Back to work.

Today I'm starting a month in the emergency room.

Day shifts, night shifts, all sorts of shifts that together make up a schedule I'm not particularly looking forward to. 2PM to midnight one day, back at 8AM to 9PM the next, then 24 hours off and working 9PM to 7AM the next day. It's as if the point is to disorient us and mess up any hope of a real sleep schedule. But that can't be the point, can it?

I'm scared. I haven't missed work these last two weeks. And I feel like that's a problem. If this is what I'm going to be doing for the rest of my life, shouldn't I miss it when I'm not doing it? Shouldn't there be some part of me that wants to go back? And maybe that's too high a standard to hold myself to -- it's been so many months since any kind of a vacation, why do I feel like it's so wrong to have a vacation and not think about work and just take the days off and be off? What is wrong with enjoying not going to work?

I think the problem is that I'm still trying to come to terms with the idea that most jobs are just jobs. I feel like I used to picture this as a calling. I used to look at adults and think their jobs were a big piece of what defined them, and of course they must enjoy their jobs because otherwise they would be doing something else. And that life was about finding a rewarding career and the rest of the pieces could fall into place after that.

But the more adult I get, the more adults I meet, and the more I realize that very few people find that calling. And for the rest of us, it's a job, and most jobs aren't so awesome. There are good things, there are bad things, but it's just a job. And if it's just a job and not a calling, we're allowed not to like it, and we're allowed to enjoy being on vacation.

So it's not so much that I'm annoyed that I don't miss work. It's that I'm annoyed to finally be realizing that I'm going to spend my life with a job, and not a calling.

But at least there'll be a paycheck.

I didn't mean to take such a break from the blog.

But I just spent a week taking an actual-- much-needed, I think-- vacation, and I stayed as far away from the Internet as I could.

Didn't check my work e-mail.

Which has turned out to be a bit of a disaster now that I'm back.

"Fall Performance Reviews" said one e-mail, requesting me to write back with some available dates and times.

"Fall Reviews -- Please Respond"

"Fall Reviews -- You Must Reply"

"Fall Reviews -- IMPORTANT"

"Please call the program director ASAP"

Five e-mails over the course of the week, each more urgent than the last, making me feel like my "fall performance review" will be taking a turn for the worse and they'll say there's an expectation that I should be checking e-mail regularly even while on vacation. Which maybe there should be, but I was hoping that one of the things that makes this career better than some others is that when you're off, you can really be off. People know when they're on call, people know when they have to work. When I get a vacation, I don't want to think about work.

And the dates they gave me for the review are all vacation days too! I certainly don't want to have a performance review over my vacation! It's supposed to be a vacation. An actual vacation.

I was afraid that I'd encounter a medical emergency while I was away and have to act. Or lie and say I wasn't a doctor. Fortunately nothing. A sort-of choking at a breakfast buffet, but the guy figured it out on his own before I needed to intervene.

More once I catch up on sleep. I still have another 4 days off before going back this weekend, and I plan to sleep a lot. And I have a week of e-mail to catch up on.

My two-week vacation starts Friday.

Not a day too soon. Clinic patient today. Came in last month for a checkup. He has hypothroidism, and his lab results were too high. I took a quick look at his chart, saw that he takes 100mcg of his medication, so I upped it to 125 and told him he really needs to take it.

He comes in today, lab results are even higher. "Why aren't you taking your medication?" "Oh, I am, I try, almost every day. I am taking it." "It doesn't seem like you are." "Oh, I will be better, I will, I am trying." Okay, whatever, everyone says they take their medication even when they don't.

I take another look at the chart.

And I notice that I didn't read quite so carefully last month. Because he'd actually been prescribed 2 of the 100mcg pills daily. 200 mcg. And I'd dropped it to 125mcg instead of bumping it up.

And so he'd probably been taking the medicine. He just wasn't getting enough of it. Because I am a terrible doctor.

Or at least a slightly careless doctor. Sometimes.

No long term issue, he's on the right dose now and he'll be fine. But, uh... oops?

I saw eight patients in clinic today, and I didn't care about any of them.

I know it's terrible to say that, but it's true. I don't know if I was unusually tired, or these patients were unusually awful, or I'm just a bad person, but they came in, I listened to their problems, I prescribed some medication, made some referrals, wrote some notes, and really didn't care about any of it. Just wanted to be done with it and come home... come home to nothing, really. The Braves-Giants playoff game on TV, I guess. Me and some Kraft Macaroni and Cheese, the Braves-Giants game, an empty e-mail inbox, and very few thoughts about these patients I saw today.

I know I complain about inpatient rotations when I'm on them, and I say I want to do outpatient work, but, man, outpatient work sucks if you don't have a life. If you have a life, it seems pretty great. You go to work, you have appointments, you come home, you make pretty good money and get to live the rest of your life. You're on call sometimes, sure, but you can own the time you're not working, and the time you're working isn't so terrible, it's pretty chill to see clinic patients, you see the same five problems, you refer the rest. But if you have nothing to come home to...

At least the insane hospital schedule lets me forget I don't have a life. How can anyone have a life working eighty hours a week, overnight every x nights, weekends, 16 hour shifts, on your feet, running codes, watching people die. You can't. You can get wrapped up in the work-- you have no choice but to get wrapped up in the work-- you can't have a life even if you want one.

But then I'm on outpatient and all of a sudden there's time to breathe, the days don't run into each other in quite the same way, I have weekends... and I have nothing to do and I realize that this can be my life if I don't do something about it. Go to work, come home, watch TV, go to sleep, do it again, and have absolutely nothing change, ever.

That's the thing about this job. Other jobs change over time. You have business trips, you work on new projects, you have things to look forward to, things to plan for. This job, you see patients. And then you see more patients. And then you see more patients. You see patients, you get paid. You sit on your couch, you don't get paid. There are no special days, there are no new projects, there are no new challenges. There are just patients and whatever they're sick with. And if I'm bored 16 months into residency, what's going to happen in five years?

Doctors don't blog. I can't quite figure out why. There is no community. There's Kevin MD and a few others, but there's not much with any real traction, at least not that I've found. Doctors write books, a few of them, Atul Gawande, Jerome Groopman, but for the most part doctors are not telling their stories. No one at work even remembers their patients from one day to the next. I feel like a lot of my co-residents wipe their memory clean every day. They barely remember each other-- or at least they barely remember me. No one reads the newspaper, no one sees movies, no one else is probably even watching this Giants-Braves game. It was like that in medical school but the excuse was medical school is insane. Now there's less of an excuse. Doctors are boring. I'm boring. Life is boring. This blog is boring. My patients are boring. Two flu shots, a urinary tract infection, bronchitis, and two referrals. Boring.

Ah, patient histories. Consider this a crash course.

"So, what brings you in?"

"I've been getting up every 45 minutes or an hour to urinate during the night."

"You get up five, ten times during the night to go to the bathroom?"

"Well, maybe not five or ten. Three. Two or three. Most nights."

"Okay. How long has this been going on?"

"The past couple of years, maybe four years."

"Wow. That's a long time. What brings you in now, specifically?"

"Oh, I have a rash."

"You have a rash on your--"

"No, no, not there. On my stomach."

"And you think this is related to the nighttime urination?"

"I don't know."

"Okay. Let's talk more about the rash. How long have you had it?"

"About a month."

"And you're first coming in now because--"

"I had microscopic blood in my urine."

"Microscopic?"

"Yes, very small amount. I could barely see it."

"Okay, that's definitely concerning. And this was this morning?"

"No, no, 1996. It was because of a weight loss pill I was taking. I stopped taking it."

"Okay. So what changed today that you came in to see me?"

"My sleep has been very poor."

"Because you keep having to get up to use the bathroom?"

"Yes, and because of my leg."

"What's wrong with your leg?"

"Well, I think have the rash because I'm not showering as much as I used to. I have trouble balancing in the shower. So I think I keep getting food on my stomach and that is causing the rash."

"And the trouble balancing--"

"That is my leg."

"So you're having trouble balancing, or trouble standing?"

"Yes."

"Which one is it?"

"I don't know. My mother had an infection on her leg a few years ago."

"Okay."

"Do you think I could have the same thing?"

"I don't think you caught an infection your mother had a few years ago, no. Whether you have an infection in your leg is something I can't tell without examining you. I'm just trying to isolate exactly what's going on now that we need to be most concerned about. Is the trouble balancing a new thing?"

"No."

"Is the leg pain new?"

"I don't have leg pain, no. I have a rash."

"On your stomach?"

"And my leg."

"Okay."

"And it burns when I urinate."

"Now?"

"It does not burn now. Only when I urinate."

"When is the last time it burned?"

"In the night. I don't urinate during the day."

"On purpose?"

"I don't know. But do you think it has to do with my mother's leg infection?"

Drunk guy I'm admitting from the ER. Checking his mental status.

"Who's the president?"

He gives me a look, mumbles something under his breath.

"I'm sorry, I didn't hear you. Who?"

"That n*****"

Seriously?

"Sir, please don't talk that way in this hospital."

"Yeah, f*** you."

Just another day.