"My doctor said he sent you the blood work."

"I'm sorry, I didn't get it."

"He said he faxed it."

"What number did you give him?"

"I don't know. It's not my fault if he didn't send it."

"I'm not blaming you. I just want to try and see the blood work while you're here. The reason I asked what number is because I don't know my fax number here at the clinic, so I don't know where you got a number-- but if I know the number, I might be able to ask someone and figure it out. Do you know where he faxed it?"

"No."

"Do you know who gave you the fax number?"

"No."

"Did you call to get it, or did you ask someone on the way out last time?"

"I don't know."

"Do you have your doctor's phone number so I can call him?"

"No."

"How do you call him if you don't have his number?"

"It's in my phone at home."

"Do you know his name?"

"I can't remember."

"Can you call me when you get home and give me his phone number so I can call him and get your blood results?"

"No."

"Why not?"

"I don't know."

"No, surely you can call me with his number when you get home."

"I don't want you to bother him."

"I just want to get the blood results, so I can see what's going on. Doctors call each other for these things all the time. I'm sure it will be fine."

"No."

"What are you saying no to?"

"You can't call him."

"Why can't I call him?"

(Patient takes a deep breath.)

"Because I didn't have the blood test, okay? I didn't do it. I forgot, I didn't feel like it, I don't know. All you people want is for me to do things. I'm busy. I can't keep doing things."

"I just wanted to see what's going on in your body so I can help you."

"I don't need your help."

"Then why did you come to your appointment?"

"I didn't want to cancel."

"Next time you need to get the blood work done. And you shouldn't lie about the blood work. It doesn't help anyone."

"I didn't want you to be mad at me."

"I'm just trying to help you. We can do your blood work here, if you like."

"No."

A reader pointed me to this New York Times article: "Eye Anatomy at Camp? Kids Get Taste of Med Careers"

It's about middle-school students, as young as 12, taking part in medical camps at a variety of hospitals around the country, where they do things like dissect an eye, stitch up cuts on pigs' feet, prick their fingers to test their own blood type, and *run a mock code.*

From the article:

Paramedics race in a mannequin: A 45-year-old woman in cardiac arrest.

The kids, each assigned an ER job, spring into action under Wagner's direction. One pumps air into the "patient's" lungs. One inserts a tube to open the windpipe. Three trade off CPR. Another sets up the defibrillator, calling "Clear!" before each of three shocks. Others give injections of heart-stimulating drugs.

Ten minutes later, they abruptly fall quiet as Wagner asks how long they should keep trying before declaring death. No one volunteers.

"How often do patients pass away?" 14-year-old Lark Nash of Warrenton finally asks.

Probably once a week, Wagner responds, describing the hardest part of his job. Nurses reveal a body bag lining the bed, and the students zip it over the mannequin.

This is traumatic enough for a medical student. If the aim of the program is to scare children about death, and turn people off from ever wanting to walk into a hospital, I think it's a great idea. But why are we exposing 12-year-olds to body bags and defibrillators? What good is this doing? This isn't what the job is most of the time anyway. Why do we want to traumatize children?

There was a high school student shadowing me last week. I forgot how little we know in high school. I asked if he wanted to take the patient's blood pressure and he said yes... then looked at me blankly. So I showed him how. He told me at the end of the week that he realized now he never wants to see patients, so he's going to try to become a researcher instead of a doctor. "Why don't you want to see patients?" "They seemed so annoying and stupid." "They weren't stupid," I said. "A lot of them just aren't very well-informed, and that's what makes the job so important." "They didn't even speak English," he said. "That doesn't make them stupid." "And what about the one who didn't know that he could lose weight if he stopped eating french fries every day?" "I think a lot of people don't think about what they eat, unfortunately."

What we need isn't mock codes and defibrillator training. What we need is a real middle-school and high school health curriculum that students are required to take, to learn something about how their bodies work. Not the science of it, but the practical piece-- what blood pressure means, how diet and exercise impact weight and health, why cancer needs to be caught early, what can happen when you fall on your head, the difference between a cold and something worse, when to go to an emergency room, how to read nutrition labels on food, what you shouldn't stick inside of your mouth, nose, ears, genitals and rectum. Practical things like that. How not to get pregnant, although I thought that's what health classes already teach.

Patient yesterday with all of the signs of pregnancy. "When was your last period?" "I don't remember." "Is it possible you're pregnant." "No. We use birth control." "What kind of birth control?" "He pulls out." "That isn't birth control." "What?"

I had another patient who was feeling chest pain and walked a mile to the hospital instead of calling for an ambulance-- or even calling a friend to drive him. "Oh, I'm self-sufficient." "You're having a heart attack."

But middle-school kids need to learn about body bags and how to dissect an eye? Middle-school kids need to learn that pulling out is not birth control and they should rush to the ER if they're having crushing chest pain.

"I see you've lost 15 pounds since your last visit-- that's great. You're sticking to the diet we talked about?"

"Yep. But, doctor, I don't think this is healthy for me."

"What do you mean? Your blood pressure is lower, eating healthier and losing weight is going to be good for your heart failure and diabetes, it'll help your back pain, you're really doing great, I'm very proud of you."

"But my foot's been hurting."

"I can take a look at it--"

"No, my foot's been hurting because of the weight loss."

"I don't understand."

"It used to be cushioned with all of this fat. Now that I'm losing weight, there's less cushioning, and when I walk, it's really the foot that's feeling the weight, without that cushion. I feel it all over. The fat made things soft. Now everything hurts."

"What you're saying doesn't make good medical sense. Maybe there's a problem with your foot."

"No, I don't think there is. I think it's the weight, and I need to put it back on, to be healthy."

"No, the weight is not healthy. It's great that you're down 15 pounds. You have a ways more to go, but this is a great start. You will feel better, I promise."

"I don't think so. I told my wife to get me two steaks tonight."

"That's not good-- not for your weight, and not for your heart."

"I like the soft fat feeling in my feet, I'm sorry."

"I need to take a look at your foot. I think you may be feeling something different from what is actually going on. I think there may be a solution that doesn't involve the weight."

"I know my body."

"Take off your socks."

[He takes off his socks.]

"I think you might have broken your ankle."

"Because the fat cushion wasn't there."

"No, because you hurt your ankle. I'm going to get you an x-ray."

"I'm worried about the radiation."

"You've had tons of x-rays."

"But now there's less fat to absorb it."

I may need more sleep. I got into a screaming match with a patient last night. She'd left the hospital-- walked out, IV still in her arm, no papers signed, she just got up and walked out-- while her parents were in the cafeteria. (She was 45 years old, so we're not talking about a minor here.) I get a page from a nurse. I call back. "Your patient left. You need to find her." Like I'm a detective. I come up to the floor. "Your patients can't just leave," the nurse yells. No kidding. "You need to control them." What am I, a prison warden? I go to her room, her parents are there, eating dinner.

"Can you call her on her cell phone and tell her to come back?"
"When we're done eating."
"Can you call her now?"

They call her, and she comes back, angry at me for making her return to the hospital.

"I can't breathe in here. There's no air."
"The air is fine."
"No, it's not. I have breathing problems. I need air."
"The breathing problems are why you're in the hospital. You need to stay here."
"No, I don't."
"Then you need to fill out some paperwork saying you understand the risks of leaving, and you need to let us remove the IV from your arm."
"I do not."
"Yes. You do."
"You can't tell me what to do."
"You can't leave with an IV in your arm."
"I'll pull it out myself."
"That is a terrible idea."
"Not as terrible as this hospital."

And then the nurse comes by again. "You need to quiet down your patient. Other patients are trying to sleep." Thank you, nurse. Helpful.

"I'm going to pull out the IV right now, and then I'm going to storm out of this hospital and never come back."
"Do not pull out the IV, and if you want to leave, I will get the paperwork."
"I'm not signing any paperwork."
"Yes, you are."
"No. I'm not signing anything."

Meanwhile her parents are still eating their dinner, in the room, saying nothing.

"Is she always like this?" I asked her mother.
"Don't you talk to my mother. Don't you dare talk to my mother."
"I'm trying to figure out if you've had a mental status change, or this is just the way you normally behave."
"This is the way I behave, doctor. Why? You don't like the way I behave?"
"No. I need you to calm down, so we can remove the IV, and then I will gladly let you leave."
"Why? You don't want to treat me?"
"You want to leave. I'm trying to let you leave."
"Now you're saying you're too good to treat me."
"That's not what I'm saying."
"No, now you're going to treat me. Now you're going to be stuck with me."
"Fine. You still need to calm down."
"No. I won't calm down. And I am not leaving."
"Fine. Don't leave."
"No. I am leaving."
"Fine. Then I will get the paperwork."
"I'm not signing any paperwork."
"I need to call the attending, because I can't deal with you anymore by myself."
"Call anyone you want. I won't be here when you get back. I'm leaving."
"You need to stay until we can remove the IV."
"You're not removing anything."

And then I jumped out the window. Or at least I wanted to. I left the room. Her parents calmed her down. The attending laughed and told me to have her sedated.

"Sir, just to get it down on the form here, who's your health care proxy?"

"I don't want one."

"No, I mean, who do you want to make medical decisions for you in case you're unable to make them on your own."

"Nobody. God will decide."

"No, let me explain. If we have to decide whether we should do a certain procedure or not, who do you trust to communicate your wishes. Your son? Your daughter? Your grandson?"

"God. God will decide."

"So you do not want to be kept alive artificially? You do not want to be resuscitated? Or you want us to do everything in our power to keep you alive? I just want to clarify, so we're able to follow your wishes if we end up in that unfortunate situation."

"I told you. I'm not making the decisions. God will decide."

"But does that mean you absolutely want to be kept alive by external means? Or does that mean you absolutely don't?"

"God will tell you."

"There's a reason we ask people to name a health care proxy. If there's no one we can ask in a situation where you can't make the decision, you're likely going to be presumed to be full code, and that we would do everything in our power to keep you alive. If that means keeping you on a ventilator, without brain activity, we would end up doing that. And we need to know if that is something you would want. Without someone to consult, you're leaving your decisions largely to the whim of whichever doctor decides to make a decision, and that may not be the decision that you would most want."

"I don't have the answer to any of that. If God wants me to be kept alive by machine, he will keep me alive by machine."

"Sir, I'm trying to explain as best I can but still be sensitive to what you're saying. God doesn't turn the machines on and off. People do. And our concern is that we want to do what you would be comfortable with, and what you want us to do, if it came down to keeping you alive artificially, or not. Neither preference is wrong, and you can change your DNR status whenever you feel like doing so. But as a default, it's important for us to know what your feelings are, because everyone approaches these issues differently. What we as doctors would do for you isn't necessarily what you want, although it may be."

"You're the doctor. Listen to God. If God wants you to keep me alive, keep me alive. If he wants you to let me go, let me go."

"And what if we don't hear God telling us what to do?"

"Then you're not listening hard enough."

"I need a phone number to put on this form."

"God doesn't have a phone."

"Yes, that's why the box is blank."

"Don't worry about me. God will decide."

"And you think God will tell us, the doctors, better than he will tell your family members?"

"Oh, definitely. I don't trust them at all."

One of my attendings wants to be my Facebook friend. For the second time. Last time he was my attending, he friend-requested me. I thought that was a little unusual, but friendly, so I accepted the request of course, and didn't think much about it.

Now it's six months later, and he's my attending again.

And I get a friend request from him.

I didn't de-friend him in between then and now. Which means he must have de-friended me. And now he wants to be friends again.

Is there Facebook etiquette in a case like this? I don't abuse Facebook. I never really post much at all. So it's not like he would have de-friended me for cause. He must have just scrolled through his friends one day and perhaps forgotten who I was, or decided he'd never see me again, so may as well get rid of me. But then why ask me again six months later? Is this just what he does? Does he just want to be Facebook friends with people on his rotation so he can monitor their activities and make sure if we're ten minutes late one morning it's not because we were out with friends the night before, or if we switch shifts with someone else it's not because we wanted to take a secret three-day weekend?

But it's not like I can say no to the request. He's my attending. I have to accept the request. But maybe I'm allowed to accept it and then de-friend him?

Am I overthinking this?

"Doctor, could I get your cell phone number?"

"Sorry. Can't give that out."

"But what if I need to call you?"

"You can call the clinic and leave a message. If it's an emergency, go to the hospital. If it's not an emergency but you want to see a doctor, go to the walk-in clinic. I'm only here twice a week, so I may not be able to return your call right away."

"I want a doctor I can call."

"I'm sorry. That's not how it works here. We're residents, and we rotate through. We're not able to be reached by phone directly-- we don't even have offices here."

"My last doctor said I called him too much."

"How much did you call him?"

"Like six times a week."

"That sounds like too much for a busy doctor to handle-- there are lots of patients to see."

"I don't know. The office was never that busy."

"That's still a lot of times to call."

"I had problems."

"I'm sorry to hear that."

"So you were going to give me your cell number?"

"Nope. Sorry."

"Just thought I'd ask again."

"I started feeling the pain right after I ate lunch. So I think it was the sandwich."

"You had a significant heart attack. The fact that you were eating a sandwich just prior is a coincidence."

"Well, I think the sandwich caused it."

"You have a completely blocked vessel leading to your left ventricle."

"It's the sandwich."

"The sandwich is not blocking your vessel."

"What if I didn't chew it completely?"

"Food doesn't get swallowed into your blood vessels. There's medication we can give you to help your heart, but I need you to understand, this is a problem that's been building over the course of years."

"I did not have a problem until I ate the sandwich."

"You didn't have any symptoms, but the blockage was building. Your heart was not in good shape-- and now, post-event, it's in worse shape. Which is why we need to start you on medication."

"I don't care what you say, it was caused by the sandwich."

"That's fine if you think it was caused by the sandwich. Even if it was, it doesn't change what we have to do going forward. You need to change your diet--"

"Of course. No more sandwiches."

"Well, it's more than that."

"No-- it's the sandwich."

"Fine. No more sandwiches. Your heart attack was caused by a sandwich. And I'm writing you a prescription for three anti-sandwich pills that will help counter the effects of past sandwiches."

"But if I don't eat anymore sandwiches, I shouldn't take the pills?"

"No, you need to take the pills either way."

"Then how is this helping with the sandwich problem?"

Dietary Changes

"So, we're releasing you from the hospital, but that doesn't mean you're well. Your heart failure is only going to improve with changes to your diet. And because you also have diabetes, it's very important to understand the types of food that are good to eat, and what you should avoid."

"Oh, we know a lot about nutrition. We read labels."

"That's great. So you know how many calories you should be eating in a day."

"Yep, three meals a day."

"I asked about calories."

"Yeah. I can't remember the number. Fifty?"

"No."

"Five thousand."

"No. Two thousand calories a day."

"Okay. Gotcha."

"And one of the biggest things is going to be really limiting the salt intake."

"We know, absolutely. We never put salt on anything."

"It's not just about adding salt. It's also about foods that already have salt. Canned food, restaurant food--"

"The restaurants we go to don't use salt."

"Most restaurants use a surprising amount of salt."

"No, we go to good places. Cheesecake Factory, California Pizza Kitchen, Wendy's..."

"All of those places serve very unhealthy food, that has a lot of salt. You need to look at the nutritional information on line. You should not be having more than 2,000 milligrams of sodium per day, or more than the recommended amount of cholesterol."

"We never have cholesterol."

"Do you eat red meat?"

"What do you mean?"

"Beef, lamb--"

"Yeah, but it's not red after we cook it."

"Sure, but it's called red meat. You have to really limit your beef intake. Think fish, think chicken."

"But veal is okay, right?"

"Veal is from a cow, like beef."

"But it's not red."

"It still has a lot of cholesterol. You need to not eat veal regularly."

"Are you sure veal is from a cow?"

"Yes."

"It doesn't seem like it."

"It's from a baby cow."

"And babies still have cholesterol?"

"They do."

"But chicken is okay?"

"Skinless chicken breast, grilled or steamed, is okay."

"And other things from chickens?"

"What do you mean? Chicken liver is high in cholesterol--"

"Eggs are okay, right? We really like omelets."

"You can have egg white omelets."

"What about the yolks?"

"They have a lot of cholesterol."

"But sometimes is okay?"

"In moderation."

"We usually have an omelet for breakfast."

"You need to use egg whites only."

"So a three-egg omelet for breakfast isn't good?"

"No, not at all. You need to look at the labels. One egg has almost a full day's worth of cholesterol."

"I don't think there's a label on our eggs."

"Well, I'm telling you eggs have a lot of cholesterol."

"What if we stop having veal in the omelet?"

"You still have to switch to egg whites only."

"When we go to Wendy's, we get the bacon, egg and cheese on a bagel. I don't think there's three eggs in that."

"Everything about that meal is bad for your heart, and your diabetes. The egg, the cheese, the bacon, and the bagel. You should not go to Wendy's."

"What if I get the salad?"

"The dressing is often very salty and fattening. You should be making your own foods at home, and trying to avoid most restaurant meals, because you never know what they're putting in there."

"But we can't have chicken every day."

"Chicken, fish, vegetables, fruit, beans that aren't from a can, unsalted nuts, tofu, there are a lot of healthy choices."

"But we like to go to restaurants."

"Your heart muscle is very weak. You have to make these changes if you want to live for years to come."

"But what if we just don't add any salt to our omelet?"

"That's not enough."

"Pork chops are okay?"

"They're not great."

"What if we get the ones without the bone?"

"That doesn't make a difference."

"Sure it does. The boneless ones are healthier, aren't they?"

"You're thinking of things that are skinless, not boneless."

"So bones are okay, but not skin."

"You should try to limit the amount of meat you are eating."

"What about vegetable skin, and fruit skin?"

"That's fine."

"So apple skin is okay even though the cholesterol?"

"There's no cholesterol in apple skin."

"Okay, I'll write that down."

"Great."

We are not your parents.

Saying no does not mean we're going to force you to do it anyway if we think it's really important.

Saying no does not mean we're going to spend three hours trying to convince you to change your mind because we know how much you need it.

Saying no is not the beginning of a negotiation.

Saying no is not part of a game.

You say no, and we can't do the procedure. So we're going to leave. And if you didn't really mean "no," but you were just trying to be difficult, well, we're not your parents, and we're legally bound to treat you like a functioning adult, whether you act like one or not, so we're actually not allowed to do anything, and you're only hurting yourself.

It's frustrating. Because on the one hand, patients say they want to be able to make decisions about their care-- and there's every reason to have that be the standard, there's every reason to inform patients as best as we can and then allow them to make choices about their own care. But on the other hand, you say no to a treatment you need, even though we're saying you need it, and explaining why-- and then we don't do it, because you've said no? A month later, you're back, worse, and blaming us for listening to you. "I didn't mean no. I figured you'd do it anyway if it was really important. Why would you ask me if it was important? If it's important, you're supposed to just do it."

You reject an MRI because you don't want to be "trapped in a box," it's on you. I'll explain it once, I'll explain it twice, I'll give you options-- but you keep saying no and at some point it's no, and we leave, and it's on you. So don't say no, if you don't mean no. Please.

Quiz: Allergies

Please choose the best response to the following question, given the choices presented.

***It says on your chart that you're allergic to penicillin. Can you tell me what happens when you take it?***

A. "Oh, I'm not really allergic. I just don't like it."

B. "I think I broke out in hives once, right where I got an injection. Though I'm not sure if that was penicillin or heroin."

C. "I don't know that I'm allergic. I wrote it down because my sister's allergic, so she says I'm probably allergic too. She's actually my half-sister. My adopted half-sister."

D. "What happens when I take it? I've never taken it! I'm allergic! Duh."

E. "When I took it, I didn't get better. That means I'm allergic, right?"

F. "When I take it, my entire body breaks out in hives. But I sort of like that feeling, so I don't mind if you give it to me anyway."

G. "Did I write penicillin? I meant to write peanuts. I'm allergic to peanuts."

H. "It depends. I'm only allergic to penicillin if it's made in the same factory where they make tomato products."

I. "I'm not really allergic. It's more like I'm penicillin-intolerant. It gives me gas."

J. "Why do you care if I'm allergic to penicillin? I'm here for an infection, not because I need medication."

K. "I just wrote down I'm allergic to it so you wouldn't prescribe it. You don't need to. I have six bottles of it in my medicine cabinet at home."

L. "Oh, I was copying off the person next to me in the waiting room."

M. "Penicillin's the one that's blue and rectangular, right?"

N. "I didn't write that. No, that's not my handwriting, sorry."

O. "I say I'm allergic because I used to be addicted to it and I don't want to start up again, so I figure it's best not to even get tempted."

P. "Oh, that was the allergy section of the form? I thought that was where I was supposed to write down my best guess about the medication I think I need."

Q. "I have trouble breathing. Three times a day, every time I take it, every day for the past sixteen years, I have trouble breathing. So I guess I'm allergic to it."

R. "When I take it, I die. So don't give it to me."

"We're going to start you on Carvedilol for the blood pressure."

"None of my friends take that drug."

"Okay..."

"I mean, is that a good drug? Why don't any of my friends take it if it's a good drug?"

"Your friends may have different medical issues, there are different interactions between drugs, every patient's situation is different."

"I have a lot of friends."

"This is the drug we think will be most effective for you. I obviously have no idea what your friends should or shouldn't be taking for whatever medical conditions they may have."

"My friends go to doctors everyone says are very good."

"I'm not saying anything about the doctors your friends use. They are probably excellent, and I'm not judging their decisions at all. We're just talking about you, and the best medication to balance all of your symptoms and help keep you healthy."

"So should I tell my friends to take this drug?"

"No, I didn't say that. What your friends need to take is entirely dependent on their medical conditions and the judgment of their doctors."

"But if this was a good drug, wouldn't some of my friends be taking it?"

"No necessarily. Like I said, there are different drugs for different combinations of medical issues, and without knowing the details of your friends' medical concerns, to the degree that their own doctors do, it would be impossible to even speculate about which medications they should be taking."

"So they should ask their doctors about it."

"They should feel free to ask their doctors any questions they might have about their medications. I have no reason to believe this medication makes any more or less sense for anything they are or are not dealing with."

"If you have no reason to believe this medication makes sense, why are you telling me to take it?"

"It makes sense for you. I'm saying I don't know anything about whether it makes sense for them."

"I just want the best medication."

"And I'm trying to give you the best medication for you."

"No, not the best medication for me. The best medication. Whatever it is, I want the best one there is."

"It's all dependent on your own constellation of symptoms and issues."

"I don't think I want this medication."

"Okay, let's start this conversation from the beginning again..."

"So I just want to do a quick history. Have you had any medical problems in the past?"

"Just seasonal allergies."

"Great. Do you take anything for that?"

"I used to take Claritin but not since my stroke."

"You had a stroke?"

"Yeah, a couple of years ago. I still have some left-side weakness from that, and some cognitive difficulties."

"And you stopped taking the Claritin because..."

"My oncologist switched all of my medications."

"You have an oncologist? So you've had cancer?"

"Yep. Breast cancer. Three years ago. Did chemotherapy and radiation. Which wasn't as bad as I expected it to be. It was a lot better than for the brain tumor."

"You had a brain tumor?"

"I did. It was an incidental finding while I was undergoing electroshock therapy for depression."

"And the depression is currently..."

"Being managed by medication. And largely held in check except for when my chronic pain symptoms flare up."

"Chronic pain in your..."

"Fingers and toes."

"Before we get any further into your history-- because this seems like a very extensive collection of issues, and I'm guessing perhaps we haven't even covered them all-- why don't I ask what you're here for specifically today."

"Genital warts."

"Okay. So I think we're going to skip the rest of the history."

"So that's all you're going to do for me?"

"I'm writing you a prescription to help with your allergies, yeah."

"I'm paying here. I want everything done."

"You have seasonal allergies. I'm writing you a prescription. That's what I've got for you-- I think it'll help, and you'll feel a lot better. Follow up in a few weeks, and we'll make sure it's working for you."

"No. I'm not following up in a few weeks. I want to do everything now. I'm paying for the full package."

"I can't tell you right now if this particular medication is going to be effective for you. My hope is that it will be, and so you'll try it, and then we'll see how you're doing."

"No, you're going to tell me right now, and you're going to give me the whole package, because I'm paying you for it."

"What do you mean by 'the whole package'?"

"I want a blood test, I want a physical, I want a heart scan, I want a brain scan, anything you can scan, I want the works."

"You don't have any medical reason for these tests. And you just had blood work done a few months ago, so there's no reason to repeat without any symptoms."

"I don't care if there's a reason or not. I want it done."

"I'm not able to order unnecessary tests, I'm sorry. You came in with a complaint about allergies. I'm addressing that complaint, and giving you a prescription. If you have other medical concerns, then let's definitely talk about them and figure out what needs to be done. But it's irresponsible to order tests without a medical reason to do so. They can be dangerous, everything has a risk."

"I don't want the risky ones."

"Everything we do has a risk. No reason to expose patients to unnecessary radiation, or invasive procedures."

"I'm paying good money for this."

"And I'm trying to treat your medical problems effectively."

"I expect more."

"I'm sorry, sir."

"I'm not leaving without at least a couple of x-rays."

"I think I'm going to let you talk to one of my colleagues, across the hall in the mental health clinic, if that's okay with you. I think he might be able to help with some of the concerns you're having today."

"Is it included in the price?"

"It's covered by your co-pay, yeah."

"Well then that's what I'm talking about. Why did you need to give me an argument?"

"I'm sorry, sir."

Secret Words

"Yes, doctor, this patient has pain caused by a large pannus. ETOH, A&O times 2."

And, you, the patient, sit there, not knowing that the doctor has just called you a fat alcoholic who doesn't know what day it is.

I looked up pannus to make sure I was spelling it right-- it's used more out loud than in the notes. And wikipedia tells me it's actually being used incorrectly. We use it to mean a large stomach, in an obese patient. But apparently that's actually panniculus, and pannus is an abnormal layer of fibrovascular tissue. The fact that I'm relying on wikipedia to tell me this is perhaps a little frightening. We use pannus all the time to mean a big fat stomach. And now I'm not really sure why, assuming wikipedia knows what it's talking about. And the entry for panniculus has a whole grading system that we don't use and I've never heard of:

Grade 1
Panniculus barely covers the hairline and mons pubis but not the genitalia.

Grade 2
Extends to cover the genitalia.

Grade 3
Extends to cover the upper thigh

Grade 4
Extends to cover the mid thigh.

Grade 5
Extends to cover the knees or beyond.

Fascinating, I suppose. Wikipedia knows more than I do.

What you say / What we hear

What you say: "I take my pills almost every day."
What we hear: "I almost never take my pills, and probably don't even know where they are-- if I even filled the prescription to begin with."

What you say: "I think I followed up with the specialist, yeah."
What we hear: "I did not follow up with anyone, and only now remember that I was supposed to."

What you say: "You told me not to eat anything before I came in, so, yeah, I basically didn't eat anything."
What we hear: "I had breakfast, but I ate it quickly."

What you say: "I probably don't exercise as much as I should."
What we hear: "The walk from the parking structure to the clinic is the longest walk I've taken since my last visit."

What you say: "Do I need to get that test done today, or can it wait?"
What we hear: "Am I actually going to drop dead on the way out of the clinic, or can I forget all about this, forever and ever?"

What you say: "But what I really want to talk about is this other symptom that I've been having for the past twenty years, unchanged."
What we hear: "Here is an irrelevant distraction I'm going to mention, that's been going on so long that if it were important, it would have killed me already."

What you say: "Do you think this has anything to do with [radiation from my cell phone / lead paint in my office / a general sense of danger in the world]?
What we hear: "Here is an uninformed theory I have. It probably doesn't make any sense. It does, however, demonstrate that I watch the local news."

What you say: "My friend thinks I have--"
What we hear: "Here is more uninformed speculation. Try not to laugh."

What you say: "And I read online that--"
What we hear: "I am now going to prove that I have access to the Internet."

What you say: "I also take some [herbal medications / illegal drugs / pills that a friend gave me]--"
What we hear: "Here's something that I think is helping me, but is probably actually causing the problem."

What you say: "--but I don't remember the names of any of them."
What we hear: "--so I thought I would just waste your time and make you guess what I'm poisoning myself with."

What you say: "No, that's okay, I'll call for a follow-up appointment."
What we hear: "Goodbye, forever."

I have a high school student shadowing my floor team this week. Part of a program for young people who aspire to go into medicine. They apparently got to choose between following an internal medicine team or a surgery team for the week. There's some down time, so I start talking to the guy.

"I want to be a neurologist," he says.

"That's great. What makes you interested in neurology?"

"I want to do brain surgery."

"You know neurologists don't do brain surgery, right? Neurosurgeons do. Brain surgery is a surgical specialty. Internal medicine doesn't do surgery."

"Shoot. Seriously? Then what do you do?"

"We prescribe medication. We make diagnoses. We try to figure out what's going on with the patient, and what to do to treat them. But if they need surgery, we refer them to a surgeon."

"So I chose totally wrong?"

"Not necessarily-- neurology is really interesting. You're dealing with stroke victims, a lot of neurological diseases, Alzheimer's, I think it's one of the more fascinating internal medicine specialties."

"But I'm not going to get to watch you cut anyone open?"

"No. That's what the surgeons do."

"I can't believe I messed this up."

"Maybe you'll be surprised, and by the end of the week you'll really be interested in what we do on the internal medicine side of things."

"Does it get more interesting than it's been this morning?"

"You've only been here an hour!"

"And all you've done is talk to people."

"That's what we do."

"No one even died yet."

"We're hoping they don't."

"I thought I was going to see people shot in the head."

"Do you want me to see if you can follow surgeons instead?"

"That would be awesome."

"I'll see what I can do."

"We need to talk about your weight."

"Oh, it's been stable."

"You weigh 317 pounds!"

"But it's been like this for years."

"And that's what we need to talk about."

"Look, it's just because my metabolism is slowing down."

"You're 39 years old. That's not the answer here."

"It's because of the water pills I take."

"They should be having the opposite effect. How many times a week are you eating fast food?"

"Clearly whatever I say, you're going to say it's too often."

"Maybe, but I want to know where we're starting from."

"You tell me-- how many times a week should I be eating fast food?"

"Zero."

"Well, it's more than zero."

"How much more?"

"A lot more."

"Give me a ballpark figure."

"I wouldn't say I eat fast food every day, but there are days I eat two or three meals that are fast food, so on average, probably nine or ten meals a week."

"That's too many."

"I knew you were going to say that."

"And let's talk about exercise."

"Do I look like I exercise?"

"No. And that's the problem."

"You can't tell me the problem is the food, and the exercise. You have to pick one."

"It's a combination of both."

"That's not fair."

"My weight is stable. Isn't that enough?"

"Not if you want to stay alive."

"I don't believe in all of this."

"In all of what?"

"Medicine. Doctors."

"Then why are you here?"

"Because of my chest pain."

"Which is caused by your excess weight."

"I don't think so."

"I can't help you if you're not willing to make some effort to listen and commit to a plan to be healthier."

"I'm not looking to be healthier. I'm just looking to not have pain."

"It all goes together."

"I'm not falling for the doctor tricks."

"There are no tricks."

"Just give me some kind of pill or something."

"That's not the answer."

"I'll pay cash."

"What?"

New year, new interns. They sent around a list with brief bios of everyone. It's cute. Young, untainted medical students, who actually believe all the patients are telling the truth, and really want to work up each and every complaint. Headache for the past twenty years? We need to run tests! No we don't. If it was something, the patient would be dead by now. And the prisoner patient is suddenly complaining of back pain, on the very day we're going to send him back to jail? Why he must be in terrible agony! The gods of scheduling somehow blessed me with a three-day weekend, which means I get the interns once they've been here for four full days...which means they will already be jaded like the rest of us.