Twenty Things To Say To Your Doctor If You Want To Be A Difficult Patient

1. "Oh, my appointment was yesterday?"

2. "Did you get the paperwork I faxed to my other doctor?"

3. "Your nurse didn't say I should remove all my clothes before you came in?"

4. "You don't mind if I eat in here, do you?  It's just a tuna sandwich, some chips, and a melting popsicle...."

5. "Yes, I'm taking all of my medications, except one of them.  But I'm not sure which one."

6. "I need a refill on my blue pill.  The smaller one.  And, really, I needed it three weeks ago."

7. "Of course I had recent blood work.  I think."

8. "My friend told me not to have any x-rays because of the risk of radiation exposure.  Can you do one without radiation?"

9. "Wait, when I told you I had the flu shot, I didn't mean I had it *this* year!"

10. "I just realized-- that rash you just touched-- it's from the bedbugs!"

11. "Six.  That question you asked at my last appointment... the answer is six.  Maybe six and a half."

12. "Thanks for all of that information, doc.  But I forgot to put my hearing aid in, so if you wouldn't mind starting all the way back at the beginning."

13. "Nope, that's it.  Except for this scab I picked off my body and wrapped in a napkin to show you."

14. "Oh, before I go, can I just ask one quick question about the worst headache I've ever felt in my life followed by left side weakness, a fever of 106, and a bloody discharge from all of my orifices that I didn't think to mention?"

15. "You could do me a favor and not report this visit to my insurance company, right?  I don't think it's covered, and I'm not going to be able to pay the bill."

16. "I know it's *my* appointment, but my wife has something near her rectum that she wanted to show you, if that's okay."

17. "Can you call my children and let them know how the appointment went?  Here are all eight of their phone numbers."

18. "You didn't get those e-mails I've been sending you?  I must have your address wrong-- give it to me again-- I'd hate for you to have missed all of those important political writings I passed along."

19. "I was hoping you could give me your personal cell phone number so I can call you whenever I sneeze."

20. "Sure, we could schedule another appointment-- but I should mention that I'm moving to a different state next week, so this entire appointment, and all of the follow-up we talked about, has been completely pointless."

Thanks for reading, and Happy New Year.

"I Thought You Were Going To Take Me To Bed"

Lovely elderly female patient who speaks not a ton of English.  She comes to the clinic with a cough, nothing too serious.  Uneventful visit.  I prescribe a couple of meds, send her on her way.

As she's leaving, from the lobby of the clinic, she yells to me down the hall:

"Goodbye, doctor.  I thought you were going to take me to bed!"

Everyone turns and looks.  Patients, my colleagues, everyone.  I walk down the hall, confused, to ask what she meant to say...

"I thought you were going to take me to hospital bed!"

"Oh.  Oh, yes.  No, you don't need the hospital."

"Yes, great.  Thank you so much.  See you next time."

She leaves.  Colleagues are being slow to move on from this one.

Limbo

The latest chapter of "there's something awfully wrong with our health care system."  I have a patient who's been ready for discharge for a couple of weeks... but is still in the hospital because there's nowhere for him to go.  He can't be discharged home -- he needs a nursing home.  His wife refuses to have him sent to a nursing home, because she doesn't want to pay for it.  They have too much money for Medicaid, but not enough to afford nursing home care.  The nursing homes don't want to take him without guarantee of payment, since he's not on Medicaid.  So we're stuck holding onto him -- we can't discharge without a safe place to discharge him to.

The usual reaction in cases like this (and this isn't the only time it's come up) is to say that the wife is the problem and she's preventing someone who actually needs the hospital bed from getting care... and that's completely true, except I also understand where she's coming from.  Her husband isn't really her husband anymore.  He has no quality of life, he's non-verbal, may or may not know who he is, or where he is, or what's going on.  But he may linger for months or years, and it'll bankrupt her, and destroy whatever they might have been saving with the hope of a decent retirement.  And then if she ends up with medical costs down the line... perhaps in a situation where she could have some quality of life remaining... the money isn't there.

Of course there are all sorts of problems and inefficiencies with government-run health care.  But there are all sorts of problems and inefficiencies with a hospital ending up in a standoff with an elderly woman, losing her husband, who doesn't also want to lose her financial footing in the process, for no good ends-- her husband will never regain function, he will never be himself again.

"Is your wife home? No, really, because we don't know where she is."

There was a new patient on my list.

I had never met this patient.

I have still never met this patient, because this patient was not in her room.

Her room was empty.

I was confused.

No one knew who this patient was.

No one had met this patient.

And yet she was on my list.

Did we lose her?

Did she leave?

Was she discharged?

Although, if she was discharged, why wasn't there a discharge note?

Cautiously-- somehow thinking I could try to find out if her family knew where she was without revealing that we had no idea-- I picked up the phone and called the number in the chart.

"Hello, I'm calling from [Hospital] about [Patient]."

"Yes, I'm her husband."

"Yes, uh, I'm one of the doctors on your wife's service, and I just wanted to check in and see how things are going..."

"Oh, yes, thanks so much for calling.  Things are going well."

"Great.  So your wife is... doing okay...?"

"Yes.  She seems to be."

[At this point, I'm trying to figure out how I can ascertain whether she is in fact at home with him, or he thinks she is here with us, because both still seemed like reasonable possibilities.]

"Uh, did you have a chance to meet any of the doctors taking care of her?"

"I did, yesterday."

[Okay...]

"Great.  And, uh, for the holidays..."

[Please finish my sentence, Mr. Patient Husband, because I don't know where it's going.  Please please please--]

"..."

[Oh no, I have to keep talking...]

"...if you need to reach anyone here, I can give you a number..."

"Oh, that would be great."

"Great."

"And the next time you'll be here..."

[I was really proud of myself for coming up with that line, because I figured it has to lead me somewhere, right?]

"Oh, she has a follow-up next Wednesday."

[Yes!]

"Oh, great.  So you're with her now..."

"Yes, she's in the living room, resting."

[Yay!]

"So her discharge went smoothly..."

"Yes, thank you.  Thanks so much for calling.  It's great to know that someone is following up and checking in."

"Yes, well, we try.  Have a great holiday."

"Thanks, you too."

Yes, another sterling bit of customer service over here, as we try to make sure we didn't accidentally misplace a patient!  Happy holidays!

"Sorry, doc, getting to the hospital is too much of a hassle."

I get paged in the middle of the night by a patient's wife, someone I've seen in clinic for a while now and have gotten to know.  "My husband had 102 fever, I gave him Tylenol and it's down to 99, but I wanted to know what to do."

"You need to bring him to the ER.  He has multiple sources of possible infection, and there's no reason to risk waiting past the holiday weekend for him to get in to see a doctor on the outpatient side."

"But it's such a hassle to get to the ER."

"I know.  But he needs to get a urine sample and a blood draw, at the very least.  It's possible he can just get a prescription for antibiotics and be sent home -- I'm not saying he's going to be admitted -- but he needs to see someone."

"Maybe the fever was a fluke?"

"You don't spike a fever for nothing.  Something's going on, and the safest thing to do is not to wait until there's a bigger problem, but to get this worked up and see what's going on."

"Can't you prescribe an antibiotic over the phone?"

"I can't.  We need to run tests and see what's going on."

"How about if we wait to see if the fever comes back?"

"I don't know what you think you'd be waiting for.  He had a fever.  Tylenol is not a cure, it's just a mask.  I'm not saying something serious is going on here, but you called me, so this is what I'm telling you to do."

"What if we wait until the fever hits 101 again?"

"I'm not sure what you want me to tell you.  You're looking for permission not to take him to see a doctor, and I'm not comfortable giving you that permission.  Is waiting going to make a difference?  I don't know that the answer is yes, but I don't know that the answer is no."

"You're not very helpful."

"I'm telling you to take him to the ER."

"He can't walk well enough to get into the car."

"I know.  And I know it's a hassle.  It doesn't have to be our ER, if that's not possible.  You can call a private ambulette to take him here, or you can call 911.  We can send his records wherever he ends up.  I'm not trying to make this difficult for you, I'm just telling you that he should be seen before the end of the holiday weekend."

"How about tomorrow?"

"I don't know why tomorrow is different from today, but I'm just his doctor, I'm not going to force you to do anything."

"Okay."

"Okay what?"

"Okay, if you're not going to force me to do anything, we're going to wait until the fever comes back."

"As long as you realize you're taking some amount of risk this becomes more serious."

"You're not helping."

"I'm trying my best."

You know, there's a tremendous health education problem in this country, and probably everywhere.  I feel like people think that if something is really an emergency, a doctor is going to force them to do something.  That they're not going to be allowed to refuse tests or refuse treatment.  That if a medication is really important, they won't just give you a pill, but they'll inject something into you against your will.  That if you're really in danger, you will be dragged, kicking and screaming, into an MRI machine, into a hospital bed, into an ambulance, wherever.  That nothing is serious unless you are physically being detained.  That we are magicians, we can see the future, we know everything that's going to happen, when it's going to happen, and how to avoid it -- and that we can hold off terribleness as long as you can come up with a good excuse for why it shouldn't happen.

"He can't have pneumonia, there's a snowstorm, and we can't get to the hospital today!"  "Oh, why didn't you say so?  We'll forget the pneumonia and hold off until Tuesday, when the streets are clear."  "I can't take my pills, because I dropped them down the sink!"  "Oh, you dropped them down the sink?  Then I'll snap my fingers and cure your infection on my own.  And, I'll magically make your insurance company send you new pills without you even having to call them."  "The fever's a fluke.  I don't want to go to the emergency room."  "Okay, well, as long as it's a fluke."

Guess what?  You're in charge of your own health.  You want to call a doctor and ask what you should do?  Great.  But if you're not going to listen, why are you calling?  Are you just trying to see how much the doctor is going to insist, and then decide, based on tone of voice, whether to take the advice seriously or not?  Your health-- surprise-- needs to matter a lot more to you than it matters to your doctor.  Because even if your doctor cares, your doctor doesn't care enough to chase you down and force you to be smart about your choices.

Your doctor is going to feel sad, and maybe even guilty, if something happens to you that could have been avoided -- but sad and guilty are a lot less serious than dead.  Your doctor can be really sad and really guilty, but you are still going to be the one to suffer the consequences.  You are still going to be the sick one, the sicker one, or the dead one.  Not your doctor.

There is only so long someone will stay on the phone with you and explain why you should do what he just told you to do.  And a lot of times, that amount of time is zero seconds, because it is more important to deal with the people who actually want your help than the people who are pretending to want your help, or think they want your help but actually have no interest in your help, no matter how many different ways you try to say the same thing.

If you are not going to go to the hospital, under any circumstances, don't ask whether you should go to the hospital.  Ask something else.  And ask someone else.  Ask your plumber what he thinks you should do, because he might have a different answer.  My answer, apparently, doesn't really matter.

Blood In The Urine

"Oh, before we finish up, I also wanted to mention... I've been having more blood in my urine recently."

"More?  What do you mean?  You had blood in your urine before?"

"Sure, always."

"What?"

"I've always had some blood in my urine.  It's just how I am."

"That's not normal."

"Well, for me it is.  Except the last few weeks there's been more of it."

"How much blood are we talking about?"

"Oh, a fair bit.  Like, it colors the whole toilet.  Funny thing is, it only happens when I urinate sitting down."

"Hold on, explain to me what you're trying to say."

"When I sit down to urinate, there's a lot of blood.  Also, it must splash back up on me, because I can usually see it when I wipe."

"I'm trying to wrap my head around what you're telling me.  Is it at all possible that what you're noticing isn't from your urine at all, but it's bleeding hemorrhoids?"

"And those would be where?"

"Your anus."

"Wait, so you think this may all be connected to the burning I feel when I move my bowels?"

"Uh, just from what you're saying, I think it might be."

"Oh, wow, doc -- you're a genius!  All this time, I thought I had blood in my urine, but I think you may be right -- I think I'm actually bleeding out of my anus.  Whodathunkit?  Wow, my wife is never going to believe this."

"Maybe we should take a look just to be sure I'm on the right track."

"No, no, what you're saying makes total sense.  I have to rush -- I have another appointment -- but this is great -- so I can just use some of that over the counter stuff -- the Head and Shoulders?"

"Uh, not Head and Shoulders.  I want you to follow up with a specialist just to be sure -- I can give you a referral."

"A neurologist, right?"

"No."

"Are you saying she needs hospice?!" ("No!")

I have an elderly patient in for a routine visit to the outpatient clinic, and find she has a fever and signs of infection.  I give her daughter a call.

"Hi, I'm calling about your mother.  It seems she may have an infection."

"Are you saying she needs hospice?!"

"No, I didn't say anything about hospice.  I'm saying she may have an infection, and I'd like to admit her to the hospital."

"I hear great things about hospice."

"Again, I didn't say anything about hospice.  Let's try to clear up this infection and see how she does.  There's no reason to be talking about anything beyond what will hopefully be just a few days in the hospital."

"You know she's DNR, right?"

"I do.  It's in her chart, and very well-documented."

"But you still want to treat her for this?"

"Well, I do think we should try treating her with antibiotics to solve this acute problem.  I don't think this is necessarily going to lead to something worse.  Anything can of course happen at her age and in her general condition, but I think we should see if we can clear up this problem and she can return to her baseline-- which is pretty good, considering."

"I was told the DNR meant that she wouldn't be treated."

"It means she won't be intubated, or resuscitated if her heart stops, but her heart is still beating.  She's in good spirits, she just wanted me to call you and give you the update."

"I don't want any heroic measures taken."

"We're just going to admit her and give her some medication."

"So no hospice?  Just hospital?"

"One more time, I have not said anything about hospice.  You're the one who keeps mentioning hospice."

"I just hear great things."

"Your mother will hopefully recover just fine."

"Be sure to give me a call as soon as you start thinking about hospice."

"I'll tell your mother I gave you the update.  Bye."

"I'm afraid..."

"So, I have to tell you, you are in really good shape for a hundred years old.  I don't see a lot of patients in the kind of shape you're in."

"I'm afraid, though--"

"Well, I know, at your age there's really no guarantees of how much longer--"

"No, no, I'm not afraid of dying.  I'm afraid of being in a wheelchair."

"Uh, you're walking okay now."

"Yeah, but slower than I used to."

"You're a hundred!"

"I know, but I used to be able to walk great.  And now I have the cane, and, down the road, who knows."

"I think you're doing great."

"No, I can barely walk around the block."

"That's a long way to walk."

"It is not."

"For someone your age, I promise you it is."

"I just don't want to end up in a chair."

"There are worse things.  You have your mind..."

"No, it worries me."

"Well, we're going to do our best to keep you as active as we can for as long as possible."

"I hope you do better than my last doctor."

"Why, what did he do?"

"He retired."

"I'm still pretty young."

"For now."

"I'm too busy-- come back later!"

I get called to do a consult on a newly-admitted hospital patient.  I knock on the door.

"Hi, I'm [me].  Your cardiologist wanted me to come see you, and--"

"Oh, can you come back later?"

"Uh, I guess... why?"

"They said I'm having physical therapy, and I wanted to get ready."

"This won't take long..."

"I'd rather you come back later."

"Okay, do you know what time physical therapy is?"

"They said they're coming any minute."

"Okay, I'll come back in an hour.  You should be back by then."

"Oh, but that'll be lunchtime."

"Okay..."

"At least you can let me eat lunch in peace."

"Okay, I'll come back after lunch."

"I can't nap?  It's like torture here."

"I think I'm just going to do a quick exam now, if that's okay."

"No-- I said it's not.  Come back when I'm not so busy."

"You're in a hospital."

"I know. And I'm very busy today."

"I think your doctor may have called the wrong kind of consult anyway.  I'll let him know I quickly saw you."

"Goodbye!"

"Goodbye."

Family Meeting Rules

1. Turn your cell phone ringer off, or at least set it to vibrate.  Or just answer on the first ring.  If you speak softly, no one will notice.

2. Set the tone right away, by repeatedly looking at your watch and acting like you have somewhere else to be.  Talk fast.  Keep things moving.

3. Always book a room that's already occupied with something either remarkably frivolous or extremely sad.  "Oh, yes, we'll start the family meeting about end-of-life care for your mother just as soon as these residents finish up their planning meeting for next week's costume party.  The intern about to talk to you about DNR status will be dressing like a sexy cat."

4. Please don't make eye contact.  Someone might think you're listening.

5. Make sure at least three people are on speakerphone.  Doesn't matter who they are.  Makes everything a lot clearer.

6. Do not call the patient by the correct name, ever.  The less you seem like you know, the fewer questions anyone will ask.

7. Never reveal your name and title.  "I'm one of the people on the team" is as specific as you should ever be about your role in the patient's care.

8. Small talk always makes a grieving family feel better, so be sure to interrupt their crying with questions about the weather.

9. Just like with fortune cookies, medical news is always more fun to deliver if you add the words "in bed" to the end of every sentence.  Usually it's accurate, too!  "He's having trouble sitting up... in bed.  We took his blood... in bed.  He's doing as much physical therapy as the hospital is able to provide... in bed."

10. Use medical jargon whenever possible.  "His creatinine is elevated," repeated over and over again is much more effective than just saying he's in kidney failure.

11. Contradict the other doctors.  You always want to seem like you're discussing the patient for the first time, now, in front of his family, and that none of you agree on the same plan.

12. Use words like "death" and "dying," whether or not they apply to this particular patient at this particular point in time.  After all, everyone will die eventually.

13. "How quickly will he be ready for discharge?  That depends on how much you're looking to donate to the hospital.  Cash only."

14. Doctors are too important for follow-up.  "A medication list?  That's the social worker's job.  Checking his labs again... uh, let's say that's also the social worker's job.  She'll also be performing CPR if his heart stops."

15. End abruptly, and without warning.  In the middle of a question, if possible.  Run out of the room.  Hide in a closet.  Never be seen again.  Feign ignorance that this meeting ever happened, and accuse anyone who insists otherwise of being crazy, especially the patient himself.  "We talked about you?  Nope, no one ever talked about you.  You're hearing things.  More Haldol, stat!"

Follow these rules and your family meeting will go, uh, about as well as most of them do.

"Your office broke my wheelchair!"

I get a phone call--

"Yes, my husband had an appointment in the clinic earlier this week, and you were his doctor..."

"Sure, is everything okay?"

"No, everything is not okay.  Your office broke my husband's wheelchair."

"I'm sorry, what happened?"

"Your office broke his wheelchair.  You owe him a new wheelchair and I was wondering where I can send the bill."

"Uh, I'm not sure I'm the right person for you to talk to.  I can give you the main number and you can ask for, uh, the clinic manager, I suppose."

"No, I'm not going to talk to a secretary who has no power to do anything.  I know how things work.  Only the doctors have any power."

"I'm sorry-- I really don't have power.  I'm just a fellow, and I'm only at the clinic one day a week.  I have nothing to do with billing or reimbursement or anything like that."

"That's what you all say, but I know how it really works."

"I really have to get back to my patients.  You should call the main number and talk to the office manager."

"Do not hang up on me.  You were his doctor.  This is your fault."

"I'm sorry you feel that way.  But I can really only deal with medical issues.  You need to call--"

"You're not even going to ask what happened with the wheelchair?"

"I really can't--"

"We were leaving your office, and as we were folding the wheelchair up to get into the taxi cab, the leg support completely broke off, and now we can't even use it."

[silence]

"Doctor, are you still there?"

"Yes.  I can still only tell you to call the office manager, but from what you're saying, it sounds like it wasn't anything that happened in the clinic itself, but what happened with the taxi cab."

"My husband would not have been getting into that taxi if not for his appointment with YOUR OFFICE."

"I suppose that is true."

"See?"

"I'm going to need you to call the office manager.  But here's what you can do.  Tell her that if she has any questions about what happened, she can ask me, and I can tell her exactly what you just told me."

"Okay, thank you, doctor."

"You're welcome.  Have a good day."

Rock Star

There's one doctor at my hospital who might be seen as a rock star within medicine.  No one outside of medicine has any reason to have ever heard of him, but at least within the hospital, he is indisputably the most famous person we have.

He's on the wards for a week every year.  I don't know if it's part of his contract, or he likes to pretend he still sees patients, or what the deal is, but 51 weeks a year, he's giving talks or writing books or traveling around the world or whatever else he does, and one week a year, he's actually being a doctor.

Somehow, I won the lottery and I'm the fellow assigned to the ward he's on last week.  At first, super excited, since any face time with this guy is surely a good thing, right?

And then he asked me to go in and close the shades in the patient's room before he walked in, because he preferred to deliver bad news in dim light.  "The aesthetics are better."

Okay...

"And when you're rounding in the morning, give the patients a heads-up that I'll be their doctor this week.  I want to give them a chance to get used to the idea, so they're not distracted when I come in."

"I don't think the patients necessarily know who you are."

"Don't be stupid, of course they do."

Okay...

Is it bad that I spent all week hoping he would make a terrible mistake?  Not that I wanted anything bad to happen to a patient, but just something a little bad, to make him realize that maybe it wasn't just about him.

"I want to draw that patient's blood.  I think it looks better if I do it."

"Phlebotomy is right outside, I can just get them."

"No, I want it to seem like I really care."

"I can get phlebotomy, it's fine."

"No, I'm going to draw her blood."

Seven (painful) sticks later, we got phlebotomy.

"She has bad veins."

"Maybe you're just out of practice."

"I don't think so.  And, like we talked about, I'd really like you to get in right at 5 tomorrow.  I don't know when interns became so lazy."

"I'm a fellow.  And I've been trying to get in as early as I can, but if you're not getting here until 9:30, I'm not sure why I need to be in at 5..."

"I just want everything to be ready, so I'm not wasting my time."

"It's only been taking me 45 minutes to pre-round..."

"But I want everything perfect.  It shouldn't be my job to have to wake up a sleeping patient."

"Sometimes they fall asleep."

"Well, if they're asleep, they're not ready for me to see them."

His knowledge is actually great, which is the most frustrating part.  He knows what he's doing, he's up to date despite not actually practicing, he somehow makes the patients feel like he cares, and he remembers everything anyone says to him.

It's just hard to appreciate that when he changes his white coat every time a patient even breathes near it, and he's ducking out of a rapid response to take a call from a magazine writing an article about best vacation spots for doctors, or whatever it is he spent twenty minutes being interviewed about while he was supposed to be running a code on a patient six feet away.

Is it that I'm jealous, or is it that we worked together for a week and then I passed him in the hall this morning-- he's giving a talk to the medical students on how to eat a healthy lunch, or something else super-critical to patient care-- and he didn't even recognize me?

Oh well...

"It's too bad he's not demented. He'd get so many more services."

Phone rings--

"I'm calling from [False Superlative] Home Care Agency about your patient, Mr. Homebound.  We're trying to arrange the appropriate services."

"Great, I'm happy to send you over whatever records you need."

"We had a few questions.  Is he able to walk at all?  We were told he's able to take a few steps."

"No, he has not been able to walk ever since they had to amputate his leg below the knee."

"Oh, the amputation wasn't mentioned by the patient.  It just says here he had surgery for an infection in that leg and that it was removed."

"Yes, it was removed.  Amputated."

"Oh, we were under the impression that the infection was removed, not the leg."

"Okay, glad I could correct you."

"Also, is the patient able to answer questions?"

"What do you mean?"

"How is his mental functioning?"

"He's fine.  He's physically limited, but mentally he's fine."

"You're sure.  No dementia at all?"

"No, no dementia."

"Not even a little?"

"No."

"That's really too bad.  He would qualify for so many more services if he was demented.  It's really a shame he isn't demented."

"I don't imagine his family feels that way."

"No, they want as many services as he can qualify for.  And he would get more if you were able to say he was demented, even a little bit.  So, if you don't mind, I'll ask you again.  Is he demented?"

"No."

"Maybe a little forgetful?  Could we say forgetful?"

"No. What did you say the name of your agency was?"

"[False Superlative] Home Care Agency."

"And your name specifically?"

"Oh, I'd rather not give that out.  If we can just continue.  I'm going to write down that you're not sure about his mental status."

"No, I am sure.  I saw him three days ago as an inpatient, and he is not suffering from dementia."

"I'll have someone do an evaluation."

"I'm just going to have the assistant here fax you the records, okay?"

"Well, I was also hoping you could call in a few prescriptions for supplies."

"What supplies does he need?"

"Gauze.  Tape.  Oxycodone."

"Mr. Homebound is not on oxycodone."

"But in case he needs it for the pain."

"Nope.  I'm faxing you the records. Goodbye."

"Please leave a message..."

I call a patient and get her answering machine:

"You have reached [name].  You can leave a message but you must speak very loud and very slow.  I do not hear well, so you need to talk very clear.  You can spell things, but I do not spell well, so I may not understand.  You should also call back when I am here, since sometimes I forget to check the machine.  If this is my daughter, I can't hear you when you call from the car.  Everyone should wait for the machine to do a beep.  Thank you for calling."

I left a message, but I guess I'll probably try her again tomorrow.

Emergency, or not?

We're on call for our own clinic patients overnight during the week. So if one of my patients calls the answering service at 2 AM and says it's an emergency, I get paged, woken up, and call them back. This is an unfortunate but necessary hazard of the job in cases of actual emergency and a terribly frustrating driver toward my own personal insanity in cases of obvious non-emergency. It is often terribly difficult to get back to sleep after you are paged, and terribly difficult to get patients to understand you are a human being who they are actually waking up if they call at 2 AM and claim emergency.

I get that sometimes it is difficult to distinguish a 2 AM emergency from a non-emergency.

But if your emergency involves the need for a medication refill, it is not an emergency.

If your emergency involves a question about your recent lab results, it is not an emergency.

If your emergency involves a desperate need to reschedule your next appointment, it is not an emergency.

If your emergency involves a pain you have had for a period of time you are describing as some number of weeks, it is not an emergency.

If your emergency involves your son, your daughter, your aunt, your friend, your dog, or anyone else who I've never met before and isn't my patient, it may well be an emergency, but for purposes of calling my answering service and telling them to wake me up at 2 AM, it is not an emergency.

If your emergency involves any type of question that begins with the word "Hypothetically," it is not an emergency.

If your emergency is only an emergency because you are worried you are going to forget your question if you wait until the morning, it is not an emergency.

If your emergency is a complaint about someone you dealt with, either in the clinic, another medical facility, or your local supermarket, it is not an emergency.

If your emergency involves the dream you just woke up from, it is not an emergency.

If your emergency is about the same thing I have already told you fifteen times is not an emergency, it is not an emergency.

If you are going to forget your question in the time it takes for the answering service to page me and for me to answer the page, please, it is not an emergency.

And, finally, if your emergency is about having missed the confirmation call about tomorrow's appointment and wanting to make sure I know you will coming to see me, no matter how good your intentions are, at 2 AM, I assure you, it is not an emergency.

Hurricane.

I've been exchanging e-mails this past week with a few friends in New York, doing their residencies over there. And it seems beyond crazy. You think that-- despite the hours and the stress-- at least your job as a resident is secure. Barring something truly awful, you don't lose your job as a resident. And then your hospital floods. And it closes for weeks. And you... might still get paid.

Maybe not. Who knows. I know people who were at NYU, carrying patients down dark stairwells after the power went out, trying to keep track of patients without access to their (computerized) patient records, without monitors, without CT scans or x-rays, without anything. Patients with life-threatening conditions barely getting care. None of us are trained for third-world medicine. We barely know how to take blood pressure without a machine. Scary over there. Seriously scary.

"I Was Hoping A Doctor Would Come See Me Today."

I'm on call this weekend, and had to go in and round on the patients in the morning.  I met one woman yesterday, 90 years old and very pleasant.  We had a very nice chat about how she was feeling, I did a physical exam, checked her recent labs, and wrote a note.  She thanked me for coming to see her and said that my visit made her day.  I finished rounds around lunchtime and felt pretty good about myself.

An hour later, the pager buzzes.  I call back.

"[Patient] is complaining that a doctor hasn't seen her yet.  She said she's been waiting all day for a doctor, is very upset that no one has examined her.  Wanted to speak to whoever was on call."

"Uh, yeah, I saw her today.  We had a very pleasant conversation.  She's stable, doing okay."

"She says no one saw her."

"I wrote a note.  Though I'll admit, I didn't notice any dementia.  But this was my first time seeing her."

"There's no dementia in her chart."

"Okay, well, I guess that's something to work up during the week."

"And you're sure you saw her?"

"I wrote a note!"

"So?"

"So I don't write notes on patients I don't see!"

"Come on, we all do."

"I saw her.  Tell her I'll see her again tomorrow."


Two hours later the pager buzzes again.  Same number.  I call back.

"[Patient] is insisting no one saw her today."

"Didn't we have this conversation already?"

"Did we?"

"I saw her.  I wrote a note.  We talked about it."

"I'm sorry, I really don't remember."

"Okay, I think we have to work you up for dementia too."

"You're sure you saw the patient?  She's very insistent."

"I wrote a note!"

"So?"


"So I don't write notes on patients I don't see!"

"Come on, we all do."

"I saw her.  Tell her I'll see her again tomorrow."

"What's the point?"

I'm testing a new patient for dementia.  Her family says they think she may be depressed.

"Can you count backwards from a hundred, by sevens?"

"100, 93, 86, whatever, who cares what's next...."

"Do you know who the President is?"

"Does it matter who the President is?  They all do the same garbage."

"Do you know the year?"

"One year later than last year.  Ugh."

"Can you write a sentence on this piece of paper?  Any sentence you want."

Writes: "What's the point?"

"Do you think you may be depressed?"

"No.  Who told you that?  My daughter?  She stinks.  My fault, of course."

Thoughts From The Depression

I am with a new 96-year-old patient:

"Where are we?"

"A bank."

"What year is it?"

"1929."

"Yeah?"

"Yeah."

"How's the economy?"

"Oh, you know.  Not so good."

"What are you doing here?"

"The normal things you do in a bank."

"And what are those?"

"You know.  Taking out money."

"Do you have a lot of money in the bank?"

"Not as much as I used to."

"What if I told you this was a hospital?"

"Well, I wouldn't be surprised.  Banks have to do all sorts of things to make money these days."

When Doctors Forget How To Use Computers...

I sit down at the computer at the nurse's station to write a few notes.  A bunch of windows are open on the screen.  I open a new window and log in to check my work e-mail.  I click back to the notes system while the e-mail is loading.  I start to write a patient note.  I go back to the e-mail and I see a couple of unread messages.  The first is from a family member of a patient whose name I definitely don't recognize.

"I had a question about my father's medication..."

Confused, I write back a short note.  "I think you may have sent this to the wrong address."  I push send and go back to the notes system.

I finish the note, and click back to the web browser.  That's strange-- the other unread messages don't seem to be there, and the one I just read and replied to isn't there either.

I notice there are two browser windows open.  I click on the other one, starting to panic.

It's another doctor's e-mail window... and the system has just logged me out automatically.  I see the login name and I realize what's happened.  An attending-- an attending I've never met-- forgot to log out of her e-mail.  I read a message from one of her patients... and answered it.  And now I'm logged out and can't even correct the mistake, or remember the name of the patient.

The right thing to do, I suppose, is to e-mail that doctor and try to explain what happened.  "We haven't met, but I'm a new fellow.  I didn't notice that you were still logged into your e-mail at the nurse's station, thought it was my e-mail, and accidentally read a message from a patient family, though I can't recall which one, with a question about medication, and wrote back that I thought the e-mail may have been sent to the wrong address. And by the time I realized my mistake, the system had logged you out.  Also, I'm not usually this incompetent."

Alternatively, I can quietly pretend this never happened.  The family will probably resend the e-mail, or call the office.  The doctor may notice a strange sent e-mail, or maybe she won't.  She may be confused.

It would be so easy to pretend this never happened.  I'm untraceable.  I don't know how to send that e-mail to the attending I don't know without seeming like a crazy person.  I read her e-mail?  I replied to one of her patients?  It's not like I said something so crazy.  It's not like it was an emergency.  It's not like I deleted the e-mail.  It would be so much easier to pretend this never happened.  I really don't want to send that e-mail.  I really don't want to send that e-mail.

Doctors have to make hard choices sometimes.

"You Stole My iPhone"

"Hey, [Mr. Hospital Patient], the nurse paged me and said you needed to talk urgently?"

"Yeah.  You lost my glasses and my iPhone."

"I never had your glasses or your iPhone.  What happened?"

"I went for an x-ray, and the nurse said she was putting my glasses and my iPhone in my bag and locking them up.  I came back and they unlocked the bag-- and they're missing."

"Wow, I'm sorry.  But I'm not sure I'm the right person to talk to.  You should ask the nurse who locked them up.  Maybe they're in another bag."

"That nurse is at lunch.  This other nurse said there's nothing else locked up.  So I think that nurse stole them."

"I'm not sure why anyone would want to steal your glasses.  And I'm sure if a nurse said she was locking up your iPhone, she wouldn't steal it."

"Well, you owe me a new iPhone."

"Let's try and talk to the nurse first and find out what happened.  Can I see the bag?"

"Why?  So you can steal something else?  My dentures are in there."

"Okay, I don't want your dentures.  I just want to make sure nothing's hiding at the bottom of the bag."

"You think I'm crazy?  Of course I looked through the whole bag before I told them to page you.  I didn't want to waste your time."

"But let's just make sure.  Since you pulled me out of rounds anyway, I may as well be thorough with the search."

"They're not in there."

"Okay, but let's just make sure."

[He hands me the bag.  I feel the bag for a moment.  I find a side pocket, unzip the zipper, and pull out his glasses and his phone... which is not an iPhone.]

"I think I found your glasses... and this cell phone.  Although it's not an iPhone...."

"Uh, yeah, that's my phone."

"You said you had an iPhone."

"I just figured if you guys were going to get me a new phone anyway, I may as well get an iPhone."

"Okay, I'm going to go back to rounds now.  I'll check in on you tomorrow."

Percent Chance

"Last week, the surgeon said it was probably 50/50 that my mother would lose her leg.  I wanted to know what the chances are now."

"I'd defer to the surgeon, but I think they're about the same."

"So, like 55/45?"

"I don't know.  It's about the same as it was."

"About the same, or exactly the same?"

"I don't know.  I'd defer to the surgeon."

"But I want to know if it's more like 55/45, or 45/55."

"I don't think we can quantify these things exactly.  We don't know how she's going to respond to the antibiotics."

"But if you were betting on it, which side--"

"I'm not betting on it.  This isn't a racetrack.  We're trying to make the best possible decisions for your mother's health."

"But should I be telling the rest of the family that she probably will lose her leg, or she probably won't?"

"I don't know.  You can tell them you don't know.  You can tell them the doctors do not know yet."

"I want to give them a more specific answer than that."

"I don't have a more specific answer for you."

"Can you ask the surgeon if his odds have changed?"

"You can call the surgeon's office and ask for him to call you back."

"And what are the odds he'll call me back today?  Are they 50/50, or more like 80/20?"

"I don't know."

Ethical Dilemma of the Week

"Hi, I think my brother-in-law, [Patient], told you I'd be calling."

"Yes, he said you were a doctor and wanted to discuss his condition."

"Yeah, I want to know if we're at the end yet."

"Excuse me?"

"I want to know how close we are to the end."

"Um, your brother-in-law is not in great shape, that's absolutely correct.  But I don't believe he is actively dying.  We're having him come in for surgery next week, and while I don't think he's going to be playing golf anytime soon, with rehab and probably a wheelchair at least for the short term, I think he'll be okay."

"I don't think my sister is capable of taking care of him."

"She seems to be doing okay, from what I've seen."

"Well, what I want to know is whether it's time for her to just leave him in the emergency room and let the state take care of him."

"I'm sorry, what?"

"You know, they're not legally married.  So I told her, she has no legal responsibility for him.  If she gets tired of dealing with him, I told her she can just drop him off at the hospital and never come back."

"She seems to be doing okay.  I'm sure they'd love the situation to be better, but we're hopeful he can have some kind of recovery and even if it's a limited quality of life, mentally he's okay, and whether or not they're married, she doesn't seem like she would want to just leave him to die on his own."

"I know, and I'm trying to convince her otherwise.  I was hoping you might be able to talk some sense into her."

"Wait, you want me to convince her to leave him in the ER and walk away?"

"Yes, exactly.  I appreciate it, thanks."

"No, I don't think that's the best option given his situation."

"For him or for her?"

"For either of them!"

"You know you'd still get paid by insurance, right?"

"Why am I in pain? My surgery was LAPAROSCOPIC!"

Patient calls me.  "Doc, I'm feeling really terrible today.  In so much pain.  Couldn't go to work.  Really feeling awful."

"Okay, one second, let me take a look at your chart..."

"Sure, sure.  Really, I'm just totally wiped out."

"Have you taken your temperature?"

"Yeah, it's normal."

"Okay, I'm looking at your chart.  Uh, you had your gall bladder removed yesterday?"

"Yeah."

"Were you feeling like this before the surgery?"

"No, no, I was feeling okay."

"Yeah, you're feeling like this because you had surgery yesterday."

"No, doc.  It was laparoscopic."

"Okay..."

"The surgeon said it would be nothing.  He didn't say anything about pain."

"Even laparoscopic surgery is surgery.  You had the procedure yesterday.  It's normal to be feeling terrible.  Have you been taking the pain medication?"

"No, I don't like to take stuff like that."

"Then it's not surprising you have pain!"

"I think he botched the surgery.  It was laparoscopic.  I'm supposed to be fine."

"You had the surgery yesterday.  This pain is normal."

"If this is normal, I'll tell you one thing-- I'm never having my gall bladder removed again."

"That's right, you're not."

"Okay, write that down in my chart."

"Uh... okay...."

"You know, the ambulance service."

My pager buzzes.  I call back.

"This is Dr. [Me].  I'm covering this weekend for your doctor.  I got a message that you called."

"Yes, I'm calling about my husband.  I need you to send an ambulance for him."

"Okay, if your husband needs an ambulance, you need to call 911.  I'm the doctor on call, I can't dispatch an ambulance."

"No, if I call 911, they're going to take him to [Local, Terrible Hospital].  I want him to go [My Slightly Less Local, Slightly Less Terrible Hospital]."

"Can you drive him, or call a taxi?"

"Oh, he can't get into a car!  He's barely even breathing!"

"Um, you need to call 911 if this is an emergency."

"No."

"No, you really do need to call 911 if this is an emergency.  I want you to hang up with me and call 911.  Then you can call back if you still need to ask me any questions."

"No, it's not an emergency.  He's been barely breathing for weeks.  I just think it's getting slower now and I want him to be seen.  And not at [Local, Terrible Hospital], because my aunt died there."

"I'm sorry."

"Oh, it was thirty years ago."

"Okay.  What is your husband's name?  Let me quickly look him up in the computer."

"[Name.]  With a [silent letter]."

"Can you spell that?"

"You need me to do everything?  You're the doctor!"

"Please, ma'am, just spell your husband's name for me so I can look him up in the computer."

"[Name]."

"Okay.  Your husband is on the hospice service.  You should call the hospice nurse.  Do you have that phone number?"

"All the hospice nurse does is give him painkillers!"

"Yes, they're trying to make him comfortable."

"I need you to send an ambulance to get him to your hospital.  That is why I called.  You are not being helpful."

"I am trying to be helpful, but this is not an ambulance dispatch service.  Your husband is on hospice.  You need to either call the hospice nurse, or you can call 911.  But, looking at your husband's chart, I'm not sure it makes sense for him to go to the hospital.  The last note from your doctor seems to indicate the goals of care are to make him comfortable."

"He's not comfortable."

"Yes, you should call the hospice nurse."

"I want an ambulance here in 15 minutes."

"Okay, I am going to see if I can get a social worker to call you back, and you can discuss your case with him or her.  I think a social worker may be able to provide more help, since I don't know your husband, and, even if you want to get him here, I'm not sure how to arrange private ambulance services."

"Not private ambulance.  I'm not paying for an ambulance.  You need to send one!"

"Do you know how to check your husband's vital signs?"

"No, I'm not the doctor!  You tell me his vital signs."

"I'm not there.  I can't check his vital signs.  Look, I want to help, but the best way I can is to have you call 911, or the hospice nurse, or let me find a social worker to get in touch with you."

"Well, don't have the social worker call between 12 and 2, because I'll be out at lunch and my husband can't answer the phone."

While I have you on the phone... do I need to put my father in a nursing home?

...so the biggest difference so far between residency and fellowship is that I have actual patients, I am their doctor, and I'm seeing for the first time what it means to be accessible to patients and able to be reached whenever they have a question.  I call back a woman who called the answering service and said she had a medication question regarding her father.

"Hi, doctor.  I don't mean to take up your time, but I was just wondering... I got my father's pills confused and I'm not sure which is the pink one and which is the white one.  I was hoping you could tell me."

"Oh.  That's really a better question for the pharmacist who dispensed the medication.  I don't actually know what the pills look like.  But if you call the pharmacist, he should have your records and be able to look at the actual pills and tell you which is which."

"The pink ones are bigger."

"Okay, that's great.  But I don't know what the pills look like.  So you'll need to call the pharmacist.  If the pharmacist needs to get in touch with me, or you have trouble reaching him, you can give me a call back."

"Great.  Oh, just one more quick thing while I have you on the phone."

"Sure."

"Do I need to put my father in a nursing home?"

"What?"

"Well, I don't imagine his situation is going to get much better, and I'm having a rough time taking care of him."

"This is definitely a discussion you should have with the social worker you and your mother met with in the hospital-- there might be some services your father can qualify for.  Or she may have some other ideas."

"No, but, just generally, is my father the kind of person who should be in a nursing home?"

"This might be a longer discussion than we should have on the phone right now--"

"No, I have time."

"Yes, but I think this should be something we look at over time, and we can talk at your father's next appointment about what services he might need, and what the best situation might be for him, now and in the future."

"Do you have any nursing home recommendations?"

"I don't, but the social worker would be the best person for you to talk to about this.  You have her card, right?"

"Yes, could you transfer me to her?"

"I'm not in the hospital right now-- I'm calling you back from home.  So if you call the number on the card, you should be able to reach her."

"I don't have the card in front of me right now-- it's in my purse downstairs.  Could you give me the number again?"

"I actually don't have the number-- I'm at home.  If you can't find the card, call again tomorrow during business hours and I can get that to you."

"I can't call during business hours.  I'm at work."

"Okay, that's fine.  I will call you tomorrow with that number."

"You can't just tell me now?"

"I don't have the number right now."

"And you can't transfer me?"

"I'm sorry, I'm not in the hospital right now."

"Wait, one more thing-- are you sure you don't know which is the pink pill and which is the white one?  I'd hate to bother the pharmacist."

"Urgent Question For Doctor"

I got an urgent page from a patient.  I call back the first chance I have, about ten minutes after I get the message.

"I got the message you called-- I'm sorry it took a few minutes."

"That's okay.  I have an urgent question."

"Okay, what's going on?"

"I wanted to know how Medicare will be affected if Obama becomes President."

"That's your urgent question."

"Yes."

"For your doctor to answer."

"Yes."

"Obama is already the President."

"Oh.  Is he?  The election already happened?"

"No, he got elected in the previous election."

"Oh.  And how is my Medicare doing?"

"It's okay."

"Is something going to change?"

"No.  Are you feeling okay?"

"For now."

"Are you taking all of your medication?"

"Yes.  When I remember."

"Are you still living alone."

"Yes."

"I'm going to give your daughter a call, is that okay?"

"Yes."

"For now on, only tell the answering service your message is urgent if it is a medical question.  I'm not the right person to answer questions about your health insurance, okay?"

"Okay."

"I'll see you at your next appointment."

Irregular periods and premature ejacularies.

"I don't think the medicine you prescribed last time is agreeing with me."

"No?  What have you been feeling?"

"Well, I've been dizzy and lightheaded and haven't had much of an appetite."

"Okay, those are all potential side effects."

"I've also been having headaches and irregular periods."

"You've had something that seemed like a menstrual period?"

"If that's what I said."

"You're 77 years old.  You were having bleeding?"

"Bleeding?  No.  Dizzy, lightheaded, loss of appetite, headaches--"

"You're just reading off the list of side effects.  I have that list too.  Are you actually experiencing these things or you just don't want to take the medication?"

"No, I've had headaches, irregular periods, premature ejacularies, dry mouth--"

"I'm sorry, premature what?"

"Ejacularies.  I think that's what they're called."

"You're a 77-year-old woman.  And you're telling me you're having premature ejaculation?"

"I don't know.  Whatever I said."

"You don't want to take this drug."

"No.  I don't need it."

"So you're telling me you're having all of the listed side effects."

"Yes."

"Why don't you want to take this drug?"

"It's expensive!"

"Oh.  Do you want me to prescribe you a similar drug, that has a generic alternative?"

"Okay."

"Great.  Do let me know if you're actually having either a menstrual period or some sort of ejaculation, because then we may have to call the record books."

"Okay, thanks."

"Nope, you should actually take your pills EVERY day."

"Your blood pressure's really high.  Are you sure you're taking your medicine?"

"Yep.  Every time I feel it acting up, I take a pill."

"Every time you feel what acting up?"

"My blood pressure."

"And what does that feel like?"

"You know, like a sensation in my blood vessels."

"What kind of sensation?"

"Like a pressure, sort of."

"Okay, that's not good.  You realize you're supposed to take the pills every day, right?  We talked about that last time."

"Yeah, yeah, that's what you said, but I don't want to overmedicate.  So I just take it when I feel something.  Otherwise I don't need it."

"No, you do."

"I don't like taking something every day."

"Yeah, but you need it."

"I just want something that can treat the problem when I have it.  Like Tylenol, or vitamins."

"Vitamins?"

"Yeah, when I eat something unhealthy, I take a vitamin afterwards, to balance it out."

"That's not how nutrition works."

"No, it works for me."

"No, it doesn't."

"I just don't like the way medicine feels.  I don't want to take too much."

"This is a very low dose."

"Can I cut the pills in half?"

"No, it's a very low dose."

"I'm going to cut the pills in half."

"If you're going to do that, I'll give you a larger dose."

"Oh, you can give me a larger dose and I can just cut them in half?"

"Uh, I guess.  If that means you'll take them.  Sure."

"Great.  I mean, I'm not going to take it every day, but I'll take it more if it's only half."

"He's an organ donor-- so where should we drop off the organs?"

I get paged by the son of one of my patients early this morning, a 94-year-old man in declining health, on hospice.  I call back--

"I wanted to let you know-- my father passed away during the night.  His aide woke up and checked on him, and he had stopped breathing."

"I'm so sorry."

"Thanks.  We haven't called the funeral home yet, because I wanted to find out-- I know he was an organ donor.  So I was wondering how we handle that process."

"Um, you should go ahead and call the funeral home, it's okay."

"No, he really wanted to help others who could use his organs."

"That's a very noble thing, and it's great that he made those wishes clear.  I wish more people would do that. Unfortunately, we can't use organs once the patient has been dead for any amount of time-- organs lose their function very quickly, so harvesting normally happens when the patient is brain dead but blood is still circulating.  So it's not practical to harvest organs from home, it's really when people die in a hospital setting."

"So if we removed the organs ourselves--"

"No, no--"

"No, I'm not saying we did that.  I'm just asking if we should."

"No, no, definitely not--"

"But you're saying we should have brought him in as soon as he died--"

"No, no, I think your father is very lucky he died at home, in his sleep, peacefully."

"But if he had died in the hospital, you could have used his organs?"

"Honestly-- and fortunately for your father, since he lived a long life-- he was past the age where we are able to use the organs.  I'm not an expert in this area, but it's not generally practical to transplant organs from people over age 50 or 60.  The organs tend not to be in good enough condition for transplant, even if they're still working quite well in their original owner."

"So I just want to be sure-- you do not want any of his organs.  We should not do anything, or bring anything to the hospital."

"No, but it's a lovely gesture.  Please give the rest of your family my deepest condolences."

"Oh, I also wanted to know if we needed to schedule an autopsy--"

I Want The Extra Strong Multivitamins

"...I also need a prescription for the extra strong multivitamins."

"Excuse me-- the what?"

"The extra strong multivitamins.  Not the ones you get over the counter.  The prescription strength."

"I'm sorry, sir-- I'm not aware of any such thing.  If you want a vitamin, just buy one over the counter."

"Don't even pretend to tell me the over the counter ones are as good as the real thing."

"Those are the real thing."

"I'm willing to pay-- up to $150 a month for the good vitamins."

"Vitamins should not cost you that much."

"The pharmacist was giving me the good ones, for $150 a month.  I just need a new prescription."

"Wait, the pharmacist was selling you some kind of vitamin for $150 a month?"

"Yeah-- they were helping, too.  I don't want to have to go back to the regular kind."

"Sir, your pharmacist is either a drug dealer or a scam artist.  He's stealing your money.  I don't know what he's selling you, but if it's vitamins, he is ripping you off."

"No, not my pharmacist.  Stop giving me the run-around."

"I'm not.  What's the phone number of your pharmacy?  I'll give them a call."

-----

"Hi, I'm Dr. __________, calling about a patient of mine, Mr. ___________.  He's asking me for some kind of prescription, telling me you're selling him vitamins for $150/month.  What are you selling him?"

"What do you mean?"

"What are you charging him $150/month for?  I know what vitamins cost."

"No, I don't think you understand how many vitamins he's buying."

"How many vitamins is he buying?"

"150 dollars worth."

"So, hundreds and hundreds of vitamins every month."

"Yes.  I get them from the back.  He doesn't like the ones on the shelf.  Same kind, I just get the bottles from the back room."

"So he's crazy."

"Yes.  Just write him some bogus prescription and I'll take care of it."

"I don't want him wasting his money."

"Well, I'm not just going to give him the vitamins for free."

-----

"Okay, I'm going to write you a prescription, but these are really strong, and you can only take 1 a day, okay?"

"Wow, they must be good."

"Yep.  And, even better, a hundred of them should only cost you like ten bucks.  If they cost more, tell the pharmacist to give me a call and I'll give him the information about the discount code.  Don't let him charge you $150.  You get my special $10 rate."

"Oh, great.  Thanks, doc."

"Sure."

"I used to be a little boy too!"

I go in to see my new 101-year-old patient.

"You're my doctor?  You look like a little boy!"

"I'm older than you think."

"No, you're a little boy."

"I used to be a little boy."

"Yeah?  So did I!"

Boards II

I guess no one was interested in my fake boards question.
And now that the boards are over, I'm not interested either.

Are there any universally-liked doctors?  Is anyone able to seem competent and pleasant to all of their patients, and not just some of them?  I would hope there could be, but I have yet to have any proof.  For everyone who tells me they miss the previous fellow, or they love the attending who's been dealing with them (and don't know why now they have to see inexperienced me, who takes twice as long and doesn't know about that terrible medical problem they had in the past that isn't in the chart), I get someone else who thinks their previous doctor in the clinic was terrible and wants me to agree.

"I never even met Dr. Johnson-- she graduated from fellowship right as I was starting."

"Well, she was terrible.  Never seemed to have any appointments available."

"That's not her fault.  We're only in clinic a couple of days a week."

"And her name wasn't on her white coat."

"Again, not her fault.  They don't give us coats with our names on them."

"And she wouldn't give me her cell phone number."

"I'm not going to give you that either."

"And she smelled funny."

"I never even met her."

"Good for you."

Bored of Boards

All anyone wants to talk about is the internal medicine boards.  I've been dodging a handful of phone calls and text messages from former and current colleagues who I imagine want to wish me luck but I'm afraid in doing so will happen to ask a question I don't know the answer to and make me freak out about which of the  two dozen heart murmurs we need to know the details of haven't quite stuck.

So many multiple choice questions.

As with everything that has come before, you end up building up such an anticipation about how much life will be when this test is done / when this rotation is done / when this year is done... but then you get to the end and, too quickly, there's a new next badness to replace the one you've completed.

Patient comes in with nausea, vomiting, nystagmus, ipsilateral Horner syndrome, ipsilateral palate and vocal cord weakness, and "crossed" sensory loss.  You correctly identify that he is suffering from lateral medullary syndrome, but before you can tell him, you instantly become unresponsive, apneic, and have no pupillary function.  Is an EEG required for your diagnosis of brain death, what kind of stroke caused the problem with your patient, and whose responsibility will it be to tell him once you have been wheeled to the morgue?

(A) Yes, hemorrhagic, neurology fellow
(B) Yes, vertebral, neurology attending
(C) No, hemorrhagic, resident called in to replace you
(D) No, vertebral, risk management officer

"You're Female, You're Male... You I'm Not So Sure."

"So, you're having trouble with your eyes."

"I am.  For a long time.  Things are blurry."

"Okay... how blurry?"

"Well, you, you I can tell, you're male.  From your voice, and your short hair.  That one over there is a female.  The one in the corner, maybe a male, maybe a female, I'm not really sure."

"That's a female medical student."

"Oh, good for her.  You sure it's a female?"

"Yes, she's a female."

"And that other one, by the door, that's a male."

"That's a coat rack."

"Yeah, I thought it was a skinny one."

"I think we're going to have you see an ophthalmologist."

"Oh, I saw one of them years ago."

"We're going to have you see one again."

"I don't know if I'll be able to see him.  If he stands close."

"We'll have him stand close."

"Great."

"I assumed I was fine, since no one dragged me, kicking and screaming, into surgery."

"So, I see in your chart that you were supposed to follow up with a gastroenterologist a few months ago, have an MRI, and potentially surgery."

"Yeah."

"But that didn't happen--"

"Yeah, I saw the doctor, he said I needed surgery, but then he never called back to schedule it."

"Did you call to follow up?"

"I called once, but didn't get a call back.  I figured the doctor decided I didn't need the surgery after all."

"Because he didn't call you back?"

"Yeah."

"But you didn't pursue it-- you just assumed that he secretly decided you didn't need surgery, and thought the best plan of action would be not to tell you that."

"When you say it like that..."

"I apologize on behalf of that doctor that he didn't call you back.  Of course he should have called you back. But that doesn't mean you didn't need surgery."

"But he didn't call me back."

"No one's going to make you have surgery."

"Okay, great!"

"No, it's not great!  You're the one in charge of your own health.  Just because a doctor doesn't hound you to do something doesn't mean that if there's a problem, it's going to go away.  You're the one who ultimately is going to deal with the consequences, so it's in your best interest to take ownership and follow up.  I'm not saying the doctor doesn't care if you live or you die, but we have lots of patients, things fall through the cracks-- it's unfortunate, but inevitable.  You have to be your own advocate.  You have to follow up.  Someone tells you that you need surgery, you need to call back and schedule it.  Or at least call back until you get to speak to the doctor and hear him tell you he changed his mind, and explain why.  It is your health."

"But I didn't want the surgery anyway."

"Not even if you need it?"

"No, I want it if I need it."

"No one's going to force you.  That's not what doctors do, or at least not what they do anymore.  You need to take ownership."

"He should have called me back."

"Yes, absolutely.  But your body doesn't care!  If something's wrong with you, it's still a problem even if the doctor doesn't call you back.  Your blood test results are really not good.  There is really something wrong.  And, yes, of course your doctor should call you back, but you have twelve different doctors, and not everyone looks at every test result, and it's frustrating, sure-- but you have to be the one looking out for yourself."

"So what do I do now?"

"I'm going to give you a referral to a different gastroenterologist, and I want you to make an appointment, and go see him, and then we'll go from there."

"Will this one call me back?"

"I don't know.  But it doesn't matter.  If he doesn't call you back, you call him back.  Call him back until his secretary puts him on the phone.  Pretend it's a matter of life or death.  Because it might be!"

"It's his job to call me back."

"It's his job to do surgery.  You'd rather he be good at doing surgery than be good at calling you back, I promise."

"He should still call me back."

"Absolutely.  And I shouldn't be two hours behind on my clinic appointments, but I am.  I will call you in a week.  I will write a note to myself to do that.  But if I don't-- call the clinic next week and ask to speak to me.  It's okay.  You're allowed to do that."

"Someone's Been Urinating On Me."

"Someone's been urinating on me."

"Um, do you think it might be you?"

"No."

"You're wearing diapers."

"I don't know how those got there."

"I think, unfortunately, it's because you're having trouble with your bladder."

"Well, you'd better tell the person who's been urinating on me to stop."

"Okay."

"Thank you."

"You're welcome."


There are days it seems terribly frightening to think about getting old.

"Oh, no, we wanted a full doctor."

"So, I see it's your first time at the clinic."

"Yes.  You're not the doctor, are you?"

"I am."

"Oh.  We came here because we were told there were some very good doctors here, very experienced."

"There are.  I'm new.  I'm one of the fellows."

"Hmmm.  We wanted a full doctor."

"I'm a full doctor.  I'm just relatively new at it.  But I assure you, as a fellow I am consulting with more experienced doctors about your case, and in fact one of those doctors will be in to see you after I finish.  They make sure you're getting the right care."

"We just-- well, we would have kept going where we going if we thought we would get someone who hasn't even finished medical school yet."

"No, I finished medical school.  And residency.  I'm three years out of medical school.  I'm a full doctor.  Licensed and everything."

"You look young."

"I am younger than some of the other doctors here, sure."

"We wanted a doctor with experience."

"I can't force you to be my patient, but I can tell you that with a fellow it's like you get two opinions for the price of one, since I will be consulting with one of the more senior doctors during each of your visits."

"Why can't we just have the more senior doctor and you can watch?"

"That's not how they do it here."

"I think we probably made a mistake to come here."

"I'm sorry you feel that way."

"If we call again, can they assign us to an older doctor?"

"I'm not sure."

"We'll try."

"Good luck."

"You seem nice.  Maybe we'll see you in a few years, once you finish medical school."

"Great.  Thanks."

"Have a nice day.  Can you validate parking?"

"They do that at the front."

"Oh, I thought maybe they have you do that, since you're new."

"Nope."

New Wounds.

"So, like the surgeon talked to you about, you need to be vigilant about the wound where they did your husband's toe amputation in order to avoid further problems.  He could end up with a very real risk of losing his foot."

"Wait, wait, wait-- I thought we just had to watch for new wounds.  I didn't realize this wound counted too."

"Excuse me?"

"I thought the amputation meant that this whole part was over, and that we were just worried about new wounds that could lead to problems, not old ones.  I thought the amputation meant we got to restart fresh."

"Unfortunately, the foot doesn't know if something is an old wound or a new wound.  Any wound can lead to problems, given the blood flow situation.  We're going to have to monitor this very closely and with a great deal of care in order to minimize the chances of future problems."

"No one said there was going to be a wound where the toe was amputated."

"I'm sorry if the surgeon wasn't clear-- but anytime they're doing surgery, they're making a cut, there's always going to be a risk afterwards.  There was a lot of dead tissue there, this is an open wound right now, the dressing has to be changed--"

"All the time?"

"All the time.  Yes.  This is a wound, and we need to try and provide the best possible conditions for it to heal, or else it's going to potentially lead to further problems."

"I just wish someone had told me this wound still counted, because I'm not sure I would have gone along with the amputation."

"Without the amputation, he had an infection that might have killed him."

"Might have.  No one was ever able to tell me for sure."

"Let's just keep this wound clean and try to protect the foot as much as possible."

"Wounds on the other foot don't count, do they?"

"Count for what?  For losing the foot they're not on?  No.  For developing into a life-threatening infection?  Sure."

"Just tell me-- which parts of the body are we allowed not to worry about?  Where is he allowed to have a wound that we don't have to watch?"

"Nowhere."

"Ugh.  Forget it.  We're leaving."

"Almost all of my patients have..."

"Yeah, this month has been really interesting.  Almost all of my patients have had AIDS."

"Wow.  I wouldn't think it would be so common."

"Yeah, it seems like once people reach a certain age-- they all have AIDS."

"So even the older patients?"

"Especially the older patients.  Some of them have had AIDS for years."

"And it doesn't kill them?"

"Keeps a lot of people alive."

"AIDS?"

"Yeah, AIDS.  Although the treatment can really vary.  Some people-- wonderful.  Others are very angry with their AIDS."

"I'd be angry if I had AIDS."

"I'd be more frustrated and disappointed than angry, I think."

"And you're saying that even the elderly can go for years--"

"Definitely.  Years and years with their AIDS, absolutely.  Becomes like part of the family."

"The AIDS?"

"Yes, the AIDS.  You know, most of the time, it's AIDS from overseas."

"They go to a foreign country and get AIDS?"

"No, no, they get the AIDS here. But originally."

"Well, yeah, they say AIDS started in Africa."

"Sure, some of them."

"And sometimes the AIDS-- terrific, really great.  But, you know, sometimes the AIDS just sit around and watch TV all day."

"What?"

"The AIDS watch TV."

"Oh-- wait-- do you mean aides?  Like, home health aides?"

"Of course.  What did you think we were talking about?" 

"Can I have your e-mail address?"

I've had a couple of clinic patients ask for my e-mail address.  I gave it to one of them, whose son is a doctor, and who had an e-mail relationship with the previous fellow in the clinic.  I didn't give it to the other one, partly because the day after I gave the e-mail address to the first patient, she sent me three long e-mails, and I found myself concerned about setting up a situation where I'm receiving e-mails that I don't have time to read and answer promptly.

I'm not sure what to do about it, as a general rule.  There doesn't seem to be a policy, at least not one that I can figure out.  The attending I asked said it's up to me.  Some fellows do it, some don't.  The issue that some doctors in practice have with e-mail is (1) it's not compensated, and (2) liability issues, if you don't reply instantly and something needs to be urgently done about the patient's condition.  I think the biggest issue is time.  There aren't enough hours in the day to have an e-mail relationship with every patient.  And the barriers to someone sending an e-mail feel like they're a lot lower than picking up the phone.  There's an expectation that if you call a doctor, they might not get back to you for a few hours, or until the end of the day.  That expectation doesn't hold with e-mail, even if a doctor may not actually be checking e-mail for hours in the middle of the day.

On the other hand, who wants to tell patients they can't contact you via e-mail, if e-mail is their preferred method.  In other professions, no one would tell a customer they can't send an e-mail if they have a quick question.

It's hard to tell tone over e-mail.  It's hard to ask follow-up questions, since you may end up in a days-long back and forth.  It's hard to give any advice more specific than, "you should come in just to be sure," which isn't advice that requires an e-mail relationship.

I don't want to e-mail with patients, if there's a choice.  There are systems in place to speak to a doctor on call 24 hours a day.  There are other ways to ask questions.  And yet that feels like a bad attitude, or at least an attitude that doesn't reflect the reality of how people communicate.  We can use the Internet without question for so many transactions and relationships-- even many that used to be in person-- grocery shopping, etc.  It can't possibly be the case that in the future people won't be e-mailing with doctors.  So why does it feel like such an imposition?  Why does it feel out of bounds, like a form of communication that is too direct, too easy to abuse, too personal?

We're on the hook for so many hours of the day.  To be able to go home and not be on the hook-- yes, there can be phone calls, and messages through the answering service, but it's different, somehow-- doesn't just feel like a relief but like a necessity.  People's health issues are important, usually require full attention, and can't be effectively dealt with in the same way you scroll through Facebook posts.  You can't half-answer a question and hope it turns out OK.  A patient e-mails saying he's feeling x, y, z symptoms and you can't necessarily just flag the message and say you'll deal with it tomorrow.  I don't want the responsibility of having to be fully engaged 24/7 with every patient.  It sounds bad to say that, but I don't know any other way to express it.

NY Med

I got out of the blogging rhythm this week.  Sorry about that.  Will try and get back into it.  I just watched a show on ABC called NY Med.  I don't know why I want to spend downtime watching exactly what I do all day, but I know someone from med school who knows someone who knows someone who's in it, or something like that, so I figured I would check it out.

This week's episode-- I think it aired on Tuesday-- had the healthiest-looking guy having a liver transplant that I have ever seen.  Do they give the patients makeup?  This guy did not look like a transplant patient.  I don't know if I can watch any more episodes of the show.  It made everything look too easy.  Everyone had a good outcome, nurses seemed like they had brains, no one messed up, it seemed like there were hardly any patients, even the homeless people seemed jolly and harmless.  I don't know if they left all of the terribleness out in editing, or the hospital only agreed to let them air stuff that reflected well on them, but where were the patients lingering on stretchers in the hallway because everyone forgot about them?  Where were the broken computers?  Where were the attendings yelling at residents for no good reason?

I'll probably give it one more episode, since the preview showed that next week, Dr. Oz will get a colonoscopy on camera.  That seems like fun.  I've always wondered what Dr. Oz looked like on the inside.

Sepsis

I just read a frighteningly well-written New York Times article about a 12-year-old boy who died of sepsis despite going to an ER at a reasonably early point in the process. The article raises all sorts of questions about information sharing and what happens to test results.  It's also a reminder of how high the stakes are.  Most jobs people have, for better or worse, are not one inadvertent oversight away from tragedy (and a New York Times article).  No one in the article is being accused of anything sinister, but, unfortunately, it doesn't take doing something actively evil to contribute to a terrible result.  Certainly a compelling, terrifying read.  Gosh.

Work for cheap in a great city.

It's odd how, in terms of doctor pay, medicine seems to work entirely differently from most other professions.  Seems like friends who are lawyers or work for companies or maybe even government work to some degree make a lot more if they work in expensive cities than if they work in the middle of nowhere.  People who work for prestigious law firms in Chicago or San Francisco make a lot more than people who work for small firms in suburban wherever.

But for doctors it's completely flipped.  Want to work in a popular city?  You're going to make perhaps a third of what you'll make if you go to an underserved location elsewhere.  Want to work for a prestigious teaching hospital?  You're going to make a lot less than your colleagues at a non-academic facility.  You make sacrifices as far as income in exchange for what seems like a more exciting atmosphere, more diverse and interesting patients and problems, and a more in-demand place as far as location and reputation.

Not that the salaries even at the lowest end are what people would call low (although servicing the medical school debt makes the net result less high than it seems), but there's a real difference, compounded even further by the differences in cost of living.  Of course, it all seems pretty astronomical compared to the resident/fellow pay scale....

Beep.

"Man, that's a nice beeper," said the guy lurking in the parking garage.

"Uh, yeah.  Thanks."

"Where'd you get that beeper?"

"I'm a doctor.  It's for work."

"Yeah, yeah, but where'd you get it?"

"I got it from the hospital.  They gave it to me."

"The hospital gives out beepers?"

"To the doctors, yeah."

"So if I walk in, and I tell them I'm a doctor-- they'll give me a beeper?"

"No.  They give beepers to the doctors who work there.  So that we can get calls from our patients."

"So they're not just giving them away to everyone?"

"No."

"Is there like a special sale or something, when they give them to whoever comes in?"

"No."

"So I just need to become a doctor, and then I can get one."

"Uh, yeah.  I guess so."

"Cool.  Cool.  You know if the hospital's looking for any new doctors?"

"I don't know.  Sorry."

"Yeah, maybe I'll check it out."

"Great.  Good luck."

"Cool beeper though.  Really cool."

"Thanks."

The Urine Sample.

Clinic patient comes in with a plastic bag.

"I brought you a urine sample."

"What?  In the bag?"

"No."

"Okay, good."

"It's in a glass.  The glass is in the bag."

"A glass?"

"Yeah."

"We give you sterile collection cups when we need to take a urine sample.  Which, incidentally, I have no idea yet-- you may or may not need a urine sample, depending on what's going on with you."

"Well, I brought it just in case."

"We need the collection cups to be sterile.  You can't just use a cup from home."

"No, it's not from home.  It's from a restaurant."

"Uh... still... it needs to be sterile."

"It's sterile.  They said it came from the dishwasher."

"That doesn't mean it's sterile.  Wait... you went into a restaurant and asked for a clean glass for a urine sample?"

"No, of course not.  They wouldn't have just given me a glass.  I took it."

"I would say you should stop by on the way home and give it back, but I'm not sure they'd want it now."

"No-- and they're not open today anyway."

"Wait, what?  When is this urine sample from?"

"I don't know, two, three weeks ago.  I brought it to my last appointment but the other doctor didn't want it."

"You know they're not good forever.  Bacteria gets in.  Bacteria that was already in there grows.  This is not a good urine sample, for so many, so many, so many reasons."

"So you're saying I should bring it home again?"

"No.  I'm saying you should dump it!"

"But it's a nice glass!"

"I Am Right" -- Dealing With Difficult Patients

I AM RIGHT:

DEALING WITH DIFFICULT PATIENTS
*          *          *

A LECTURE FOR RESIDENTS AND FELLOWS

BY AN ATTENDING WHO NEEDS A SMACK IN THE HEAD

*          *          *

I am right.  See, before you’ve even asked me a question, I’m already telling you I know the answer.  Say it with me.  I am right.  Make it your mantra.  You can’t be afraid.  All we have is our authority, and as soon as we start letting any doubt creep into our patients’ minds, we’ve lost our power completely.  This is what separates us from WebMD.  This is what keeps us in business.  This is what their insurance companies are paying for.  Confidence.  Decisiveness.  Answers.  I am right.  I am always right.  I am right, I am busy, and I don’t have time for you.

That last bit is especially important.  Patients are expecting more and more from us.  24-hour access.  Calls back when they leave a message.  An answering service that actually answers.  E-mails.  Web chats.  Doctors on demand.  They’re starting to forget how the system has always worked, and who holds all the cards in the doctor-patient relationship.

Be upfront.  “I don’t have time to hold your hand and walk you through it.”  Leave them wanting more.  It's an old theater trick.  Whether they’re asking about their prognosis, or they’re asking where the bathroom is.  You are the one with the information.  You are the one with the power.  Yield it only when you have to, and tell them only enough to get them to the door.  You tell them too much, and they get greedy and want more.  And pretty soon you’re spending your whole day explaining the pros and cons of eight different kinds of birth control when really you should just be sterilizing any patient who dares even ask you a question.

They want second opinions, let them try.  But don’t make it easy.  “You can look for other answers, but you’ll only be wasting your time.  There are people out there who will tell you anything.  There are always going to be people who will prey on your vulnerability and give you the answer you want to hear.  They’ll drag you down a path of false hope and wishful thinking, dead ends in the maze of life, until you finally get back to the very same place you’re sitting right now.  And we’re just talking about directions to the bathroom, which, as I’ve already said three times, is only for doctors and hospital staff, and we really can’t have you using it.”

People have forgotten that we’re the ones who went to medical school.  Ten years ago, would anyone even think of bringing in a printout of a medical study and asking us to look at it?  Not a chance.  They would accept whatever disease we’ve told them they have, and learned to deal with the consequences.  If your doctor didn’t know something, that piece of information simply didn’t exist for you.  We can’t know about every new protocol, every new treatment, every new cure.  But the way to learn is not from people handing us pieces of the Internet.  It’s from drug reps or the natural course of information-sharing.  They can’t expect to have every chance to survive.  They’re lucky we give them a fraction of the medicine that’s out there.  And we can’t let them forget that.

Don’t admit mistakes.  Blame the patient.  Pretend you have to leave.  Create a distraction.  Hide the ball.  Instead of dwelling on the cancer, and how you should have seen it on the previous scan except you never even looked at it before it went into the file, berate the patient for having the nerve to keep you waiting.  “Why people like you don’t go to the bathroom before you come see me will never make any sense.  I kept you in the waiting room for an hour and a half.  Surely at some point, it could have crossed your mind that you’d be better off going to the bathroom now than waiting until I’m ready to see you.  But, no, let’s waste my valuable time—and the less valuable time of everyone else still sitting in the waiting room.  I know, it’s too late for this visit, but maybe you’ll remember next time.  If there is a next time.  The cancer’s inoperable, and I don’t know how much longer you’ll live.  So this may be the only time I see you.  Thus my last time to teach you this lesson.

“Although I’ll try to squeeze in another appointment, since your insurance has an unusually high reimbursement rate.”