We had our annual winter party last night. I was lucky enough to have the night off so I could go. I should rephrase that. I was unlucky enough to have the night off so I could go. And spend my day off with work people, talking about work, instead of anywhere else, not talking about work.

It's not that I don't like a lot of the people I work with. It's just that all we talk about is work. It's my fault as much as anyone else's. I talk about work. What else is there to talk about? Except I wish that there was something else to talk about.

"Did you hear that Bill is dating Jessica?"

"I thought Jessica was married."

"She was, but she's not anymore."

"What happened?"

"She was spending too much time at the hospital. Her husband left her."

Even the people who've already found a mate-- the people who I take for granted are lucky because they're done, they don't have to worry about that stuff anymore-- they still have to worry about it. Maybe it's as hard to be a married resident as a single resident. Especially if your other half doesn't understand what the lifestyle is.

I'm amazed at these kinds of things, when people bring their spouses and the spouse has absolutely no idea what their doctor wife or doctor husband does all day.

"Oh, she never tells me anything about what happens at work."

"Oh, are you in the same division as my husband? What's it called?"
"Internal medicine?"
"Yeah, that's what it's called, right?"
"Yeah, I'm in that too."
"Oh, is everyone in that, or it's just a few people?"
"It's a good number of people."
"And everyone else is surgery?"
"No."
"Oh. What is everyone else?"
"There's psych, and derm, pediatrics, OB, a whole bunch of things."
"Oh. My husband never tells me anything."

"Oh, I don't even know what my wife does all day and night. I don't know if she sees patients, or it's classes, or what this whole residency thing is all about."

"Oh, I just wish my wife would work less. I don't understand why the chief doctors always pick her to work the nights and weekends."

Are they just never talking about work, is the spouse not listening, I don't understand. I know more about what my third cousin does at work than most of the non-doctor spouses I meet know about their husbands or wives. No wonder people get divorced. They must never be talking if they know this little. I thought part of the point of being married is having someone to share with, and to talk to. I guess not. I don't know what these people talk about at home. I don't know what kind of lives they live. It makes me less sad about my own situation. Maybe I've idealized what marriage is, what having a partner is about. Who knows.

And today, half the doctors on the floors have a hangover from last night, which makes for great patient care. Free open bar until midnight, and half of us working the next day? Smart.

Get ready for this one. Woman comes into clinic with a urinary tract infection. Talking through the translator phone--

"Yes, it has been painful when I urinate."

"Okay, have you noticed any other symptoms?"

"When I tasted the urine, it was sweet, not salty."

"Excuse me? Translator-- did she say she tested the urine?"

"No, she said tasted."

"Can you ask her to repeat what she said?"

"When I tasted the urine, it was sweet-- usually it is salty."

"Wait, why are you tasting your urine?"

"I wanted to see if it was different."

"Why had you tasted your urine in the past? You should never be tasting your urine. Do you understand what I'm saying? You should not put your urine in your mouth."

"Doctor, this is the translator. She's asking me to clarify."

"Please tell her not to drink her urine. Ever. Not something she should do."

"She's asking how she is supposed to know when something is wrong if she does not taste it."

"Tasting it is not the answer to anything. She needs to see the doctor if she thinks something is wrong, and we can test-- test, not taste-- test her urine for any abnormalities, but she should not drink her urine. Can you make sure she understands this?"

"Yes, she says she understands."

"Okay, great."

So we hang up, and I go talk to the attending-- we do this for each patient, we run our plan by the attending and then go back and finish up with the patient. So I go back in, and use the translator phone again, and this time we happen to get a different translator. We go over the plan--

"And please remind her that she should not taste her urine."

"I'm sorry, this is the translator speaking-- I'm not sure I heard you correctly."

"I think you probably did. I'm trying to tell her that she should not taste her urine."

"Test her urine?"

"No, no. Drink her urine. Put it in her mouth. She should not do that. Can you make sure she knows that she should not do that?"

"This is the translator speaking again-- why would she be drinking her urine?"

"There was a different translator earlier in the visit, and this was part of the conversation. I just need you to make sure she knows never to taste her urine."

"Okay, she says she understands. But she also wanted me to make sure you knew that it was sweet, not salty."

"Yes, tell her I know what she is saying, and we are testing her urine."

"She wants to know why it is okay for you to taste her urine, even though she is not supposed to."

"No, no, testing. We are testing her urine, not tasting. Please make sure she understands."

"Okay."

"We're good? Everything's clear."

"Not to me, the translator. But the patient says everything is good."

"Okay, great."

"I don't know what just went on, doctor."

"Me neither, translator. Have a good rest of the day."

I think my diabetes video somehow leaked into the cosmos and made all the diabetic patients find me in clinic. I had like three in a row this morning.

"My blood sugar keeps dropping really low after I take my medication. Like 35, 36. And I feel like I'm going to pass out. Then I eat something and after a little while I feel better. And it keeps happening, like once every day or two. But it's all happened only for the past two weeks. Before that it was all fine."

"Are you taking your medication?"

"Yes."

"Are you eating anything different than usual?"

"No."

"Are you doing anything different at all?"

"No."

"Are you taking your other medications?"

"Yes."

"So you can't think of anything different you're doing?"

"No."

"Are you sure?"

"Uh, I don't know, I guess one thing but it's probably nothing."

"No, what is it?"

"I've been taking the medication sometimes after I eat instead of before I eat."

"Uh... yeah, that's the problem."

"No, no way."

"Yeah."

"I didn't think it mattered."

"Yeah, it says on the label you need to take it before you eat. There's a reason."

"I didn't think there was a reason."

"No, you need to follow the instructions on your medication. The instructions are there for a reason."

"You mean every medication, I should read what it says and not just take it?"

"Yeah. Definitely."

"Oh, no one ever told me that before."

"Yeah, there's a reason we put labels on everything, with instructions."

"And when I take the medicine can really make a difference? You're not just screwing with me, doc?"

"No. It really does matter."

"Aw, that's crazy."

"No, it really matters. Please take the medication when it says to take it."

"Even if sometimes I have to go upstairs and get it, when I'm about to sit down and eat? I can't just take it afterwards?"

"No. You should go upstairs and get it."

"Seriously?"

"Yes."

"Oh, man, that sucks."

"Not as much as feeling the way you've been feeling, right?"

"I don't think that's really what's causing it."

"I think it is."

"I don't know. We'll see."

"Yes. We will see. Anything else today?"

"Do I really have to take this much medicine? I hate taking all this medicine."

"Yes."

"Really?"

"Yes."

"Really?"

"Yes."

I had a patient in clinic today who'd been referred to the medicine clinic for a routine checkup after a visit to the dermatology clinic last month. I read the chart before I saw him, nothing remarkable. Nothing listed in the medical history, no other problems besides the skin issue he had gone to the dermatologist about.

So I start to do a physical exam, we're talking about how his skin issue is doing, and I casually ask if he has any other problems.

"Oh, yeah, I've been feeling some itching on my leg stump."

"Excuse me?"

"Yeah, some itching."

"Uh... you don't have a leg?"

"Yeah, no leg."

"This new, since you saw the dermatologist?"

"No."

"And the dermatologist didn't notice this?"

"I don't know."

"And you had the brace, and everything?"

"Yeah."

He saw I was looking at the chart, a little perplexed.

"Yeah, I don't think he asked."

"Didn't even have you take off your shoes?"

"Nope."

"Hmmm."

Okay, one more video makes it four. This one's about patients and their medication issues. Enjoy...

I made a new video. "Is This Your First Pelvic Exam?" I'm not sure the green screen works as well as the generic hospital location in my other videos, Nurse This Patient Is Dead, and World's Worst Clinic Patient. Still figuring all this out.

As I wake up for an exciting day of long Saturday call... I notice someone found this blog yesterday with the Google search, "kicked out of residency positive drug test."

Just thought I'd share that.

I don't even know how I'm writing this, or what day it is, or what time it is, or whether I'm awake or asleep. I've worked like 60 of the past 72 hours, and it feels like I've worked 80 of the past 72 hours. Everyone in the program has a number of days during the year when we can be called in to do nighttime admissions if there's too much going on. Maybe it's payback for the post about passing off admissions to the night team. I mean, it's sort of perfect payback for that post when you get a call at midnight, when you're fast asleep, and are told to come in to do six admissions overnight, and then you have to do your regular shift on top of that. And then the same thing happens the next night, just as the mandatory 10-hours-between-shifts is coming to an end.

If this was my life-- if this was the permanent schedule I had signed up for-- I couldn't do it. Maybe some people can thrive on the lack of sleep, but I'm not one of them. I am not the person you want doing your middle-of-the-night admission, I'm just not. Whether you're the patient or the attending, I'm not the person you want. I yelled at patients. I yelled at someone for coming in at 3 in the morning with a cold, and demanding to be admitted. "You have a cold. Go home. You don't need a hospital. You are wasting everyone's time." Of course, the patient had no idea what I was saying, because she didn't speak English, and we couldn't get a translator at 3 in the morning, not even on the phone, so I have no idea what she thought I was saying, and what happened to her after we sent her back into the ER with directions to the outpatient clinic, where we made her an appointment for 6 hours later, when they opened.

You don't realize how many residents are sleeping with other residents until you work the midnight-8AM shift. It had been a good long while since I'd been on nights. I think the last time I did nights was in August. At night, everyone's guard comes down. You hear the gossip that you don't hear during the day. This one got sent to see the house staff's psychiatrist, that one has genital herpes, that other one might be getting kicked out of the program. No one talks about these things during the day. During the day everyone talks smack about the nurses and the support staff. It's only at night that everyone turns on each other and shares all the juicy stuff. So now I know that everyone's seeing some action except for me, because I'm sleeping, and blogging, and whatever it is I'm filling my pointless days with.

There are people who sign up for this stuff. Once we have our license, we can sign up for moonlighting shifts and make $75/hour to do admissions when there's overflow. They use the moonlighters first, then they call the people on emergency backup like I was, if they can't get a moonlighter or if the inflow is just too big. So I'm working alongside people making $600 for the night, and I'm making nothing. But I don't understand how anyone can think it's worth $600 to kill yourself and get no sleep for days. At least I was forced. They're volunteering. And no one's even paying any attention to the work hour requirements when you're doing a volunteer moonlighting shift, so you can have someone on the day team who just worked overnight, exceeding the work hour rules and running on literally zero hours of sleep. I got my ten hours in between thirty hour shifts, so I guess I'm not legally entitled to complain even though it is insane to work 60 of 72 hours. I was a zombie on rounds this morning. I didn't remember anything about anyone, whether I'd admitted one guy or another guy, what they had, what they needed, I couldn't even read my notes. And now my body has no idea what time it is, and I can't fall asleep.

I have like 22 hours now until I have to be back. That's enough time to catch up, I hope. Who knows. I don't know if I showered in the past three days. I think I did. I think I showered when I got home. But I don't know. There is toothpaste on the floor. I think I sleep-showered. I think I was asleep when I was in the bathroom when I got home. My phone is off. They cannot reach me. If they try and call me-- and they're not, because I'm off, but I don't even want to take the risk that someone makes a mistake and dials my number-- they will not get me. Good night, good morning, and don't go to the emergency room at 3 AM with a cold.

I understand the comments on the previous post. I should have been clearer, maybe, so that it would be more obvious that the problem is the system, not the ethics of the doctors. Even if the patient cap wasn't an issue, we would still save the discharges until the end of the day. Because discharges take time, and every minute we spend on a discharge is a minute we can't spend on patients who have active problems we need to deal with. The priority is the sick patients who need our help, not the patients waiting to go home. To stop in the middle of the day, when there are still things on our list, to discharge someone is a poor use of our time. There are only so many things we can do at once.

Similarly, every minute we spend processing an admit is a minute we can't spend running our list and dealing with what we have to deal with. If I'm called at 2:00 to process a new admit, it means everything on the patients I already have on my list gets pushed. We're simply never sitting around doing nothing. It's not a matter of avoiding work. We are always doing something. We are always busy. We are always left with less time than we need. And any of us would rather prioritize the patients we're already dealing with and trying to treat over the new admissions that are waiting to be processed. Because we already know the patients on our team, and they need us. The new admits can be processed by anybody.

The night team ought to process the new admits. They don't come in with a list of things to do for the current patients. They come in with a blank list. We work the whole day trying to get as much done as we can to get out at a reasonable hour and get a little bit of sleep before coming back in to do it all over again. If we have nothing to do, sure, give me a new admit. But otherwise we are busy. And if we have to spend the whole day processing new people, the old people will crash and burn. I need to protect my people. My patients, and my interns. So I will do everything I can to avoid new admits if I can push them off, because I don't want to deal with all of my patients dying on the floor because I was distracted.

There ain't enough people. That's the problem. We have an unlimited amount of work. No one's being lazy. We're just trying to manage our day and not get overwhelmed and sacrifice care. This is vastly different from the ethical problem of buying your way into medical school. Or I'm just delusional.

Oh, and I probably overstated how much control we have anyway. Even if we process the discharge, they're usually there for hours waiting for social work or pharmacy or nursing or someone to come pick them up (that's always a fun one). They're just as busy as we are, and they're just as likely to have sixteen other things to do that take priority over a discharge. So it's not like we're really in control.

But I won't pretend I'm backtracking from the post. None of us want new admits if we can push them off to the next shift. Not the doctors, not the nurses, no one. We have too much to do already with the patients we have, and we don't want to be at work 24 hours a day. And we shouldn't be.

I have three patients right now that I could discharge.

But I'm not.

See, the system here creates very perverse incentives. Our team is capped at a certain number of patients. You reach that cap, and they can't give you any new ones. So new ones end up with a different team. You discharge patients, and it frees up spots for new ones.

Every new patient you get means at least an hour and a half of work. Taking the history, getting the initial labs, figuring out the plan, seeing if they're stable. You get 4 or 5 new admissions in a day, and that's a full day of work on top of whatever you need to do for your patients that are still around. It means your work gets backed up, it means you can end up staying late, it can really make the day pretty impossible.

There's a point in the day after which you can't get new patients-- depends on the rotation, but usually 5:00 or 5:30-- patients who come in after then get processed by the night teams and then given out in the morning. This saves the day team a ton of time-- you come in, pick up your new patients, and they've already been worked up, you get to skip that hour and a half you'd normally have to spend on them.

So there's a great incentive to hold your discharges as long as you can. If you can wait to get rid of your patients until after the 5:00 admit clock rings, you don't have to do the extra work. The night team gets screwed, but at least you get to go home at a reasonable hour.

Of course, if the night team doesn't get to the new admission, you get them delivered to you first thing in the morning-- a patient who's been sitting in the ER all night, without anything done for them, waiting for a doctor to finally get to them.

But a new admit at 7AM is slightly better than a new one at 5PM, because you're there anyway. I mean, it screws things up for the rest of your patients, who have two extra hours to go downhill before you finally have time to come see them, new admit processed. But at least you can go home for dinner.

Everyone's always trying to push admits to the next team. No one wants to ever admit there's room on their team, or acknowledge they had a discharge. And, I mean, it doesn't really matter because the only people actually hurt are the patients. The patients who have to chill in their rooms for an extra 6 hours because I don't want to discharge them before 5:00, wondering why this is taking so long. And the patients who end up sitting in the ER all night because the night team was too busy with the leftover day admissions to ever get to them.

So if you're wondering why your discharge is taking 7 hours, that's the story.

I got notified the other day about a new follower on Twitter. I won't say her name. She apparently runs some kind of business where she charges aspiring medical students as much as $2000 to edit their application essays. She's a doctor. From a real medical school. My first thought was what kind of money can a doctor be making editing application essays. And then I saw what she charges. And then I read some of the testimonials on her website. Stuff like "residency director said my essay was the best essay he's ever read."

And I'm sure that residency director would be thrilled to find that testimonial and realize there's a good reason that essay was the best one he's read-- someone paid an awful lot of money for it.

I'm not presuming to know how this business works, but if I was paying someone $2000, I think I'd expect more than just the kind of edit you get from a friend you might send an essay to. I know it's not illegal to get essay help-- or take test prep classes, or pay money for all sorts of things to give you an edge in the admissions process-- but I feel like there must be a line somewhere, and I feel like an $2000 essay coach who is in fact also a doctor is on the wrong side of the line.

I wasn't going to write this post, but when I followed this person back on Twitter, I got an automated message that said something like, "I level the playing field for applicants to selective medical schools. Check out my website..."

Hold on just a second. You do what? You level the playing field? What does that mean? Seems to me you do exactly the opposite. You enable rich kids to game the system. You enable people who don't think paying someone to write their essay is a bad thing to get into a better medical school than they would have otherwise (assuming her work actually makes a difference and the whole thing isn't just a scam).

I don't want the playing field leveled. I want the people who deserve to get into a good medical school to get into a good medical school. And we could debate whether or not the current system works, and whether a lot of well-qualified students are actually denied entry -- they are, of course, and I'm not arguing otherwise. But essay coaching is an enemy, not a solution.

How much does she charge to help me with rounds? To save my patients? To take my boards? The people who can afford to pay someone $2000 to write their essays are the last people I want getting a leg up in the admissions process. This is not leveling the field. This is an unsavory way for a doctor to make money on the side, and a disgrace to the profession.

Comments have been split on previous posts where I whine about medical television shows that don't make any sense.

Nevertheless, I will do it again.

Off The Map.

Three young doctors go to a third-world country to practice medicine in a ramshackle clinic. From the makers of other medical shows that make no sense either.

I am happy to give them a pass on the biggest bit of ridiculousness, a myth perpetrated by pretty much every medical show that ever existed-- that medicine is medicine, and if you're one kind of doctor, you can be every kind of doctor. Surgery, internal medicine, OB/GYN, whatever, whether trained or not, you can do it all. The last time I was in an operating room was medical school. If someone handed me a scalpel and told me to perform surgery, I would only be marginally more capable of doing this than a bus driver. I know enough anatomy to not do anything insanely stupid, but that doesn't mean I can remove someone's appendix and not kill them in the process.

But, like I said, I'll give them a pass on that, because otherwise, I admit, they wouldn't have much of a show.

Let's start with my favorite stupidity. Performing CPR involves actual pushing on the actual chest of the patient. I get that they don't want to injure the actors, but use a dummy or something. Because it is a disservice to the universe to repeatedly show people performing utterly preposterous CPR that would revive absolutely no one. The actress on this show mimed it. I don't even think her hands touched the patient. It was improv class CPR. Anyone who tries that at home will be left with a dead patient. Sorry.

Wrong tuberculosis masks. Not going to protect anyone from anything. And he ripped it off anyway when he had to make his big speech.

And speaking of the tuberculosis family, what kind of attitude was "you're a doctor, make them take the medicine or don't come back" ! You can't make anyone do anything. You're a doctor, not a dictator. You can explain the benefits, but you can't force someone to take medicine against their will. You can't.

Taking a patient to dump his wife's ashes in a lake, when he's supposed to be med-evac'd in a helicopter off the island. Let's see... was this an emergency, or not? If was not an emergency, why the urgent med-evac? If it was an emergency, no matter how tear-jerking his story is, you need to get him to a hospital. He can come back and dump her ashes later. It is extremely poor practice to let your patient die on a river adventure to dump his wife's ashes when there's a helicopter waiting to take him to safety.

Taking your own asthma inhaler out of your purse and giving it to a patient-- without, I don't know, wiping it off(!), is unsanitary. Also, giving a patient an inhaler without using a translator to explain to her what it is and how to use it is pretty pointless. I know they didn't want to have to translate everything, the entire episode, but just have the translator standing there and pretend, just so we know you're not sending her off with a weird medical device she has no idea how to use.

Coconut water as a blood replacement. I'm going to trust Google on this one and give them a pass, but this is not something they teach us in medical school.

Scalpel on the zipline. The doctor pulled out what was basically a paring knife. I think it's what I used in high school to dissect a frog. This is not a knife you would use to cut a patient's skin out of a zipline. Sorry.

And, finally, the crazy story the doctor played by Meryl Streep's daughter told about how she ended up on the island. Went something like this: "I was moonlighting, hadn't slept in 72 hours, was on duty, sent someone home with bacterial meningitis, he died, I got kicked out of residency, and so here I am."

First-- so you were grossly violating work hour limits? Who is letting you moonlight? What hospital administrator is allowing you to sign up for three consecutive days of work?

Second-- you're the resident, not the attending. Why are you on duty alone? How are you the only one responsible for sending someone home with meningitis? Where was the attending? He didn't catch it either?

Third-- they're not going to kick you out of residency for that, unless you've already done a whole bunch of other terrible stuff. AND IF YOU'VE DONE A WHOLE BUNCH OF OTHER TERRIBLE STUFF, WHY DO THE DOCTORS IN THE JUNGLE WANT TO TRUST YOU WITH ANY OF THEIR PATIENTS?

That's all I've got...

2:17 AM.

My cell phone rings. Unknown number.

"Hello?"

"Hello. Doctor?"

"Uh, yes. Who is this?"

"This is [John Smith]. My father was your patient two weeks ago in the hospital. He is having some pain in his leg."

"What? Who? How did you get this number?"

"This is [John Smith]. My father was your patient two weeks ago in the hospital. He is having some pain in his leg."

"Why are you calling me?"

"I wanted to see what to do."

"I'm sorry, I'm not your father's doctor anymore. If it's an emergency, you should get him to the nearest emergency room. Otherwise, he should make an appointment with his regular doctor or come to the clinic during regular business hours. It's two in the morning."

"Should we put ice on his leg?"

"It's two in the morning. And, I'm sorry, I'm not your father's doctor anymore. You need to call his regular doctor. How did you get my number?"

"Would heat be better than ice?"

"How did you get my number?"

"The hospital gave it to me."

"Who at the hospital gave you my number?"

"I don't know."

"You can't call this number anymore. I'm not your father's doctor."

"The operator connected me to a nurse. I told the nurse you were his doctor and she gave me this number."

"This is my personal cell phone number, and, I'm sorry, I'm not your father's doctor anymore. Do you happen to know the name of the nurse--?"

"So we should not put ice on his leg?"

"If this is an emergency, you should take him to the emergency room. Otherwise, you should make an appointment to see his regular doctor. I'm sorry. There's nothing else I can tell you. I'm not your father's doctor."

"You were his doctor in the hospital."

"Yes, I probably was. But once the patient leaves the hospital, I'm not their doctor anymore. It's not your fault, but no one should have given you this number. You need to take him to the emergency room if this is an emergency, and otherwise call his regular doctor."

"His regular doctor is on vacation."

"Then call the answering service and they will get him a message."

"He doesn't have an answering service."

"Then take your father to our outpatient clinic in the morning and someone will see him. You can't call this number. It's two in the morning."

"I just want to know if I should put ice on his leg."

"Sure."

"Ice, not heat?"

"It doesn't matter."

"It doesn't matter?"

"I'm hanging up the phone now. Please don't call this number. If this is an emergency, call 911, or bring your father to the emergency room. I hope his leg feels better. Have a good night."

I had to do a scrotal exam on a patient on Friday.

I tried to be gentle.

He got an erection.

It was a little awkward.

It was actually the first time I'd done one alone. We're supposed to call a third-party observer into the room whenever we do a genital exam. Not just any third-party observer, of course. Another doctor. Partly to have a witness so the patient can't claim anything inappropriate happened, and partly because we're still learning how to do these things correctly and it doesn't hurt to have a guide.

The normal practice is to ask whichever attending is supervising the clinic to come in and watch. I've been good about doing that. I was talking to a friend the other day. Apparently some of my co-residents don't bother unless they feel uncomfortable with the situation. It's a little annoying to have to find the attending and hold off on the exam until the attending is free to come help. It slows down the rest of your schedule. It can keep you there longer, which is, of course, wonderful. You have to pass through the waiting room, and when your other patients-- your waiting patients-- see you, they start asking how much longer it will be, and try to start telling you about their medical problems. So I can understand why people just want to get it over with and quickly do it themselves.

But like with blood and vomit and everything else, I kind of hate touching my patients' genitals or sticking my (gloved!) finger in their rectum, and I don't mind having someone else in the room who will sometimes offer to do it for me.

So on Friday, before doing the scrotal exam, I went to get the attending. And he was busy dealing with a patient in the waiting room who'd passed out. Not my patient, fortunately. (And in the end, he was fine.) But he told me to do the scrotal exam myself. Understandable, since he was working on something slightly more important.

And so I did the exam myself. And the patient got an erection.

"Oh, this happens all the time," I told him. "Don't worry about it."

"Yeah, but that's so weird. Because part of the problem I'm having, besides the pain, is that I'm not able--"

"This is an artificial setting, though. But I think it's a good sign, because maybe the problem is more a mental one than physical--"

"You're saying I'm crazy?"

"No, no, not at all. I'm just saying that at least now we have evidence that the physical part of it is working, so that's a good thing, and we can rule out some--"

"I'm not, like, attracted to you or anything."

"Of course not. Like I said, this happens all the time. It's the artificial environment, the rubber glove, it's totally normal, just forget about it."

"Yeah, yeah. Can you stop touching it?"

"Of course. I'm just about done with the exam. I just want to make sure I'm thorough and don't miss anything."

"Yeah, you don't have to be so thorough."

"I just wouldn't want to miss anything. I can get someone else to finish the exam if you'd be more comfortable."

"Like a woman?"

"There actually aren't any female doctors in the clinic this afternoon."

"Well, I don't want some other guy touching it too. Just hurry up and finish."

"Okay, I'm all done."

I start scribbling down my notes.

"You're not gonna say that I got--"

"Please don't worry about it. It's completely normal."

"How am I supposed to tell my girlfriend that this happened here when it doesn't--"

"It's really completely natural. We'll do the blood work and see if anything's going on, but you should try not to worry about it."

"I'm not, like, attracted to you."

"Don't worry about it. It really doesn't mean anything. I think it's just the stimulation, from anything--"

"Except my girlfriend."

"I really wouldn't obsess over it. We'll get the tests back and figure out if there's a problem, and then we'll figure out next steps."

"You're not touching me anywhere else."

"Nope, not planning on it."

Some of the comments on the previous post surprised me.

Yes, maybe I am a little squeamish when it comes to bodily fluids. But it seems like it would be different if it were my own kids. Who, hopefully, wouldn't be harboring the kinds of infections that many of my patients are.

If my child threw up on me, I would feel icky, sure.

But if a patient threw up on me, I would feel like running into a decontamination shower, and would probably throw up too.

And so would you. I think.

Even if you're used to what comes out of your pets and your children, I think it's different when it's a homeless guy with scabies and bedbugs and the plague. Maybe that sounds bad, I don't know. Maybe it makes me a terrible person to not want to touch my patients who have open sores all over their bodies, or to go near my patients who smell like sewage.

My hair touched a patient's arm the other day, just barely grazed me, did not make any real contact. And I couldn't stop thinking about it for the rest of the day, and the first thing I did when I walked into my apartment is take a shower.

The first thing I do every day when I walk into my apartment is take a shower. I smell. After a day of work, I smell like hospital patients. I don't want to smell like hospital patients.

I signed up for this, sure. I absolutely signed up for this. And I don't blame the patients for whatever they come to the hospital with. We're here to treat them, it's our job, I totally understand that. It does not make my patients bad people if they have body lice, or if they haven't showered in six weeks, or if they have pink eye. I will treat them. I will do what I can for them.

But it doesn't mean I want to give them a hug, and it doesn't mean I'm not putting on gloves whenever I'm anywhere near them.

Look, some of the things I'm talking about-- smells, urine, vomit-- probably aren't going to actually make me ill, they're just unpleasant.

But I have no interest in bringing home bedbugs or scabies, or catching any illness I don't have to catch.

And then there are the real dangers. I know two residents who've had needle sticks when dealing with patients with HIV, and they've had to take six weeks of HIV post-exposure prophylaxis drugs-- which has side effects-- diarrhea, headaches, fatigue. Not fun. A risk I signed up for, but I don't want it.

Patients scare me. They have things I don't want. This should not be controversial. We're still people, who are still icked out by whatever we were icked out by before we became doctors.

I accidentally touched a patient's feces.

I was doing a rectal exam, and I was taking off the gloves... and my hand slipped... and... feces.

I don't know how I'm ever going to feel clean again.

And it seems terrible to obsess over it.

But we're only human.

And just because I'm a doctor doesn't mean I can't get just as disgusted by what comes out of people's bodies as everyone else.

At least I'm not a nurse.

But still.

I have to see blood and urine and semen and feces and pus and mucus and all sorts of other nastiness.

At least I'm not doing OB.

Because watching someone give birth was truly horrifying.

But seeing the things I've seen on people's genitals in the clinic is almost as bad.

Seeing the things I've seen growing all over my patients.

Rashes, warts, pimples, cysts, blisters, pustules.

At least I'm not a podiatrist.

Because feet are pretty terrible.

Fissures and fistulas.

I did a rotation in medical school shadowing a doctor whose entire practice was the surgical repair of anuses.

Anii?

No, I think it's anuses.

I can't believe I touched a patient's feces and now I'm touching the keys on my computer with those very same hands.

I have washed so many times, my skin is raw. I used an entire bottle of Purell.

Travel-sized, but still.

Disgusting.

Why couldn't I have become an accountant?

Happy New Year, a couple of days late. I ended up getting out early enough on New Years Eve to meet up with a couple of friends for dinner and watch the ball drop on TV. I don't know if it's that residency has sucked the life out of me, or the hours I've been working have made it impossible for me to stay even semi-connected to anyone in my life, or it's just a function of getting older and drifting away from people who used to be a part of my life-- but, I don't know, it's not that I don't like my friends anymore, but I feel like, more and more, every conversation I have with anyone is so shallow, so surface-level. Whether at the hospital or outside of it. That the people in my life have gone from being people I share things with to people I report things to. I don't even know if that makes any sense.

It's like, I feel like every time I see anyone or talk to them, or even e-mail, we have to "catch up" and the whole conversation is about catching up and bringing the other person up to date on what's going on. It never moves to the next level, where we're all caught up and can just have a conversation about something else. And in the hospital, it's just about medicine. Even the friends I've made at work, they're work friends. I don't really know them. I don't know what they think about when they're not at work. If I see them outside of work, we just end up talking about work, which is why it sort of sucks to see them outside of work.

And I hate the fact that a good number of the people who I would absolutely call friends and who would absolutely call me a friend-- if they dropped off the planet tomorrow, it would probably take me weeks to notice, and then once I did, I would miss the idea of them, and the history I have with them, more than their actual current presence in any aspect of my life.

Of course I put the blame on me as much as on anyone else-- and probably much more on me, since I'm impossible to schedule anything with, and I have pretty much no free time at all-- but I think I do try, I do make an effort, I do reach out-- I just get less and less back over time. And even when I do end up catching up with someone, we're only catching up so that in a few weeks we can catch up again and too much time won't have passed. I'm never actually caught up with anyone. I'm never not catching up.

I think what I'm saying is that my New Years Eve was kind of lonely, even though I was around people.

And if I'm being honest with myself, I have to admit I almost wished I was at work. Because then I don't have to think about it. Because it's not my fault, because of course I can't blame myself for feeling lonely when I'm forced to be at work-- it's a get-out-of-feeling-sorry-for-yourself-free card. "How can I be expected to deal with the rest of my life? I'm stuck at work!"

So my New Years resolution is to do something about this. And also to make a few more videos. And not kill anyone.

My team was on long call yesterday, which means we can get new admissions until 6:30 and have to stay until at least 8:00, longer if we still have work to do. (The long call team on any given day takes the post-lunch admissions-- when you're on regular call, you don't get admissions after noon-- and you hopefully get to leave by 6:00 or so.)

Post-6:30 admissions go to the night team. A new admission takes at least an hour to work up, so you really don't want to get a late admission. You will be there longer if you get a late admission. It's unequivocally a good thing that we can't get any new admissions after 6:30, or we'd be there all night.

This is all information just to set up today's post.

The emergency room attending calls me, ridiculously excited, at 8:15.

"I've got an awesome admission for you. Really interesting case. You're going to love it."

"It's 8:15. We're not supposed to take admissions after 6:30. Shouldn't this go to night float?"

"I know, but I wanted to give you first dibs on this guy. He's great. Tons of stuff going on, he's gonna die in like six hours, from any of like nine things. He's great. I knew you'd want this one."

"He sounds like a mess."

"He's totally a mess. It's a great case."

"Look, I have three admissions I'm still working up. I'll be here until midnight if I take a new one."

"I can't believe you don't want this guy. Come on. What's another few hours?"

"I've been here since seven in the morning-- would you think I'm crazy if I said I want to get out of here when I can and go to sleep?"

"I can't believe you're passing up a guy that's going to die TONIGHT. This is what it's all about."

"I've had such a long day."

"Okay, okay, I get it. I'll give it to night float. But, man, you're going to regret passing this one up when you read the notes. Residents passing up admissions, not in my day."

"I'm really sorry."

"Don't worry about it, your loss. I was just trying to save you a good one."

"I appreciate it."

"So if another awesome one comes in later, just straight to night float?"

"Yeah, if it's okay--"

"Yeah, yeah, Rip Van Winkle. Get your precious six hours of sleep."