Yesterday I had to go down to the emergency room with my resident for an internal medicine consult. Chest pain. Or so we thought. Her daughter arrives, in a panic, looking for her mother... they talk in a foreign language for a few minutes... ankle pain. She has ankle pain, not chest pain. She stumbled through English well enough to convince the triage folks that a translator wasn't necessary, and somehow she ended up being understood as a chest pain patient. Oops. Chest pain? Admit. Ankle pain? You go home.

I am surprised at how much fun it is to have med students around, more confused than I am, making me feel like I'm a genius, or at least that I'm a doctor. Hey, after five months I know things! I know the abbreviations people use! I know what's probably serious and what's probably not! I know when to call a rapid response! I sent one of the med students an e-mail with a link to an article about a condition one of the patients has, I told him to read it and then he can tell the resident about it, impress her, make her think he knows something, since she's the one evaluating him. I think he appreciated it. I remember being a med student. I remember wishing someone would help me out like that. So I'm trying to be a good intern and help them feel not so lost. It helps that it's a slow week, not too many patients. Low stress level.

I can't actually tell if the lowered stress level is because of the actual work-- fewer patients, easier stuff going on with them, just by chance, could change any minute-- or it's because I'm actually starting to figure out what I'm doing and getting comfortable. It's probably some of each. And I think perhaps the third piece of it is that I'm getting to know some of the other interns and making friends. It's harder than I expected it would be to make friends. Not because of anything about the people, but just because there is no communal downtime. Everyone is on a different rotation, in a different part of the hospital or even a different hospital, and we never actually have a chance to get to know each other. In med school you have classes, you have lunch, you have extracurricular activities. At a "normal" job you have downtime, people chat, people get to know each other. But here it's so busy and you're often so isolated in the call room, just dealing with your resident, and maybe one other intern, that it's hard to actually have a conversation with someone.

Not to mention there isn't a lot of "not at work" time that people have in common and can make plans. My day off might not be your day off, my early night is probably your on-call night, you're on days and I'm on nights... so even if I wanted to make plans with someone, it's almost impossible. But bit by bit the five minute conversations add up. The guy on night float who I have to sign out my patients to, and then get them back in the morning-- we talk for a couple minutes, I know where he's from, what he wants to do, we chat about the patients... slowly, we're becoming friends. The other interns on the floor, we see each other when a patient is coding or during a rapid response-- you know, it's not the most opportune time to get to know someone, but little by little.... And so I can sort of see the light at the end of the tunnel. That after a year, after two, after three, I'll know some of these people pretty well, I'll have some friends, I won't be completely alone here, sad, frustrated, depressed. Or at least that's the hope.

Off Saturday, working Sunday. Hopefully out early enough tonight to feel like it's a full day off tomorrow and not just a break between two shifts. Hopefully.

A patient rose from the dead yesterday.

Okay, not quite. But almost. She had been basically catatonic-- unresponsive, a tremor in her leg but otherwise practically paralyzed, unable to speak, completely out of it-- for days, we thought maybe from her psych medications but even after we stopped the meds nothing changed. We ran tests, couldn't figure out what was going on.

Then yesterday her son runs into the hall-- "she woke up," he starts screaming. I go into her room, and sure enough, she's sitting up, talking, acting as if nothing had happened. "It feels like I had a stroke," she said. I asked what she meant, but she couldn't really verbalize. We've done an MRI-- there's no evidence she had a stroke. But everyone was talking miracle yesterday, we were telling her that she was in such bad shape, but what a miracle that she's better, we don't know what happened, we'll keep trying to figure it out....

I get in this morning... and she's back to how she was before. Unresponsive, like she's in a trance.

It's like she's possessed. For Halloween, perhaps. And we don't know what to do. And her son is even more distraught than before, since he had that glimmer of hope-- more than a glimmer, really-- for half a day she was back to some degree of normal.

People getting better, only to get worse. Very frustrating part of the job.

A new crop of third-year med students started today, doing their sub-internships. It's nice to feel smarter than they are. To know a little bit about what to do, to feel like I'm not the most useless one on the team. It's silly for me to feel that way-- it's silly for me to like feeling superior, and to actually think I'm superior-- I'm sure they know more than I did when I was a third-year med student. But still, it's nice to feel like after a few months of doing this, I know enough to teach someone something. I know enough to feel like I'm not completely lost all the time. I know enough to be able to distinguish real crisis from fake crisis. Sort of.

It's been a running joke with the girl night float that nothing ever happens to my patients. They're pretty boring. When I'm signing in every morning we joke about it, maybe we're flirting a little bit, I'm not sure. So today when she said, "Your patients! What a night!" I thought she was kidding, like she usually is. But no. One of my patients was discovered at 4:45AM unable to move the left side of his body. That's when these things are discovered, since the nurses mostly ignore the patients all night until they round just before 5. He had a massive stroke during the night. They didn't know how long he'd been that way, so there wasn't much treatment to do. It's unfortunate-- I mean, he wasn't in good shape beforehand, he probably only has a few weeks left, so even while I feel bad and it's a sad situation, it's less sad than if the same thing happened to someone healthy. So instead of the playful flirting with my co-intern, I had to go run and check on the patient and see what was going on. Another one of my patients fell out of bed just after midnight, but luckily didn't break anything. And another one threw a little fit in the middle of the night wanting to check himself out of the hospital. "They didn't call you," he told me in the morning. "I told them to call you and you would say it was okay for me to go home." Uh, no. I would have said you need to stay in the hospital, and I'm glad they didn't call me, because I was fast asleep. Patients don't really understand the work schedules. I'm glad they don't give out our cell phone numbers to the patients.

I didn't mean the last sentence of my previous post. The commenter is right. I apologize.

I can't sleep. I don't know why. Usually I have no difficulties. I don't think it's tied to anything from work, except maybe it is. Maybe it's the work itself, a week of it accumulating after two weeks of vacation.

I almost did a bad thing the other night. Okay, I did do a bad (negligent) thing, but luckily nothing bad happened. I accidentally left a patient off my sign-out list, to the guy on night float. Easy mistake to make, but shouldn't have happened. If something had happened to the guy during the night-- nothing did-- they would have paged the guy on night float, and he would have said he didn't know that patient, wasn't on his list, he would have had to pull up the file, he wouldn't have known what was going on. He would have figured it out, but it would have taken a few minutes, he would have been caught off-guard, and something could have happened to the patient. Teaches me to triple-check. I didn't realize until getting my patients back in the morning. Saw he wasn't on the list. Went to check on him. He was still there. He was okay. A bit of a relief. Wouldn't have been disastrous, in 99% of cases, but still, I should be better than that.

I saw someone pass out this afternoon. And it wasn't even a patient.

The things we see... and that we're totally unprepared for. I was in a patient's room with one of the medical students, we're talking to the patient about his medications, surgical history, allergies... and all of the sudden the med student makes this noise, kind of like a hiccup, and then crumples to the floor.

I froze. The patient's wife screamed. I ran into the hall and grabbed a nurse, told her to call a rapid response. Went back in, made sure the student was breathing, and by then he'd regained consciousness. The code team arrived, made sure the student was okay, and took him out of the room to rest in the nurse's station. I had to calm the patient and his wife, assure them that this was atypical and not indicative of any sort of illness in the hospital or anything they needed to be worried about. Swine flu? Random death disease? In their minds, it could have been anything.

I was pretty shaken up. It was crazy. I'm a little scared how shaken up I felt -- I'm a doctor, I should be able to handle these things better, shouldn't I? But a med student passing out? It's scary.

In med school someone passed out while watching a surgery-- something bloody and stomach-turning, but he said something when he started feeling faint, and one of the doctors watching with us was able to grab him before he fell and make sure he was okay. This time, it was just in the course of normal business, and he went down to the ground.

We're not quite sure what happened. I thought they should have admitted him, just to make sure it wasn't something more than dehydration (the student's excuse), but they decided not to. He said it's happened before (!!) and he's always been okay... I'm not sure I'm completely on board with that, but it's not like it's my call.

The patient was justifiably freaked out. Most of the patients seem to get freaked out about things they shouldn't be freaked out about-- taking medication, getting their blood pressure checked-- so at least this one had a real reason. Gosh. I don't want to work with that med student anymore.

A good doctor would never actually leave. There's always more to do, there's always labs to check on, there's always tests to run, there's always follow-up. When I look at my watch and see it's time to sign out to the night float, I'm genuinely excited to leave. I race to finish up what needs to finish up, and I leave. And then as I walk to my car I remember eight more things I should have done, calls to make, results to check on. And I feel like I'm not giving my patients enough, that if I was a good doctor, I'd still be there.

That's the problem with this profession. The problems are never all solved. There's always another patient, there's always another illness. Everyone will die of something, no matter what we do. We will never reach the end of the stack. It's like being a public defender, I guess. There are always more criminals. So what's the point? I mean, of course there's a point. There are the ones you can help, the ones you can save. But there are so many more. My work doesn't make a dent. Even for these specific patients I'm not sure my work makes a dent. But in the overall scheme of things it certainly doesn't.

The solution, if there is one? People say this stuff is why they're drawn to research. They want to be involved in the bigger questions, they want to make an impact. Well, okay... but then you look at the research actually being done, and the vast majority of it is pointless. Maybe not pointless, but at least very specific. Even in the best journals-- I went to the JAMA website. We've got "Implications of Hypertrophic Cardiomyopathy Transmitted by Sperm Donation," "Laser Photocoagulation and Intravitreal Injection of Triamcinolone for Retinal Vein Occlusions," "Computed Tomographic Colonography for Detecting Advanced Neoplasia." These may well be important and useful studies, but they're relevant for such a tiny percentage of the population. And this is a *good* journal. There are all sorts of less-good journals. And unpublished papers. And research that finds nothing. This isn't a knock on research. We need good research. Research helps us. But doing research doesn't actually sound that interesting, especially not at the level I'm at. Helping a professor collect data, input data, sort data. Calling a list of folks who've broken a hip to ask them about the fall precautions they've taken in their homes. This is one step above telemarketing.

A good doctor would leave. A good doctor can't do everything. A good doctor shouldn't feel guilty for passing things off to night float. That's what night float is there for. That's the job. We can't care about everyone and everything. We can't get personally invested in every patient, in every test result. We couldn't do our jobs if we did. There aren't enough hours in the day. A good doctor should leave. A good doctor should sleep. A good doctor should leave.

Maybe.

Why do patients think that threatening to leave the hospital is going to motivate us to try and stop them? "I got the wrong lunch and I'm going to pack up and leave if you don't fix it," one of my patients said this afternoon. You want to leave because you got the wrong lunch? What do I care? It just means less work for me. You're not doing me any favors by being in the hospital. You should want to get better. You're not a child. I feel like half the patients in the hospital act like five year olds. "I'm not getting that test," another patient insisted. "Sir, we can't figure out what's wrong with you without the test." "Well I'm not getting it, and that's final." "That's your choice, but if you want to get better, you need to think about letting us do that test so that we can find out what's wrong and help you." "Well you need to find another way to figure that out." I don't gain anything by giving invasive tests. I don't even get paid for it. We're just trying to help. Why do the patients have to make it so difficult?

I have a schizophrenic patient who refuses to talk to doctors. At least he has an actual mental illness to excuse the behavior. He'll talk to nurses, physical therapists, the guy who cleans the floor... but not to doctors. I didn't know this at first, and went in with my white coat, introduced myself... and he said nothing. Wouldn't even look me in the eye. I thought perhaps he was deaf, or completely zonked out by some medication. Then a tech comes in and he's suddenly chatting away, friendly as can be. He let me relay my messages through her. "Can you ask the patient how he is feeling?" And she would ask him, and he would tell her, and she would tell me. I sent a med student in without her coat, told her to pretend to be a nursing student, and gave her the questions we needed him to answer. That worked, for now, but I'm not sure he'll keep buying the act.

I have a secret.

I can't read an EKG.

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

I can't.

Not yet.

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

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

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

Last precious hours of vacation.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

I just got back from the doctor.

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

On my vacation, and I get sick.

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

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

She definitely hated me. Doctors are bad patients.

It felt good not to set an alarm this morning.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Examining my first patient this morning:

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

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