Spent the day in gynecology clinic yesterday.

I don't know what motivates some people to become doctors. Particularly what motivates people to choose certain specialties when they seem to have no real interest-- animosity even-- toward patients with the particular issues they're supposed to be trying to treat.

This guy had one solution for every problem. Stop having so much sex. Fewer partners. "Keep your legs closed." "You won't get this again if you aren't so promiscuous." "You want birth control? How about underwear. How about you use self-control as birth control instead." "You were sexually assaulted? Go to trauma clinic. I don't deal with that here."

I found myself apologizing to most of his patients after he left the room. Never a good situation when the resident has to apologize for the attending. Thing is, everyone knows this guy is a lunatic. The clinic manager apologized when she assigned me to shadow him. "If you'd gotten here early, I could have given you someone else. I'm sorry." Early? I got there on time. Why would I want to get to clinic early?

And, yes, I'm reporting this guy to the medical director.

In the clinic, there are sick visits and routine follow-up. Although it sounds counter-intuitive, you want the sick visits. The sick visits are supposed to be about one thing. One specific problem. They come in, tell you the one problem, you come up with a treatment plan, and they leave. The "routine" visits instead often involve a laundry list of issues that have come up since the last visit, we're talking about weight loss, we're talking about diabetes management, we're talking about depression screening, foot pain, headaches, cataracts, anything and everything they're worried about. Which is fine, and that's what we're here for, but a sick visit is supposed to be so much easier. One problem. And we write a prescription for an antibiotic and off they go.

Problem is, the patients know the system even better than the doctors do. They know that routine follow-up appointments are six weeks out, and the fifteen-minute sick visit slot can be available the same day if you're willing to wait for a while in the waiting room.

"So what brings you in today?"

"I don't know, I just don't feel great."

"Is there a specific problem?"

"No, but I knew it would be a month before I'd get a regular appointment, so I told the secretary I was having chest pain."

"You know, that's not fair to the people who are actually having chest pain and need these slots. There are only a certain number of slots set aside for acute issues."

"They can find a different doctor."

"You know it's not that easy."

"Well, I didn't do anything that anyone else couldn't do."

"For next time, I'd appreciate it if you didn't make up a story to get a faster appointment."

"Like you'll be my doctor next time."

"I could be."

"I know how the clinic works. You won't be."

"Tell me what's bothering you."

"Well, first there's my life and how it's a total mess."

"I'm sorry to hear that. Do you have a specific medical complaint?"

"I want someone who will listen."

"Can I refer you to the mental health clinic?"

"I'm not crazy."

"I didn't say you were."

"Then let me talk."

And she talked. For twenty minutes about her ex-husband and her boss and her ungrateful daughter and the rude clerk at the Department of Motor Vehicles.

"I really have to see the next patient, if you don't have a medical issue that I can help you with."

"But I'm not done telling you about my neighbor's dog--"

"I'm going to have to cut you off."

"Okay, okay, okay-- I'll go. Just one more thing."

"Fine. What?"

"I have a lump in my armpit."

I started working a couple of shifts at a new clinic site this week. The examining rooms are on the first floor. And have floor-to-ceiling windows. Visible to the parking lot on one side, and the street on the other. Was this building a gym before it was a medical clinic? I had a patient changing in the room when I realized... as someone walked by and stopped to watch. I start lowering the shade, but it's not a complete shade. I have a naked patient being watched from the outside. Who built this clinic?

And they worry about the privacy of patient records? How about the actual privacy of patients being examined?

"I heard you can calculate my risk of a heart attack. Some kind of score?"

"You mean the Framingham Risk Score?"

"Yeah, I think that was it."

"Wait a second. You're homeless?"

"Yeah."

"You were not always homeless."

"No. I was a lawyer in Burundi."

I don't think I realized before working in the clinic how common this is. People who were professionals in their home countries-- educated, high-status professionals-- who sacrifice everything to come here for a better life... and end up as home health aides, cab drivers, busboys, homeless-- the lowest-status workers in our society. It's a shame. And I always want to ask whether life is really better being a cab driver here than it was being a lawyer in Burundi. I expect the money is better. But I wonder if that's enough to make it worth it.

Ethical question.
An e-mail to all residents from the program director-- i.e., our boss--

"Just wanted to let everyone know about a Lupus Walk I'm doing next weekend. Would like to invite everyone to check out the website and hopefully donate a few dollars for the cause. Thanks.

Also, if anyone wants to make an appointment to talk about their fellowship recommendation letter, let me know."

Of course it's all well-meaning, but is there not a little bit of coercion when your boss asks you to donate to a cause-- and then mentions those fellowship recommendation letters in the same e-mail??

You'd think doctors would get out of jury duty.

People got out for having doctor's appointments! I wanted to stand up and say, "you have one doctor's appointment-- I have forty doctor's appointments!" I got questioned for three different cases, finally excused because, hey, guess what, no one wants a doctor on a personal injury case because I might actually be able to make up my own mind about whether someone is injured or not.

I suppose I appreciate the idea of the jury system, and that if I were ever accused of a crime, I'd want-- no, wait, no. Having seen who actually serves on the jury, if I'm accused of a crime-- assuming I'm innocent-- I want a judge deciding my fate, not some random people who couldn't come up with excuses why they can't serve on a jury. I want someone who's trained to hear cases deciding whether I did it or not, someone who is (hopefully) a little harder to sway than a jury of the retired and unemployed.

For one of the cases, I was asked, "have you ever had an elbow injury?" One of the prospective jurors said, yes, he broke his shoulder.

I ended up excused before the trial started, because of a scheduling conflict. Sorry for the lack of posts. Normal posting will resume tomorrow.

"I have some swelling on my leg."

"Okay. Can you show me?"

The patient takes off her pants. Then pulls down her underwear. Points to some swelling.

"That's not your leg, that's your labia."

"Oh, I thought it was part of my leg."

Taking a patient history...

"So, are your parents still alive?"

"My father just died last month."

"I'm sorry to hear that. What did he die of?"

"Old age."

"He had no medical problems before his death?"

"No, no. Just old age."

"And how old was he?"

[Some readers may be thinking what I was thinking at this point... which was that I was about to hear a very low number... 55? 60?]

"One hundred and thirty two."

"Excuse me?"

"One hundred and thirty two."

"Your father could not have been 132 years old."

"Oh, no, he was. People in my family live a very long time. My grandmother is still alive."

"And how old is she?"

"One hundred and thirty six."

"No, that's not possible."

"It is."

"Wait. Is this your father's mother?"

"Yes."

"Even if she was 136. If your father was 132, that would mean she was 4 years old when she gave birth to your father."

"I don't know. All I know is that is how old they are."

"That is not how old they are."

"It is. We have very good genetics."

"You are 42. You walk with a walker. You have significant heart failure. You are not unfortunately not on a course to live to 136."

"You'd be surprised."

"And, wait, also, if your father is 132-- he had you when he was 90?"

"I guess that would be true."

"Your father was 90 years old when you were born?"

"I guess he was."

"I'm sorry to get bogged down in your family history here. But I just can't get past it. Your father was not 132 years old."

"You can ask his sister."

"How old is his sister?"

"About 17."

"Wait, what?"

"Yes. She's about to graduate from high school."

"Okay, we're going to skip the rest of the family history."

Whenever anyone in the hospital tells a story about a complicated medical situation, usually something that's led to a terrible outcome or a death, the response is always the same.

"Good case, good case."

Said in the same dispassionate tone, completely disregarding the fact that this "good case" is about an actual human being, and quite often an actual human being who's now missing a few of her organs, or who unexpectedly died.

You never want to be a "good case." If you're a "good case," it means something unusual has happened, and unusual is almost never a good thing.

"So the patient was in the OR, and the fluorescent light fixture somehow came loose from the ceiling, dropped onto the operating table, and immediately killed the patient!"

"Good case, good case."

"And then when her husband came to identify the body, he had a massive MI right there in the morgue, and the pathologist had to perform CPR-- unsuccessful, of course, since he hadn't dealt with a live patient in 25 years."

"Good case, good case."

"And when the son was on his way to identify both of his parents, he got into a car accident, came into the ER with his leg dangling from his body, barely attached, and he bled out, right there in the waiting room while the receptionist was checking his insurance status."

"Good case, good case."

"The daughter is fine though. Healthy. No medical issues."

"Oh. That's a terrible case. Why would you even tell us that?"

"No, I don't need a pap smear."

"What? You're 62 years old."

"I've never had sex. So everything is fine down there."

"That doesn't mean everything is fine down there. You still need the test."

"No, it's all like new. Untouched. No damage."

"You still need a pap smear. You're 62 years old."

"No, factory new. Clean and shiny. No test."

"You need the test."

"After sex, I will. Until sex, no thank you. Not needed."

"On a scale of 1-10, how would you rate this stomach pain?"

"I don't know."

"You had a bleeding ulcer last month. You had pain then. How does this pain compare?"

"I don't know."

"I'll tell you, I'm trying to figure out whether you're bleeding again, or this is a different kind of pain."

"Yeah, I don't know."

"What color has your stool been?"

"I don't really know."

"Did you look at it?"

"I can't remember."

"How long has the pain been going on?"

"I'm not sure."

"Hours? Days?"

"I don't know."

"You know your body better than I do. I need you to help me figure out if this is a serious problem, or this is indigestion. Because otherwise I have to treat it like it's a serious problem and send you to the emergency room."

"I don't think I want that."

"No one wants that. But I'm trying to figure out if you need that. Your blood pressure is normal. Your last blood work came back OK. I don't think you're actively bleeding, but it might make sense to try and make sure."

"Wait, I'm feeling a little better."

"Great."

"Oh, no, it's worse again."

"If I tell you to go to the ER, are you going to go?"

"No."

"So I don't know what you want me to do for you. You're on all the right medications. There's no evidence you're bleeding. I don't know what more I can do except tell you to eat and drink fluids and rest and try and go to the bathroom, and monitor how you're doing."

"I still don't feel well."

"I don't know if there's anything I can do without sending you to the emergency room, where I do think there's a good chance they will send you home."

"You know, you're totally f***** useless. Can I make an appointment for next week?"

"I don't know what's going to be different next week."

"I'm probably still going to have this stomach pain, obviously. I'll make an appointment for next week. Goodbye."

A patient in the hallway.

In her hospital gown.

All day.

Panhandling.

And everyone walked by her.

Some giving her change from their pockets.

But no one bothering to question.

Why she is panhandling.

In the hallway.

Near the elevator.

Why no one is looking for her.

And helping her back to her room.

I flagged down a nurse.

But she wasn't her patient.

And I had other patients to see.

And when I saw her again.

Three hours later.

Still in the same place.

I asked another resident.

But she wasn't her patient.

She didn't have a bracelet.

Which might mean she wasn't a patient at all.

Or might mean she tore it off.

Or might not mean anything.

She wouldn't tell me her name.

And I had other patients to see.

I heard someone else.

Saying she saw her too.

But she had other patients to see.

I don't know what happened.

I haven't been back to that floor.

I assume someone dealt with it.

Though I probably shouldn't.

I would check again.

But I have other patients to see.

[A bunch of people left comments on my post from Tuesday saying my post was fine but useless if I didn't say HOW to tell if their doctor is good and HOW to find a better one. Those comments are correct. I consulted with a couple of friends for help with an answer here. Knowing if your doctor is good, or how to find a better one, isn't necessarily easy. If you know people in the field, that's a start-- recommendations from doctors or nurses who you know, recommendations from people who are medically savvy and plugged into the field. Where they trained can be an indicator, although it's not perfect. Rankings of programs exist (U.S. News, etc), rankings of medical schools exist. One commenter accurately points out that judging foreign medical schools is more difficult. Many states have online databases where you can type in a doctor's name and see where they trained, what specialties they're licensed in, and whether they've been sued for malpractice (not always an indicator, but, hey, I'd probably avoid a doctor with a long list of lawsuits). And you ask questions and see if you're happy with the answers. It's often pretty clear if someone knows what they're talking about or they're faking it. If you think your doctor is faking it, ignoring your questions, brushing you off... maybe that's a signal.]

"The medication you prescribed is causing diarrhea," said the patient, loudly, and with more anger than diarrhea ought to cause.

"I'm not sure it's the medication, but I can give you something to see if it helps."

"No. I'm not taking any more medication from you. And I'm stopping all of the ones you already prescribed, because I can't live my life having to run to the bathroom every day."

"Wait, how many times a day are you having diarrhea?"

"One."

"That doesn't sound disabling. We'll try to get to the bottom of what's causing it, but you need to take your medications. Unfortunately the consequences of not taking them could be far worse than the diarrhea."

"I went through a whole roll of toilet paper in a week."

"Um... how often were you going to the bathroom before you first started taking the medications I prescribed?"

"Once a week, maybe twice."

"That's not normal."

"It's normal for me."

"That's not a thing. It's healthier to be going more often than that. And now I'm thinking, just to be sure, let's take a step back for a second. Describe what you mean by diarrhea."

"It comes right out. I hardly have to push. And then I have to wipe a couple of times."

"Is it watery?"

"No. Watery? What are you talking about?"

"I think what you're doing now may in fact be normal bowel movements. You were terribly constipated before."

"It was normal for me."

"That's not a thing. Going once a day is fine. It's healthy."

"You're not serious."

"I am."

"You can't be serious that it's normal to go to the bathroom every day."

"I am."

"No. No way. That's crazy. I don't have time to go to the bathroom every day. I work two jobs."

"I'm sorry that the medication has made your bowel movements normal and healthy. I don't know what to tell you."

"You can tell me how to get back to the way it was."

"You can't, and you shouldn't."

"So you're saying you ruined me."

"I'm saying I fixed you."

"Forget it. I'm finding a new doctor."

"I'm sorry you feel that way."

"Is there a bathroom I can use on the way out?"

"It's in the waiting area."

"Goodbye."

There's an article in the New York Times today about patients being overtreated and how they should ask more questions and see if there are alternatives to what the doctor recommends that involve less invasive procedures or fewer medications.

This may be a minority opinion, but I think the article is stupid.

It's stupid because if you need to push your doctor to talk about less invasive options that may be just as effective, or medications he or she prescribed you may not need to be taking, guess what?

You need to find a better doctor.

What the article basically says is you should bully your doctor into ordering fewer tests and letting you stop taking some of your medications.

Which is great advice, until you miss something that one of those tests would have picked up, and you end up in worse shape. If I'm a patient, I don't want a doctor who I have to bully into not ordering a CT scan. I want a doctor who's smart enough to know when a CT scan makes sense and when it doesn't. I want a doctor who knows when he can take me off certain medications. Not a doctor who I can nag until he gives in, and lets me, the uninformed patient, dictate my care whether or not I know anything useful.

If I've learned one thing these past two years, here it is:

All doctors are not the same. All hospitals are not the same. If you go to a mediocre doctor, you will get mediocre treatment, and you will encounter avoidable risks that you may not even know you're being exposed to, whether it's from the wrong medication, the wrong treatment plan, outdated advice, failure to think proactively, or just plain stupidity and carelessness.

Somehow, people understand that there's a difference between a diner and a four-star restaurant, that chefs have different levels of capability, and that if you want the best meal you can find, the diner is probably not the place to go....

And yet people pick a doctor with less care than they choose a restaurant.

People don't ask where their doctor went to school, did their residency, what hospitals they're affiliated with, how many patients with similar conditions they treat, and whether they have a financial incentive to push whatever treatment they're pushing.

If you have an upper respiratory infection and need an antibiotic, most doctors can probably deal with you appropriately. If you're young and healthy, and don't have a bunch of medical conditions, most doctors can probably deal with you appropriately. Beyond that, I'll take the one with the fanciest diploma, thank you. It's not a guarantee-- there are smart people who are bad doctors, and there are certainly people who went to ordinary schools who are excellent doctors, but at least it's something. It's a proxy for some level of competence. I want the smartest person I can find, with the most experience and training, dealing with my medical decisions. The stakes are often too high to risk anything less.

It is incredibly frustrating to see patients who come in with, say, a bleeding ulcer, and they in fact tried to do all the right things-- they went to their doctor, who sent them to a GI specialist, who did an endoscopy... and missed the ulcer completely. Or exacerbated the problem. Or didn't look at what other medications the patient was on. Or didn't check labs before doing the test. And then we get the result-- a patient with a BP of 80/50 bleeding into his intestinal tract. And, no, we may not have done any better if we were the first stop, but we probably would have. You can avoid problems if you start with the most competent doctors you have access to, and don't assume that every doctor is fine, and every doctor will give you the same answers.

If you have to rely on your own skepticism to force your doctor to think about whether he's recommending the best possible treatment, like the Times article assumes, you are in bigger trouble than just needing to ask a few questions. You need a different doctor.

You should not have to come armed with your own independent medical research in order to get satisfactory care. There is something wrong with the system if you need to know more than your doctor does.

"I need a new prescription, but I don't want the generic this time."

"It's the same thing. I'm just trying to save you money. The generic is going to be a lot less expensive."

"Everyone says that, but they're not the same."

"It's the same exact chemical formula."

"The shape of the pill is completely different."

"The shape of the pill doesn't matter."

"Come on. The generic is this little tiny pill. The regular is like three times the size. That means there's a lot more medicine in it."

"That's not what it means. It just means the pill is bigger. The amount of medicine is the same."

"That doesn't make any sense. Isn't the whole pill medicine?"

"Some of the pill is just innocuous ingredients to make it into a pill you can swallow. The shape and size is not important."

"What about the color? The generic is a totally different color."

"The color doesn't matter."

"I don't like green drugs. That's the color of mold."

"The drug is not green. The color of the pill does not matter. The pills aren't moldy."

"Well, I don't care what you're saying. I don't want the generic."

"I can give you the brand name. But I promise you it's a waste of money."

"Don't worry about that. I'm probably not going to fill it anyway."

"What? Why not?"

"I don't like the way it tastes."