Sorry for the lack of new posts for a few days. Fighting a cold, which probably will end up meaning all of my patients will soon be fighting a cold. I have a 90 year old patient I am trying to avoid seeing so I don't infect her. Sending in the intern. So then her daughter finds me and asks me why I haven't checked on her mother in a few days. I tried to explain and she yells, "I don't care if you have a cold, I want you checking on my mother.". So I can't win. Trying to help and I can't win.

Watched the Royal Wedding. I wonder how someone gets to be the Royal Doctor.

Clinic patient yesterday, having some chest pain. Ruled out heart attack, did some other tests, he was fine, no need to admit him.

"Can I get a note to get out of work?" he asked.

"You mean a note saying you were here and saw a doctor?"

"No, I mean, I probably shouldn't do my job for a few days, right? Because it's pretty stressful. Physically, I mean."

I look at his chart. Because I was pretty sure I'd read what his job is, and so I was a little confused.

"You're still at the same job as last time?"

"Yeah."

"And your job is physically stressful... how?"

"It's a lot of sitting. Hours at a time."

"Yeah, I'm not sure why you can't do that job. I'm happy to write a note saying you saw a doctor, but I think you'll be okay at work."

"You don't know how it is. It's very physically taxing."

"You review television shows for a website. I'm happy to write you a note, I'm just not sure why you feel like this is physically strenuous work."

"I told you, it's a lot of sitting. And eye strain."

"Those didn't cause your chest pain."

"I think all the sitting might have."

So I wrote him a note for his employer, saying that he shouldn't sit for so many hours a day, for the next 5-7 days, to avoid physical strain. He thanked me profusely. I didn't really know what to do. I think he probably faked the chest pain for a note, so that he could, I don't know, go on vacation? I have no idea. I don't know what his motives were, what kind of website boss needs a doctor's note, what kind of boss is going to take this note seriously... maybe the patient was insane, I don't know. But he got a note.

So, people looking for doctor's notes-- apparently, I can be convinced to write a stupid note, as long as you ask me enough times and tell me a ridiculous story. Good to know, right? I'm bringing his case up in our discussion group this week, to find out more appropriate responses...

"So, I'm looking in the chart-- we said you'd bring in a stool sample this time?"

The patient opens up his backpack, pulls out a paper bag, tries to hand it to me. I put my hands up, take a step back.

"No, no, we'll give that to the tech-- the specimen cup is in the bag?"

He gives me a blank look.

"What?"

"The specimen cup is in the bag-- the cup with the sample in it."

"Oh, you gave me a cup?"

"Last time, we gave you a cup."

"I must have forgot."

"So what's in the bag?"

"My stool."

"Just in the bag, plain?"

"Yes."

"And you carried this in your backpack?"

"Yes."

"Okay, I'm going to get the tech. Next time, just a little bit, in the sample cup. Not the whole thing, not lying in a paper bag. Okay?"

"Okay."

"Okay."

"You still gonna be here in a year, doctor?"

"Just barely-- I finish residency next July."

"Okay, so I'll still get to see you again."

"What do you mean?"

"I can't come back for a year. I'm going to prison."

"Really?"

"Yeah, next Tuesday. I was on parole, and I messed it up. So I'm going back."

"Mind if I ask what you did?"

"Oh, you don't want to know. Doesn't concern you."

"Okay."

"No, you're supposed to ask again and make me tell you."

"No, it's okay. You're probably right that I don't want to know."

"Yeah, yeah, nothing with a doctor though. So you don't have to worry."

"Okay."

"No, really, I like you. I wouldn't do anything to you."

"I'm glad. I like you too."

"So you'll give me an appointment when I get out."

"Sure."

"I can schedule it now?"

"I don't know what my schedule is going to be in a year, but we can put something in the computer now and I'll slot you in once I know my schedule."

"That's great. Thanks, doc."

"Sure. Don't catch anything in prison."

"What do you mean?"

"I don't know what I mean. I just assumed people have illnesses and stuff. I don't know a lot about prison."

"It's not so bad. Could be worse."

"Okay. Well, good luck."

"I'm gonna try to lower my cholesterol while I'm in there. You'll see. I'll come out with lower cholesterol."

"Great. Looking forward to it."

"Cool. See you in a year."

"See ya."

Okay, time for a relaunch. Remember my fake hospital site from a few weeks back, St. Deathsdoor? I've made all the links work. Hopefully something funny behind each click, if I've done my job. There's like a hundred pages of stuff there, and some of it is really bizarre, so I urge you to check it out and click around the site if you're so inclined.

St. Deathsdoor Hospital

There's even a Get Well Soon e-card you can send to a friend.

If you do find the site amusing, do me a favor and help me spread the word.

(And if you don't, that's okay too-- new post coming later, I think.)

"I see in your chart you never followed up from your last exam. The doctor found blood in your stool, and sent you for some additional tests."

"There's no blood in my stool."

"The doctor last time didn't tell you the tests showed blood in your stool?"

"No, he did. But there's no blood in my stool."

"The tests showed there was."

"No, no, I don't see any blood. I told the doctor. He said it was microscopic."

"Yeah, you wouldn't see it."

"Yeah, that's what I'm saying."

"No, it still means it's there, even if you can't see it."

"No, he said it was microscopic. So I figured I didn't have to worry about it."

"No, you do. That's why he sent you for more tests."

"But it's barely even there."

"But it shouldn't be there at all. We need to see if it's gotten worse, and get some other tests."

"Oh, it's definitely gotten worse."

"How do you know?"

"I can see it now. That's why I came back. I wanted to get it checked out."

"Okay, well, I'm glad you came back, and I'm glad now you want to get it checked out. In the future, you should know-- if the doctor wants to get something checked, you should, even if you can't see it. Problems can still be problems even if you can't see them."

"No, I like to wait until I can see them."

"That's not always a smart thing to do."

"It's what I believe."

"That's not necessarily the best thing to believe. I don't want to dwell on what you should have done, let's just get the tests done now and see what the problem is and hope we're catching early whatever it is."

"Definitely early."

"How do you know?"

"Because I still have a lot of blood left."

"That is not how we would measure whether we're catching something early, but I'm glad you still have a lot of blood left and have not lost all of it in your stool."

"Yes, that is right."

"Okay, I'm glad we're on the same page now."

I saw a patient of mine in a shopping mall yesterday.

And I quickly turned the other way.

I mean quickly.

I ducked behind a pole.

I watched, until she was far enough away that I knew she wouldn't see me, and then I left. The mall. Completely.

Which makes me a crazy person, right?

She's not even a terrible patient. I just couldn't imagine having to have a conversation with her outside the hospital. I couldn't imagine even having to say hello. I've been traumatized by the job! I can't even bear to think about having one second of a patient interaction when I don't have to. It's not like she was even necessarily going to recognize me out of my white coat. Or even if she did, like she'd want to say hello to her doctor? Probably not. But I couldn't take the chance.

I have become a crazy person.

I am fighting a cold, which is why the slowdown in posting this week. Hard to summon the energy. I've written before about how it's very silly that we don't get sick days, and we're supposed to show up, throw on a mask, and pretend that we're able to do just as good of a job as we can when we feel okay. Aside from the fact that I'm sure my patients aren't thrilled to see that their doctor is sneezing, I have to imagine that my Sudafed regimen doesn't exactly sharpen my diagnostic skills. But that's what we're told to do, if we're able, because calling in sick means we have to make up that shift with our copious free time, and that the hospital has to find someone to take our patients, which they don't have any desire to do.

I had a translator have a nervous breakdown on the phone today, which was completely bizarre. The patient was explaining something about his condition, and all of a sudden the translator stops and says, "doctor, I can't do this anymore. I understand what he is saying, but I do not want to deal with him, please, I need to hang up the phone and you should call back and get a different translator, goodbye." And she was gone. And the patient continues to talk in a language I don't speak. So I tried to stop him, and then called the translator service back, got someone new... and we started from the beginning. This patient has been in the U.S. since 1964 and speaks not a word of English. I don't have a political opinion about this (or anything), I don't have any kind of opinion about this at all, I just find it baffling that someone of seemingly normal intelligence can live somewhere for over 50 years and not pick up the language, or at least a little bit of it. Or want to pick up the language, even if he doesn't use it in his everyday life. You'd think you'd have some interest in knowing what everyone else who lives here is saying. Or it would be unavoidable.

But, no, we got to "hello," and he said, "no, no English." And I told him to sit down and he stared at me blankly until I pointed to the chair and made a 'sit down' motion. And sneezed.

"They do not want you to take any more blood," said the translator. "They are saying they gave enough blood last time, and if you cannot figure out what is wrong from that blood, they will go home because they have had enough and no one can have any more blood."

"Tell them we really need to run more tests, and I apologize, but the tests we ran were inconclusive and I still don't have a diagnosis. I want to help, but I need to run more tests."

"Don't you know that in Chinese culture, some people are reluctant to give blood?" asked the translator.

"No. I don't know that. They don't teach us that in medical school. Tell them, I don't know that. I don't mean to offend, I am not trying to hurt them. I'm just doing what I think is best for them."

"They are asking how anyone can not know that. How you can call yourself a doctor without knowing about that."

"I don't have an answer for them. But I don't have any way to make a diagnosis without more blood. I'm sorry."

Cultural expectations and beliefs are interesting. We deal with people from all over the world, who have all sorts of superstitions, religious beliefs, habits, ideas, customs.... I've had patients who refuse transfusions, I've had patients who refuse any medication, patients whose families demand every treatment no matter how futile, patients whose families demand no treatment at all. There's no coursework in this. There are no manuals. It's just surprises, day after day, when we learn something new. People from this country think x, people who speak this language think y. New languages I've never heard of and we can't find translators for. New herbal medications I've never heard of and neither has Google. New treatments-- well, old treatments-- that they don't explain to us. Someone has probably written a book about this.

"I came to the clinic two weeks ago and they said I was having a girl."

"Okay..."

"But then my herbalist said it was definitely a boy."

"I see..."

"So can you do another test and see what it really is?"

"It's a girl."

"But you didn't even do a test--"

"I can refer you to the OB clinic for another ultrasound, but if they said it was a girl, I think you can be pretty sure it's a girl."

"But my herbalist--"

"Is not a doctor."

"I call her doctor--"

"She's not a medical doctor. And I will admit that we are not perfect, and there are a lot of things we don't know. But the OB clinic is pretty good at telling a baby's gender. You can trust them."

"I don't know who to believe."

"Think of it this way. You can believe whoever you want, and in the end, you'll have a baby."

"But I need to know what color clothes to buy."

"Pink."

"But what if it's a boy?"

"Boys can wear pink."

"You're wearing white."

"So are the female doctors. We have to."

"Ugh, I should just get another ultrasound."

"Maybe you should."

* * *

I appreciate the comments on the previous post, from the perspective of patients. I feel like this post is sort of related. I don't mind patients who want to believe their herbalists about the gender of their fetus, as long as they don't yell at me and call me a liar and eat tuna fish in my exam rooms.

Requested post-- what you *do* want from a patient.

-- Tell the truth, the first time. "Do you always take your medication?" "Yes." "Every day?" "Yes." "So you never miss a day?" "Oh, I miss days sometimes." Argh.

-- Answer questions like we're on the same team, not like we're the police investigators. "Can you describe your pain?" "No." "How long has it been going on?" "I don't know." "Is it always in the same place?" "Sometimes." This is not that helpful.

-- Realize there is uncertainty in medicine. Even if we run tests, we might still not find the answer and that doesn't mean we're bad doctors. Things don't always show themselves right away. Things aren't always clear. There is ambiguity.

-- Not think they're an expert because a friend told them something crazy. If your friend tells you cholesterol has to do with how many times a week you shampoo your hair, that doesn't make it true. If you think you have three lungs and one eye, that doesn't mean you're right. If you do actually possess knowledge, terrific, I am happy to talk about it. But "I thought meat doesn't have calories, and there's nothing you can tell me to change my mind," is nonsense, and if you won't let me tell you things that aren't nonsense, we are wasting our time.

-- Have appropriate patience. Scans take time to get read. Tests have to be scheduled. There are other patients. We can't spend three hours with you when someone's coding in the next room. We can't call twelve of your family members and tell them all the same thing. We can't track down your cat. We can't always give you an appointment at the most perfect time for you. We can't respond to your 3AM phone call about your gas pain. Understand that we're trying our best, but you need to accept the uncertainty in the system and have some flexibility.

Requested post-- ten things I wish I knew before residency.

1. No one's reading the notes, so you really don't have to spend a lot of time worrying about the language. Just put the facts in and move on.

2. You will never get anyone to do anything when you need them to do it, no matter how many times you ask. Accept that the MRI won't happen until tomorrow and move on.

3. The other doctors aren't always right, don't always have the right intentions, and aren't always particularly nice people. Don't defer to someone just because you don't want to cause trouble. It'll just cause more trouble later.

4. If you really think you're right about something, you still might be wrong, but it's probably worth ordering the test anyway, just to double-check.

5. That stuff you didn't pay attention to in medical school will actually turn out to be useful. And med school was probably the only time you were ever going to see it. You should have paid better attention.

6. You will never get a lunch break. Pretending you will, and not bringing anything to eat because you assume you'll be able to sneak down to the cafeteria for ten minutes, will only leave you hungry. Bring lunch. Every day.

7. Go to the bathroom when you have a chance. You don't want to be holding it in while you're performing CPR. You will always be busy later. Always. Go now.

8. You are going to make mistakes.

9. No website/TV show/e-mail is worth missing sleep for. Go to bed, now. Now. Right now. You'll thank me in the morning.

10. Overnight shifts really suck.


[Update 8/10/11, 12:09 PST -- since I see a bunch of people are coming to this post via Reddit, thought I'd add the link to one of the videos I've made, that may or may not be funny enough to watch.]

Requested post-- how people maintain relationships when they're so overworked. Like I'm the right person to ask. I've blogged about this a little bit. There's at least one resident I know of that's gotten divorced since residency started. But is it worse than lawyers or finance or other jobs where people work long hours? At least we know our schedules in advance, so people can plan. For the long hours-- and they're often long, absolutely-- at least there are seldom surprises. You're on overnight, you're going to be there overnight. You're not on overnight, you will not be there overnight. There are hours here and there, sure-- you want to get out at 5 and you get an admission and you're stuck until 7. A patient's going downhill and you're there until 9. But it's only on some rotations, and it's not every day. You often know when you're leaving. That's a good thing. From what I know, lawyers don't, bankers don't. Plus, when you're off, you're off. There's not really any working from home, aside from some reading you feel like you ought to do, or studying for boards when that's going on. But you're not working surprise weekends that haven't been scheduled, you're not going in on your days off, you're not logging in to the computer system after dinner to check on things. Attendings have different responsibilities, sure, but being a resident is not a 24/7 job, thankfully. You are not tethered to a Blackberry.

So in that way, it's hard to complain. Also no business travel. No Monday-Thursday at a client site, no airports, no suitcases. Look, people live crappy lives. I mean everyone. I look at what other people do and I can't imagine how they get up in the morning. I know a married couple that lives a thousand miles from each other and the wife flies back and forth every weekend so they can see each other. That is terrible. I know consultants who work all week at client sites and are almost never home. I know people who have to pull unplanned all-nighters at the office-- people with kids. That is really terrible. And in pursuit of what? Money? Is it worth it? I don't know, I don't know how we've created a society where work-- and often not even socially useful work-- is the only piece of a lot of people's lives and it's all about that paycheck. I don't know how people motivate themselves to do it, how the money can seem so important. Or how they have the focus to be motivated by an end game that's very far away-- I mean, the end game is retirement with no money worries, no? I can't imagine what else it can be for a lot of jobs.

I've gotten way off topic. People maintain relationships in the same way anyone maintains a relationship with anyone doing anything. They make it a priority. And, I don't know, I think people go into this-- or at least they go into medical school, I'm not sure if the feeling can persist all the way through to residency-- thinking that there's some magic to being a doctor, some feeling you're going to have while doing the work that's going to carry you through. And maybe some people have that feeling, but I'd be surprised if anyone has it in the moment. You can look back and say, sure, some of that was useful, some of that helped people. But in the moment it's not special, it's just work. In the moment it's typing notes and looking up drugs and entering orders and arguing with the translator phone. And looking at the clock.

And hopefully staying busy enough to distract yourself from the reality that what you do doesn't really matter all that much, most people could do it just as well as you can, most patients aren't getting better, and this is what you've signed up to do for the next forty years. Day after day after day after day.

My version of the Pain Scale

[Those are puppies over by the second image. Excuse the poor photo editing skills.]

OK, will try to get to some of the post requests today. Will dispose of some of the easy ones in one post now, and then get to some of the others in separate posts later or during the week.

WarmSocks (4/1, 12:38). Macrophages and the behavior of white cells? Really? I think you'd be better off reading your immunology book or asking some of your classmates to explain it. Haven't really talked about, uh, I guess it would be the pathophysiology of immunology, since med school. If a patient asked the question, I think I would either say I'd get back to her and do a Google search, or-- hey, even better-- I'd send the med student in to answer. If it was a good med student. Maybe.

Natalie (4/1, 5:38). Things people bring or smuggle in. Food. All sorts of food. Scroll down a bit for the person who almost killed their family member with a ice cream. Here. Also there's a post from a long time ago about a guy who was hiding his naked girlfriend in the hospital bed while the doctors came in to check on him. Here. And a story that was posted about thinking someone had smuggled in alcohol but really he had eaten the hand sanitizer. Here. The one thing hardly anyone thinks to bring are their medication bottles, which would be useful.

Anonymous (3/31, 11:16). Don't know that there's hidden resentment between doctors and nurses. Resentment isn't the right word. When residents hang out with residents, frustrations with less-than-awesome nurses are a topic, but I'm sure that when nurses hang out with nurses, frustrations with less-than-awesome residents are a topic. Nurses do very unglamourous work. I would not want to be a nurse. And re: clandestine hospital relationships, there's flirting sometimes but not sure there's anything to write a post about.

Sonja (3/30, 9:12). Pain sheets. Hmmm, maybe I'll play around with Microsoft Paint, I'll see what I can do.

Sufu (3/31, 4:40). Will read the Hyperbole post and see if it inspires anything.

Jeremiah (3/31, 6:58). A bunch of posts about med students if you scroll through the archives. Here, try this one, with the follow up here.

Which leaves a few posts I'll try to write-- ancillary staff (honeygold), best and worst (anon), how people maintain relationships (anon), 10 things I wish I knew beforehand (anon), discussion with pre-med version of self (anon) [and the last two are probably one post since they're asking basically the same thing].

Thanks for the post suggestions-- I'll see if I can tackle a few of them this weekend.

In the meantime, I've been involved for the past couple of days in the launch of my hospital's new website. Check it out-- would love any feedback.

http://decenthospital.com