Last day of my Grim Reaper rotation. Two patients died this morning. So far.

I got into a long conversation with a patient's daughter yesterday. I had time. Things were slow. The daughter had been staying overnight with her mother, sleeping in the chair. Just in case her mother needed her. She said it seems too hard to be a doctor, to deal with death every day. I told her it is hard, but you try to depersonalize it, you try to keep a healthy distance.

And then I felt guilty. Because I basically told her I won't be that sad when her mother dies. I mean, I'll be a little sad, but I won't be that sad. I didn't know her when she was well. I didn't know her when she was herself. I didn't know her. And I have a dozen other people I need to have enough energy to deal with.

We released her mother this morning, to go home on hospice. The daughter asked for my e-mail address. I didn't give it to her. I'm not her mother's doctor, I can't answer medical questions over e-mail, it's unprofessional-- maybe-- I don't know-- okay, the real reason is that I don't want to know when she dies. I don't want to get an e-mail saying she died. If I find out, I find out, but I don't want to know unless I have to know. She's going to die. It's sad. But I don't need to know.

I'm actually looking forward to working nights. Two weeks of nights, how can I be looking forward to two weeks of nights? I can't just be a doctor to people who are dying. I want to be a doctor to people who get better. To people who are still themselves, to people who have some life ahead of them. I want to help people, not watch them die.

You're called a doctor no matter what kind of medicine you practice, but I wonder if that's a mistake. There is something fundamentally different between healing people and watching them die. I guess hospice is supposed to be that bridge-- hospice is supposed to be what happens once there's nothing more that a doctor can reasonably do. But it's grossly underutilized, and often too late to matter much anyway. And that's fair enough-- I'd want medical treatment for as long as there's a chance-- but I don't want to be the doctor there at the end.

I should have studied harder for the MCAT, gotten into a better medical school, gotten better grades, and gone into dermatology. Yeah, they're probably sort of boring, but at least you're dealing with problems that you can often solve, and when they're really serious you can pass them along to someone else. Is it really what I want to do? Probably not, but the temptation is pretty clear. Plus they earn three times what I'll ever make. Not that I have anything (or anyone) to spend money on.

"We should really talk about how your mother is doing. You know, she's 88, and the progression of disease has been really rapid over the past few weeks, she's had all of these complications, I just want to talk about how we might transition to some kind of comfort care, so she can get out of the hospital and spend the time she has left back at home."

"Doctor, I know what you're saying, but I see her looking at me. I know she's still in there, and I know she'd still want treatment."

"I'm not saying we don't want to treat her. I'm just saying there's not much left that we can do."

"She looks better today than she did yesterday."

"Yesterday we thought we were losing her, that's true. But if it comes to a point where she has to have a breathing tube, or chest compressions-- I want to talk about whether we think that's actually in her best interests at this point."

"I want everything done that can be done. Even if we can squeeze one more minute of life for her, that's what we want."

"I understand. I just want to make sure you're thinking about what she would want, and whether she'd want to be kept alive artificially at this point."

"But she could get better."

"It's very hard to imagine that scenario. You've seen the progression of disease, and the other issues she has going on."

"But it's possible."

"It's not something that we would expect, medically."

I feel like I've been having these conversations all too often, and they're very difficult. Because as much as we want to pretend that we're trying to give patients an informed choice about end-of-life care, and the options they have, I'm absolutely sent in there with an agenda. "Get them to make her DNR [do not resuscitate]," the attending says, and I go in there and see if I can make the family come around. It's not out of a desire to do harm, or to stop treating-- it's out of a desire to be humane, and do what's right for the patient-- she's dying, there's no way to avoid it, and she's not going to have any more moments of what we see as meaningful life. Of course, what we see as meaningful life may be different from what the family sees as meaningful life, and it's hard to know where the line is. No brain activity is not meaningful life, I don't think. Not being able to respond or communicate is not meaningful life, I don't think. But it's impossibly hard for families to make the decision to give up, and to accept that it's the end. And I feel like the Grim Reaper when I go in and have to convince them to make her DNR.

"I think maybe we should postpone this discussion until tomorrow."

"Yes, she'll be better by then, I feel it."

"I hope she will be."

Three family meetings today.

I feel so distant right now, I think it's just three weeks of being on this service, where everyone is basically waiting to be sent home to die, I don't know, I walk in there and these family members are crying and in most cases haven't been prepared at all by their outpatient physicians as far as what the prognosis is... and I feel so powerless and ghoulish and so utterly removed from it emotionally.

One of our med students has grown close to one of the patients-- today was his last day in the hospital, he went in to say he wouldn't be on this team anymore... and he gave the patient his personal e-mail address in case he wants to stay in touch. And the patient mentioned it later, said that was so nice of the med student, and they really bonded.... On the one hand, I think it's great that the med student formed this nice relationship with the patient. On the other hand, I think it's probably a mistake and he's crossing some hard-to-articulate line. There's nothing bad about becoming friends with a patient. But I can see how this could go in some really unfortunate directions.

One problem is that the med student isn't this guy's doctor, and isn't yet a doctor at all. If the patient uses the e-mail address and asks a medical question, the med student shouldn't be in a position where it seems like he'd be speaking as this guy's doctor, or speaking on behalf of the team. He knows that-- but it seems like it would be way too easy to say something, casually, that could be misinterpreted as actual informed medical advice.

The other problem is that, emotionally, to get so invested... he's setting himself up to feel sad. And he'll feel sad anyway, but he's setting himself up to feel sadder. This job is sad enough. Why do anything to make yourself even sadder than you have to be?

In clinic today. Patient is talking into the translator phone. The translator translates:

"I think I have fluid in my bones."

"Yeah, I'm not sure what that means. Can you ask her to say that again?"

"I think I have fluid in my bones."

"Can you ask her if there's another way to describe what it is she's trying to say?"

"My bones feel like there is fluid in them."

"I'm still not quite sure I understand. Can you ask one more time?"

"There are bones in my body, and I sense that some of them are made with fluid."

"It's just getting more confusing each time you ask. Do you think there's a word you're not quite translating properly?"

"Doctor, this is the translator speaking for myself. I am translating exactly what she is saying, and I take offense to the idea that I am not telling you her words."

"I'm not saying you aren't translating properly. I'm just not sure what the patient is trying to tell me. Maybe there's a idiom in your language that isn't coming across?"

"This is the translation. I'm sorry if you don't like it, but all I can do is translate the words she says."

"I'm just trying to help the patient."

"And I don't appreciate being insulted."

"I did not mean to insult you. Can you please ask the patient one more time, and ask her to give me a little more detail about the problem?"

"I think I have a bone fluid in my body. It's coming in from the bones, and makes me feel like fluid."

"Is there a different translator we could try?"

Nurse talking to my 88-year-old patient:

"Your junk is hanging out."

"What? What junk?"

"Your boys."

"What?"

"Put your boys back in your shorts."

"What?"

"Your junk."

"What are you talking about?"

"Your balls are hanging out of your shorts."

"What?"

"Your balls."

"What balls? What?"

"Your junk."

"What?"

I ran a rapid response.

I couldn't have done this a year ago.

Six months ago, really.

Maybe I really am learning something.

(And the patient even survived.)

People are beginning to talk about fellowship applications.

For anyone reading who's outside of this world-- internal medicine residency is 3 years, and a lot of people go on to 1-3 more years of training to specialize-- whether in cardiology, gastroenterology (GI), endocrinology, hematology/oncology, rheumatology, or a few others. The more competitive ones tend to be the ones where people can make the most money-- cardio, hem/onc, GI.

So people have to get recommendations, write an essay, decide where to apply. It's like residency applications all over again.

To be a primary care doctor, it's not necessary to do a fellowship-- next year I'd apply for jobs, and hope to find something that's a good fit. But I feel like you're definitely looked down upon if you don't want to specialize. Well, at least you're looked down upon by specialists.

My co-resident has been working on her applications all month. I've read her essay like six times. Not because she asked me to, but because it's on her computer screen all day and I'm bored and I can't resist taking a look. It's the typical essay you'd expect in any of these situations-- "my father had xyz disease, and watching him go through that made me realize I want to be an xyz doctor, and seeing patients with xyz this past year has only made me further committed to the idea of helping people with xyz and hopefully getting involved in the xyz community and making it my life's work." Fine, whatever, it makes enough sense.

But the reason why I have trouble seeing myself pursuing a specialty like that is because you end up being like a widget maker. If you're, say, an interventional cardiologist, you spend all day doing angiograms and cardiac ablations. They serve a function, absolutely-- but it's boring after a month-long rotation, let alone a lifetime.

Of course, on the flip side, being a primary doctor, you end up seeing the same five problems over and over again, and anything of any importance, you refer off to a specialist anyway. So maybe that's boring too.

Hospital work is draining because you never see anybody who's well. Private practice is boring because you never really deal with anything interesting. It all seems boring-- which is the frustrating part. The attendings who come through are all bored with patient care. They want to get back to their research, some of them spend as little as 6 weeks a year seeing any patients at all, they don't have their own practices. But if I wanted to do science research, I would have gotten a PhD instead of going to medical school. I feel like I rarely meet anyone who will actually admit they enjoy what they do. So it leaves me with no idea what the heck I ought to actually do with my life, and not really any time to give it real thought because I'm working 80 hours a week.

So I can (secretly) make fun of my co-resident for her fake enthusiasm about xyz disease-- because most of it has to be fake, it really does-- but at the same time at least she has a destination. I just have, I don't know, almost two hundred thousand dollars of debt and a sleep debt probably almost as big.

Interesting comments on the previous post. Thanks for all of them. I do think it's hard to maintain the right perspective, and especially to remember that every patient is different, has a different understanding of their illness, and wants/needs explanation at different levels. I had a patient last week-- she comes in with her husband, and after some tests we see that the situation is not a good one. I start explaining things, in very simple terms, slowly and carefully. Then it happens to come up that she's a doctor herself-- it wasn't in the chart-- and it's like a complete 180. "Why didn't you say so?" "Oh, I didn't think of it." And then I really found myself completely changing the kinds of words I was using and the tone I was saying them in. She was following-- but her husband from that point on really wasn't. And he asked me to back up, and slow down. And I did. But just my whole mental process-- from "she's just a patient" to "she's a doctor, so I can use the medical words now"-- was interesting. I don't know what the lesson necessarily is, but I was surprised how different it felt to talk to "just a patient" vs. "a doctor." Because of course she shouldn't be "just" a patient. She's a patient. Period. They're all patients.

I don't know if any of that makes sense.

On a lighter note, I think one of the interns on my team took a secret vacation.

She had switched shifts so that she didn't have to work either day this weekend. On Friday, she said she had to leave at noon for a meeting with the program director.

Today, she texts me at seven in the morning saying she wasn't going to be in until 2:00 because she totally forgot about a required lecture she had to go to.

I wouldn't have thought anything of it, except she looked so different today than she did last week-- so relaxed, so calm, so tan. And maybe it was just the weekend, but you sit in the call room long enough staring at the sun that you never get to see that you can start to drive yourself nuts with theories. So I've decided she actually cut out early on Friday, flew to some tropical island, and the flight was delayed last night, she panicked, and had to send the text about the (fake) lecture so she wouldn't get in trouble.

I don't really care if she took a secret vacation-- I'm her supervisor, but I'm not her boss-- I just think it's crazy to imagine someone risking her job just for an extra half-day on each end of the weekend. She already had the two days off. If she'd asked, I would probably have let her out a couple hours early on Friday, and told her she could come in an hour late today. I hate to think I'm a monster resident that my interns would be afraid to talk to. And I don't think I am, so maybe she really did have a meeting and a lecture. It just seems too coincidental for them to bookend the weekend like that.

I think I'm just hallucinating from the lack of two-day weekends for the past six months, and the fact I still won't have one for another few months. At least I have one-day weekends. One is better than none.

Is false hope better than no hope?

You have end-stage cancer, the chance of any sort of meaningful recovery is pretty close to zero, if not actually zero. Do you want the doctor deluding you into believing there's hope, and offering a stream of experimental treatments that there's no rational reason to believe will work? Or do you want her to help you accept that this disease is going to kill you, and most likely really, really soon?

I mean, obviously there's no good answer. Of course if there's any chance of success, most patients are going to want even the most long-shot treatments. And if there's any reason for optimism, the doctor certainly shouldn't be discounting it.

But I think what's been getting to me these past few weeks-- as I've been on a service with probably the sickest patients I've seen since I started residency-- is that the amount of hope presented is so disproportionate to the reality. "We'll try this, and hopefully it'll work," is not a lie, but when you've tried three similar treatments, and the patient has the genetic markers that indicate this one won't work either, and even success at this point is extending life by a few weeks-- it's hard to watch the patients get so excited about the possibility, to watch them use that hope to plan the future, to hear them talk about a future that is so unlikely to exist...

No one's trying to do a bad thing-- you worry, to some extent, that at some point treatment takes away from quality of life, and the costs and benefits of doing it-- but in a lot of cases, that isn't even an issue-- the disease causes pain, the disease causes enough problems that even failed treatments aren't necessarily making things worse. If you can barely get out of bed anyway, then, sure, why not try the experimental treatment with a 0.1% chance of helping, if it's not going to make you feel any worse while it's happening?

And the doctors are trying to make miracles happen, absolutely-- they genuinely hope the treatments will help, they genuinely want things to work-- it's just that there's a disconnect between the reality and what's communicated to the patient.

And so when the end does come, there's a level of surprise that it's so hard to see. "How did this happen?" She's been extremely, extremely ill for weeks now, the disease was running its course, this is what we knew would happen-- "But we thought the latest treatment--" The treatment didn't work. We didn't think it would work. We hoped we'd be wrong, but this was the most likely outcome. "But how did she go downhill so quickly--" She's been going downhill for months, this wasn't quick, this wasn't surprising-- Except it's surprising when you're prepared for success, when you're holding on to so much hope that the hope exceeds the reality.

I don't have an answer. I don't think we should make patients and their families sadder than they need to be. I think we should let them hope, and keep trying treatments that might work, even if they probably won't-- as long as the patient wants them. But I also think there's a line-- a line where the hope becomes false, and the interaction is a lie. And I don't know if I could spend a career lying to patients and creating hope that I don't really believe in. It's too hard for the patient, and for the doctor.

I mean, it's hard in any case. People dying-- it's hard. Period. I don't know. I haven't yet seen a miracle cure happen, so I guess I have a hard time understanding how the doctors can make a career of this. I feel like I'd have to see some long-shot treatment work, at least once, to believe it can, and to believe there's good to be done here. Otherwise it just all seems so futile, and like practicing this kind of medicine is pointless. They're dying, soon. We're not really helping. It's hard.

I have a patient on Facebook.

I mean, I'm sure I have a bunch of patients on Facebook, but I mean here, in the hospital, I have a patient who brought her computer, and she got onto the hospital's wireless network, and she's on Facebook.

Over in the call room, we're all on Facebook. I'll check a couple of times a day, one of my interns seems to be on the entire day, on her iPhone, whenever she's not, you know, saving people from death.

There's a nurse who's definitely on Facebook, at the computer terminal, when she's not playing one of those games with colored balls that you have to eliminate color by color.

And a whole bunch of the residents and fellows I've worked with have sent me Facebook friend requests, so I know they're on Facebook.

So how far away is a future where Facebook has replaced all current medical communication. You're in your room, and you start to feel funny, why page the nurse? You page the nurse, it takes time for the nurse to respond. Just update your status. I'll see it, the nurse will see it, the intern will see it... even if we're not your Facebook friend, I'm sure we have friends in common, or friends of friends-- what, they say everyone's no more than six degrees separated, right? So everyone can comment on your status and I'm sure soon enough I'll see it on my screen.

So I find out you're not feeling quite right, and I can send a Facebook message to the nurse, reminding her to check on you-- easier than picking up the phone, and if the nurse is away from the nurse's station I know she'll at least be carrying around her iPhone and checking Facebook-- so it's a faster way to get in touch.

And why have to call a consult, and then circle back with the fellow, and make six phone calls to get everyone on the same page? I can just update my status with my patient's status, and let everyone else comment on it. Maybe there's another doctor, not involved with the case, who has something useful to add. We'd never know without Facebook.

And maybe we don't want to schedule that MRI quite yet, because the MRI technician is pretty busy with his Farm and some Zombie Attacks, and we should probably wait until all of that slows down before we wheel the patient in for a test.

And why wait for the scan results to be read by Radiology, anyway? Just post the picture on Facebook, we'll all see it, thumbs-up if it looks clean, otherwise we can just tag all the notable spots on the photo.

And don't worry about HIPAA, everyone can just set their own privacy settings, it's no problem at all.

I think this is a future that's not too far away.

Plus, I totally want my patients to see my vacation photos.

I want to write a post about the line between life and death, but I'm not entirely sure what I'm trying to say. I mean, does our obligation to our patients stop the moment they die, or is it our job-- as doctors, as people-- to continue to care, at least enough to help the family through for a couple of minutes.

What's making me think about it is a patient who died this morning, after a few days of steadily going downhill, on top of a few years of fighting a constantly-losing battle against her cancer. I wouldn't say the death was unexpected, but a week ago no one thought it would be this soon, and it was only in the last two or three days that it became pretty clear that this was the end.

At 8:30 this morning, this patient was absolutely on everyone's radar screen. We were trying to get the patient stable enough to move from one unit to another, we were trying to get consent for a procedure that would make her more comfortable, we were talking to the family, there were doctors in and out of her room. Nothing was going to change the ultimate outcome, but there was active work being done on our part to manage her death as well as possible.

And then she died.

Before we could do what we were planning to do, before we'd really finished explaining to the family why she'd suddenly taken a turn for the worse...

And that's it. There's nothing more to do, you move on to another patient, who you can hopefully help. But there's a family still in there-- with their daughter/sister/mother lying in the hospital bed, dead-- grieving. What do you say to them? What can you possibly say to them?

And I think because we don't really know what we can say, most of the time we say nothing. My intern had been getting set to go talk to the patient's family about the plan for the day, and then we get the call that she died, and my intern sits back down.

"Aren't you going to go talk to the family?"

"Oh-- about what? It's not like there's anything to do."

"No, but-- maybe they have questions--"

"I don't even know how exactly she died. You want me to go and-- do what exactly? We failed, she's dead, aren't we done?"

And I don't know the answer. I went down to the unit where she died, and I can hear the family from all the way down the hall, crying, wailing-- and everyone's just casually at the nurse's station.

"Has anyone talked to them?" I asked.

"About what?"

"About what happened?"

"Oh, we figured someone from your team was going to deal with that. Is that supposed to be our job?"

Deal with that-- as if it's another task on a list. I didn't know what to say, but I felt like I should go in there, just to-- I don't know. I mean, everyone else is right. There's nothing we can do, our job is to treat the patients who are alive, there's nothing more we can do. Except there's a family in there grieving, and I can't just turn it off-- I care at 8:29 when she's alive (barely), I'm running around, trying to help her-- and then at 8:30 she's dead, so it's okay not to care anymore.

The family stayed for twenty minutes, until transport came to move the body, and the nurses asked the family to move to the waiting room. I told them I was sorry for their loss, and I meant it, except I don't really know what I meant, what I'm supposed to feel, and what I'm supposed to do.

We never know these people healthy. That's part of what makes it easier and part of what makes it more difficult. In outpatient settings, doctors know their patients healthy. When they get sick, you feel it-- it's a loss. We see them at their sickest, in a lot of cases when they'd be better off dead. It's harder to feel the loss. I don't know what my point is, or if I even have one. It's just, I don't know, hard to feel like you make much of a difference when they come in sick, they leave sick, besides my clinic hours I haven't seen a healthy patient in months. Everyone who leaves the hospital is a ticking time bomb until they come back. I've seen so many repeat patients just in the past year. It's a revolving door. It's so easy to forget that there are healthy people in the world. Somewhere. Not here. Somewhere.

Phone rings last night.

On my day off!

"Yeah, I just wanted to give you the update on your patients. I'm going to write it all in the notes, but I thought I'd call and--"

No! The notes are there for a reason! I'll read it tomorrow! What use is knowing it the night before? I'm not going to be doing anything about anything, I'm not there, the night float people will do whatever they need to do, why are you spoiling my day off??

Oh well. Ten minutes on the phone. "Yeah... sure... oh... yeah... yep... yeah...." At least I'm not a fellow. The fellows on this service do overnight call from home, but they cover the whole hospital, and have to pick up no matter what-- there's no system here where non-urgent calls get held until the morning, everyone who calls gets the covering fellow... so every night, they get like 75 phone calls.

"I feel this strange feeling..."

"Go to the emergency room."

"I have a fever..."

"Go to the emergency room."

"I'm having trouble sleeping..."

"Keep trying."

"Oh, I just wanted to leave a message..."

"Yeah, I'm the answering machine."

I'm just imagining that's how it goes. One of the few good things about residency is that when you're off, you're really off. No one can call me in, no one can make me cancel a vacation, it just doesn't work that way.

So don't call me on my day off! I don't want to think about the hospital! At all!

I'm the assigned code leader once a week on this rotation, including today. I feel like over the course of the past year, I've become reasonably competent at a few things. For the most part, I can distinguish between urgent problems and less-urgent problems. I feel reasonably confident about which tests to order and when to order them. I'm starting to recognize patterns, and how certain situations unfold. Lab value says this means we need to do that. Okay, fine.

Running a code is not something I'm comfortable doing.

Putting in a central line, also not something I'm comfortable doing, but that's for another post. Running a code is scary. Being the person in charge of trying to bring someone back to life is the opposite of a responsibility that I'm happy to have. I don't think I'm alone there. I remember when I was 16 or 17, my grandfather fainted in the waiting room of the doctor's office when I was taking him to an appointment. The doctor freaked out. He ran into the hall and screamed for another doctor. Any other doctor. Just not him. He said to me-- as if this was something I'd done to punish him-- "don't bring any more dying patients to my office." He wasn't even dead. He fainted. We called 911, the paramedics came, he was okay. This was a real doctor, with a real medical degree, freaking out.

I am better than that, but not by much-- or at least that's my fear. The beeper goes off, I panic. I do not want to run a code. If I'm the patient's family member, I do not want me running the code. I want a real doctor running the code. Someone who actually knows what they're doing.

We practice this, but practicing is not the same as really doing it. And I've been at codes, but never alone. And hopefully I wouldn't be alone here either-- people are supposed to come. People are supposed to come help. People more senior than me, even. They can take over. I can let them. I'm happy to let them.

But I'm the designated one in charge. If no one else shows up, it's on me. It's on me to tell everyone what to do and where to go. It's on me.

I'm told there's been like two codes in the past month. The odds the next one falls on my day are low. I'm keeping my fingers crossed. Hang in there until tomorrow. When someone else has the beeper. Just a little longer.

Yesterday I started my new rotation-- no more overnights for a while.

My first month as a resident has been... okay. It is so much better to be the resident than the intern. I don't even think I completely realized it as the intern. It's not that you're that much less busy, but the fact that you're not at the bottom-- that you can delegate, that you can prioritize, that you're not being micro-managed, someone standing over you expecting a progress report every thirty seconds-- it makes it a lot easier to get through the day.

I think I've been a little bit spoiled this month, as far as the thing about being a resident that scares me the most-- being in charge, being ultimately responsible. Because in this rotation, I haven't been. There's been a fellow, there's been third-years on call for consultation, the attendings have been very involved. I've made decisions, but not really anything big, and there have been people to call with questions. I worry more about when I'm on the regular floor, and I'm really the one making the call a lot of the time. But by the time I'm on a regular floor month, I will have had more months of this, and I'll know better what I'm doing.

One of the nice things about being the resident is being able to set the tone for the team. As an intern, you have to adapt to your resident's style-- as a resident, the interns had to adapt to me. I'd like to think I was pretty easy to work with-- hopefully my peer evaluations will bear that out-- and that my "style" wasn't anything particularly bizarre or demanding-- but to not be beholden to someone else's idiosyncracies about how they wanted the notes written or what information they wanted in what order or which patients should get seen when-- was freeing, a little bit.

I think mostly what I learned is that I don't mind the teaching part of this, I don't mind being in charge of interns. I've written before about how we're not selected for our ability to manage people, we're not selected for our ability to teach, but those are really important parts of the job. And I didn't know what it would be like until I had to do it. And maybe it's because I had good interns this month, but that part of it has been fine-- and I think that's why I've had less to say on the blog this month. My hours have been long, the patient situations have been stressful and crazy, I've been sleep-deprived and exhausted-- but it's all been far better than the worst of intern year.

I say that now, but day #1 of month #2 is making me think I won't be so lucky the whole year... I've already been yelled at by an attending, a nurse... and a patient.

I can't understand how some patients think about hospitals and doctors. This isn't a hotel, and the things we need to do aren't really menu items from which you can pick or choose. "I'll have that test, but not the other one," is not a sensible thing for a patient to insist on. "You've already taken enough blood today," is not an acceptable patient response. We're not taking blood for our own vampire-like purposes. We're taking it because we need to check something that's going on inside of you, to hopefully make you better. When you refuse things, and make our job more difficult, you're only hurting yourself. Why do so many patients have such a hard time understanding that.

It's not just, "you've already taken enough blood today." It's, "I've already had an x-ray," and "I don't think that medication does anything," and "I should be getting more food," and "That's not where I want the IV," and "I'm supposed to take my pills in the morning, not in the afternoon," and "I don't need an MRI," and "you can come in here one more time, but then I'm closing the door."

I don't know how to convince the unconvinceable, and I don't have all day to try. If you don't think we're trying to help you, leave. Otherwise you're just making things worse.

End of rant.