Have you ever been tested for HIV?

"Have you ever been tested for HIV?"

"Oh, sure, I had that once."

"An HIV test?"

"No, HIV. I got it from some bad seafood or something. A lot of vomiting. Went away after a few days."

"I don't think you mean HIV. I'm talking about HIV, the virus that causes AIDS."

"Yeah, I know. I had that too."

"What, AIDS?"

"Yeah. It was terrible, just like they say. Felt really itchy. Took about a week to go away."

"I think we'd like to test you, just in case."

"I'm telling you, I don't have it. I haven't slept with a hooker in, like, at least a month."

A sandwich

They catered in lunch for a staff holiday party this afternoon. Sandwiches, soda, some cookies. I'm rounding on a couple of patients an hour later, and I get to the room with my two cirrhotic diabetics-- low salt diets, etc--

And they each have a sandwich in their hands and a can of Coke on their bedside tables.

"Uh... where'd you get that food?"

"Seemed like there was a party."

"The party wasn't for the patients. You shouldn't be eating that."

"Come on, doc. What's it gonna do, kill us?"

"Uh... what if I said yes?"

"I'd eat it anyway."

* * *

An hour later, their nurse pages me.

"BP is 90/50, what should I do?"

"Um... I'll come by again. What did it drop from?"

"Drop from? No, it was 61/41 half an hour ago."

"Excuse me-- I think I misheard you. Did you say 61? Six-one?"

"Yes, doctor."

"Why didn't you call a rapid response?"

"There were no symptoms?"

"You mean he wasn't dead?"

"I don't know."

"So 60/40 you ignored, but 90/50 and you call me?"

"Yes, doctor."

"I'll be right there."

* * *

"So you think it was the sandwich that caused the blood pressure to drop?"

"No."

"So I can eat another sandwich? I put one in my closet."

"No."

"Come on, why not?"

Merry Christmas

"...so, I don't really know that I needed to come in, but I've been having a little bit of chest pain and my wife wanted me to get it checked out, and it's been going on most of the day, and I guess the past few minutes it's been getting worse, and AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA---"

It's not every day the patient literally has a heart attack while talking to you.

Yikes.

Merry Christmas.

I can't walk as fast as I used to

72-year-old man. His complaint?

"I can't walk as fast as I used to."

Are you having trouble breathing? No.
Any pain? No.
Any limitations on how far you can walk? No.
So it's just the speed that you're walking? Yes.

"And what would you like us to do?"

"I don't know. You're the doctor. Make me fast again."

"This is part of the aging process, unfortunately."

"There's no surgery?"

"Surgery on what?"

"I don't know, my legs?"

"No."

"Well, you're going to admit me, right?"

"No. Unless there's something you're not telling me, there's no reason you need to be in the hospital. There's nothing wrong with you."

"Tell that to my wife."

"Where is she?"

"She's right here."

"Sir, there's no one else here."

"Did I mention I've been seeing things that aren't really there?"

"No.........."

Too old for med school?

A friend of mine, almost ten years out of college, just told me she wants to go to med school and asked me what I think. And so much of me wants to tell her she's crazy, and tell her to look at this ridiculous life I've had for the past 7 years, either studying 80 hours a week or working 80 hours a week, for far less than no money-- as a resident, I'm pretty sure I haven't yet earned back my tuition money, even if I didn't have living expenses to take into account, and of course I have living expenses to take into account-- having far less than no fun doing it. I mean, whatever rewards I thought there were to a career in medicine-- and I don't mean just financial, at all-- do not make themselves clear as a student or in residency. No one should want to spend this much time in a hospital. Anyone who enjoys most of residency-- really, truly enjoys the moment-to-moment work of a resident, most of the time, not just the very occasional non-torturous moments-- has something seriously wrong with them.

And yet-- she's not crazy. Because-- unlike so much of what so many people I know do-- there is an endgame here. Not even 4 years of med school and 3 years of residency have convinced me (yet!) that being a doctor can't be a rewarding way to spend a career. There is human interaction. There is job security. There is financial stability. There are opportunities to think, and to read, and to be engaged in something important. Not in every setting, of course. And not right away, certainly. But there is an endgame, and I'm not yet convinced that the endgame has to be terrible. And I'm not yet convinced the endgame is incompatible with having a life you can enjoy and feel fulfilled by. And, as I look around at people I know and what they're doing, I'm not sure that medicine isn't unique that way. Because I don't know what else has stability, intellectual reward, and the chance to have some control over your time and your life. Tenured professor, probably. But getting a PhD and then tenure somewhere you want to live seems like as much of a slog as residency.

My friend, if I'm doing the math right, will be 34 when she can apply, after taking the appropriate post-bac classes. 35 when she starts med school, 39 when she finishes, likely 42 or 43 or 44 when she finishes residency, depending on what residency she chooses. Older if there's a fellowship too. I don't know what the job market looks like for 45-year-old brand-new doctors, and if that job market is different from the market for 35-year-old brand new doctors. Realistically, the debt is going to be around for a while after that. Realistically, my friend can't be doing it for the money, because the money isn't going to be visible until she's 50. Realistically, while being a doctor is hopefully compatible with having a life, I know that being a resident isn't.

I couldn't do this again. Having done it once, I couldn't do it again, at all. If someone wiped the slate clean, somehow my 4 years of medical school and 3 years of residency vanished and I had to experience it all again or I couldn't be a doctor, I could not do it again. But if I'd never done it, if I put myself in my friend's shoes, then maybe. I see the allure. I don't want to see the allure. I want to shake her and tell her she's crazy and it is not a smart plan to go to medical school when you're 35.

But I didn't shake her. Partly because the conversation was over the phone. But even if it were in person. I understand the impulse. I understand the allure. If I didn't, I guess I wouldn't still be a resident. There are people who've dropped out of the program. I don't know what they went through medical school for, and how they're able to justify the years and the work and the expense, but, I don't know. And then I look at most of the attendings, and they all seem kind of miserable, so I don't even know how I can still delude myself into thinking there's a light at the end of the tunnel, but I guess all the hope hasn't been wrung out of me yet.

Four patients today have asked me what I'm doing for the holidays. Four patients feel bad that I'm working. They shouldn't. They have it worse, because-- and I'm not sure they realize this yet-- they'll still be here too. And come Friday, I really don't think anyone's getting discharged over the short-staffed holiday weekend-- or, really, most of the week-- so, if you're here tomorrow, you may very well be here until 2012. Hope your beginning-of-the-year deductible isn't too high...

Me: "This patient's asthma attack is like nothing I've ever seen before. She's breathing really strangely."

Not me: "That's because she's faking it."

"But why would she want to fake an asthma attack? We're going to end up intubating her. Who wants to be intubated?"

"She's a psych patient. Why should what she's doing make sense?"

"Because even a psych patient shouldn't want to be intubated."

"She wants the attention."

"And you're 100% sure she's faking it?"

"99%. But you should still treat her like she's faking it."

"And what if she's not?"

"Boy who cried wolf. Serves her right."

"Really?"

"Yes. I have other patients. Page me if she dies."

I'm not really sure how the American Board of Internal Medicine can be a non-profit organization when they charge so much for their tests. My internal medicine boards registration just cost me almost as much as one of my paychecks. This is what I end up doing on a "slow night" as medical consult-- almost remarkably slow, practically no admissions, no consults, but instead of trying to take a nap (which, realistically, I guess I know won't happen because the pagers are still going off every twenty minutes), I end up sitting front of the computer spending hours falling down a rabbit hole of reading about study guides and review materials. MKSAP vs. MedStudy, how much do they update each version or can I get by with an older edition, and if so, how old, and is anyone selling this stuff on Craigslist, do I really need to spend hundreds of dollars on study materials after spending hundreds and hundreds and hundreds of dollars just to sign up for the test...

And then I come across a 5-year-old thread on KevinMD filled with comments about doctors who fail recertification and get kicked out of their practice. As if 4 years of medical school and 3 years of residency isn't enough.

I actually don't mind taking tests. This isn't a post complaining about the existence of the tests. They shouldn't make us pay for the tests. And the tests should actually measure something useful. I have no idea if the boards up to this point have measured anything useful. Step 1, Step 2, Step 3, you study, you take the test, you have no idea when you finish the test if you passed or not. I think there's something wrong with the test if you can't tell whether you've passed or not after you take it. Step 2 CS-- the clinical skills test, with fake patients-- almost made sense. At least it was trying to test us on stuff we actually need to have in our heads, we actually do need to remember what questions to ask patients and how to do a physical exam. We actually do need to develop hypotheses and some working ideas of what's going on with our patients. But what dose you give of what drug in what context, we look that stuff up anyway. I shouldn't need to memorize the eight steps of whatever, because when I'm faced with needing to know it, I pull out the card and I use it. I check drug interactions on an iPhone app. And, yes, over time you memorize some of them, and it's a good thing to know as much as possible without having to check, but you check anyway, to make sure, and there are too many possible interactions to memorize every single one.

In principle, I think it's good that we have to take tests to get certified and then re-certified every x number of years, because doctors who aren't up to speed on the latest knowledge are almost certainly hurting their patients at least to some extent. But they make it such a burden, not just the cost but the time you end up spending reviewing things for a test instead of reviewing things for the patients you're actually treating. And who knows if there's any correlation between test score and doctor quality. I'm guessing there is a small and barely-significant correlation. Which is also the correct answer to any epidemiology question on the boards. There is a small and barely-significant correlation. Answer choice C, usually. So, MedStudy 12? 13? 14? Is there a difference? MKSAP? Mayo?

Through the translator phone:

"Doctor, I don't know why I am here."

"You had an appointment. You made this appointment because...?"

"My kidneys."

"You have a problem with your kidneys?"

"Yes. I had a pain in my chest area."

"Okay, that's not your kidneys."

"I went to Mr. Wong. He gave me a kidney medicine."

"Is Mr. Wong a doctor? What medicine did he give you? How did he determine it was a problem with your kidneys?"

"I don't know. All of those questions, I don't know."

"Did Mr. Wong have a business card?"

"No. He is not a business. He is just Mr. Wong."

"And you don't know what he gave you?"

"No."

"Was it a pill?"

"I don't remember."

"Was it something you swallowed, something you drank, something you rubbed on your body?"

"I don't remember."

"Where was Mr. Wong's office?"

"Not an office. On the street."

"Great. Do you remember where?"

"Not really."

"And he told you the pain in your chest was your kidneys?"

"Yes."

"Did he do any kind of test to make that guess?"

"He looked at my front area."

"Your front area?"

"He looked at my body."

"On the street?"

"Yes."

"And the pain, you still have it?"

"Usually no."

"But sometimes?"

"Sometimes."

"Okay, I'm going to do a physical exam and then run a few tests to see if we can figure out what's going on. But I don't see any reason to believe it's your kidneys, and I think you should avoid listening to people on the street and taking whatever kind of medication they might give you or recommend you take, okay?"

"He said it was my kidneys."

"I'm going to run some tests and we'll see what's going on."

[Postscript: Kidney cancer. Amazing. Who is this Mr. Wong and is he covered by my insurance?]

3:46 AM

Me: "Hey, I was just here about that consult ten minutes ago. I left the patient's chart at the nurse's station. Have you seen it?"

Nurse: "No, sorry. Which patient?"

Me: "I don't remember the name. But I was just here, 10 minutes ago. It was, uh, chest pain. Older man, alcoholic."

Nurse: "That's, like, everyone. I wasn't here, I don't know. Let me ask the other nurse."

Me: "Okay, thanks."

Other Nurse: "No, doc, I don't know, you haven't been here for hours."

Me: "No, I was here 10 minutes ago."

Other Nurse: "I was here 10 minutes ago. I didn't see you."

Me: "I went right to the room. Then I entered an order in the computer, but left the folder."

Other Nurse: "We don't have the folder. You don't remember the patient's name?"

Me: "Robert something, I think."

Other Nurse: "Roger Jones?"

Me: "Sure. Maybe."

Other Nurse: "He died."

Me: "What?"

Other Nurse: "Three hours ago."

Me: "I know the guy who died three hours ago. I ran that code. This is a different guy. This guy wasn't dead, ten minutes ago."

Other Nurse: "Then I don't know who you mean. What room was it?"

Me: "I don't know. 613, maybe? 615? 617?"

Other Nurse: "You mean 913, 915, 917?"

Me: "No, I mean 6--"

Other Nurse: "You're on 9."

Me: "What??"

Other Nurse: "You're on 9, not 6."

Me: "Oh, stupid, ugh. It's 4 in the morning and I'm half asleep. I'm sorry about that. I'm on the wrong floor."

Other Nurse: "Don't worry about it."

Me: "They shouldn't make all the floors look the same. It's confusing."

Other Nurse: "Get some sleep, doc."

Met a very pregnant 14-year-old today. It's weird, we see all sorts of people in the hospital who, I don't know, I started to write "who have made poor choices in their lives," but that's not entirely fair, and I know some situations are out of people's control, at least in part, or thrust upon them through no fault of their own-- but there are drug addicts, criminals in and out of prison, alcoholics, people mistreating their bodies in all sorts of ways, morbidly obese patients who won't change their diets, people who won't take necessary medication, people who can't seem to follow up and get the tests they need, etc. It's hard to keep from judging, but, in most cases, I don't think most judgments are necessarily obvious to the patients. I don't see people outwardly rude to their patients, for the most part. The goal is to help. But a pregnant 14-year-old, somehow-- and I wouldn't have guessed this-- seems to be far harder for a lot of people to deal professionally with than, say, a drug dealer, or an unreformable alcoholic. The tone, the looks, the attitude. Maybe it's because in medicine we don't generally see OB patients, this was an unusual circumstance, and so we're not sensitized to it. But I don't think that's it. I don't know quite how to put my finger on it. Yes, birth control is pretty accessible in today's society, but is getting pregnant at 14 objectively worse than a lot of other unfortunate situations seen in the hospital? I don't know. Maybe it would be different if I were female. Maybe it would feel like something more terrible, not that it makes any sense to be ranking terriblenesses. And, frankly, for me it tends to be the people-- especially the parents-- who won't quit smoking who I sympathize with the least. If I were a sociologist, this feels like an interesting research project-- what do people feel deserves the most stigma, off a list of unfortunate circumstances that are on at least some level within someone's control to prevent. By the end of the consult, I felt really bad for the patient and the attitudes she was surely dealing with to a much greater extent than just the 20 minutes I was with her. Yes, maybe she made some bad choices, and maybe it's going to seriously impact her chances of what the people who work in a hospital would call a successful life. But it is better than being a crack addict, no?

Ever see someone bleeding from the tip of his penis? Neither had I.

I don't know if it was better or worse that he was conscious and fully aware. But this was no trickle. It was pouring out. Soaking through his underwear, through his gown. And then spraying across the room.

"Why's this happening, doc?"

"I don't know."

"You don't know?"

"I don't know. Your blood is very thin, from your blood thinner. Too thin."

"And so this is what happens when it's too thin?"

"I don't know. I've never seen it before."

"And how long have you been a doctor?"

"Not that long."

"So I'll be okay?"

"We're going to try our best."

"That's not encouraging."

"Well, hopefully they'll be more encouraging once we get you to the ICU."

"I'm going to the ICU?"

"Indeed you are."

"In the morning, you mean?"

"Nope. Right now."

"So it's an emergency?"

"It is."

"And it's happening because..."

"Still don't know."

"So should I be panicking?"

"Panicking isn't going to help."

"But you'd be panicking?"

"To be perfectly honest, yes, I would."

About as close to losing it as I've been since starting residency. This rotation is awful. I'm the enemy. No one wants to hear they have a new patient on their team, especially not at 2AM, and I'm spending most of the night listening to arguments from the other residents about why this patient is too critical / not critical enough to be on their service. "He should be in the ICU." "She should be discharged." Fine, I get it, I was in their shoes three months ago, and I'll be back in their shoes next month, and I'll be fighting my hardest not to get slammed with more patients too. But we're all low on sleep, we're all here to serve the patient, why do you have to make me feel like I'm personally doing something to you? It's just the job, and we all rotate through it. I hate feeling like the bad guy. I'm just doing the job.

I had to call someone in at 3AM off the emergency backup team-- I had no choice, we couldn't handle the number of patients coming in, and that's what the emergency backup team is there for. I got called in in the middle of the night when I did emergency backup, and I was absolutely annoyed to be paged in the middle of the night-- and then realize when I got there that in the 30 minutes since they called, they took care of their backlog and didn't really need me after all. So I tried really hard not to call someone in. I waited until we were absolutely maxed out, no question. I probably waited too long. I probably should have called at midnight, but I hoped things would slow down. And then we had a rapid response and two codes and it was 3AM and I had 4 patients on beds in the hall waiting for someone to do their admissions... so I had no choice.

I call, I get an argument (of course) from the resident on emergency-- a friend, or at least a friend until I woke her up-- and then she comes through the doors right as her assigned patient's heart stops. She joins us mid-code, I'm leading a team of 9 people trying to do CPR and push drugs and get this patient's heart beating again. The family is in the hall, pissed that their mother/daughter/sister has been laying on a cot in the hallway for hours, untreated-- she was stable when I got her, she was stable throughout-- and we couldn't get her back. 45 minutes we're trying, finally I have to call it. I don't think there was anything we could have done-- the attending told me there was nothing we could have done, this was going to happen whether she was in the hall or in a room, whether someone had taken her full history or not, whether I'd called in backup at midnight or at 3AM. These things just happen. People come to the hospital and die. Unfortunately.

And the first thing my friend says to me as I'm calling to get a death certificate to fill out--

"You woke me up for a f[***]ing dead woman? Go to hell." And she storms out of the call room.

As if I planned this. As if I thought, hey, I know, I'll play a great trick on the poor resident on backup by calling her in just before the patient I need her to write a note on suddenly dies. That'll be a great plan! Really mess her night up. Awesome.

I'm supposed to let the backup person go at whatever point the backlog is handled and we can do without her. Of course the backlog wasn't handled-- we'd just spent 45 minutes trying to bring someone back to life, and the other patients didn't disappear during it. So she still had 2 or 3 admissions I needed her to do. But she didn't. She sulked through one admission in 5 hours before I freed her at a quarter to 9. Now this case with the woman in the hall is our big M&M (morbidity and mortality) case for the week. So I have to come up with a presentation to explain what happened and what we could have done better. With slides. Can't wait.

And then today a nurse blamed me for using all the paper towels. Excuse me. To clean up a patient's blood. I'm sorry I grabbed a ton of towels and threw them down. I figured it was better than having people slip and fall. Guess not.

I am not the enemy. I don't think I'm the enemy. Ugh.

Night of the living dead. Or, more accurately, night of the dead. Sorry this rotation is such a downer. Rapid response after rapid response. It's not until you run five codes in an eighteen-hour span that you realize, hey, these don't work all that often. If you're dead, unfortunately, you're probably going to stay that way. Realize that sounds glib. Don't mean it to. These were fortunately all end-stage patients, no brain activity, not people who anyone was expecting to be leaving the hospital. Doesn't make it better, but it does make it a little less tragic. 32 people in the room at one point, with me leading the code. I don't know what to tell 32 people to do. I barely know what to do myself. More than anything in residency, this was actually how it looks on TV. This was an episode of ER. A terrible episode of ER where no one lives and there really aren't any good guest star roles to cast at all. I'm screaming out orders, just trying to be heard over the commotion, people are grabbing drugs, people are doing chest compressions, it is chaos, it is intense, it is overwhelming. And it was dinner time-- three in a row, right at 6:00, we were running codes solid from 6 until after 9, so everyone was cranky, tired, had to go to the bathroom, hungry, everything. Unsustainable. If this rotation were longer than a month, unsustainable. I don't know how someone can be an overnight attending, a hospitalist, these jobs must be unfillable, I just don't know who could ever choose to do this. I want 15-minute blocks to my day, I don't want to carry five pagers, I don't want rapid responses. I want medication refill conversations. I know, I say that now, and then once I'm doing it, it'll be dull and horrible. But at least I won't be pronouncing people dead. Couldn't even read the clock by the end, just tired. Staring at it. Like, 7... 8... I don't even know. Why don't we have digital clocks in the hospital? We have all of this complicated equipment, and we can't have digital clocks?

Rapid response in a surgical suite. I get there, and people are frantic.

"Does anyone have a stethoscope?"

"Yes, I have a stethoscope."

"We have no idea what to do."

"Start chest compressions."

"We don't remember how to do that."

It's amazing how quickly knowledge and instinct can atrophy when they're not used. I mean, I did surgical rotations in med school, but don't remember anything useful, if I ever knew anything useful anyway. And the surgeons don't know anything about medicine anymore. And pretty soon, once everyone starts fellowship and is immersed in whatever specialty they're in, that's all they'll know and a patient comes in with a problem outside of their field and they won't have any idea where to even begin. This is why patients end up coming to clinic telling me they see nine different doctors, and why it's hard to find someone who can effectively coordinate care between them. We pretend we can divide problems into these individual silos, but not every problem is so easy to assign to one specialty. Things interact. The patient's diabetes affects multiple organ systems, etc.

At least we eventually got CPR going. Gosh.

Just tired. 27-hour shifts are torture. Don't even know what day it is anymore. Someone said something about the 28th, and it took me a few minutes to even know what month he was talking about, and whether he meant today. Yesterday becomes today. I go to sleep in the light, I wake up in the dark, I don't know what is going on. I eat two breakfasts and a half-dinner. This doesn't serve me or the patients very well.

Weird to be in charge. Don't feel in charge. Don't feel like I should be in charge, or like I'm ready to be in charge. I had to run a rapid response for a baby having a seizure. I don't know what to do with babies. We don't learn anything about babies. But in the middle of the night, we all do everything. Weekend overnight meant I was carrying six different pagers at once. I didn't know what was going on. I got paged four times while I was in the bathroom. I don't think I'm supposed to go to the bathroom. 27 hours and I don't think, technically, I'm supposed to go to the bathroom. This rotation cannot end soon enough.

It's so strange to be in the position of giving out admissions instead of receiving them. People see me coming down the hall, and instead of smiling (or, more typically, ignoring me completely), they try and run away. I'm the terrible person handing them more work that's going to keep them there for more hours. But it's not my fault! It's the job! Blame the patients for coming in! Blame the guy whose spleen ruptured!

The comment thread on my post from Nov. 14th got pretty interesting, by the way. And I think one commenter got unfairly criticized perhaps. The system is broken. Without a doubt, the system is broken. I think asking whether doctors should be treating people in emergency situations who can't pay is the wrong question for a civilized society to have to ask. I think, on the surface, a lot of countries seem to have figured this problem out better than we have. I think the insurance system is a mess. I don't have a solution, but I would be surprised if the current system was really the best one, in terms of cost, equity, and overall care. It would be one thing if we were lapping the field as far as life expectancy. And I know there are issues of demographics, and it's not fair to compare the U.S. to countries with a more homogenous population, but still, I have a hard time believing we've really figured it out.

I am thankful for...

--The turkey in the call room, or at least the idea of it, because in reality it sort of sucks.

--The fact that I'm not the only one stuck here working tonight.

--Respiratory masks, so I don't get pneumonia.

--Sleep, or the promise of it, eventually, someday.

--Not being an alcoholic or drug addict.

--The patients who say thank you, or seem like they're thinking it even if they don't actually say the words.

--Only having to carry three pagers instead of four, because it's a holiday.

--The excellent blind date I went on last week.

--My own health, and the health of family and friends.

--The confidence that I will almost definitely be able to pay off my student loans eventually, even if it's hard to think so many decades into the future.

--Blog readers, even if they're calling each other horrible people in the comments (and I'm intending to write some thoughts on that comment thread from Nov. 14th, but not today).

--Wounds that heal.

--The Bridesmaids DVD that someone left in the DVD player in the call room.

--Less than two dozen overnight shifts left in my residency.

--Wireless internet, as a general concept, even if it doesn't work in most of the building.

"I called you, doctor. I called your office three times and you didn't call me back."

"I don't have an office. I don't know who you called."

"The main desk. They connected me, but the phone just kept ringing. That's no way to treat your patients."

"I don't know where they connected you. I'm a resident. I have a pager, but I don't have an office, I don't have a desk, and I don't have an assistant. I'm sorry. I can't be reached on the phone by patients. That's just how the system works."

"But I called three times!"

"It doesn't matter if you called a hundred times. I can't be reached that way. You need to ask the nurse to page me. I told you that yesterday."

"I expect to be able to speak to my doctor at my convenience."

"And that's just not possible in a hospital setting. I'm sorry."

"You're sorry? Well, I'm leaving."

"You're not in a condition to be released."

"I'm leaving anyway."

"Can I at least get you to sign some paperwork that you're leaving against medical advice?"

"Medical advice? Medical advice is exactly what I wanted, but you didn't answer your phone. Goodbye, and I hope I never see you again."

and all I can think is... YAY, ONE LESS PATIENT ON MY SERVICE!

I'm sorry that a week has passed without a new post. I took the second half of my vacation seriously. Vacation ended yesterday and now I'm back in this mess, with the worst rotation of the year, so posts will be fast and furious. I'm the senior admitting resident for the entire medical department-- or at least I'm one of them, in a rotation with 3 others. So anything crazy that happens, I will be part of it.

I'm nervous-- I'm in charge of who goes to what department, of doing medical consults on patients from other services, I'm the one making decisions-- but, hey, if I screw up, the worst that can happen is that patients die.

So it's no big deal.

Posts 6x/week for the next month or I won't be mad if you stop reading the blog. If I renege on this promise, I will sacrifice a patient to compensate for my lack of blogging discipline.

I have an attending friend who wants to write a guest post sometime. So look out for that too.

Helped someone on the street yesterday. Can't escape the job even on vacation. Saw someone on the ground, struggling to get up, first instinct to walk past without stopping but saw that he was really struggling. Went over to him, someone else stopped too, we tried to help him up, asked what had happened. He said he was weak, couldn't get up. He was outside a medical office, so I asked if he had just come from the doctor. He said he hadn't. Someone went into the medical office and called for help. The guy said no, no, he didn't want help from the medical office.

"Why not?"

"I don't have insurance."

"But you can't even stand up by yourself."

"But I don't have insurance."

"You need help."

"But I don't have insurance. Just leave me here."

We got him to a bench, asked where he lived. He said he only lived a few blocks away, and said he just needed to catch his breath and call his wife.

"Are you sure you don't want us to call an ambulance, or get a doctor?"

"No, no doctors. I don't have insurance."

"You sure you're going to be okay?"

"I'll be fine. I don't have insurance."

Clearly, there is something wrong with our health care system.
(I don't have any answers.)

My two weeks of vacation started on Monday. Actually thinking about taking some moonlighting shifts, so I can make some extra payments on my student loans. First year, it felt like I had to go somewhere, had to take advantage of the time off. Second year, kind of felt that way too. Third year, the light at the end of the tunnel is visible. Sort of. I'm using one of my weeks to go somewhere, but this week is more of a decompress, catch up on the DVR kind of week.

Any book recommendations?

I have a new clinic patient who has high cholesterol, is overweight, high blood pressure, diabetes. I asked him what his job is. He runs an ice cream cart. This is not my first patient who deals with ice cream for a living. I didn't realize there are so many people in the ice cream business, and how it (predictably) affects their health.

"And do you eat the ice cream?"

"No, not really."

"You sure? You can tell me if you do."

"No, no, I know it's not healthy for me. I try not to eat it."

"What do you eat, most days?"

"Oh, not the ice cream. It's not healthy."

"I know. You said that. So what do you eat instead?"

"I get food."

"Yes, sure. What kind of food?"

"Me and the other food carts, we trade."

"Okay..."

"So usually a hot dog, pretzel, some, uh, funnel cake."

"Those are also not so healthy, unfortunately."

"I like the corn dog on a stick."

"Yes, not healthy."

"But better than the ice cream."

"I'm not really sure about that."

"I sometimes eat the cotton candy. Is that healthy?"

"No."

"The, uh, hot dog without bun?"

"Not so much."

"What cart should I eat from?"

"Maybe you could bring lunch?"

"I thought of that. But I have nowhere to keep lunch cold."

"What about in the ice cream freezer?"

"Oh. Oh, wow. I never thought of that."

"I'm all prepped for my colonoscopy, Doc."

"Yeah?"

"Yep, I drank all of that stuff. I was on the toilet all night!"

"That's great."

"I'm all cleaned out. It was pretty terrible, but I know how much you wanted me to get the colonoscopy."

"Yep, it's important."

"So where do I go for the test?"

"What?"

"Where do I go?"

"You go to the endoscopy suite-- what time is your appointment?"

"I don't remember. Can you check in the computer?"

"Sure, but you're sure it's today? I don't know if they're usually able to schedule the tests on the same day as you have a regular appointment."

"I sure hope it's today. Hey, Doc, can I use the bathroom while you check the computer? There must be some stuff still left inside me."

[I go to the computer and check. I come back.]

"I'm so sorry to have to tell you this. Your colonoscopy appointment is in January."

"But I don't have to drink that stuff again, right?"

"Uh, not unless you don't eat anything until January."

"You're saying I shouldn't eat until January?"

"No. I was kidding. You have to drink the stuff again."

"Oh, man."

"I wish we could squeeze you in today, but I have no control over the scheduling. I'm really sorry you got the appointment time confused."

"You're sorry? I'm the one who went to the bathroom all over my bedroom floor."

"I'm really sorry."

"See you in January."

Was doing a shift in the ICU and was assigned to write a note on a patient being transferred back to the regular floors. She'd been in the ICU for two days.

I look at the previous note. "Patient is in ICU. Doesn't appear to be in too much discomfort. Stable."

Well. That's not very much information.

I go over to talk to the patient. Doesn't speak English. I ask for the translator phone. Oh, it's in the closet. I go to the closet. There is a phone there. It has no cord.

"Has anyone actually spoken to this patient in the past two days?"

"I'm not sure, no. I think we just went off the transfer note."

"So no one has any idea what the patient is actually feeling, her mental status, nothing?"

"Not sure we do. Nope. You should just write the note and let them deal with her on the floor."

"I don't know what to write if I can't talk to the patient."

"Just copy the last note-- and hurry up, we need the bed."

"My stomach hasn't been feeling well since this afternoon."

"Did you eat anything funny?"

"Well, now that you mention it, I had some chicken that didn't look exactly right."

"What didn't look right about it?"

"It was sort of pink in the middle."

"Okay. Your symptoms are starting to make a little bit of sense."

"Really? You think it was the chicken?"

"Could be."

"I also had a pretzel wrapped in a hot dog."

"What?"

"Oh, sorry. I mean a hot dog wrapped in a pretzel. It was pink too. Is that okay?"

"Hot dogs are pink, yeah."

"I thought maybe because you said the chicken shouldn't be--"

"No, chicken shouldn't be pink. But hot dogs are pink."

"I also had a funnel cake."

"Were you at an amusement park, or a state fair?"

"No, I was at home."

"You make funnel cake at home?"

"Sure."

"Did you eat anything else?"

"Just a couple of candy apples."

"I'm going to set you up with the nutritionist after this food poisoning subsides, if that's okay."

"Oh, I already have a boyfriend."

"No, not for a date. For an appointment."

"I know what to eat."

"I'm not sure you do."

"One of my friends said you can give me cookies if I ask."

"We're going to skip the cookies until you stop vomiting, if that's okay."

"I guess."

"Thanks."

Spent the day in gynecology clinic yesterday.

I don't know what motivates some people to become doctors. Particularly what motivates people to choose certain specialties when they seem to have no real interest-- animosity even-- toward patients with the particular issues they're supposed to be trying to treat.

This guy had one solution for every problem. Stop having so much sex. Fewer partners. "Keep your legs closed." "You won't get this again if you aren't so promiscuous." "You want birth control? How about underwear. How about you use self-control as birth control instead." "You were sexually assaulted? Go to trauma clinic. I don't deal with that here."

I found myself apologizing to most of his patients after he left the room. Never a good situation when the resident has to apologize for the attending. Thing is, everyone knows this guy is a lunatic. The clinic manager apologized when she assigned me to shadow him. "If you'd gotten here early, I could have given you someone else. I'm sorry." Early? I got there on time. Why would I want to get to clinic early?

And, yes, I'm reporting this guy to the medical director.

In the clinic, there are sick visits and routine follow-up. Although it sounds counter-intuitive, you want the sick visits. The sick visits are supposed to be about one thing. One specific problem. They come in, tell you the one problem, you come up with a treatment plan, and they leave. The "routine" visits instead often involve a laundry list of issues that have come up since the last visit, we're talking about weight loss, we're talking about diabetes management, we're talking about depression screening, foot pain, headaches, cataracts, anything and everything they're worried about. Which is fine, and that's what we're here for, but a sick visit is supposed to be so much easier. One problem. And we write a prescription for an antibiotic and off they go.

Problem is, the patients know the system even better than the doctors do. They know that routine follow-up appointments are six weeks out, and the fifteen-minute sick visit slot can be available the same day if you're willing to wait for a while in the waiting room.

"So what brings you in today?"

"I don't know, I just don't feel great."

"Is there a specific problem?"

"No, but I knew it would be a month before I'd get a regular appointment, so I told the secretary I was having chest pain."

"You know, that's not fair to the people who are actually having chest pain and need these slots. There are only a certain number of slots set aside for acute issues."

"They can find a different doctor."

"You know it's not that easy."

"Well, I didn't do anything that anyone else couldn't do."

"For next time, I'd appreciate it if you didn't make up a story to get a faster appointment."

"Like you'll be my doctor next time."

"I could be."

"I know how the clinic works. You won't be."

"Tell me what's bothering you."

"Well, first there's my life and how it's a total mess."

"I'm sorry to hear that. Do you have a specific medical complaint?"

"I want someone who will listen."

"Can I refer you to the mental health clinic?"

"I'm not crazy."

"I didn't say you were."

"Then let me talk."

And she talked. For twenty minutes about her ex-husband and her boss and her ungrateful daughter and the rude clerk at the Department of Motor Vehicles.

"I really have to see the next patient, if you don't have a medical issue that I can help you with."

"But I'm not done telling you about my neighbor's dog--"

"I'm going to have to cut you off."

"Okay, okay, okay-- I'll go. Just one more thing."

"Fine. What?"

"I have a lump in my armpit."

I started working a couple of shifts at a new clinic site this week. The examining rooms are on the first floor. And have floor-to-ceiling windows. Visible to the parking lot on one side, and the street on the other. Was this building a gym before it was a medical clinic? I had a patient changing in the room when I realized... as someone walked by and stopped to watch. I start lowering the shade, but it's not a complete shade. I have a naked patient being watched from the outside. Who built this clinic?

And they worry about the privacy of patient records? How about the actual privacy of patients being examined?

"I heard you can calculate my risk of a heart attack. Some kind of score?"

"You mean the Framingham Risk Score?"

"Yeah, I think that was it."

"Wait a second. You're homeless?"

"Yeah."

"You were not always homeless."

"No. I was a lawyer in Burundi."

I don't think I realized before working in the clinic how common this is. People who were professionals in their home countries-- educated, high-status professionals-- who sacrifice everything to come here for a better life... and end up as home health aides, cab drivers, busboys, homeless-- the lowest-status workers in our society. It's a shame. And I always want to ask whether life is really better being a cab driver here than it was being a lawyer in Burundi. I expect the money is better. But I wonder if that's enough to make it worth it.

Ethical question.
An e-mail to all residents from the program director-- i.e., our boss--

"Just wanted to let everyone know about a Lupus Walk I'm doing next weekend. Would like to invite everyone to check out the website and hopefully donate a few dollars for the cause. Thanks.

Also, if anyone wants to make an appointment to talk about their fellowship recommendation letter, let me know."

Of course it's all well-meaning, but is there not a little bit of coercion when your boss asks you to donate to a cause-- and then mentions those fellowship recommendation letters in the same e-mail??

You'd think doctors would get out of jury duty.

People got out for having doctor's appointments! I wanted to stand up and say, "you have one doctor's appointment-- I have forty doctor's appointments!" I got questioned for three different cases, finally excused because, hey, guess what, no one wants a doctor on a personal injury case because I might actually be able to make up my own mind about whether someone is injured or not.

I suppose I appreciate the idea of the jury system, and that if I were ever accused of a crime, I'd want-- no, wait, no. Having seen who actually serves on the jury, if I'm accused of a crime-- assuming I'm innocent-- I want a judge deciding my fate, not some random people who couldn't come up with excuses why they can't serve on a jury. I want someone who's trained to hear cases deciding whether I did it or not, someone who is (hopefully) a little harder to sway than a jury of the retired and unemployed.

For one of the cases, I was asked, "have you ever had an elbow injury?" One of the prospective jurors said, yes, he broke his shoulder.

I ended up excused before the trial started, because of a scheduling conflict. Sorry for the lack of posts. Normal posting will resume tomorrow.

"I have some swelling on my leg."

"Okay. Can you show me?"

The patient takes off her pants. Then pulls down her underwear. Points to some swelling.

"That's not your leg, that's your labia."

"Oh, I thought it was part of my leg."

Taking a patient history...

"So, are your parents still alive?"

"My father just died last month."

"I'm sorry to hear that. What did he die of?"

"Old age."

"He had no medical problems before his death?"

"No, no. Just old age."

"And how old was he?"

[Some readers may be thinking what I was thinking at this point... which was that I was about to hear a very low number... 55? 60?]

"One hundred and thirty two."

"Excuse me?"

"One hundred and thirty two."

"Your father could not have been 132 years old."

"Oh, no, he was. People in my family live a very long time. My grandmother is still alive."

"And how old is she?"

"One hundred and thirty six."

"No, that's not possible."

"It is."

"Wait. Is this your father's mother?"

"Yes."

"Even if she was 136. If your father was 132, that would mean she was 4 years old when she gave birth to your father."

"I don't know. All I know is that is how old they are."

"That is not how old they are."

"It is. We have very good genetics."

"You are 42. You walk with a walker. You have significant heart failure. You are not unfortunately not on a course to live to 136."

"You'd be surprised."

"And, wait, also, if your father is 132-- he had you when he was 90?"

"I guess that would be true."

"Your father was 90 years old when you were born?"

"I guess he was."

"I'm sorry to get bogged down in your family history here. But I just can't get past it. Your father was not 132 years old."

"You can ask his sister."

"How old is his sister?"

"About 17."

"Wait, what?"

"Yes. She's about to graduate from high school."

"Okay, we're going to skip the rest of the family history."

Whenever anyone in the hospital tells a story about a complicated medical situation, usually something that's led to a terrible outcome or a death, the response is always the same.

"Good case, good case."

Said in the same dispassionate tone, completely disregarding the fact that this "good case" is about an actual human being, and quite often an actual human being who's now missing a few of her organs, or who unexpectedly died.

You never want to be a "good case." If you're a "good case," it means something unusual has happened, and unusual is almost never a good thing.

"So the patient was in the OR, and the fluorescent light fixture somehow came loose from the ceiling, dropped onto the operating table, and immediately killed the patient!"

"Good case, good case."

"And then when her husband came to identify the body, he had a massive MI right there in the morgue, and the pathologist had to perform CPR-- unsuccessful, of course, since he hadn't dealt with a live patient in 25 years."

"Good case, good case."

"And when the son was on his way to identify both of his parents, he got into a car accident, came into the ER with his leg dangling from his body, barely attached, and he bled out, right there in the waiting room while the receptionist was checking his insurance status."

"Good case, good case."

"The daughter is fine though. Healthy. No medical issues."

"Oh. That's a terrible case. Why would you even tell us that?"

"No, I don't need a pap smear."

"What? You're 62 years old."

"I've never had sex. So everything is fine down there."

"That doesn't mean everything is fine down there. You still need the test."

"No, it's all like new. Untouched. No damage."

"You still need a pap smear. You're 62 years old."

"No, factory new. Clean and shiny. No test."

"You need the test."

"After sex, I will. Until sex, no thank you. Not needed."

"On a scale of 1-10, how would you rate this stomach pain?"

"I don't know."

"You had a bleeding ulcer last month. You had pain then. How does this pain compare?"

"I don't know."

"I'll tell you, I'm trying to figure out whether you're bleeding again, or this is a different kind of pain."

"Yeah, I don't know."

"What color has your stool been?"

"I don't really know."

"Did you look at it?"

"I can't remember."

"How long has the pain been going on?"

"I'm not sure."

"Hours? Days?"

"I don't know."

"You know your body better than I do. I need you to help me figure out if this is a serious problem, or this is indigestion. Because otherwise I have to treat it like it's a serious problem and send you to the emergency room."

"I don't think I want that."

"No one wants that. But I'm trying to figure out if you need that. Your blood pressure is normal. Your last blood work came back OK. I don't think you're actively bleeding, but it might make sense to try and make sure."

"Wait, I'm feeling a little better."

"Great."

"Oh, no, it's worse again."

"If I tell you to go to the ER, are you going to go?"

"No."

"So I don't know what you want me to do for you. You're on all the right medications. There's no evidence you're bleeding. I don't know what more I can do except tell you to eat and drink fluids and rest and try and go to the bathroom, and monitor how you're doing."

"I still don't feel well."

"I don't know if there's anything I can do without sending you to the emergency room, where I do think there's a good chance they will send you home."

"You know, you're totally f***** useless. Can I make an appointment for next week?"

"I don't know what's going to be different next week."

"I'm probably still going to have this stomach pain, obviously. I'll make an appointment for next week. Goodbye."

A patient in the hallway.

In her hospital gown.

All day.

Panhandling.

And everyone walked by her.

Some giving her change from their pockets.

But no one bothering to question.

Why she is panhandling.

In the hallway.

Near the elevator.

Why no one is looking for her.

And helping her back to her room.

I flagged down a nurse.

But she wasn't her patient.

And I had other patients to see.

And when I saw her again.

Three hours later.

Still in the same place.

I asked another resident.

But she wasn't her patient.

She didn't have a bracelet.

Which might mean she wasn't a patient at all.

Or might mean she tore it off.

Or might not mean anything.

She wouldn't tell me her name.

And I had other patients to see.

I heard someone else.

Saying she saw her too.

But she had other patients to see.

I don't know what happened.

I haven't been back to that floor.

I assume someone dealt with it.

Though I probably shouldn't.

I would check again.

But I have other patients to see.

[A bunch of people left comments on my post from Tuesday saying my post was fine but useless if I didn't say HOW to tell if their doctor is good and HOW to find a better one. Those comments are correct. I consulted with a couple of friends for help with an answer here. Knowing if your doctor is good, or how to find a better one, isn't necessarily easy. If you know people in the field, that's a start-- recommendations from doctors or nurses who you know, recommendations from people who are medically savvy and plugged into the field. Where they trained can be an indicator, although it's not perfect. Rankings of programs exist (U.S. News, etc), rankings of medical schools exist. One commenter accurately points out that judging foreign medical schools is more difficult. Many states have online databases where you can type in a doctor's name and see where they trained, what specialties they're licensed in, and whether they've been sued for malpractice (not always an indicator, but, hey, I'd probably avoid a doctor with a long list of lawsuits). And you ask questions and see if you're happy with the answers. It's often pretty clear if someone knows what they're talking about or they're faking it. If you think your doctor is faking it, ignoring your questions, brushing you off... maybe that's a signal.]

"The medication you prescribed is causing diarrhea," said the patient, loudly, and with more anger than diarrhea ought to cause.

"I'm not sure it's the medication, but I can give you something to see if it helps."

"No. I'm not taking any more medication from you. And I'm stopping all of the ones you already prescribed, because I can't live my life having to run to the bathroom every day."

"Wait, how many times a day are you having diarrhea?"

"One."

"That doesn't sound disabling. We'll try to get to the bottom of what's causing it, but you need to take your medications. Unfortunately the consequences of not taking them could be far worse than the diarrhea."

"I went through a whole roll of toilet paper in a week."

"Um... how often were you going to the bathroom before you first started taking the medications I prescribed?"

"Once a week, maybe twice."

"That's not normal."

"It's normal for me."

"That's not a thing. It's healthier to be going more often than that. And now I'm thinking, just to be sure, let's take a step back for a second. Describe what you mean by diarrhea."

"It comes right out. I hardly have to push. And then I have to wipe a couple of times."

"Is it watery?"

"No. Watery? What are you talking about?"

"I think what you're doing now may in fact be normal bowel movements. You were terribly constipated before."

"It was normal for me."

"That's not a thing. Going once a day is fine. It's healthy."

"You're not serious."

"I am."

"You can't be serious that it's normal to go to the bathroom every day."

"I am."

"No. No way. That's crazy. I don't have time to go to the bathroom every day. I work two jobs."

"I'm sorry that the medication has made your bowel movements normal and healthy. I don't know what to tell you."

"You can tell me how to get back to the way it was."

"You can't, and you shouldn't."

"So you're saying you ruined me."

"I'm saying I fixed you."

"Forget it. I'm finding a new doctor."

"I'm sorry you feel that way."

"Is there a bathroom I can use on the way out?"

"It's in the waiting area."

"Goodbye."

There's an article in the New York Times today about patients being overtreated and how they should ask more questions and see if there are alternatives to what the doctor recommends that involve less invasive procedures or fewer medications.

This may be a minority opinion, but I think the article is stupid.

It's stupid because if you need to push your doctor to talk about less invasive options that may be just as effective, or medications he or she prescribed you may not need to be taking, guess what?

You need to find a better doctor.

What the article basically says is you should bully your doctor into ordering fewer tests and letting you stop taking some of your medications.

Which is great advice, until you miss something that one of those tests would have picked up, and you end up in worse shape. If I'm a patient, I don't want a doctor who I have to bully into not ordering a CT scan. I want a doctor who's smart enough to know when a CT scan makes sense and when it doesn't. I want a doctor who knows when he can take me off certain medications. Not a doctor who I can nag until he gives in, and lets me, the uninformed patient, dictate my care whether or not I know anything useful.

If I've learned one thing these past two years, here it is:

All doctors are not the same. All hospitals are not the same. If you go to a mediocre doctor, you will get mediocre treatment, and you will encounter avoidable risks that you may not even know you're being exposed to, whether it's from the wrong medication, the wrong treatment plan, outdated advice, failure to think proactively, or just plain stupidity and carelessness.

Somehow, people understand that there's a difference between a diner and a four-star restaurant, that chefs have different levels of capability, and that if you want the best meal you can find, the diner is probably not the place to go....

And yet people pick a doctor with less care than they choose a restaurant.

People don't ask where their doctor went to school, did their residency, what hospitals they're affiliated with, how many patients with similar conditions they treat, and whether they have a financial incentive to push whatever treatment they're pushing.

If you have an upper respiratory infection and need an antibiotic, most doctors can probably deal with you appropriately. If you're young and healthy, and don't have a bunch of medical conditions, most doctors can probably deal with you appropriately. Beyond that, I'll take the one with the fanciest diploma, thank you. It's not a guarantee-- there are smart people who are bad doctors, and there are certainly people who went to ordinary schools who are excellent doctors, but at least it's something. It's a proxy for some level of competence. I want the smartest person I can find, with the most experience and training, dealing with my medical decisions. The stakes are often too high to risk anything less.

It is incredibly frustrating to see patients who come in with, say, a bleeding ulcer, and they in fact tried to do all the right things-- they went to their doctor, who sent them to a GI specialist, who did an endoscopy... and missed the ulcer completely. Or exacerbated the problem. Or didn't look at what other medications the patient was on. Or didn't check labs before doing the test. And then we get the result-- a patient with a BP of 80/50 bleeding into his intestinal tract. And, no, we may not have done any better if we were the first stop, but we probably would have. You can avoid problems if you start with the most competent doctors you have access to, and don't assume that every doctor is fine, and every doctor will give you the same answers.

If you have to rely on your own skepticism to force your doctor to think about whether he's recommending the best possible treatment, like the Times article assumes, you are in bigger trouble than just needing to ask a few questions. You need a different doctor.

You should not have to come armed with your own independent medical research in order to get satisfactory care. There is something wrong with the system if you need to know more than your doctor does.

"I need a new prescription, but I don't want the generic this time."

"It's the same thing. I'm just trying to save you money. The generic is going to be a lot less expensive."

"Everyone says that, but they're not the same."

"It's the same exact chemical formula."

"The shape of the pill is completely different."

"The shape of the pill doesn't matter."

"Come on. The generic is this little tiny pill. The regular is like three times the size. That means there's a lot more medicine in it."

"That's not what it means. It just means the pill is bigger. The amount of medicine is the same."

"That doesn't make any sense. Isn't the whole pill medicine?"

"Some of the pill is just innocuous ingredients to make it into a pill you can swallow. The shape and size is not important."

"What about the color? The generic is a totally different color."

"The color doesn't matter."

"I don't like green drugs. That's the color of mold."

"The drug is not green. The color of the pill does not matter. The pills aren't moldy."

"Well, I don't care what you're saying. I don't want the generic."

"I can give you the brand name. But I promise you it's a waste of money."

"Don't worry about that. I'm probably not going to fill it anyway."

"What? Why not?"

"I don't like the way it tastes."

To answer a commenter on the previous post, I don't think he's a terrible doctor, but I don't see it from the patient's side, just from the doctor's, and those are very different perspectives.

My current attending is a terrible doctor.

Or at least the Internet thinks so.

I don't usually Google the attendings I'm working with. It just never crosses my mind. I don't know where most of them went to med school, or did their residencies, or what they did before they came here. I don't know how much teaching they do, or much about their personal lives unless they happen to mention something. But I happened to Google the guy I'm currently working with.

And he has like 15 reviews on Vitals.com, a half-dozen on Yelp, and almost all of them are pretty darn terrible. And consistent in the kinds of things they say.

Obviously, Internet reviews of doctors have limited utility. One patient's experience is likely to be vastly different from another's, depending in part on expectations and temperament and what the medical problem is. Some patients get worse, no matter what the doctor does. Some get better even if the doctor is terrible. Some people need more hand-holding than others. Some people want their doctor to be decisive and confident, even if the best treatment isn't necessarily clear. Some people expect more than a doctor can provide-- in terms of treatment when there isn't one, or instant availability when there are dozens of other patients waiting as well.

And I'd imagine that the patients most likely to write a review on the Internet are the ones who are upset with their care, not the ones who are satisfied.

[Or at least I assumed that, until I checked some other doctors, who largely had very positive reviews. I don't know what moves people to review a doctor on the Internet, I really don't. (Anyone who wants to tell me, the comments are all yours...)]

Fortunately, I don't yet pop up in any online review systems-- frankly, I think it would be a major bummer to read something negative about my doctoring, although it probably would help to change behavior, if I really think about it. If a couple of people said I was [anything-- hard to reach, wrong about their diagnosis, unfriendly, etc], I would probably work pretty hard to do better. And I think lots of my colleagues of this generation would act similarly. We grew up with online reviews of all sorts of things. It is a little weird and a little disturbing to think that one day in the not-too-distant future, I will probably be able to Google myself and find anonymous patient reviews out there. And just from a business sense, I assume it helps get patients to want to see you if there aren't dozens negative reviews out there telling them not to*.

But I expect my middle-aged attending is (probably) not Googling himself, and if he is, and finds these reviews, I expect he's probably dismissing them as cranks and outliers. This world we live in, where everything gets written up on the Internet, is a little scary. It must be horrible for people who own restaurants, who are trying to serve good food, to constantly read negative things about what they're doing. And I assume they read these things. And I assume most of them want to make customers happy. Yet they do tend to be fairly consistent. And yet the food doesn't ever seem to change. My local Thai place has mostly one- and two- star reviews on Yelp. The food sucks. I've tried it two or three times, because it's convenient. It sucks each time. What is stopping them from either telling their chef to make better food, or hiring a better chef? I assume it's because most people don't read or don't care, and they have enough business that they're making money. Or that getting better would cost money that they don't want to spend. But "the food sucks" is a fixable problem, at least.

"My mom went to this doctor and then she died," unfortunately, is not a fixable problem, and not necessarily the doctor's fault. I understand why that son or daughter would feel powerless, and ultimately might decide to tell the Internet not to go to that doctor, but so much of what a doctor does won't affect outcome. If someone is choosing, say, whether to anticoagulate a patient, and she falls and bleeds and dies, he gets blamed for that decision even though maybe she would have had a stroke if the decision went the other way. If your doctor pushes chemo and radiation and the cancer comes back despite the better odds, it's easy to want to blame the doctor, but the doctor didn't necessarily do anything wrong. Except perhaps explain things well, be upfront about the odds, and the decision process, and make you aware that the outcome isn't always positive even when the decision is the right one. Some patients can understand that, and some patients maybe can't. Intellectually they can. Emotionally no one is really going to be able to understand why they did everything right and the cancer came back anyway. You want someone to blame. And the doctor is an easy target.

All this, from Googling my attending and realizing all of his patients hate him. Or at least some of his patients hate him. I hope my patients don't hate me.

* Although I have never read a doctor review before seeing them, and never thought to search for one. I've looked up where they've gone to medical school and did their residency, and absolutely made choices about doctors based on their education, but I don't actually think Yelp or Vitals or any of those sites ever popped up when I was looking for information, and so I'd honestly never read a doctor review before today. Do people read these things? Do people know about these things? I have no idea.

Why do I do this to myself? Hart of Dixie, on the CW, starring Rachel Bilson as a doctor. A few years ago, I would have said that there's no way Rachel Bilson could pass as a doctor, but I had all sorts of med school classmates and have all sorts of fellow residents who don't look or act or talk any more like a doctor than she does, so I'm not going to judge based on appearances. She could be a perfectly excellent doctor...

Except I don't think any doctors were consulted in the making of this TV show, or if they were, I think they should get their licenses suspended.

Honestly, it lost me in the first five minutes, and, unfortunately, I'm never going to be able to get past the premise. The head of her "New York Hospital," where she's done a magical 4-year surgery residency, won't give her the one cardiothoracic surgery fellowship slot because she doesn't care enough about her patients.

So he forces her to be a "general practitioner" for a year, before applying again.

Let's stop there for a moment. She is a surgery resident. Surgery and medicine are two entirely different things, with different training. She isn't licensed to be a general practitioner, and she certainly isn't qualified to be a general practitioner. She cannot be a general practitioner. And that's putting aside the question of why anyone would even want her to be. She wants to be a surgeon. She's apparently good at surgery. If she has a crappy bedside manner, well, she'll fit right in. No one is denying fellowships to talented surgeons because they don't remember their patients' names. And if someone was denied a fellowship for that reason, no one is going to tell them to go slum it in the primary care clinic. Because that doesn't make any sense. Surgery isn't some super-medicine that floats above general practice. It's a separate thing. You wouldn't tell a cardiologist that before he can do heart transplants, he needs to spend a year as a dentist. That would make about as much sense as this show's premise does.

I'm going to ignore the timeline problems with the fellowship application process-- you apply more than a year in advance, you know well in advance, nothing is being sprung on anyone last-minute forcing them to take a bus to rural Alabama for the only general practice job left in the country...

Which, by the way, didn't make sense either. We have a primary care shortage in this country. If she could fake an internal medicine license, she could work in any city in the country. "New York has no general practitioner jobs," she says. What nonsense is that?

And then, of course, she ends up delivering a baby in the episode. Which makes perfect sense, since she has apparently done a residency in everything. OB/GYN, of course, is an entirely separate field from either surgery or internal medicine. And there is no way I'm trusting someone with no training at all in delivering babies to deliver one. All she needed to do was perform brain surgery on a cow and the entire spectrum of things an all-knowing medical practitioner can do would be complete.

I won't even go into the mechanics of state-by-state licensing and how she would need some amount of time to get an Alabama license even if she were qualified to be licensed in medicine, or how it makes no sense that this guy would leave her his practice without telling her (maybe a lawyer wants to tell me if you can leave a bequest in your will that the person doesn't learn about until they show up rolling a suitcase down the road), or why this town doesn't seem to know about appointments or medical insurance.

At least Grey's Anatomy pretends well enough that a doctor can watch it. This simply didn't make any sense at all.

Which likely means it will become a huge hit.

Well, that was a first. I think. Who knows. The blog probably remembers better than I do. I had a clinic patient leave mid-appointment. I stepped out of the room to talk to the attending about one of his issues, I come back and he's gone. Checked the bathroom, the waiting room, nope. He left. My fault? Probably. Could have done a better job dealing with him? Probably. Do I actually feel bad that he left? I don't know. We're not the police. We can't detain people against their will. But I spent forty-five minutes with a patient who left before he got any actual treatment, so mostly I feel bad for the people waiting, because he wasted their time if he didn't actually want to be helped. And he's not going to get any better without treatment.

He had an untreated infection. He needed IV antibiotics-- he needed to be admitted to the hospital. Maybe. He at least needed a plan. I mentioned hospital and he freaked out. I tried to calm him down, backtracked, said maybe we can deal with this as an outpatient, let me go talk to my attending and we can figure something out. And he left. The possibility that we would tell him to go to the hospital scared him and he left. I guess he thought we were going to forcibly bring him to the emergency room? I don't know. So now he has an untreated infection that he believes whatever doctor he tries to go to will send him to the hospital for, so he's not going to willingly go to a doctor, and he's not going to get treatment, and... he'll get worse. Great. Left a voicemail. I'm not holding my breath for a response to that. I'll hear he's in the ER when it gets worse, I guess.

I read a note on another patient. 82 years old. The note begins: "Patient is young female...." That is my second favorite note recently. Favorite is: "Patient is postmenopausal." Patient in that case was a man.

Here's something you never want to hear:

"Does anyone know where the crash cart went?"


Here's something you never want to hear next:

[No one says anything]


Here's something you never want to hear a couple minutes after that:

"Never mind, too late."


And, finally, here's something you never want to hear three minutes later:

"Oh, that's funny, it was right here all along."

"So what brings you to clinic?"

"I had a fever a couple of weeks ago. I called and this was the first appointment they had. So I am here."

"But you're feeling better?"

"Yes."

"So why did you come today?"

"Because I had an appointment."

"Okay. But the problem you had a couple of weeks ago resolved itself?"

"Yes. I was very sick. I had a fever of 112."

"A fever of what?"

"112."

"I'm going to write that number down on a piece of paper, just to make sure we're talking about the same number. Your fever was this number? 112 degrees?"

"Yes."

"I think there is probably something wrong with your thermometer."

"Oh. That might explain things, because I actually felt pretty good when I had that fever, but I thought since the fever was so high, I must be very sick, and I should go to the doctor. And that's when I made the appointment."

"So you felt okay even when your thermometer said you had a fever of 112?"

"Yes. But that was two weeks ago. Now I feel fine."

"You just said you felt fine before too."

"Yes. I did."

"Have you taken your fever since you had 112?"

"Yes. Today I had 47."

"Okay, clearly your thermometer is broken."

"Do you know how to fix it?"

"No. I'm a doctor, not a thermometer repairman."

"Oh. Is there another clinic where I can get it fixed?"

"...just one more thing, doc."

"Sure."

"I've been feeling heart palpitations."

"Okay... we'll start with the easy question. Are you using any drugs?"

"You mean drugs drugs, or medication drugs?"

"Either one. I mean, I have your list of medications-- are you taking something else?"

"Not really."

"Does that mean no, or yes?"

"Just some weight loss thing a nutritionist gave me."

"And it's called...?"

"Oh, it's unlabeled."

"Great. I think you should stop taking that."

"But I've lost 20 pounds."

"I can set you up with a nutritionist here. I think that would be better than taking some unlabeled supplement from someone else."

"But she says she's a good nutritionist."

"Does she have any sort of license or degree?"

"No, she's a nutritionist."

"There are degrees they can have that make them qualified to give advice."

"I don't think she believes in that stuff."

"I'm going to set you up with a nutritionist here."

"But I've lost 20 pounds!"

"But you're having heart palpitations!"

"But I've lost 20 pounds!"

"And there's no reason to think we can't come up with a safe regimen that will help you continue to lose weight without taking risks that unlabeled medication can instigate."

"I'm sure there was a label on it at some point."

"Great."

"I can ask her if she still has the label."

"Great."

"Does your nutritionist also do massage?"

I just watched the Emmy Awards on television. The one thing I'm left thinking is how differently you end up thinking about the word "infectious" after you spend any time at all in a hospital. There was someone giving a speech, and she mentioned that the "everything about [the director] was infectious," and I couldn't help having the reaction that everyone ought to be staying away from him. The people near him in the audience should move, now, quickly, far away. The cast should not be complimenting him, they should be quarantining him, and figuring out how to best address whatever the problem is, and why everything about him was infectious. What is the infection, is there medication they should be taking, should they be wearing masks.... It's almost unfathomable that in normal usage, that is a good word, and means you're complimenting someone. Because nothing about it is good in the hospital. No one will ever happily say that anything about anyone is infectious.

And the worst thing I can imagine is an infectious laugh, because then you're just spewing whatever it is you have over everyone around you, and they don't even know when it's coming.

It's interesting when patients have questions that sort of seem crazy at first, but then actually make a little bit sense. Or at least I see where they're coming from.

"I have a question about my back pain. Is it hurting the rest of my body?"

"Excuse me?"

"Is my back pain affecting my organs?"

"No."

"So having back pain isn't causing my heart to have to work too hard?"

"No."

"Or my lungs to get distracted?"

"No."

"My back isn't causing less blood to flow to my penis?"

"No."

"How about my arms and legs? Is my back pain hurting those? Are they going to get weaker because all of my strength needs to be used for my back?"

"No."

"And my kidneys and livers are going to be okay?"

"Yes. And it's just one liver."

"I find that I think less well while my back is hurting. Does that mean my back is hurting my brain?"

"No, it just means you're distracted by the pain, I expect. That's why we're going to try and figure out some pain medication that will relieve the discomfort."

"But it's not lowering my intelligence?"

"No."

"And it's not going to make my teeth fall out?"

"Why would back pain do that?"

"I don't know, it just seemed like maybe they were connected."

"Fortunately, they're not."

"Do you have any literature about back pain that I can read?"

"I'll see if I can print something out."

"Great. Thanks."

"We think your son might be having a reaction to the pain medication. He's having paranoid delusions, has been very irrational and disturbed. We're hoping it wears off over the next few hours, otherwise we'll have to think about medication options."

"Oh, no, that's just how he is."

"He normally has paranoid delusions?"

"Oh, yes, all the time."

"And is he on any medication? Does he see a psychiatrist?"

"Oh, no, we don't believe in any of that."

"So he just walks around at baseline completely out of touch with reality, and you've never sought treatment?"

"Both of my sons are like that. It's just how they are."

"You realize there is likely help that doctors could provide, and their delusions could be controlled, and they could live more normal lives without the anxiety that their mental illnesses are likely causing?"

"I don't want to start playing around."

"No, we can really help them. It's not playing around. Is your son even able to function normally?"

"He lives with me. We get along just fine."

"Does he have a job?"

"No, he could never have a job with the way he thinks."

"We could help with that."

"I'm not going to start experimenting on my children."

"It's not experimentation. They likely have diagnosable and treatable psychiatric disorders."

"I don't like to talk about that."

"Their lives don't have to be this way."

"We're fine."

"I want to get a psych consult and have someone talk to you about possible options."

"We'll just take more pain medication. But thank you for the concern."

"Doctor, aren't you worried about my mother's low urine output?"

"Your mother has no brain activity. Her last set of labs were incompatible with life. I'm not specifically worried about her urine output. She is not doing well."

"But don't you think she'd be doing better if we figured out why she's having so much trouble producing urine?"

"No. I'm sorry. Your mother is not doing well. She probably doesn't have more than a couple of hours. I'm sorry."

"But I want to get to the bottom of the urine thing. Are there any tests we can run?"

"She's on a ventilator. She's not able to breathe on her own. She is not doing well. There is no reason to subject her to more tests without any plan to use those results to improve her condition. There's nothing we can do at this point. I'm sorry."

"...and I didn't like the color of the urine she did pass."

"The urine is the least of her problems. I think you should spend this time with her, unfortunately it is not looking promising right now."

"I want to run the tests."

"There's no indication to run any tests. Unfortunately, she's septic, there's nothing we can do at this point."

"Should we try dialysis?"

"There's unfortunately no benefit to anything we can do right now. We're just trying to make her comfortable and minimize suffering at this point."

"She'd be suffering less if she could urinate."

"This is not the acute problem. I'm sorry. There's a bigger picture I want to do my best to make sure you're seeing."

"She needs to urinate."

"You need to go be with her. I will check on her a little later, but I need you to know, things aren't looking good."

"I also want to make sure she's getting the diabetic meal."

Re: previous post-- in a reassuring turn, we are still not sure. Perhaps intestinal material. Perhaps some material placed inside after a recent surgery. Perhaps something else entirely. But the patient's still alive, so that's a good thing. Can't possibly be a good thing coming out of his rectum, but, whatever it is, it seems to have stopped.

One of the things it's hardest to get used to about residency is never knowing what happens to most of the patients. I switch rotations, or they switch services, and there's no system to know what the result is. Not that I want an endless daily report on everyone I've ever treated, but sometimes, a couple of days or weeks or months later, a patient crosses your mind, and you don't remember the name, and you don't have anyone to ask, and so you just never know. Maybe you see them again, months later-- it happens, more than you think it would-- and they're back on your service, so you end up seeing how they're doing-- but, usually, you never have a clue. Part of why this is less rewarding than perhaps private practice would be. Although, there too, people move, people change doctors, people die without you finding out, I'm sure. You're such an important part of someone's life often for such a very short time. It surprises me sometimes when I realize I care. When someone happens to have some quality that reminds me of someone in my family, or is in a situation I can empathize with, or we just have that little connection that makes it feel like more than just ticking the boxes each day and writing the note. But, far too often, it just feels like an academic exercise. I wonder what's wrong, I wonder what the plan is, I wonder if they'll get better. The same way someone might wonder how their science fair experiment will turn out. Oh, look, giving a sedative does exactly the opposite of what I would have expected! Interesting! Hope to remember that next time. Maybe I should write it down.

"Doctor, we were cleaning this patient, and we thought we were cleaning stool, but the more we're cleaning him, the more we're realizing, it's not stool... you should really come take a look... it's definitely not stool, and we keep pulling--"

"You should stop pulling--"

"But there's more of it--"

"Whatever it is, I think you should stop pulling--"

"Okay, it's not stool--"

"I understand what you're saying. I'll be there in a minute."

Indeed, it is not stool.

And that is all I am able to determine.

"What are those people selling?"

"Nothing. They're just visiting your roommate."

"They have bags. They look like they're selling something."

"They're just visitors."

"I think they're selling something. What are they selling? How much is it?"

"They're not selling anything."

"I want to look at whatever they're selling. I want to buy it."

"They're just visiting their family member."

"No, they have bags. They're selling something. Why won't you let me buy it?"

"They're not selling anything."

"They are. What are they selling?"

"Nothing."

"Tell me."

"They're selling your organs."

[Silence]

"Do I get a commission?"

I have a new intern who tends to save the punchline for the end. In a medical context, this isn't a good thing.

"...Remember that patient we admitted, with hypertension, and she was doing better, and then she was doing worse, and then her family was here, and then she didn't really eat anything yesterday, and then the attending said we should monitor her, and so we ran an extra set of labs overnight, and then I checked this morning and she seemed stable... yeah, she's not breathing."

"...And remember the guy who came in yesterday with the chest pain, and his wife was concerned because he'd lifted something heavy the day before, and she thought he's been having memory issues, but she wasn't totally sure, and there was no documented dementia but you wanted me to call a neuro consult just to check what was going on, but then they didn't get to him yesterday so they were going to see him today... yeah, he just fell out of bed and he's bleeding from the back of his head."

Not exactly the conversation I just had:

"Oh, it's you! I recognize you! Why do I recognize you? And why do I recognize you and feel an instant revulsion?"

"Doctor, remember me? My mother was your patient!"

"Yes, that's why I remember you! Oh no! You're terrible!"

"We're back!"

"I was sure your mother would be dead by now."

"Nope, she's not!"

"Well, as long as I'm not her doctor again--"

"They told me you're going to be her doctor again!"

"Does that window open? It doesn't? Oh no."

"She's doing really well."

"That's her, on the ventilator, with the PEG tube and the implanted defibrillator, right?"

"Yes, can't you see her spirit shining through?"

"Nope."

"We want to do everything we can to preserve her quality of life."

"..."

"And anything medical that comes up-- remember from last time-- we need unanimous consensus from all seven siblings, and we'll need you to make those calls. Here's the list again."

"..."

"We've also added two more names to the list. She made some good friends in the nursing home we want to keep updated on her condition."

"You're going to have to make these calls-- I really don't have the time. We will do everything we can for your mother, but she's the patient, not you and your six siblings, two nursing home friends, and the homeless guy you picked up on the way in."

"Oh, I can't. I have a job. And I have to go there now. Goodbye."

"Your mother is still in the hall, waiting for a room."

"Yeah, I'll be back tomorrow to find her. I'll get your cell number from the nurse's station and call you fourteen times in the middle of the night if I have any questions. Bye."

"..."

"Also, I'll need you to fax all of her results to these six numbers every day, and call to confirm the faxes went through."

"Who are these people?"

"Four of her doctors and two family friends who are good on the Internet. They'll be consulting on her care. But I can't talk anymore. I'm really leaving now."

"Bye."

"Oh, wait, first I'm going to accidentally unplug all of her wires. Alarms are ringing? Oops! Was that me? Gotta go!"

The middle of an overnight shift.
In the call room.
Finally getting a chance to lay down for (hopefully) a little while, until the pager next goes off.

I hear a whirring outside the door.
It gets louder.
I open the door.

I see a man waxing the floor, with a very large and noisy piece of equipment.

"You gonna be in there long?" he asks.

"All night, except when patients need me. It's my call room-- and I'd like to try and get some sleep if I can."

"I need to know when you're gonna leave."

"When they page me."

"Yeah, when's that?"

"When something's going on with a patient."

"Yeah, I gotta wax the floor, so you're either in or out."

"No. I'm in, until my pager goes off, and then I'm out."

I close the door. I try and sleep through the noise.

Half an hour later, my pager goes off. Rapid response. I open the door. The guy is still waxing.

"You leaving?"

"I'll be back."

"How long?"

"I don't know."

He points. "You can't go down that hall or that hall."

"A patient isn't breathing."

"I just waxed."

"I have to get to this patient."

"You need to go around the other way."

"The patient!"

"Sorry. How long until you're back?"

"I DON'T KNOW!"

"Doc, I'm just trying to do my job."

It has been a long past couple of days. Sorry for two days without posts. Went from doctor to patient. Picked up some sort of crazy virus, probably from one of my interns, because my interns are terrible people. I'm kidding. Sort of. Fever spiked to 102.4, at which point I ended up in the ER myself for some fluids. ER patients are far more entertaining when you're not the one who has to deal with them. Like the diabetic whose mother brought him a bag of chocolate bars. He gave me one-- said he knows he shouldn't eat them all. Uh, your blood glucose was a thousand. You shouldn't eat any of them. Regular posting should resume this weekend.

Patient Note -- J. Doe

Patient has been here for 187 days and shows no signs of change. Building on the observation in note 184, it does in fact seem like patient believes that every day is Tuesday. Patient continues to complain that there is not enough variety in the hospital menu, but this complaint is unlikely to abate as he proceeds through his 13th rotation of the two-week menu cycle. Patient is continuing to recover from infection which developed on day 174, which was a result of the medication given to aid recovery from infection which developed on day 159, which was caused by the catheter needed while patient was being treated for infection which developed on day 132, which was caused by bedsores that developed while patient was in recovery from infection developed on day 119, which was caused by parasite that may or may not have been introduced to patient by his hospital roommate, who has also yet to be discharged. Patient was last intubated on day 104, extubated on day 105, intubated on day 106, extubated on 107, intubated on day 108, and may have swallowed the intubation equipment, resulting in a prolonged stay. Patient's first hundred days were marked by seventeen infections, fourteen procedures, and one new grandchild. These second hundred days have been less eventful. The third hundred days promise to be thrilling. Resident to write next note on this patient tomorrow, or when circumstances dictate.

This is probably not a story I should be sharing. I had a clinic patient yesterday who I knew-- I was his doctor three weeks ago when he was an inpatient. It was not a good couple of days when he was on my service. We were at capacity, there were rapid responses all over the place... in any case...

"Oh, I really like you, doctor. You really listen."

"Thank you so much. That means a lot."

"When I was in the hospital a few weeks ago, I had a doctor who didn't listen at all."

"Um..."

"Do you know Dr. [Me]? I would never want him as my doctor. I want you to be my doctor instead."

"I was your doctor in the hospital. I'm Dr. [Me]."

"No, it must have been someone else. I did not like Dr. [Me]."

"Dr. [Me] is me."

"Are you sure there isn't someone else with your name?"

"No, I remember you. You were my patient. And I'm glad you're feeling better, and sorry you don't feel like I was listening as well as I could have been. It's not an excuse, but it was a tough week when you were here."

"No, it definitely wasn't you. You should keep your eye out for Dr. [Me]. I hope you don't have to work with him."

"I hope I don't have to work with him either."