We had a team dinner last night after work that I wish I had something to say about. See, it's not that the program doesn't try to forge social connections and give us all the chance to be friends-- we had orientation activities that were social, there are weekly happy hours, we're divided into "teams" that have occasional dinners like this one, there's going to be an overnight retreat in a few months-- but it's hard to force these things especially when the workplace itself is not that friendly day-to-day just because of the nature of the work. We all have different patients, we all spend most of our day either with those patients or in front of a computer entering orders and writing notes. The interaction with other interns is minimal-- sometimes there are two interns to a resident, in which case you're in the same call room as the other intern most of the day, but you're each working on your own things, and basically competing for your resident's attention (or competing to avoid your resident's attention, depending on the resident...), not really hanging out and getting to know each other. And it's tough to become too close to a resident, because he or she is your boss-- and that goes quadruple for an attending. We don't really have direct colleagues-- and even if you become friendly with someone on one cycle, two or four weeks later, you're both onto a different unit in the schedule and won't see each other for six months. The people I've found I become friendliest with during each schedule chunk are the ones I sign out to or sign in from-- the night float folks, when I'm on days, or the day team, when I was on nights. Because you're chatting for 10 minutes, twice a day, about the patients, and it's actually like a conversation. Then you go the rest of the day staring into patient charts and feeling stressed and on your own.

Anyway, the other piece of it-- which isn't the program's fault at all-- is that so many of us are at completely different life stages. It was sort of nice that of the ten people at this team dinner, five of us are single, and so we were there alone and had the chance to talk and get to know each other a little better. But even so, two of the five of us are more than a decade older than the rest, medicine is a second career, and they're single and 40-- which is a different place than single and 27. And of the other five, three are married and brought their spouses (none are doctors-- we hear about doctors marrying other doctors, and of course it happens, but what really seems to happen is doctors date other doctors, or doctors marry and divorce other doctors, because the number of actual doctor-doctor marriages in the hospital, at least among the resident and fellow population, is much smaller than it first seems-- although maybe a lot of them meet down the road as attendings or in private practice, because there do seem to be a fair number of attending-attending marriages), one brought her boyfriend (a resident on another team), and one was on like a first date-- she (rightly) claimed she has no time to date, so when a thing like this came about, she figured she'd invite a guy she'd been e-mailing on Match.com for weeks to come along. Which of course was awkward and weird-- the rest of us know each other or at least know the spouse we came with, and then there's this guy who doesn't even know his own date, and we're in someone's house having dinner, and the host (an attending) is worried this guy is going to steal things, and the joke was that he was some psych patient she picked up on the ward-- which maybe he was.

The spouses didn't have jobs that sounded more interesting than this one, they all seemed to wish they were doctors (they shouldn't), but, hey, I guess the grass is always greener on the other side. Am doing nothing with my two-day weekend-- it's so soon after my lazy vacation that I almost don't feel entitled to be lazy again, but what else can I do. I'm invited to an intern's place to watch some Pro Bowl football thing-- I don't like football but I'll probably go anyway.

"Oh, don't worry about making mistakes," said the attending. "It's not like any of the clinic patients would ever be savvy enough to figure it out. You think someone who's here illegally and doesn't even speak English is going to find a lawyer and sue us?"

Ah, yes. The reason it's okay to make mistakes is because the clinic patients probably won't sue us. Unquestionably the right way to think about our job. Patients who can afford lawyers? Be careful. Patients who can't? Eh, what's the difference, who cares if you get the diagnosis right, maybe we should let the surgeons experiment on them too, while we're at it.

I seriously think I'm going to tell my friends to pretend they're lawyers whenever they go to the doctor. You tell a doctor you're a lawyer, and maybe they won't just pick the sterile instrument off the floor if they accidentally drop it. Maybe they'll get a new one, a clean one, one that won't cause an infection. Maybe they'll double-check the prescription. Maybe they'll order the right tests. Maybe they won't. But at least they'll think twice.

I had a patient come in to clinic today complaining of depression. I think. She brought her boyfriend to be her translator. But that makes it difficult to be sure the boyfriend isn't a contributing factor. How do you ask "does your boyfriend abuse you?" when the boyfriend is the translator? I asked him to leave the room, and called the translator phone instead. He seemed insulted. He probably had a right to be. She gave no indication he's abusing her. I had no reason to suspect. But why have the doubt? The translator today was not putting 100% into the job. She was probably watching TV or something while translating. Even my terrible Spanish was enough to know she wasn't quite right. I don't know where they find the translators, who these people are. It's a work-from-home job, I'm sure it doesn't pay that well, I feel like these people have two or three phone lines and switch off between whatever rings. They do some translating, and then when we're done, they're also the phone psychics and on the sex hotlines. Same people, no doubt. Medical translation and phone sex. Heck, there's probably about the same amount of talk about genitalia on each of those lines. Although we may get a little more graphic.

One day back from vacation and I get a clinic patient with a butt rash. It's the exception that proves the rule: I've written before that whenever it's a young guy coming to the clinic, it's because there's something wrong with his penis. There is no other reason an uninsured guy under the age of 50 goes to a free clinic to see a doctor. Except, apparently, for a rash on his butt.

At first I thought he was a test patient-- they've said that they will sprinkle test patients into clinic throughout the year, so our progress can be evaluated. The test patients are prepped with answers to all of our possible questions, and armed with a checklist to mark us against ("did the doctor do a complete and thorough physical examination?" / "did the doctor wash his hands?" / "did the doctor explain the possible side effects of the medication?"). It's sort of fun to know that somewhere along the line, we'll get a couple of fake patients. It's like trying to figure out which section on the SAT is the experimental one, which won't count. Anyway, this guy just seemed so textbook-- he was too quick with all of his answers, and much too excited to be sharing. "I just got out of a relationship, and I'm concerned my girlfriend may have been cheating on me, and could have given me a sexually transmitted disease. I had gonorrhea a few years ago, but it was effectively treated with medication." Thanks. And he was just a little too clinical with a couple of answers. "We use protection approximately 75% of the time." Are you keeping a log?

So when I went to talk to the supervisor before going back to examine the patient, I told him I thought this might be a test patient, and handed him the file. He laughed. "Trust me, you will never have a test patient with a butt rash." Oh. Well, I guess that makes sense.

Went back in, examined his rash, and sent him off with some cream that will hopefully clear it up. I understand why outpatient medicine gets looked down upon by the specialists-- it doesn't take a genius to deal with butt rashes-- but, hey, I helped him, I don't have to worry that he's going to die overnight, and I got to leave the office before 5. Is it worth looking at butt rashes to get out in time for dinner? I don't know, but it might be.

I'm sorry for the break in posting.

I stayed at my parents' house longer than I expected I would, and just got back. Getting ready to go back to work tomorrow. And since my parents still live in the past, Internet access was spotty. I don't know why I spent a week with them. It's too long. Even though I didn't get to see them over the holidays. It's still too long. But given the choice of being alone in my apartment or tagging along on their pointless days, I chose them. You'd think they'd be happy that I'm a doctor. You'd think any parents would be satisfied that their kid is a doctor. All throughout high school and college that's all they wanted for me, that's all they kept pushing-- do something with your life, become a professional, make sure you have a career. And now that I've done it, they're still not happy. "You need a wife, you need a family...." Well, it's not like I'm not trying, and it's not like you need to remind me. And, frankly, it's not like becoming a doctor isn't what has made the other piece of it so difficult. I asked someone out right before vacation, someone else in the hospital. She said she doesn't want to date another resident because she knows what the schedule is like. So if I can't even get someone at the hospital to understand, how in the world can I have a chance with someone in the real world? The schedule is crazy, there's no way someone with a normal job wants to deal with this. It's one thing if you're already in a relationship, but to start something when you're working 80 hours a week? I'm exhausted most of the time, I'm irritable, I'm not myself. Although if I'm always feeling like I'm not myself maybe I just don't know who "myself" is anymore. Maybe I'm becoming this person I don't want to be. This person who's going to end up alone and miserable. I kept snapping at my parents. I don't know why they even tolerated me being around for a week. I was obnoxious. I was mean. I don't want to be like that, but it's the knee-jerk reaction. I'm trying to be an adult, I'm trying to figure out what an adult life ought to look like. But it's hard. And all I can really do is keep getting up and going to work and hope it figures itself out eventually.

In the morning I start two months of outpatient service, which should be considerably less stressful than the past few months have been. I might actually have free weekends. Which would be great if I had something to do, but since I hardly even know my friends anymore and the only people I talk to are other residents, I don't know why I even need the days off. Maybe I'll do research so I can get a good fellowship. That's the smart thing to do, right? Spend my days off in the library just to fill the hours, pretending I'm doing it for the right reasons?

Going to sleep early tonight, to bank a few extra hours just in case. Awesome.

Vacation is going well. I am sleeping a lot. Catching up on the backlog of TV shows on my DVR. Explaining to friends that even though I have officially been a doctor for six months, I still can't write them prescriptions until I pass Step 3 of the boards, and even then, I'm going to require an actual doctor's visit.

It's kind of nice to go a week without being called "doctor," without having to ask anyone if they moved their bowels today, without having to find a vein, and without having to check lab results. So much of what we do is tedious, dull, mindless work. Interrupted only occasionally by moments of excitement or reward. I guess that's any job though.

I don't think I've talked about this before, but the doctor/nurse divide is weird. One of my intern friends called me the other night and said there's a nurse he likes, and in theory wants to ask her out, but doesn't think he should. It would be awkward, he's like her superior... he doesn't feel comfortable doing anything. And maybe he's right. But the whole dynamic is weird. They call us doctor, and we call them by their names-- and sometimes not even. At one of the hospitals, there's this strange custom where the nurses all go by Miss or Mister and their first names. So I'm Dr. Lastname and they're Miss Jenny or Mister Steve. It's bizarre. Miss Jenny sounds like a kindergarten teacher. Maybe. And some of the residents use these names when they talk about the nurses to each other, like-- "did you give the order to Miss Amber?" "did you tell Miss Jeanette?" Are we children? I feel like we're colleagues, and we should all just call each other by our first names. Like colleagues do. Patients can call us Dr. Whatever, but I don't feel like I need the nurses to treat me like a superior, and I also don't want to treat them like they're my nursery school teacher.

Back to my DVR.

After today's shift is finished, I will be on vacation for my assigned two week block. It's great to have vacation right after everyone I know who isn't a doctor has already taken vacation for the holidays and is back at work without any time to hang out.

I have big plans to sleep, visit my family, and read at least a couple of books that aren't about diagnosing and treating medical conditions. I will also clean my apartment and buy more ketchup, which I've been trying to find time to do for the past three weeks but instead I end up taking tomato paste and mixing it with maple syrup to get a sort of ketchup-like slurry that approximates the taste pretty well.

The past couple of weeks haven't been too bad. I like the people on my team, which I'm starting to realize makes all the difference. It's like any other job-- you like the people you're working with, it makes the days a lot easier. Sort of.

More later.

I walked into a patient's room today, and with the curtain wide open, no blanket over him, no clothing over him-- he was cleaning his penis.

His roommate was watching, riveted.

This is why you don't want to be in a hospital. Ever.

I asked him if he wanted a minute to cover himself up before we talked.

He said no, not necessary.

I asked him if he could please cover himself up.

He said he was just cleaning himself.

I said that's fine, but I wanted his full attention while we talked.

He didn't look up.

I got my resident to deal with him instead. :)

I got home a couple of hours ago, and just got a call from the resident on night float. They hardly ever call-- and it never means something good. Some piece of information is either lost or confusing, or something terrible is happening with a patient and they need to know if there was anything relevant that happened during the day.

This call wasn't a good one.

One of my patients died. Unexpectedly, I guess. If the death of a 90-year-old with multiple cancers, a feeding tube, and a blood infection can be called unexpected. It's just that we didn't expect him to die today. He looked better today. His family went home. He talked about getting out of the hospital.

We should have sent him home as soon as he came in. We should have called hospice and let him die at home. We shouldn't have poked and prodded and given him more pain than he already had. Instead, we tortured him for a week and then he died, in the hospital, alone. Instead of in his own bed, surrounded by people who loved him.

They come, we treat. That's the default. They come, we treat. To send someone home because there's hardly anything we can do isn't how it usually works. As long as hardly anything means maybe something, we do it. If they ask for treatment, we treat. Even if we know it's probably not going to make anything better. So maybe we gave him an extra day. Maybe. Maybe we cost him a week. I don't know. He wasn't going to make it another two months, for sure. And he was in pain. But he was alert, and talking... he was alive. Until he wasn't.

I tell people I don't want to spend my life dealing with death and they ask me why the heck I went to medical school. I want to deal with life. Living patients. People who get better. People who leave the hospital, and not just in a bag. People with years ahead of them, not days. Death is depressing. To be surrounded by it is unceasingly sad.

The resident called the family. The family thanked the resident for his help, said they were relieved that at least his suffering was over. But what were they really thanking us for? We did nothing. There was nothing for us to do. Too often, there's nothing for us to do, and yet we find something to keep the patient there, in the hospital, just one more day. One day too many. One day too many.

I went into a patient's room yesterday to check on him, I pull back the curtain--

And his girlfriend is in the hospital bed with him, naked from the waist up. I immediately closed the curtain, apologized for interrupting, and told him to let me know when they're ready for me. I hear some rustling, he yells out "okay" and I open the curtain back up--

And the girlfriend is pulling up her pants, over leopard-skin underwear.

The patient seems to be feeling better. :)

Happy New Year.

I celebrated by going to sleep at 10:00. Which means I just woke up, 6 and a half hours later, and I think trying to get that last 90 minutes of sleep is going to be a futile effort.

I've been trying to come up with some New Years resolutions, but they're not ready yet. I'm hoping for something more than "do a better job at this doctor thing" and "do a better job at this life thing". We'll see what happens.

My patients finished off the year by simultaneously going downhill all at once. We have one who seems to have acquired a nickname. "The Cadaver." As in, "how's the cadaver looking today?" His blood pressure spiked, so we called a cardiology consult. The doctor came to see him when none of us were in the room, so he went to the nurse's station to make sure this was the right patient, and this was his baseline status-- he said he was worried something had happened to him between the call and when he got there, because he couldn't imagine we were calling a consult on someone who looked like he was already dead. We were like, no, that's what he looks like, and he's looked like this for a week and he's still here. The cardiologist had no recommendations, and said next time if we could refer him the living instead, he would appreciate it.

Which brings me to a weird practice that goes on in the private hospital-- specialist consults.

The way it seems to work is that whichever resident or attending wants the patient to see a specialist just calls whichever specialist they want, there's no system, there's no process-- so if you're a smart gastroenterologist, you just need to befriend all of the residents, make sure you get your contact info in their phones, and you'll get all the referrals and make money. See, the specialists aren't on salary-- they get paid per patient, they get paid per consult. And the way they get new patients, at least at the beginning, is to get hospital referrals-- they see the patient in the hospital and then the patient comes back as an outpatient. If all the residents know cardiologist X, and haven't met cardiologist Y, cardiologist X will get every referral, because it's like cardiologist Y doesn't exist. He has an office down the hall, he would love to see patients-- but it's not about availability, or competence, or a particular sub-specialty, it's just about who the resident likes and wants to send business to.

It's kind of absurd. You could have two neurologists, one who's awesome with stroke patients and one who's awesome with movement disorders, but unless the resident knows that, knows both of them, and doesn't have anything against one of them, one of them might get all of the business. It puts pressure on the specialists to be oddly and extraordinarily polite to us-- they are economically incentivized to be friendly-- they need us to send them business.

But it shouldn't work this way. The specialist you get should be the one who can get there fastest, or the one who will best serve you, not the one who's friendliest with your resident.

It's like you have to be a schmoozer and a salesman besides just being a good doctor. And the potential for corruption is enormous-- if I'm a specialist, what if I tell the residents that I'll give them a kickback for every patient they send me, under the table. Because what's the difference to them, they just need the consult-- and this way they get the consult and I get the business. I'm sure there's a rule against this. There must be. But if no one enforces it, the potential for abuse is obvious.

I guess that's enough on my soapbox for this morning. Maybe 2010 will bring an end to illness and accidents, and then I can sleep more.