That is not your penis.

Through the translator phone, my patient says:

"I've been having pain in my penis."

"What kind of pain?"

"Burning."

"Okay, well, we're going to want to do some testing for sexually transmitted diseases. Are you sexually active?"

"In the normal way."

"Excuse me?"

"In the normal way."

"What does that mean? Do you have sex?"

"I guess."

"I need a yes or no answer, if you can. Translator, tell him to say yes or no. Thanks."

"Yes. I have sex."

"With men or with women, or both?"

"Um, they are women."

"You're sure?"

"Yes, I think so."

"Okay, I'm going to put on a pair of gloves and take a look. Can you show me where you feel the burning."

He pulls down his pants. Grabs his scrotum.

"Sir, that is not your penis."

He points to an area on his scrotum.

"Sir, that is not your penis."

At this point, the translator completely loses it. I say to the translator:

"Tell him he is showing me his scrotum, which is different from his penis."

"He says for him, he feels it is all like penis."

"Okay, well, he has a rash, not an STD. So I guess that's a good thing."

"He wants to know what he should do to make his penis feel better."

"That is not his penis."

"Okay. I will tell him."

The value of a good screening questionnaire

The nurse flagged me down just as I was going in to see one of my clinic patients. "Oh, doctor, you need to take a look at his depression screener. His score is off the charts."

"Really, this guy? I've seen him before, he didn't seem depressed."

"But look at his questionnaire!"

"Okay, I will definitely talk to him about it."

***

"Sir, I just wanted to talk to you about the questionnaire you filled out in the waiting room."

"The what?" he asks, through the translator phone.

I show him the piece of paper. "The questionnaire."

"Oh, oh, okay."

"Yes, you scored very high on this."

"Oh, good, yes."

"No, it's not good. It shows you're very depressed. In fact, you said you're a victim of domestic violence? Is someone hurting you at home?"

"No, no, of course not."

"But you checked the box."

"Oh, no, I'm sorry."

"And you said you have thoughts of hurting yourself?"

"No, no, I don't do that, no."

"But you checked that box too."

"I'm sorry, doctor, I could not understand the questions."

"But we gave you the Spanish version, right? Spanish is your language?"

"Yes, Spanish is my language. But I don't know how to read."

"Oh. Hmmm. Well, the boxes you checked somehow added up to very high score on the depression survey, so, interesting. Maybe I'll just ask you the questions out loud then?"

Death to the death certificate man

I get a call at the nurse's station during rounds, from the morgue. They need me to come down and fill out a death certificate for one of my patients.

"And we'd really like you to do it now."

"I'm seeing patients right now. I'll come down after rounds."

"Come on, it's the weekend, we'd really like to leave early."

"Fine, fine, I'll come down now."

I get there. The guy I need to talk to is on the phone.

"Yeah, totally, bar, drinking, bar, personal conversation, blah, blah, blah...."

He holds up a finger-- give him a sec. I think about holding up a different finger. I don't. His co-worker sharing the office gives him a look. He keeps talking. I usually have a decent amount of patience. I have less patience for someone having a personal call while I'm waiting, to do him a favor, interrupting rounds to fill out a death certificate rather than deal with my live patients.

Two minutes pass.

"...girls, bar, drinking, bar, blah, blah, blah..."

Two more minutes pass.

"...club, drunk, bar, bar, blah, blah, blah..."

Two more minutes pass. He hangs up the phone. And is angry. At me.

"You know, I don't appreciate you standing there, listening to my phone call."

You're crazy... I mean, uh, you're crazy.

So, my schizophrenic patient is telling me she doesn't want to take her very much necessary medication, because she doesn't like how it looks.

"If you don't take the medicine, you're crazy."

[long, awkward silence]

"I didn't mean it like that."

"No, it's okay, I am crazy. I know I'm crazy."

"You're not crazy, you have an actual illness. I didn't mean to call you crazy. The medication is important."

"Well, if you think I'm taking it, you're crazy."

When doctors attack... patients... while students are watching... ?!

I was planning on responding to one of the comments from yesterday's post. I was planning to say that, yes, we do have a system for reporting errors and other incidents, but it doesn't seem like anyone uses it, I have no idea where the information goes, and certainly no one ever talks about using it, or has ever encouraged us to use it. So, it's a great system.

For dramatic purposes, let's imagine I was writing that post, when one of my medical students interrupts me.

"Doctor, we're back from that test you had us accompany the patient to."

"Oh, great. I wanted you to get a chance to see an actual procedure done on one of our patients. Was it interesting to watch?"

"Uhhhh... sort of. It was awkward."

"Awkward?"

"Yeah, the doctor was kind of yelling at the nurses."

"That's unfortunate."

"And the patient."

"What?"

"Yeah. She wasn't fully sedated, and she was struggling a little when he put the tube in, and he started calling her names--"

"Maybe he just wanted to make sure she didn't get hurt--?"

"He slammed her head down on the bed pretty hard."

"He did what??"

"Yeah, we were all looking at each other and felt really uncomfortable, because it definitely seemed like he crossed a line. Should he have been that rough with a patient?"

"Rough is really not a word you should ever be using to describe how a doctor is treating a patient."

"And we didn't want to say anything, because he's an attending and we're just students--"

"Of course. That's obviously a very awkward position to be in. And the other students felt the same way?"

"Yeah, we were talking about it the whole walk back here. We're not sure if there's something we should do, some way to report this. Oh, he also called her crazy, and then said she won't remember anything anyway because of the sedation."

"This seems like a setup for something they would use to test whether people use the incident reporting system."

"So you think we should report it?"

"Yes."

"How do we do that?"

"I don't know. But let me figure it out, and then later I can show you and we can definitely report this. I don't want you to think that's an appropriate way for doctors-- for anyone-- to behave. To anyone, let alone a patient. And you're sure this couldn't have been interpreted in some other way?"

"Uh, yeah. We were all pretty scandalized."

......So I find the incident reporting website, and it's broken. I call one of the administrators, who's never heard of the site. He refers me to another administrator, who tells me I have to sign up for a username and go to another site. He refers me to another administrator......

"Are you sure you want to report this?"

"Are you sure you want to ask me that? Why wouldn't I report this? I think it's a valuable lesson for my students, and definitely not an appropriate way to treat patients."

"But you want something to be in writing? Maybe you should talk to the attending first."

"I didn't see what happened. My students did. I don't think they should have to talk to the attending. There's a good reason something like this can be reported anonymously. It shouldn't be the responsibility of the students to have a conversation with an attending about how he treats patients. It needs to be reported, and investigated."

"Come on, it starts a whole process."

"Uh, yeah, that's the point."

"And you're sure you have all of your facts straight?"

"I have the facts of what my students-- three of them-- all agree they saw, and I think it rises to a level where there should be further investigation. I'd rather err on the side of patient safety."

"I'd rather you err on the side of not reporting things. I wouldn't want you to regret it down the road."

"Can you please just tell me how to log in to the system?"

.....So, yes, we have a wonderful incident reporting system, and it works tremendously well to protect our patients and our staff. My students filled out the form. The system shot them back an error message. They will be submitting it by hand tomorrow. And, I fear, and unfortunately expect, that no one will ever hear anything about it again. Excuse me while I go slam some patients' heads into the wall.

Medication; No notation; Complication; Pure frustration; Utter incoordination

This is what happens when I find a rhyming dictionary online. Sorry.

Patient has very low whatever for like a week and we can't figure out why. We keep supplementing the whatever but the level still stays really low. All sorts of working theories, infections, rare complications, things that no one can really figure out.

And then I'm reviewing the chart, just checking my intern's note, and I happen to notice one of her medications.

Not a medication we gave her, but a medication she's been on, for weeks. A standing order. (She's been in the hospital for a while.) Given three and a half weeks ago by another doctor, filling in for someone else's overnight shift.

A medication it might have made sense to give once, depending on what was going on, but didn't make a lot of sense to give every day for weeks, especially when the patient didn't need it.

We get lots of justification for long shifts by saying they want to minimize handoffs and have the same doctors following patients for the whole day. But nothing we do really minimizes the handoffs when every 2 weeks or every 4 weeks, the entire team changes-- attending, fellow, resident, interns, students. You come on to a team and get 15 patients you've never met before, and, sure, you go meet them all, and you read their charts, but you also assume that whatever plan has been put in place is a plan that someone was paying attention to. So you don't just come on and discontinue every standing medication order. You assume that the medications the patient is taking are medications that someone wants them to take, and so while you're always looking, and certainly with a change of condition, or a change of plan, you're reassessing, but the background assumption is that what the patient has been taking every day for weeks makes sense and is something they're supposed to be taking.

The order should have been for one dose, not a standing order to take it every day. Fortunately, no permanent damage, we discontinue the medication, level of whatever will come back up, and she should be as fine as the rest of her condition enables her to be. But, still, that's weeks of poking and prodding and testing and risking potential longer-term issues because as a collection of doctors, no one noticed. The previous team assumed the night team wasn't adding a standing medication order, and so didn't notice when the next day, the patient had one more medication in the chart. We come on and replace that team, and we assume the medication is being given for a reason. Or we don't spend a lot of time worrying about it, since the patient's condition isn't changing. Until we notice a problem and go back and... oh, this isn't a rare and complicated issue, this is a powerful medication being given unnecessarily for weeks because someone checked a box by mistake.

In most jobs, I'm certain stupid, minor, tiny mistakes get made all the time, and they're not even on the radar screen. Books are published with typos, restaurants send out food that's too salty, lawyers misplace a document. But the stakes here are real, even for mistakes that are too small to notice. I spent a good part of the night running through this one-- why we didn't catch it, why it took a week to figure it out. We have 15 patients. By the time I really know them, I'll be moving to a different rotation.

This is not an interview.

Sometimes the only way to stay sane in the hospital is to force yourself to stop for five minutes, go off into the stairwell or something, take a deep breath, check your e-mail, maybe write a blog post, you know, just five minutes away from the beeping and the screaming and the nurses and the interns and the patients. Pager on, nothing terrible happening, I'm just talking five minutes. People take bathroom breaks longer than that. I mean, it takes longer than that just to clean the seat if you're taking a bathroom break in most parts of the hospital.

Yesterday, I had a prospective resident shadowing me. Part of the recruitment process. She apparently wanted to shadow a resident, and I was the lucky winner. The incentives for helping the hospital recruit, incidentally, aren't exactly there. I don't care who the new interns will be. I'm a third-year, I won't be here, it doesn't matter to me who they fill their class with. That sounds bad, but this isn't college, I have no institutional loyalty, and I'm never going to work with these people. They invite us to recruiting dinners all winter, but the idea of spending my off time at recruiting events (even for a free meal) is sort of horrifying. I don't believe this hospital is any better or worse than anywhere else these med students can decide to do their residency. I don't know enough about the competition to have anything useful to say. Residency is what residency is rumored to be. They can do it here, they can do it elsewhere, I have no useful comparisons to draw. Some places get called "toxic programs," but, really, I have no idea what makes one place toxic and one place terrific. This place seems like a lot of other places. See, this is not useful advice.

So this prospective intern is shadowing me, and taking it very literally, as she stands six inches away from me. Asking questions. Which are fine, and I understand she has questions, and I understand that asking actual residents might get her more honest answers than asking the program director. But asking questions while I'm running a code is probably not the smartest idea. Or asking questions while I'm telling a patient about her test results. Or asking questions while I'm on the phone with the attending, trying to figure out a plan for the patient who we thought we were discharging, but, guess what, we're not!

Finally, I have a moment to breathe, and I decided to take just a tiny break, eat the banana I've been carrying around for three days, check my e-mail, see if the world has collapsed or six more Republican debates have happened or what is going on the world. For five minutes.

"I'll be back in a couple of minutes."

"Oh, I'll come."

"No, stay here. I'll be right back."

"Wait, I wanted to ask you a question."

"Please, I promise, we'll figure out some time later when I'll answer any questions you have. But I just need five minutes."

"But if you're not doing anything--"

"This is the only five minutes I've had in ten hours to eat this banana. I will be right back."

"Can't I just ask one--"

"Please--"

"One question."

"What is this question that's so important?"

"I just wanted to know how you chose internal medicine."

"I'm sorry. We can talk about this later today."

"--because I'm deciding between medicine and--"

"No, I'm sorry if I'm being rude, but we're not having this conversation now--"

"--and I've done a bunch of volunteer work in the one area, but on my own time, with a professor, I've been working on a research project--"

"No, no, no, please, stop talking--"

"--and of course, my recommendation letters--"

"Stop. This is not an interview. I don't care. I'm not evaluating you. No one is going to ask me about you. I don't need to know this. If you want to shadow me, fine. But that means watching and not talking. And when I say this is not the time to ask me questions about why I chose internal medicine, and why I chose this program, and whether you should choose it too-- no. You need to stop talking. If you need to talk to someone, go talk to a patient. I will be back."

I imagine she will not be ranking this program very highly.

That's probably a good thing for everyone.

The Intern Who Doesn't Sleep

"Hey, intern, this is going to sound crazy, but I heard from one of the night float residents that you came back in the middle of the night and were rounding on patients and editing your notes?"

"Yeah, I just wanted to finish some things up."

"You know that once we sign out, you don't need to be back until the next day, right?"

"Yeah, but I wanted to check and make sure I didn't screw anything up."

"The night team is here overnight. They'll handle it if anything is going on. We work 12 hours a day, you should be sleeping."

"I know, but I just get worried."

"Here's the thing. You're not supposed to be here without your supervising resident. There's a reason we all sign out together. I'm in charge of you. It's one thing to stick around for another fifteen minutes to finish up a note. That's fine, if it helps the rest of the team get out a little earlier instead of waiting around. But if you come back here at night and something goes wrong, it's not just you responsible. It's also me. And I'm not coming back in the middle of the night, because I'm sleeping, and it's not our job to come back in the middle of the night. SO PLEASE STOP DOING THAT."

"But I don't want to miss anything--"

"We're here 12 hours a day. That is more than enough time to not miss anything. You can't come back and round in the middle of the night. You're making more work for night float, because you're giving them unnecessary things to follow up on, that we should just be waiting to do in the day, as a team. PLEASE STOP DOING THAT."

"But--"

"You have a wife, don't you?"

"Yeah."

"And didn't you say you have a six-month-old baby?"

"Yeah."

"And everything's okay at home? Because besides it being generally hard for me to understand why anyone would want to be here instead of not here, it is especially hard for me to understand why someone with a family would want to be here when he doesn't have to be."

"You wouldn't understand."

"Try me."

"My baby is a monster."

"That is unfortunate. But that doesn't mean you should come back HERE. I don't care where you go if you need to escape from your family in the middle of the night. I just need you to STOP COMING BACK TO THE HOSPITAL."

"But Starbucks isn't open."

You get no blood unless I get soup!

We have an elderly Japanese patient who is not a fan of the hospital breakfasts. He won't touch the cereal, doesn't want milk, no juice, nothing. Through the translator phone, he says he wants miso soup, natto, rice, fish.

"I talked to the woman next door. She gets people to bring her what she wants to eat for breakfast."

"Sir, you can have people bring you food, that's fine. If you have people to bring you food, they can bring you whatever you want. But unfortunately what we have in the hospital is what's on the menu. We don't have other food we can give you."

"But I have no family that can come in the day. I want you to get me Japanese breakfast."

"I can't get you a Japanese breakfast. I have to see patients. I'm sorry."

***

The nurse comes and finds me a few hours later.

"He won't let me take his labs. He said he won't let us take blood until he gets miso soup."

"I don't know what to tell you."

"He said one of the interns said she would get him soup."

"I hope one of the interns didn't say that, but it doesn't matter. I'll go talk to him."

***

"I told the nurse, no blood until I get soup."

"Sir, if we don't take your labs, they're not going to let you start treatment."

"I don't care."

"If you don't care, I don't know how you expect us to care. You're allowed to refuse the blood draw, but what that means is that they're not going to start treatment, so I don't think you want to refuse. It's not serving your best interests to refuse."

"Then get me soup."

"I can't get you soup. I told you, my job is to help you, but I can't leave the hospital and get you soup."

"The other doctor said she would."

"The other doctor said whatever she said. I'm telling you we need to draw blood."

"You just drew blood yesterday. I only want you to take blood once every three days."

"That's not how we do things."

"That's what I want."

"Sir, it doesn't work that way."

"How much could blood change in one day?"

"That's what we're trying to find out."

"Get me soup, I give you blood."

"Sir, it's your health you should be concerned about. It does not help us to take your blood, it helps you."

"No soup, no blood."

"Not gonna happen."

"Chinese woman said she got dumplings."

"Not from us."

"Can you ask Chinese woman's family to get me soup?"

No, that definitely was *not* the highlight of your nurse's day...

"Funny story, doc," said my 350-pound patient with an oozing stage 2 pressure sore on his backside. "I got a new nurse today. He said he was gay. So I bet it was the highlight of his day to change my dressing back there. He probably enjoyed it."

"Sir, I don't think anyone would enjoy anything about that, and I think it's inappropriate and insulting for you to make comments like that. We're all professionals trying to do our best to treat you, and you should realize it's in your best interest to treat us with the same respect you'd like to be treated with."

"Fair enough. But I think the women enjoy it too."

"Sir, no one enjoys dealing with your pressure sore. We deal with it because it's our job and we're trying to help you. But I assure you, dealing with open wounds is not anyone's favorite part of this job."

"Come on, how bad can it be back there?"

"Instead of answering that, I'm going to leave the room and go see another patient. You should be appreciative of the care you're getting. Have a good day."

Not Sneezing Yet

My interns have colds.

My attending seems to have the flu.

And most of my patients have something I'm sure I could catch.

This might be what I hate most about this job. I hate being sick. Ever since a stomach virus over the summer, I've been absolutely hyper-vigilant about washing my hands, using hand sanitizer, often enough to make the people around me just slightly uncomfortable. I use alcohol wipes to wipe down my cell phone whenever I touch it after I've touched anything else, or whenever it ends up on a hospital surface. The other day I found myself putting on a glove to eat a banana. This is not normal behavior. But to whatever extent I can prevent myself from catching something, I can't resist.

And it's honestly not the patients, mostly. I mean, the things I'm most worried about catching from patients are things I should be worried about-- bedbugs, scabies, things that are harder to shake, and far more (property-)damaging, than a cold. It's the other doctors.

It continues to make no sense to me why we don't get sick days. I understand the hospital needs to be staffed, but when you're forced to make up any shifts to have to miss because of illness-- when you don't even get one day a year you can call in sick without penalty-- then people are going to come to work able to infect. And it's one thing for them to infect their colleagues-- I don't want to catch someone's cold but I understand it's a risk of the job and it's not going to damage me too much beyond some crappy-feeling days-- but it's another thing to put the patients at risk. And, just about every day, there's someone coming in to see a patient with some sort of cold, something the patient can catch.

Just another reason you don't want to be in a hospital unless you really must.

Now excuse me while I use an alcohol wipe on the outside of the pack of tissues I just touched.

I'll come back and visit... if you're still here

We switched rotations the other day, so I was on rounds for the last time, and telling the patients that they'd have a different doctor in the morning, that I just wanted to say goodbye and wish them well.

"I've really enjoyed having you as my doctor," one patient said. A patient I like, but who has an unfortunately poor prognosis, and probably doesn't have a whole lot of time left. "Will you come back and visit me next week?"

"Sure, I'll come back and visit, if you're still here."

Silence for a beat. Now, what I should have said next is nothing. But sometimes you start to overthink things. And so, instead, what I said next, as I experienced a terrible inability to stop my mouth from saying words:

"Oh, no, I meant 'if you're still here,' as in, if you're still in the hospital. If you hadn't gone home yet."

"I know what you meant."

"No, no, or not even home, but to a different facility. Or if you're taking some tests when I stop by. Or if you're in the rehab building. I didn't mean I didn't think you were going to be around next week, in the bigger picture sense."

"No, no, it's okay."

"Not that I know more than what we've told you, or that I can guarantee anything one way or the other. The doctors coming onto this rotation are really good. I'm sure they'll do whatever they can--"

"It's okay."

"So, yes, I will absolutely stop by and visit."

"You don't have to, it's fine. I was just saying that."

"Good luck. I'll miss you."

"Thanks, doc."

"And I just meant I'll miss you because I'll be gone-- I mean, I'll be somewhere else-- not because you'll be. Although hopefully you'll get to go home."

"Okay."

"And I mean home like the physical place, not in a spiritual sense."

"Gotcha."

Okay, so maybe it didn't go on for quite that long, and the hole I dug for myself wasn't quite that deep. But it certainly felt like it. And more.

You can read the research papers after you're dead...

A new patient, admitted with chest pain. Actively complaining of every heart attack symptom we've got-- left-sided chest pain, pressure, sweating, shortness of breath-- with a history of uncontrolled high blood pressure.

"While we're dealing with the acute problem, we're also going to start you on some medication. I don't know why your primary doctor hasn't been controlling your blood pressure."

"He thinks there are pros and cons."

"With your blood pressure, the standard of care is absolutely to medicate. There's not really a debate about this."

"Well, my doctor believes in alternative medicine."

"Did your doctor go to medical school?"

"I think so. I assume."

"Okay, well, I don't know what alternative medicine he has you on, but regardless of what you want to think about alternative medicine, in this circumstance it's just not working. Your blood pressure is way too high. You're experiencing a set of very alarming symptoms. You're in a hospital. What you've been doing has not been effective. We need to actually start treating you and address what's going on."

"I'm not taking anything without reading the literature."

"I'm happy to share whatever literature you want, but the nurses are telling me you're refusing any medication, and that's not what ought to be happening here. I'm trying to help you. I can't help you if you're refusing all medication."

"I want to read first."

"What do you read?"

"Every paper there is. Every argument, on both sides. Not the complicated medical jargon, but every study, simplified so I can understand it. I want to read all of it, I want to talk it over with my doctor, and then I want to pray on it, until I come to a decision about whether the medication is something I want to try."

"That seems like it will take longer than the time frame I think we're dealing with here. I want to know what we can do to help you feel comfortable taking the medicine now. Today. Tonight. Here."

"I want to give it a few months."

"That's not a reasonable plan. I don't feel comfortable going along with that plan."

"Then I want to be discharged."

"We're not going to discharge you in the condition you're in. I can't stop you from leaving against medical advice, but we're not going to discharge you. I'm trying to help you, but the medication isn't really a choice I want to give you. It's something you need. I can try calling your doctor, and seeing if he is actually a doctor, but I have eighteen other patients, and I can't spend the entire day trying to convince you to take medication that you need, and that isn't in any way controversial."

"I'll take half."

"Half of what?"

"Half of whatever you were going to give me."

"How about I give you all of what I was going to give you, because that's the dose that will actually help you, and if you want to pretend you're only taking half, I can pretend I was going to give you double?"

"Can I have one research paper?"

"I'll print out anything for you, that's fine."

"But can you have someone read it to me? I don't feel like reading. I feel, uh, I don't feel well."

She's bleeding from where?

Oh, interns.

One of my interns pages me. "We have a major problem with the patient in 1218."

"I thought she just has a cough."

"Yeah, yeah, but there was blood on her gown. And she said it was coming from, uh, you know."

"No, I don't know."

"Her, uh, you know."

"No, I don't know."

"Her private parts."

"We can use the word vagina."

"Okay, yeah. That. So I did a pelvic exam, and there's like, bleeding."

"Okay..."

"I don't know why she's bleeding, why there, I thought we're just working her up for a cough, I don't know what to do-- the chest x-ray was okay, but do we need to do a CT? I haven't seen this before, so I don't know."

[I go in to see the patient, have a little chat with her. Turn back to my intern.]

"Congratulations. You just diagnosed our patient with menstruation."

Can I have some pregnancy medicine?

"Doctor, I've been trying to get pregnant."

"Great."

"I've taken two pregnancy tests. They say I am not pregnant. I want to be pregnant. What else can I do?"

"How long have you been trying?"

"Two weeks."

"Okay, that's not nearly long enough for us to think you're having any sort of difficulty. Just keep trying and see what happens."

"Is there a medicine I can take to get pregnant?"

"No."

"I want a medicine."

"It's only been two weeks. Your body ovulates once a month. You may not have even ovulated yet, while you've been trying."

"I was on the birth control pill. Then I stopped two weeks ago. Now I am trying to get pregnant."

"If you were on the pill until two weeks ago, then you really need to be patient. It takes some time for your body to adjust and for you to start ovulating. Just be patient and keep trying."

"Maybe I am too old to have a baby?"

"You're 24. You're healthy. Just give it some time."

"But I really want to be pregnant."

"I understand."

"When should I take the next pregnancy test?"

"You don't need to take a pregnancy test. You may get your period."

"And then I should take a pregnancy test?"

"No. If you're not smoking, or drinking, or anything else you wouldn't be doing if you were pregnant, there is no urgency to know if you are pregnant, and you're wasting your money on pregnancy tests."

"I get them at the dollar store."

"Then you're wasting your time, and a little bit of money. And I'm not sure I'd trust those tests anyway, but it doesn't matter. You're not smoking or drinking, right?"

"Not much."

"Well, let's make that 'not at all' if you actually want to be pregnant. You don't need to take pregnancy tests. And two weeks after stopping the birth control pill is way, way, way too early to be worried about this. Just be patient and see what happens."

"So no medicine?"

"Take a multivitamin with folic acid."

"But no real medicine?"

"You know that to have a baby, you and your husband need to be having sex, right?"

"Yes, of course."

"Okay, I'm just making sure."

Just trying to be helpful...

"Pssst!" whispered the patient as I was leaving the double room after examining his roommate. "Pssst!"

"Do you need something?"

"Shhhh. Come over here."

"What do you need?"

"He sneaked in food. His wife brought him a cheeseburger."

"Um... thanks?"

"No problem. I'm here for you."

***

"Pssst!"

"What is it?"

"Shhh! Come over here!"

"The other doctor didn't wash her hands."

"Um... okay?"

"No problem. Just trying to help."

***

"Pssst!"

"Sir, you don't need to be my informant."

"Come over here."

"What is it now?"

"You need to change the passcode on the door to the call room--"

"How do you know it's called a call room--"

"It's 3-7-2-4. The guy down the hall sneaked in and took a soda."

"There's soda in there?"

"Someone brought in soda and some leftover sandwiches. And that patient went in and took one."

"I don't know what to do with that information. I wish you'd just worry about your own issues."

"I'm doing you a favor. I know the code, I could go in there and take a soda too, but instead I'm telling you."

"Okay. Thank you for trying to be helpful."

"You're welcome. Don't I get a reward?"

"Uh... what do you want?"

"A soda and a sandwich."

Searching through the trash for... what?

So, I pass by one of the patient rooms and see my intern digging through the trash. Not a recommended procedure for... anything. So I decide to stop and ask.

"Hey, what's going on?"

"Oh, yeah, it's crazy. I'm really sorry."

"Sorry about...?"

"I totally forgot to run a stool guaiac [test for blood in the stool] on patient."

"Okay... well, we can collect a new sample..."

"That's what I'm trying to do."

I pause for a moment to try and put the puzzle together.

"Did the patient go to the bathroom in the garbage pail? Why would he go to the bathroom in the garbage pail?"

"No, no, I'm looking for his diaper--"

"That doesn't make it better. Get out of the garbage pail. You do not have to search through the garbage for a patient's feces. In fact, you should not search through garbage for a patient's feces. Please. Stop doing that. He'll make more, I guarantee it."

"I just wanted to be a good intern."

"I know. Please get your hands out of the garbage and find some sanitizer. Please. Thank you."

"You're sure?"

"Yes."

Because, you know, this isn't a job for the interns, it's a job for the med students (I'm kidding).

Consenting the unconsentable...

4:30 and the day is going almost too well.

Until I hear a scream coming from a patient room.

"You amputated our mother's LEG?"

"Well, not me, personally. But, yes, your mother needed emergency surgery. It's unfortunate, but, I promise you, without that surgery, your mother would not be able to survive. The infection was too profound. ... But I was under the impression you knew about the surgery."

"You think I would have gone to work today if I knew about this surgery? I would have been right here, with my mother! I did not know a thing about this surgery!"

"I was told we had consent..."

"Not from me, you didn't."

***

"Hey, med student, the patient with the leg amputation-- you informed the family and got consent, right?"

"Oh, I got consent, absolutely. But I forgot to call the family. Is that okay?"

"Not really, but first-- who did you get consent from?"

"The patient. Obviously, right?"

"The patient-- who has at least some level of dementia?"

"No, no, she totally understood what I was saying. I explained everything, answered any questions, and she signed the papers. I thought she totally knew what happening."

"Did she ask any questions?"

"Not really."

"And she signed the paper, with her name?"

"Well, it was sort of a squiggle, but it looked like her name, yeah. I just thought that was her signature."

"And you didn't call the family?"

"We were rushing her into surgery-- I barely had time to talk to her before transport came-- and I had three other patients to write notes on-- I was going to call them later."

"They missed the surgery. It went well, but-- you have to call the family if the patient is having surgery! What do I tell this woman's daughter?"

"But they had to do the surgery no matter what-- it was an emergency."

"I know. But how would you feel if it were your mother?"

"I don't know."

"Okay, I'm going to talk to the family. Even when families are difficult, we really want them on our team, and we really want to take pains to keep them in the loop when someone is having surgery."

The black toe mystery

"So, med student, you're getting more comfortable with the physical exam?"

MED STUDENT: "Yep, definitely."

"Great. You want to take me back in to see the patient and walk me through what's going on?"

MED STUDENT: "Sure."

[And he talks me through the highlights, from head to... lower leg.]

"You know, with a diabetic patient, it's especially important to check the feet."

MED STUDENT: "Oh, his wife said he's fine."

WIFE: "Yes, he's fine. I check his feet every night."

"Okay, that's great, but I'm just going to take a quick look."

WIFE: "It's so hard for him to get his socks off."

MED STUDENT: "I didn't want to create a whole problem with the socks."

WIFE: "Yeah, it's really hard to get them back on."

"Well, let's just take a quick look, and we can get a nurse's aide to help with the socks if it's a problem."

...And we remove one sock, and his big toe is... black. Like, gangrenous, dead, completely black. The wife gasps. Audibly gasps.

WIFE: "I have never seen that. I swear, doctor, it was not like that yesterday."

"I think it probably was."

WIFE: "Well, it certainly wasn't like that a year ago."

"Okay... somewhere between a year and yesterday seems plausible..."

WIFE: "I don't understand. It was never like that. This is a sudden change. I think it's something in the hospital."

"He's been here for three hours."

WIFE: "And I think something must be going on that made his toe like that."

"I'm sorry. That's not a sudden kind of development. That's not something that happened in the past three hours. I promise you."

WIFE: "Well, it looks terrible. Are you going to have to get him a new toe?"

"Excuse me?"

WIFE: "Will he need a new toe?"

"Um... I think we're going to have to get a specialist to take a look. Why don't you put the sock back on, and we'll be back in a bit."

And as we exit the room:

MED STUDENT: "I don't mean to ask a stupid question, but... should we also look at his other foot."

Yes, uh, indeed. Yes, we should. Thanks, med student.

Young Obese, In Surgery, and being treated by a doctor with poor grammar

I just read this New York Times article about young people getting gastric band surgery.

The article focuses on a 19-year-old woman, 5-foot-1 and 271 pounds.

[The doctor] told Ms. Gofman that, going by the averages, she could expect to lose about 40 percent of her excess weight, or 70 to 80 pounds. “Which is better than any diet out there,” he said. “We’d be looking for you to come in around 200.”

But, he warned, “If you don’t follow along the average way, like have a milk shake every night or don’t exercise at all, you will end up in the worser half.”

I'm sure this isn't what I'm supposed to take from the article, but-- "the worser half" ? "follow along the average way" ? And we're supposed to trust this person to perform surgery??

[A] study in Australia found that one-third of operations on teenagers required follow-up surgeries within two years, often because of “pouch dilation,” when the stomach above the band becomes enlarged, which can happen if the patient does not follow the regimen and tries to eat too much.

Which begs the question... should teenagers even be expected to have the self-control and understanding of the risks to take proper care of themselves post-procedure?

[At a visit to the doctor in November, she] had regained not quite half of what she had lost. He did not scold or blame her. He tightened her band, so it now took an hour and a half to force down two scrambled eggs.

She does not want to reveal how much she weighs, but she is fighting constant hunger, and progress is slow.

So you're not really a movie star?

A patient comes in yesterday, claiming new-onset neurological deficits-- word-finding issues, trouble walking, weakness on one side.

Perfect opportunity to give one of my med students a chance to get a complete patient history.

Which he does, and it's a doozy. Entire family killed in a terrorist attack overseas. Was a movie star in his home country. Long history of medical problems. Long list of allergies. Tons of medications.

A few hours later, urine test comes back positive for drugs.

Claims he never took drugs. Claims someone's tampering with his urine.

Which is when I start to get suspicious. Probably should have gotten suspicious earlier. See, in my zeal to make sure the med students would learn something, sure, I let them take the history... and waited to check the computer for any past notes and discharge summaries.

Nine previous admissions. In each case, claiming a completely different set of symptoms, and giving out a completely different history. In each case, ending up on the psych service, and eloping from the hospital. In each case, nothing actually found to be physically wrong with him, drugs in his system, and, all in all, a hefty waste of taxpayer money.

Called his "emergency contact." Who hasn't seen him for 25 years. And confirmed that he's crazy. No family killed in any terrorist attacks. Not a movie star. And, upon some quick testing, no neurological deficits.

"So, how many patients fake their entire story?" asks the med student.

"Oh, not too many."

"But from now on, I should be skeptical?"

"I guess. I wasn't, at first. But, yeah, I guess we should be."

"And this whole thing wasn't just a test?"

"Uh... if I said it was a test, would it make me look less ridiculous for not realizing it for a day and a half?"

The least physical physical exam

"So, med student, you saw your patient this morning?"

"Yep. Absolutely."

"And how was he doing?"

"Said he was feeling great."

"And the physical exam?"

"He said he was feeling great."

"Okay... and the physical exam?"

"I didn't do one. He said he was feeling great."

"And what if he had a problem he didn't know about? Some new crackles in the lungs? Swelling? Tenderness?"

"Oh."

"Yeah, it's good if they say they're feeling great. You still have to do the physical exam. Did you at least look at his chest?"

"He had the gown on."

"Yeah, you can move the gown."

"I didn't want to bother him."

"He has a rash on his chest. It's okay to move the gown to look at the rash."

"He said it was getting better."

"You need to look at it."

"So I should go do that after this?"

"Yes."

"I'm allowed to see him twice in one day?"

"He's your patient. You're allowed to see him as many times as you need to. Spend the day with him if you think you should. Get to know him. He's your patient."

"So we're not limited by insurance just to see him once?"

"We're not limited by anything to go see our patients in the hospital, no."

"I just wanted to make sure, so I don't get in trouble."

"You won't get in trouble for seeing your patients."

"Okay. I'll write that down."

Well, at least I don't torture them

I said to one of the residents from another team this afternoon -- "Hey, I passed one of your med students crying in the stairwell. Everything OK?"

"Yeah, whatever, she's ridiculous."

"What do you mean?"

"She's just crying because she thinks she killed someone."

"Huh?"

"You know, I tell the med students one of the patients is going to die in an hour if we don't figure out what's wrong, and then I see what they come up with. It's a teaching tool. You don't do that?"

"No, I have them shadow the team until they have some idea what's going on, and then I give them each a patient to follow, and include them in the discussion about the treatment plan."

"And what do they learn from that?"

"They learn what we do. And if there's time, I give them some reading about something one of our patients has, and we talk through it."

"Your med students are walking on easy street. I feel like it's much more fun to throw them into the fire. Test their skills. See what they can handle."

"They're not supposed to be able to handle anything yet, they're third-year med students."

"Oh, come on, they should know what it's really like. Making decisions on the fly, feeling responsible for life or death, last week I told them one guy was bleeding out, made them hold pressure on a wound that wasn't even there, told them if they let go, he's gonna die. Patient was basically dead anyway, didn't even matter."

"Why would you waste their time?"

"I'm not wasting their time. I'm preparing them."

"I would have hated to be your med student."

"Of course you would have. I have them running around right now looking for test results that don't exist. I want them to see how to navigate the chain of command, figure out all the different ways scans can get lost, blood can go missing, all the places you need to check before you declare something isn't going to turn up."

"So you're sending them on a wild goose chase for information that can't be found."

"Exactly. And it gets them out of my hair for half the afternoon. What are yours doing?"

"Patient history."

"Which you need?"

"No, but it's good practice for them."

"It's stupid, easy practice for them. I bet the patient even speaks English."

"Uh, yeah..."

"No, you give the students the ones who don't, and don't tell them about the translator phone. Then you see what they're made of. They need to learn communication skills."

"I'm gonna go back to, uh... something. I'll catch you later. You should get the one that's in the stairwell, tell her she didn't kill anyone."

"I'll give it a few more minutes. Want to see if she quits or something. Weed them out."

Oh, med students!

I have two new medical students on my team, their first medicine rotation. It's hard-- although, sadly, not impossible-- to remember when I knew so little. After rounds, I asked them to go back to one of the patients and get a more detailed history.

"So should we pretend we're starting from scratch?"

"What do you mean?"

"Should we pretend we don't know anything he's already said?"

"No... why would you do that?"

"We just thought if you want us to pretend we're starting at the beginning..."

"No, I don't need you to be crazy. The patient knows what he's told us. I just want you to confirm everything and dig a little deeper, get a real sense of his medical history. It's partly for his benefit, and partly for yours. I want you to start seeing the kinds of issues the patients deal with, and start building up some experience in asking the right questions and getting the important information."

"So we shouldn't pretend we've never met him..."

"No, you were just in there ten minutes ago. He met you. You met him. There's no reason to pretend you didn't. Just tell him you want to get a little more history from him."

"And you want us to record it on a phone or something?"

"No... I want you to take some notes, and then write up a summary. You can look at the notes in the computer to see what a note looks like, and try to model your notes after the ones we've been doing. I don't expect your first notes to be perfect, but you'll start to get the hang of it."

"We're allowed to use the computers?"

"Sure. You'll be using them to type up your notes."

"So we're going to be doing this a lot?"

"Yep. I'm going to assign you each a couple of patients, and those will be your personal patients. You'll check on them every morning before rounds, and give the team a report about how they're doing, before we all go in and visit them."

"Like, we don't get to work together? We'll be going in alone?"

"Yep. You won't be making decisions alone, but you'll be going in and gathering information to bring to the team, so we can all talk about what's going on and figure out the treatment plan."

"We don't have to touch them, do we?"

"Uh, sure, you'll be doing physical exams, and hopefully before the end of your rotation, you'll be drawing blood, things like that."

"I don't want to draw blood."

"I don't want to draw blood either. It's part of the job."

"I'm not good at it."

"And that's why you have rotations. So you can learn and get better. I wasn't good at it either. Now I'm slightly less terrible at it. You learn."

"I think I'm going to do radiology or something like that. I don't need to draw blood."

"You're going to have to draw blood."

"I don't want to draw blood from the sick patients."

"You're in a hospital. They're all sick."

"No, you know what I mean."

"Why don't we start with the patient history and we'll go from there."

Confessions of a Surgeon

A Twitter follower asked if I could put titles on the posts to make them easier to share. Anything to please my Twitter followers... :) And, really, anything to make the blog easier to share... so I've gone back and added titles to the last half-dozen posts or so, and I'll make a post title for new posts going forward. Happy to do whatever would make the blog easier to share with others, so let me know if there's more I should be doing.

A friend sent me an book excerpt today from The Wall Street Journal-- from a book called Confessions of a Surgeon, that's apparently coming out tomorrow.

"Get this thing out of my operating room!" The colon stapling device exploded into pieces when I hurled it against the operating room wall.

Basically seems like the stereotypical surgeon. A bunch of the comments on the piece are either (a) What a mean guy, I don't want him operating on me, or (b) Oh, nothing like that would ever happen in my hospital, at least not in the present day.

I don't know. (a) I don't know if I care so much about how nice a surgeon is, as long as he's good at what he does, and (b) Maybe they don't throw things, but they definitely still scream.

It may be silly, but I think bedside manner does matter a lot more on the medicine side than surgery. They're not forming relationships with patients, they're not following them through the entire course of treatment, and certainly not for months and years and decades. They're technicians, in large part. They need to be good at the specialized skills they practice and when they're dealing with you, it doesn't matter if they're screaming, because you're under anesthesia anyway. "Seems like a surgeon" isn't a compliment, if you're talking about someone's personality. The personality to want to be surgeon is like the personality to want to be an investment banker. You are important, you are skilled, but it's about adrenaline and power and technical skills, not necessarily about comfort and hand-holding and relationships. There are exceptions, sure. Personally-- and obviously this is a generality, since I've read a lot of terrific books by surgeons-- I'd rather read a book by someone on the medicine side than a surgeon, because I'd expect it's more likely they have feelings. The excerpt in the WSJ neither shocked not surprised me. I guess it only surprised me that so many people commented on it, and were in fact surprised. Then again, if I could figure out how to get 351 comments on a post over here....

Mr. Wallamazzani... or is he?

Attending: "So this next patient is Mr. Wallamazzani. He was brought in last night, drunk and passed out on the street. Going through alcohol withdrawal. Claims to have recently been in rehab, but we called the place he said he had treatment, and they have no record of him. He also claims that he's been here before, but he's not in the system. So either he's lying, or, well, he's lying. I don't think there's another possibility."

[We enter his room]

"Mr. Wallamazzani?"

[No response]

"Mr. Wallamazzani? Are you awake?"

"Who? Me?"

"Yes. You. Mr. Wallamazzani."

"Why does everyone keep calling me that?"

"Is that not your name? It's the name on your bracelet."

"I don't care what it says on my bracelet. My name is Williams."

"Then why does it say Wallamazzani on your bracelet?"

"How the hell am I supposed to know?"

***

[On the phone with the admissions desk]

"Yeah, we have a Mr. Williams, but his bracelet is wrong. It says he's Mr. Wallamazzani. I don't know if he got someone else's bracelet, or---?"

"No, no. I dealt with Wallamazzani when they brought him in. You know, he was drunk, slurring his words, no ID. I just wrote down what it sounded like he was saying his name was."

"So you started a record for a new patient and just tried to guess his name from what he was saying, without making sure that was actually his name...?"

"Yes."

"OK. Thanks."