* * Anonymous Doc: September 2011

Friday, September 30, 2011

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

Wednesday, September 28, 2011

My current attending is a terrible doctor.

Or at least the Internet thinks so.

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

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

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

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

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

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

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

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

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

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

Monday, September 26, 2011

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

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

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

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

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

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

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

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

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

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

Which likely means it will become a huge hit.

Friday, September 23, 2011

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

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

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

Thursday, September 22, 2011

Here's something you never want to hear:

"Does anyone know where the crash cart went?"

Here's something you never want to hear next:

[No one says anything]

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

"Never mind, too late."

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

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

Tuesday, September 20, 2011

"So what brings you to clinic?"

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

"But you're feeling better?"


"So why did you come today?"

"Because I had an appointment."

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

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

"A fever of what?"


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


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

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

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

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

"You just said you felt fine before too."

"Yes. I did."

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

"Yes. Today I had 47."

"Okay, clearly your thermometer is broken."

"Do you know how to fix it?"

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

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

Monday, September 19, 2011

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


"I've been feeling heart palpitations."

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

"You mean drugs drugs, or medication drugs?"

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

"Not really."

"Does that mean no, or yes?"

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

"And it's called...?"

"Oh, it's unlabeled."

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

"But I've lost 20 pounds."

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

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

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

"No, she's a nutritionist."

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

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

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

"But I've lost 20 pounds!"

"But you're having heart palpitations!"

"But I've lost 20 pounds!"

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

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


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


"Does your nutritionist also do massage?"

Sunday, September 18, 2011

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

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

Thursday, September 15, 2011

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

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

"Excuse me?"

"Is my back pain affecting my organs?"


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


"Or my lungs to get distracted?"


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


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


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

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

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

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

"But it's not lowering my intelligence?"


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

"Why would back pain do that?"

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

"Fortunately, they're not."

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

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

"Great. Thanks."

Wednesday, September 14, 2011

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

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

"He normally has paranoid delusions?"

"Oh, yes, all the time."

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

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

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

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

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

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

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

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

"Does he have a job?"

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

"We could help with that."

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

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

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

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

"We're fine."

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

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

Tuesday, September 13, 2011

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

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

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

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

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

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

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

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

"I want to run the tests."

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

"Should we try dialysis?"

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

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

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

"She needs to urinate."

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

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

Monday, September 12, 2011

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

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

Friday, September 9, 2011

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

"You should stop pulling--"

"But there's more of it--"

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

"Okay, it's not stool--"

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

Indeed, it is not stool.

And that is all I am able to determine.

Thursday, September 8, 2011

"What are those people selling?"

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

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

"They're just visitors."

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

"They're not selling anything."

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

"They're just visiting their family member."

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

"They're not selling anything."

"They are. What are they selling?"


"Tell me."

"They're selling your organs."


"Do I get a commission?"

Wednesday, September 7, 2011

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

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

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

Tuesday, September 6, 2011

Not exactly the conversation I just had:

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

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

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

"We're back!"

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

"Nope, she's not!"

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

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

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

"She's doing really well."

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

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


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


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


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

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

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

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

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


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

"Who are these people?"

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


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

Monday, September 5, 2011

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

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

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

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

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

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

"When they page me."

"Yeah, when's that?"

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

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

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

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

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

"You leaving?"

"I'll be back."

"How long?"

"I don't know."

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

"A patient isn't breathing."

"I just waxed."

"I have to get to this patient."

"You need to go around the other way."

"The patient!"

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


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

Saturday, September 3, 2011

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