Happy Memorial Day. I'll end up having worked only 30 hours this weekend, which is at least 6 or 7 less than I expected. So, yippee.

Spent an hour in the emergency room with a guy who had done something unusual and unpleasant with his testicles. (For the holiday weekend!) Let's just say that he had used some kind of tanning cream combined with a scrubbing brush-- and in the process irritated the entire area down there, first from the scrubbing and then from some kind of reaction to the cream, whatever it was (if you use a cream on your testicles, it causes a reaction, and you go to the emergency room-- please bring the cream with you!). Why any of this seemed like a good idea, I have no idea.

And what someone thinks we can do for this problem in the ER (besides some pain medication and a urine test) I have no idea.

"I see on your form that you've had a lot of health problems recently."

"No."

"No, on the form, I see you checked that you've been having headaches, stiff neck, coughing, stomach pain, diarrhea, fever--"

"No, I am fine."

"Did you check all these boxes on the form?"

"Let me see that."

I show him the form.

"I do not know why I checked all those boxes."

"But you did check all the boxes-- I'm wondering, if you have trouble reading, we have some programs we can refer you to, it's really okay if that's a problem, I just want to make sure we have an accurate medical history."

"I can read just fine."

"Then I'm just trying to figure out why you checked all of these boxes."

"Sometimes things are blurry. I use eye drops. Visine."

"You have blurry vision?"

"Yes. When I have things close to me, like reading, the letters are blurry. I use eye drops. Is there a more powerful eye drop I can get a prescription for?"

"Have you been to an eye doctor?"

"No. I use eye drops."

"Is it possible you need glasses? It sounds like you might just be farsighted, and need glasses. Would be an easy fix to this problem."

"No, I don't want glasses. Not interested. I'll just use eye drops."

"Yeah, eye drops don't fix this problem. I think you need glasses."

"Never. I'm not interested in glasses."

"Do you drive a car?"

"Sure."

"I am going to have to refer you to an eye doctor."

"I have no interest in an eye doctor."

"I think it's important. And it's really not a big deal-- tons of people wear glasses, and they would help your life tremendously."

"Just give me a prescription for eye drops."

"I don't believe eye drops will help this problem."

"This is why I don't like doctors."

"Oh, I was having trouble sleeping, but then I started taking a sleeping pill every night before bed, and it's been great."

"What are you taking?"

"Tylenol."

"That's not a sleeping pill."

"What?"

"It's for pain, fever, that kind of thing."

"Seems to put me to sleep."

"Well, if it's working for you..."

"Yep."

"Great."

Presenting: The Placebo Effect.

It's hard to always wrap my head around it, but, more and more, I'm becoming convinced that it's really just as much about what patients think and expect and want to believe than what any particular medication is actually doing, especially for things like sleep, pain, and anxiety. They want to be heard, they want to be doing something they can believe is productive... and sometimes that's enough. The people who come in talking about herbs or teas or homeopathic remedies. The people who come in talking about how they take a quarter of the dose every day and it's enough. The people who suddenly get better once they have a label to put on whatever is bothering them. It's real. I think.

"...so I can call in these things to the pharmacy if you want them to put them aside and you can just pick them up. So it's the stool softener, cream for the hemorrhoids, and a package of the adult diapers."

"Yes, okay, doctor. But can you tell the pharmacy it is for Roberto Johnson?"

"Oh, will someone else be picking it up for you?"

"No. I don't want it under my own name. It is not the kind of thing I want them to know."

"Uh, sure."

Clinic patient about to leave-- turns back to me--

"Oh, I saw the condoms on the desk out front. They're free?"

"Yeah."

"So I can take a couple?"

"Yep. That's what they're for."

"Um... do you have any other brands?"

"What?"

"I don't really like the LifeStyles kind."

I saw the movie Bridesmaids with some fellow residents last night. Our discussion topics after the movie (minor spoilers below):

-- So, the food poisoning. What do we think, e.coli? C. perfringens? How long was the trip from the restaurant to the bridal store? Did we see any blood in the stool? I feel like we didn't get enough of a closeup to see the consistency, or if there was mucus in the vomit or not.

-- Biggest unanswered question of the film-- what drug did she take when she was on the plane, and how many milligrams?

-- Or did her freak-out on the plane have nothing to do with the pills, and it was in fact untreated syphilis from her sex with Jon Hamm that led to mental illness?

-- Seriously, no screening at all for STDs? The cop especially should be more responsible than that.

-- They think the bridal store scene was messy, what about three hours after everyone dipped their fingers into the chocolate fountain? That was hepatitis waiting to happen. They're lucky she dumped the whole thing over.

-- How old were most of these women? Half the cast was pushing 40-- it's not like they're doctors, why are they just starting their adult lives at 38 years old? Are we sure the mood swings and incontinence weren't actually symptoms of early menopause?

-- The British woman and her infected tattoo-- they just dropped that storyline completely. What happened? Did the infection spread? Did she ever seek help? What did the medical bills look like, since she didn't have a job, and (presumably) no insurance?

-- And speaking of health insurance, Kristen Wiig's character-- she was self-employed, then worked in a jewelry store, then unemployed-- what was her health insurance situation like, and did that play a part in her failure to visit a doctor for either the food poisoning issue, the anxiety related to flying, or her possible STDs from sleeping with multiple partners? Might she have sought help from a mental health professional if she had comprehensive health coverage and a low co-pay?

We had to get our CPR re-certification over the weekend-- I ended up in a class with a bunch of different folks from around the hospital. One guy was completely freaking out the whole time, had no idea how to do any of this stuff. He was my partner in a couple of the exercises, and kept asking me for help, and I couldn't understand how he could be a doctor and be this awkward just dealing with mannequins, not even real people.

Finally, he realizes everyone's looking at him, and he says--

"I'm sorry, I know this is ridiculous. But I'm a pathology fellow. I don't know these heart rhythms and what you do with someone who's breathing. When I see them, they're done with all of this. Anyone needs CPR once I get them-- I send them back."

Okay then.

"I don't need you to come see me anymore," I said to my clinic patient. "I'm not the right doctor for you. You need to see a specialist."

"But I like seeing you."

"That's flattering, but I can't really help you as well as someone else is going to be able to."

"I don't want to start over with a new doctor."

"You need to be followed, more closely than I can follow you, by an expert, which I'm not."

"It sounds like you're breaking up with me."

"I'm just trying to make sure you get the best possible treatment, and I know that I'm not the doctor who can provide it, given my limited clinic hours-- and my limited experience."

"I'm going to keep making appointments with you."

"I need you to not do that."

It went on like this for a few more minutes, until I finally got my supervising attending to come in and explain to the patient that she needs a different doctor, and that the clinic will make a call for her and get her an appointment. And on the one hand, everything I said was accurate-- I can't see a patient as often as she needs to be seen, just because of my hours, and I don't have the expertise to be the best person to be treating her and managing her condition and her medications. And it's great, on that one hand, that I realize this and am willing to admit when I'm not the right doctor for someone.

But on the other hand, I'm absolutely getting rid of this patient because she's annoying and I don't want to treat her anymore. Not lying about the other stuff, just not telling the whole truth. I can't very well say, "every time I see you, I want to strangle you, so please see a different doctor and make my life easier." Or maybe I can say that, but I don't want to say that. So I'll hide behind "you need a specialist" and get this patient off my list. Way off.

Posting will be back to normal by tomorrow. Today, finally, is the last day of an insane two weeks on an every-third-night-overnight rotation that has killed me and made it impossible to get rid of the cold I'm fighting which I think now isn't so much a cold but some sort of allergic reaction to not sleeping enough. I realize that is not a medical diagnosis, and I apologize for that. Part of the struggle is that the rotation was designed to be every 4th night overnight, but one of the other residents just had a baby, and so the way the program compensated was to just make the rest of us work longer hours. I don't begrudge someone for having a baby, of course. But how a medical program-- that knows exactly what pregnancy and having a baby involves, because of the work we do-- can make it so difficult for someone to have a baby is really absurd. They don't get maternity leave at all-- they have to use vacation time. And if there's no one who's able to cover-- if the two extra "swing" people at any given time are already being used for something else-- the other residents just have to make up the slack. As if the hours weren't too long already. All it does is force us to resent the person who had a baby, which isn't fair. Not that it's a walk in the park for her either-- so now she has no vacation time for the next year, after a phenomenally generous 4 weeks off to spend with the baby. Because why would a new mother need any days off for the next year? And she goes right back into an every-4th-night-overnight rotation herself, two weeks from now. Fortunately, outpatient clinic time returns tomorrow, and even though most of my colleagues find outpatient clinic time to be insanely boring, at least it lets us have some tiny semblance of a life. Next year's schedules being released on Friday-- something terrifying to look forward to! Yay!

Patients I can deal with, families I really can't. You don't get to tell me you won't pick up your 96-year-old mother for discharge until next Tuesday... because you "aren't ready to deal with her yet." Yes, dealing with frail, ill, elderly parents is without a doubt difficult, and, yes, I have sympathy... but this is not a babysitting service, it's a hospital, and the bed needs to go to someone else, and without any medical condition keeping her here, what are we supposed to do? "If you can't take care of her, I need to get social services involved." "No." "Then tell me what we should do." "Leave her where she is. We will come next Tuesday. Unless she gets sick again before then." "She has a better chance of getting sick if she stays in the hospital." "Then she'll have to take that risk." "I am getting social services involved." "Then I want to speak to your supervisor."

Because what I'm doing is sitting at a customer service phone bank and let me just get my manager to solve your problem. Ugh. It is hard not to yell at people sometimes.