"Are you looking to meet someone?"

Woman, 75, wanders into the ER, confused. I'm assigned the admission.

"Do you know what year it is?"

"Nineteen eighty... something...."

"A little later... Twenty..."

"Twenty-twelve."

"Okay, great. And the month?"

"I know this. It was just my birthday, and my birthday's in August. So, August."

"Nope, it's March."

"Okay, I was close."

"And the President...?"

"Bush."

"Okay, not quite."

"I'll tell you something. I have a granddaughter. She's very pretty. Are you looking to meet someone?"

"Let's worry about you and not me for a minute, okay?"

"She's in college."

"I'm a little past college. Now do you know why you ended up in the hospital?"

"Something must have happened. Maybe I fell?"

"There's no evidence you fell..."

"Do you like food? Because she's a very good cook, my granddaughter."

"I want to figure out what's going on with you, not your granddaughter. Do you take any pills?"

"I have a big pill I take every day. My husband knows the name. Do you know my husband?"

"I don't."

"But you know my granddaughter, right? Because if you don't, I want to introduce you."

"Do you know if you have high blood pressure? Diabetes?"

"That sounds familiar. I can show you a picture of my granddaughter."

"Do you carry a medication list?"

"I carry a picture of my granddaughter."

"Do you know how I could reach your husband?"

"I do, but he's going to be very angry if you're trying to steal me away. I think my granddaughter would be a lot better for you."

"I'm going to try and reach your husband. You stay here."

"Of course I'll stay here. Now, just between you and me-- where am I?"

One beer. Just one beer.

"Hey, doc, I could do this visit myself."

"What do you mean?"

"I mean I've been here enough that I know the drill. You're gonna tell me to quit drinking, quit smoking, quit eating--"

"I'm not going to tell you to quit eating."

"You will after you hear what I eat."

"What do you eat?"

"What don't I eat? I eat coffee cake, the ice cream, big sandwiches with the meats in them, the cheeses, the doughnuts, lots of doughnuts."

"Yeah, none of that is good for you."

"But when I try to eat the vegetables, I'm still, uh, hungry. I'm not satisfied."

"There's a middle ground. Do you cook?"

"Do I cook? My lady cooks."

"Your wife?"

"No, I've had two wives. That didn't work out so well. Now I have a lady. She used to be, oh she was very nice. Now she put on some weight, she's not so healthy, but it's okay, we're a good match. If she was still pretty, she'd leave me. So I think it's a good thing."

"Is she a good cook? Can she incorporate healthier ingredients into her cooking? Vegetables, grains, things like that?"

"She is a good cook. She makes these doughnuts--"

"She makes doughnuts, at home?"

"Oh, you should try her doughnuts, doc. All greasy and thick--"

"This may be part of the problem."

"No, don't tell me that's the problem. We have these doughnuts, a couple bottles of beer--"

"How much are you drinking?"

"Just a couple of beers, three or four, like, uh, seven days a week? I think seven."

"That's every day. There are seven days in the week."

"Then, yeah, seven."

"You need to cut back. You're showing early signs of cirrhosis. You want to be around, right? You have grandchildren?"

"Yeah, a few of 'em."

"You want to be around for them, right?"

"I mean, sure. I don't know if that's the reason I want to be around, but, sure."

"So you can't be having three beers a night."

"Can I have one or two?"

"Not every night. You should try cutting back."

"Can I have one?"

"Every so often? I'm not going to tell you something unrealistic and give you guidelines you're never going to follow. So for me to say you can never have a sip of beer again--"

"I have one in my bag, you're saying I can have it?"

"Not in the office!"

"Oh, man, I wanted it. I want a cigarette too, it's been like half an hour."

"You need to quit smoking."

"No, doc, I like it too much."

"It's important. You need to decide you're going to quit."

"Next time."

"I'm not your teacher, I can't force you to do things. I can tell you what you should be doing, from a medical point of view, but you have to decide you care about your health."

"Next time I'll care."

"I'm going to set up an appointment for you to see the nutritionist, if that's okay."

"Is she a looker?"

"I don't know if it's a he or a she and certainly not what they look like."

"Come on, find me a she nutritionist, I'll promise to go."

"Stop eating so many doughnuts."

"I'll bring you one next time, you'll see why I keep eating them."

My wife says it's premature, but I don't know

"So what brings you in today?"

"My wife wanted me to see someone. I don't think it's anything."

"Well, what is she concerned about?"

"She says I have premature ejaculation."

"You don't agree?"

"I think it's fine."

"How long does it usually take you?"

"I don't know, the normal time, a second or two. I don't know what her problem is, I think it just means I'm better than the other guy she was with, she says it took him forever, I think something was wrong with him."

When I spin around, I get dizzy

"Doctor, I'm really concerned about these dizzy spells."

"How often are they happening?"

"Whenever I spin around and around, really fast."

"Why are you spinning around really fast?"

"Because it's fun."

"It's normal to get dizzy from spinning yourself around and around. You should stop doing that."

"I don't want to."

"Then you're going to get dizzy. It's not a medical problem. What else?"

"I get hungry in the morning if I don't eat."

"Also not a medical problem. Eat breakfast."

"I don't like breakfast foods."

"Then eat lunch foods, in the morning."

"That's ridiculous."

"It's not a medical problem."

"Also, last week I passed away."

"What?"

"I passed away. Multiple times."

"What do you think passed away means?"

"I fell down and didn't remember what happened."

"You passed out, not passed away."

"Same thing."

"Did this happen after you didn't eat?"

"Yes. And after I spun myself around and around."

"You should stop doing that. And you should eat. You have no medical problems."

"Then why did I come see a doctor?"

"I have no idea."

I'm supposed to *take* the pills?

"Your numbers haven't gotten any better since your last visit. Have you been taking the pills I prescribed?"

"Which pills?"

"The ________."

He pulls out a pill bottle.

"You mean these?"

"No, I mean _________. These are for something else."

"Oh. Sorry."

"The ones I prescribed for you-- have you been taking them?"

"I don't know."

"Why not?"

"I don't know which ones they are."

"They're __________. The ones I prescribed you last time."

"I don't know what they look like."

"They say ___________ on the bottle."

"I didn't tell you this last time, doc. But I don't know how to read."

"Oh."

"Yeah, so I have no idea which pills I've been taking."

"That's a problem. And thank you for telling me-- I wish you'd told me last time-- because now at least we can try to figure out a way for you to know which pills you're taking and when to take them. I can also get social work involved if you want to see if there are some reading programs you can get involved in..."

"Oh, it's too late for that."

"No, no, don't say that. Let me get social work involved. But in the meantime, let me write out the prescriptions, and I want you to go to the pharmacy, fill them, and then come back here. I'll find a gap between patients and, I don't know, we'll draw some pictures on the bottles, or something. I want you to take the pills you need to take, and I want you to know you're taking them correctly."

"What do you mean taking them correctly? Don't I just swallow them?"

"I mean some you take once a day, some twice, some with food--"

"I usually just take one of everything in the morning. And then usually I throw up."

"What? Why do you throw up?"

"I don't know! That's one of the things I wanted to ask you about."

"Okay, social work, GI consult, pills-- but first let me actually examine you, okay?"

...and my other patients wonder why I'm running an hour late...

Wouldn't Birth Control Be Easier?

"Are you sexually active?"

"Well, uh... I guess...."

"With men or with women?"

"Men."

"And what kind of birth control do you use?"

"Uh... I don't really like... I don't like taking pills, and the other stuff I always forget."

"Well, you really should be using some form of birth control, unless you're trying to get pregnant."

"Oh, no, I'm not trying. No, definitely not."

"And you've been having unprotected sex, but you haven't gotten pregnant?"

"Oh, no, I've been pregnant. Absolutely."

"And..."

"I've had abortions."

"More than one?"

"Yes, yes, definitely."

"How many abortions have you had?"

"Oh, uh, let me count... um, fifteen, I think. No, sixteen."

"That is a large number of abortions. I think birth control would probably be easier."

"I really don't want to deal with any of that stuff..."

"Also, condoms would go a long way toward helping to prevent disease..."

"Trust me, I've had all the diseases. I can handle them."

"You're not doing yourself and your body any favors..."

"Look, doc, I came here for allergy medication, not for a lecture about condoms."

The Fake Evils of Prednisone

Someone forced me to watch an episode of NBC's SMASH last week. I can't watch TV anymore. The episode wasn't even really about this, but there's a plot line running through it where the lead actress is having vocal problems and the doctor prescribes her Prednisone-- which she doesn't want to take because it's so awful and horrible and addictive and causes every possible medication side effect in the world.................... apparently, SMASH doesn't have a medical consultant, and if I were the makers of Prednisone, I would be calling my lawyers and seeing if there's any way we can sue NBC, because they made Prednisone out to be some sort of evil drug that causes mood swings and instant dependence and turns everyone who even thinks about taking it into a drug addict. What terrible thing did Prednisone do to whoever wrote this episode?

I wasn't going to write this post, but then the same person forced me to watch another episode this week, and they mentioned the Prednisone again! As in, OH NO, she's become so desperate that she had to take the Prednisone the doctor prescribed and this is indicative of a terrible character flaw. It's a useful medication. I wouldn't advise taking it for fun or anything, but if you need it, you need it, it's not heroin.

How do people become medical consultants on TV shows, or does the job simply not exist anymore, and that's why nothing ever makes any sense?

How about listening to your doctor instead of listening to Xanax?

Someone forwarded me this idiotic article from New York magazine about how Xanax is awesome and everyone should take benzos and there are no side effects and they're super cheap and you can get them from your relatives on hospice or your zonked-out friends so you don't even need a prescription.

I, the author of an anonymous blog, am certainly not one to preach about responsible and irresponsible writing, but, hey, I'm not calling this journalism.

The article pushes to the side the fact that these things are addictive, dangerous to stop, and for the writer of the piece to toss away the idea of therapy, to toss away the idea THAT YOU SHOULD GO TO A DAMN DOCTOR instead of experimenting with random pills from your dying mother's bedside collection is seriously screwed up. Maybe she wants to meet some patients going through rehab for benzo addiction.

In my social circle, benzodiazepines are traded with generosity and goodwill. My first Klonopin was given to me three years ago by a friend ... (Such casual bigheartedness is perhaps abetted by how cheap alprazolam can be. “How’s this for something nutty,” the same friend wrote to me in an e-mail. “Just refilled alprazolam. It was $2.56 for 30 tabs. Less than pretty much anything in the drugstore except maybe gum or Blistex.”)

Was this article paid for by the drug industry??? Also, who thinks it makes any sense to give out drug prices? Is that an insurance co-pay, or the price from her dealer in a back alley?

Unbelievable.

To celebrate St. Patrick's Day:

"I have a green discharge..."

* * * *

Patient the other day, telling me, after years of uncontrolled blood sugar, being on insulin, etc. "I don't really think I have diabetes."

"Oh, yeah? Why not?"

"I heard something on the TV. Dr. O-Z. [pronounced 'Oh-Zee']"

"You mean Dr. Oz?"

"No, no, Dr. Oh-Zee."

"I think it's Dr. Oz."

"Like the wizard?"

"I suppose so. Like the wizard."

"No, no, Dr. Oh-Zee says diabetes is something you other doctors make up."

"No one made up diabetes. Diabetes is real, and, unfortunately, you have it."

"No, no, you should talk to Dr. Oh-Zee."

"I don't work with Dr. Oz, but you've seen a number of different doctors in the clinic here, and in the hospital, and, I assure you, everyone is on the same page about you having diabetes."

"Well, I don't want it, and they say mind over matter, so I say I don't have it."

"Okay. You still need to take your insulin."

"Whatever. I'm trying to get an appointment with Dr. Oh-Zee."

"Good luck with that."

"What, you think he only takes people with insurance?"

I can't write you a note.

I'd say a solid 20% of my clinic patients ask me for some sort of note at the end of their visit, that they need to show their boss to prove they went to the doctor and didn't just flake out on work. And of that 20%, maybe half want an actual note that reflects the reality of their visit and what their medical limitations are, and the other half want, well, something else.

"Can you say that I can't work until Thursday? I wanted to go to the casino tomorrow."

"Can you write that I need a break every hour, for my health?"

"Can you say I need to be allowed to eat on the job?"

"Can you write that I won't be better until the middle of June?"

"Can you say I can't walk distances."
"Distances of how far?"
"Any distances at all."

"Will you say I should have extra time on my exam?"
"You have a rash."
"So? Scratching it takes time."

"Can you write that I need to have a more comfortable chair?"

"I need you to say I saw you yesterday, okay? Because I didn't go to work yesterday either."

"Tell them the medication is going to make me sleepy."
"It's not."
"But this way I can take a nap and no one will care."

"Write that I can't lift heavy things."
"You work as a nanny."
"But the kid is really fat."

"You need to tell them I was in the waiting room all day."
"It's 10:30 in the morning."
"But you need to tell them that."

It's actually really hard to say no sometimes.

Patient in the closet

Literally.

There was a smell coming from one of the supply closets.

We send a Nurse's Aide to go check it out.

A homeless patient we discharged last week is living there.

Has been for a week.

Guess no one needed any supplies.

He's been going to the bathroom in there too.

He started yelling that he didn't want to use the regular bathroom because it's dirty.

He's right.

"Who Ya Voting For, Doc?"

"Who ya voting for, doc?"

"Excuse me?"

"Who's your Presidential candidate?"

"Let's worry about medicine, not politics."

"No, I'm serious. I don't want to be treated by someone who doesn't see the world the way I do."

"You want a doctor who sees the world in terms of health and illness. You don't want a doctor worried about politics."

"Sure I do. I want a doctor who wants to keep folks like me alive to vote for the right person for President."

"I assure you, I'm trying to keep you alive no matter who you want to vote for."

"Well that's just stupid of you."

"Probably is."

Gas

"Doc, I'm here because I've been having a lot of gas."

"For how long?"

"About twenty years."

................................."And what made you decide to come in today?"

"I don't know."

"Okay."

"The gas is really terrible. I've been fired from a number of jobs because of it."

"Because of the gas?"

"Yes. Every time I stand up, I pass gas. People hear it. They know it's me."

"And they fire you?"

"Yes. My friends tell me too. Everyone. It's terrible."

"And it's been going on for twenty years?"

"Yes."

"And you've never sought help?"

"No."

"Have you tried any home remedies?"

"I drink tea."

"Any special kind of tea?"

"No, just tea."

"Have you tried changing your diet? Avoiding gassy foods, like beans, or dairy?"

"No."

"Why don't we try some dietary modifications before we look too much further. I'll run some labs, but since it's been going on for so long, I don't expect it's anything acute going on. What if you avoided all dairy products for a little while, and we see if that makes a difference?"

"Even ice cream?"

"Yes."

"No, I'd rather not."

"So you don't want to figure out what's causing the gas?"

"Not if I can't eat what I want to eat."

"Okay. Thanks for coming in today. It was nice to meet you."

Reviewing doctors

There is a New York Times article this weekend about the Internet lacking useful sites with doctor reviews. Here.

The writer comes to the conclusion that more patients should write reviews of their doctors, so that more information is out there....

I don't know. I expect the people most motivated to go online and review their doctor aren't going to be the ones who are particularly happy. Of course, we already deal with that situation for everything else we review. Restaurants, etc. But at least with restaurants, we know whether we like the food or not. I think one problem with doctor reviews is that we don't usually know whether our doctors are actually practicing good medicine, following the right treatment plan, prescribing the best medications... everyone gets sick, everyone eventually dies of something. Maybe a doctor helped you, maybe a doctor hurt you, I don't think patients always know. Maybe the doctor did all the right things, and the outcome sucked. Maybe the doctor did all the wrong things and the problem went away on its own.

I think the other problem with doctor reviews is that the kinds of things patients can review are not the same things as you should really care about when it comes to your medical care. Wait time. Politeness of staff. Friendliness of doctor. Magazines in the office. Availability of appointments. Yes, all of these things are important, sort of. All else being equal, sure, I'd rather have a friendly doctor with competent staff, and not have to sit in the office for two hours waiting. But some of these things aren't necessarily in the doctor's control-- hiring staff, if part of a larger practice or a hospital, for instance-- and all of them are seriously secondary to the real value a doctor provides-- figuring out how to best treat your illness. If I'm the patient, I would rather have a brilliant, thorough, up-to-date clinician who's completely unpleasant than a very nice incompetent moron.

I should qualify that, I suppose. For something easy, most doctors are probably fine. But we don't come into the office with signs around our necks saying what's easy and what's hard, what's a common cold and what's a rare syndrome. And for complicated situations, you want the doctor who knows what he or she is doing, even if he's a jerk. Better if he's not a jerk. But I'd rather have to deal with a jerk than die of, say, Legionnaire's disease.

This isn't quite an argument against online doctor reviews. Sure, the more information, the better. And people should know not to trust everything they read.

"But it's only my wife and one other!"

"Doc, my erections are very weak. I need a prescription for Viagra."

"How long has this been going on?"

"About six years."

"And you're asking now because...?"

"I am, uh, trying to do sex more often."

"Are you having sex with men, women, or both?"

"Doc, I have a wife, I am married. I have sex with women. I need the Viagra for sex with my wife, and sex with my mistress."

"Are you using any sort of protection?"

"My mistress takes, uh, the birth control pills."

"I mean protection against sexually transmitted infections. Are you using condoms?"

"It's not a problem, it is only the two of them. The wife and the mistress. No infections."

"You could be passing infections around. It doesn't matter that it's only two of them. You should be using protection."

"They don't have infections."

"How do you know your mistress doesn't sleep with other men?"

"Oh, she would never do that. She is a good person."

"You realize you can never know for sure. That's why protection is so important."

"I know for sure. If my mistress was sleeping around, I would find a new one."

How far can you walk?

"How far can you walk without having chest pain or shortness of breath?"

"I don't know."

"You don't know?"

"I drive everywhere."

"But I mean, like, from the parking lot to the store?"

"My wife drops me off in front."

"But if you needed to walk, can you walk a block?"

"Why would I have to walk a block? My wife drops me off."

"Can you walk across a shopping mall?"

"I use a golf cart."

"But can you walk, if you have to?"

"I have no idea."

"Aren't you curious how far you are able to walk?"

"No, I don't want to walk. I drive."

"But you want to be able to walk."

"Whatever."

"You don't care if you can walk?"

"Like I said, I don't need to walk."

"In your house, can you walk without getting short of breath?"

"I live in an apartment."

"But you can walk to, say, the bathroom."

"It's three steps from the couch to the bathroom, and three steps from the bathroom to the kitchen."

"And you can walk those three steps without getting short of breath?"

"I guess."

"You guess, or yes?"

"I don't know. Usually my wife brings me my food."

"Do you have to walk down the hall in your building?"

"We're right next to the elevator."

"Do you walk in the grocery store?"

"My wife does the shopping."

"You literally don't ever walk more than a handful of steps at a time, ever?"

"That's what I've been trying to tell you."

"I think I'm going to have you walk down the hall."

"I'm really tired today. I'd rather not."

Maybe you should have mentioned that first...

"Doc, I've been having some back pain."

"Can you describe the pain? Sharp? Dull?"

"Sharp. When I move. Hurts a lot."

"And how long has it been going on?"

"Couple of weeks. Pretty intense."

"Have you taken anything for it?"

"Advil. Tylenol. Helps a little bit, but not much."

"And the pain came on all of a sudden?"

"Yeah. Just all of a sudden. Been pretty terrible."

"Did you lift anything heavy?"

"No, nope."

"Strain yourself, like, playing sports, something like that?"

"No, I don't think so."

"So it just started out of the blue-- morning? Evening? Do you remember?"

"Yeah, it was like 6:00 in the evening."

"And you remember that why...?"

"It was right after I was thrown from my motorcycle onto the sidewalk."

"Oh. You probably could have mentioned that first."

"I didn't know if it was relevant."

"Yeah, I think it's relevant."

"Okay. Great."

It's a good kind of pain...

As we come to the end of a 35-minute clinic visit...

"So, anything else I should know about? Any discomfort, pain, etc.?"

"Well, I have this chest pain sometimes. When I'm walking. Or in bed. Sometimes when I'm moving around and sometimes when I'm still."

"Um, I think we probably want to look into this a little..."

"No, no, no, it's a good kind of pain."

"What do you mean?"

"It feels like a release, like something is freeing itself in my body, like something is really working hard to do something useful."

"Like your heart is having trouble pumping blood through your organs?"

"Maybe. But it's good to feel it working."

"No, it's not. I want to at least run some tests..."

"No, no, I like this pain. I'm okay with it."

"I think it's good that you're not worried, but I want to order some tests just to make sure."

"Will the tests hurt?"

"No, they shouldn't."

"Oh, I like it when the tests hurt. Makes me feel like they're important."

You need the translator phone. And other mistaken assumptions.

I go into the clinic waiting room and call out a patient's name. No response. I try again, being more careful with my pronunciation of this very long, very unfamiliar name. A woman raises her hand and gets up to walk over to me.

"Habla ingles?"

"What?"

"What language do you speak?"

"I'm sorry--"

At this point, I assume she didn't understand me. When, in fact, in the noisy waiting room, she almost certainly just didn't hear me. We proceed into the exam room. Speaking slowly:

"Okay. Have you used the translator phone before?"

"The what?"

Again, I assume she didn't understand me. When, in fact, if you have never used the translator phone, there is probably no reason you would have any idea what in the world I am talking about.

"Language. What language do you speak? Habla espanol?"

"...Si..."

So I assume, at this point, I should get a Spanish translator on the phone. And I do. And the patient, looking slightly confused, seems to be struggling to communicate with the translator.

"Ask her if Spanish is her first language, or we should switch to something else."

The patient looks at me.

"I speak English. English is my first language. I don't know why we can't just do this visit in English."

"I didn't think you spoke English."

"You asked me if I speak Spanish. I took Spanish in high school, so I said yes."

"But in the waiting room--"

"I'm slightly hard of hearing. But I speak English."

"Oh, good. Then we should do this in English."

"Yes, we should."

"Thank you, translator. We won't be needing you."