern, at least on some of these rotations.

We have colleagues (and supervisors, of course), but for the most part we're alone, in the call room, inputting orders, checking labs, and waiting for the nurses to page us. Even when there's another resident in there with me, it's all shop talk. And certainly with the patients, it's not like there's any real conversation going on. For a lot of the day, I feel like I'm acting the role of doctor-- but I feel like that's part of the job, honestly. You can't express uncertainty or doubt to the patient-- you can't even really express it to the attending if you want to be taken seriously, at least not in an honest way. We're not really allowed to be affected by death and illness. There's no one to really turn to.

Now, I don't know if it's any different than any other workplace-- my workplace experiences are obviously limited-- certainly it's unprofessional in most fields to really let your guard down and be honest about your fears and uncertainties in front of the client or the boss. But we're dealing with things a lot more important than in most jobs. And it takes a toll. I don't know that I really feel like my doctor self and my real self have merged yet, that we're the same person. I have to turn it off when I get home, certainly when I talk to my parents on the phone or the rare occasions I get to hang out with a friend. I have to avoid being the doctor self, worrying about the consequences of everything, watching my words, watching my body language.

I think I just miss having friends, and maybe that's what I mean by all of this. I only have colleagues. I don't have time for anything else. I have colleagues and I have patients. And I have me, and everything just ends up festering inside my head and has no outlet. Except this, I guess, if anyone's actually reading it.

I don't know what time the sun rises. I don't know what time it sets. I don't know how the electric bill in my apartment was as high as it was when I'm never home. I should call the electric company, except I don't have time. I should at least twitter them or something. I read an article about how companies are responding to people who twitter. I honestly have no idea if I read that article a week ago or a month ago. Time moves in a really strange way when you're up all night and sleep all day. And now I go back to working days and sleeping nights and that'll probably take a few days to make sense again to my body.

I'm hungry. Maybe.

Why does everyone die at 5AM?

Oh, maybe it's because that's when the nurses do their morning rounds to check if everyone's still alive... and some of them aren't.

I wish I could say I was off for Labor Day, but I wasn't, and instead, for the fourth night in a row, I did chest compressions at 5AM on someone who'd probably been dead for hours, and they're still dead. Not that any of these people weren't going to die in the middle of the night, but it's sort of pointless to have night nurses if they're only checking on the patients every 4 hours. The big secret no one gets about hospitals is that, by and large, we're not doing a whole lot more for you than you could have done at home.

Unless we're performing surgery, or you're getting IV drugs or fluids, what are we really doing except giving you a bed, making you (terrible) food, and giving you brief daily access to a doctor who may or may not know all that much about your file, and might tweak your medications, mostly a stab in the dark to see if maybe you aren't actually as close to death as it seems.

For most people, probably better off at home.

Plus, it's filthy here. I did get to lay down for two hours on Sunday night, because no one was paging me and the dead patients had yet to be discovered by the nurses. We have cots here. Dirty, stained cots. And then today my head started itching. And itching. And finally I had my co-intern check if there was anything going on-- and I had lice.

The hospital gave me lice. Maybe that's why I'm especially angry today, or especially fed up, or, I don't know, especially negative about this whole enterprise. The cot for the interns to sleep on gave me lice. You're not supposed to get lice in the hospital. (I would add, "especially if you're a doctor," but, hey, we're exposed to the same stuff the patients are.) Now, maybe you could argue it's not the hospital's fault-- if another intern had lice, and slept in that cot, what are they supposed to do?

Well, how about CLEANING the bed? How about making it a policy to sterilize the places anyone-- patient or doctor-- might be sleeping, since, hey, it's a hospital, there's illness floating around. If a patient has lice, and then leaves the hospital, I would hope the next patient wouldn't be exposed. I would hope they'd be cleaning things thoroughly enough that whatever you have doesn't pass to the next person who's in your bed. That hope would be false hope.

We have patients every night threatening to leave AMA (against medical advice). We're supposed to convince them not to-- and a few of them probably shouldn't, because they'll just end up back here in 24 hours, or dead. But a lot of them, hey, they should probably just go. Not just so they'll stop being terrible patients and taking our attention away from the people who actually want our help, but also because they'll probably do better outside of here, where they can eat real food and spend time with their families and not be tortured and prodded and poked all day.

And they probably won't get lice.

And we don't even have any lice shampoo here-- it's over the counter, I have to go to the drug store on the way home and get it myself. This is a HOSPITAL. A dirty hospital where every night patients are dying and no one's noticing for hours.

This is my job. This is the life I've signed up for. 33 more months.

Tomorrow I start days again. I have two hours in between tonight's night shift and tomorrow's day shift. I don't know where sleep falls into that schedule. But I wouldn't really want to be my patient tomorrow afternoon, when I've been awake for more than 24 hours and am running on fumes. And I have lice.

We have a 44-year-old woman who weighs 400 pounds. We can't even listen to her lungs because the fat is too thick for us to hear anything. She can barely fit in the bed, she can barely move, we can't examine her, she's complaining of non-specific pain. Of course she has non-specific pain, she's 400 pounds.

One of the things that makes this job so incredibly frustrating is that for pretty much everyone in a public hospital, we're seeing them way too late. We're seeing alcoholics who are dying of liver failure, we're seeing stage IV cancer patients who were never even diagnosed until it had spread throughout their bodies. There really is nothing to do to make these people better. There were things we could have done, years ago, but not now. So all we can do is watch them die.

If the 400-pound woman went to the doctor when she was 250 pounds, maybe there are things we could have done to help her, so she wouldn't be 400 pounds and suffering from mysterious pain that probably isn't very mysterious at all, we just haven't found it yet. (And, no, I don't necessarily blame her entirely for not seeing a doctor sooner-- I don't want to make this blog about the health insurance debate, and I don't know what her health insurance status has been over the course of her adult life, and I don't know when she gained most of the weight-- I'm just saying that I'm frustrated, and she's just an example of these kinds of patients, who we can't do anything for, and they're just here and they're dying.)

I get a call from a nurse last night: "[Patient] is refusing to put on his oxygen mask. He's saying he doesn't need it, he's getting extremely aggressive and belligerent toward the nurses."

So I go see the patient, I try and calm him down. He insists no one told him he needs oxygen. he's breathing fine, but finally I'm able to convince him this is for his own good and it will keep him from having trouble during the night. So he puts on the mask.

I go back to write a note in his chart.

And I see it's the wrong patient. He doesn't need an oxygen mask. The patient three rooms down with a similar name needs an oxygen mask.

Oops.

Went in, woke the first guy up, took away the mask, apologized.

At least the mistake wasn't that we cut off his leg.

How far do you go when no matter what you do, the patient's going to die?

We have a woman with end-stage cancer, in terrible pain, barely responsive, does not have a lot of time left, will never have any quality of life, will die either here or in a nursing home, no upside potential here-- it's sad, she's sick, she's dying.

At the same time, she has a gangrenous infection in her leg that's spreading quickly. In a healthy patient, we would absolutely have to amputate the leg, now.

The infection will kill this patient, most likely before the cancer will.

But it's crazy to think this woman has much of a chance of surviving the surgery-- and even if she does survive, she's not going to do well post-op, certainly she's never going to get out of bed again, and post-surgery she'll be in even more pain than she's currently in.

So what do we do?

Keep in mind, there are no good answers here. Not amputating her leg will kill her. Amputating her leg might buy her a couple more weeks, but they'll be painful weeks with no light at the end of the tunnel, and there's a good chance the surgery won't end up buying her any time at all, because she'll die on the table.

Her family has no grasp of the reality of the situation. They want us to do "everything we can."

In other words, they want the surgery.

And the surgeons are happy to try and do the surgery-- they legitimately do want to help this woman, and not doing surgery means she will certainly die.

So every day the surgical team comes in to evaluate her. Is she stable enough? Is she more responsive than yesterday? Is she moaning quite as loudly? I don't know quite what they're looking for-- she's in terrible shape, she doesn't answer to her name, she barely opens her eyes, it's absurd when I hear the resident tell the attending, "oh, she's looking much better than yesterday-- she's not quite so curled up into that fetal position like before."

She is going to die no matter what we do. We are torturing her. But if we don't do the surgery, we are killing her.

There is no good answer. There is just a very ill woman who is unfortunately going to die. And I suppose if it were my mother, I'd want her to have the surgery-- anything to buy any amount of time, any chance for a miracle. Except I think I'd be wrong. I think I'd be completely wrong.

Would you want the surgery? Can you even justify the surgery? But-- assuming it's not taking away from someone else's chance for surgery-- how do you justify not doing everything you can?

"The family wants to speak to the doctor."

I don't blame the family for not realizing this, but if you ask for a doctor at 8:30 at night, you're not going to get a doctor who knows all that much about what's going on. I have 75 patients when I'm working the night shift. I'm executing orders from the day team, I'm making sure nothing bad happens, I'm reading the chart-- but I don't feel terribly qualified to say anything to the family about the patient's condition without worrying I'm going to say something wrong or stupid. I'm only the babysitter, not the parent.

This is an unsolvable problem with hospital care. Because the patients are here 24 hours a day, 7 days a week, and the doctors aren't (or at least we shouldn't be), there are so many handoffs-- on the doctor side and on the nurse side-- and it's impossible to always be fully informed about everyone. Especially when you're on nights, or you're floating between hospitals filling in. You'll have one person during the day, another person at night, then the fill-in on the weekend, and another fill-in when the night person has his day off.

It's not a problem, it's just how it is. But it means that for the patient and the patient's family, there's not always going to be someone equipped to tell you everything you need to know. Which is frustrating for the family, I'm sure. Which is why I like to tell the families what time the attending does his or her rounds. Not that it helps.

"Be here at 8AM, and you'll get to talk to the whole team that's dealing with your mother's care."

"But I want to talk to someone now."

"I'm the only one here now, and all I know is what they've written in the chart. I met your mother an hour ago, and she was asleep. And she's still asleep. I understand you want to know what her prognosis is, but I'm not the one who's able to talk to you about that. I don't want to give you wrong information."

"This is a hospital. My mother should be getting medical care 24 hours a day, not just when her doctor feels like coming to visit."

"She is getting medical care. If she needs medical care, the nurses and the doctors are able to provide it, 24 hours a day. Right now, she's sleeping, she's stable, she's taking the right medications, we're giving her all the proper treatment. But if you want to talk to the resident in charge of her file, that can't happen until the morning."

"But I'm here now."

"I know."

"And I want to talk to someone now."

"If you'll tell me the questions you have, I can leave a note for the resident and he can either find you in the morning if you're here, or he can give you a call."

"I don't want to talk to the doctor on the phone, I want to talk to him now. What kind of doctor are you if you can't tell me how she's doing?"

"She's stable. Right now your mother is doing fine."

"But when is she going to get to go home?"

"I don't have the answer to that."

"Well, you should."

"I will have someone give you a call in the morning, if you'll leave your phone number."

"I don't want to give you my phone number."

"Then you can leave your phone number with the nurses when you leave, and they can relay the message."

"I want to speak to your supervisor."

"My supervisor is saving someone's life right now."

"Then I want to speak to his supervisor."

Surprisingly enough, the patient seems like a lovely woman.

I was surprised at the strong reaction to my post on Saturday about creepy patients.

If I asked a patient to touch my penis, I'd be fired. (I'd also be insane.) Creepy patients are lucky. We can't fire them. We still have to treat them. And we do. But doctors and nurses are still human beings-- of course there are going to be patients we like and patients we don't.

The thing it seems like too many patients don't understand is that when we want to take tests, when we want to keep them another day, when we tell them something-- we're not trying to torture them, it's not punishment, and it's not for our benefit. It's for theirs.

So if someone's going to throw a fit when we tell them we need to do another MRI-- of course I'm going to try and explain why they need it, of course I'm going to try to convince them it's for their own benefit-- but at some point, what more can I do? Because, really, I don't care. If you don't want us to figure out what's wrong with you, if you're going to throw a tantrum every time we want to give a necessary test or give you a pill or do something YOU NEED, if you're going to "threaten" to leave-- at some point it's like, fine, it's your body, it's your health, if you want to go, go-- you're not here for my benefit, you're here for us to help you. If you're going to stand in the way of your own care, then you can leave and give us another bed to treat someone who actually wants our help.

Because, yeah, the customer is always right-- except when the customer is a patient who thinks his cancer was caused by the Advil he took that morning, and doesn't understand when we say we need to do a whole bunch of tests to see what's going on.