Body, meet pathogens

Substitute attending on rounds this morning.  Hasn't worked on the wards in a while, is doing a favor for his colleague by filling in.  Brought a doughnut and coffee.

Touched the patient.

Touched the doughnut.

Put the doughnut in his mouth.

Touched another patient.

Touched the doughnut again.

Touched a bathroom door handle.

Touched the nurse's station.

Touched the doughnut.

Touched another patient.

Touched his eyes.

Touched the doughnut.

Guess who he will not be touching?

Me.

"Don't you think you should wash your hands?"

"I washed them on my way in."

We accept admissions until 5. It's 5:02.

"I'm sending someone to your team."

"Nope.  Our team doesn't admit after 5.  Sorry."

"Come on, it's 5:02."

"I know.  Lucky us."

"No, you're not serious."

"I am.  I want to go home before 7."

"So if I'd paged you three minutes earlier--"

"Yep."

"It's ridiculous that you residents have it so easy these days.  Back in my day, we had it so much harder."

"No, you didn't.  You didn't have to deal with people like you."

"Excuse me?  I'm just trying to give you a patient."

"Give him to night float."

"Tomorrow, I'm giving you a patient at 4:59."

"Not if I don't get the page."

Nope, still not happening.

MONDAY...

"...so I really think we should try that experimental treatment I read about on the Internet."

"Sorry, patient, we don't do that treatment here.  And we don't think it's effective.  So that's not going to be part of the plan.  Sorry."

"...but I really want it."

"Not here, not from us.  Sorry."

TUESDAY...

"...so, I was hoping you'd thought more about that experimental treatment we talked about."

"Nope.  Like we said yesterday, not part of what we do here.  You're free to go elsewhere for your treatment if you'd like, but we don't do the experimental treatment, and we don't recommend you seek it out, because we don't believe it will positively impact your chances of recovery.  But it's up to you.  We're happy to let you go elsewhere."

"...but I want to stay here, and get that treatment."

"That's not going to happen, I'm sorry."

WEDNESDAY...

"...so I know we talked yesterday about plans for that experimental treatment."

"Nope, we did not.  Not happening here.  Sorry."

"...I thought the other doctor said we could explore it."

"Nope, there is no other doctor.  You only spoke to us, and we said we're not doing that."

"...I really thought we said we were going to try it."

"We did not say that.  Sorry.  We never said that."

"...I'm only staying here to get that experimental treatment."

"Then you should go.  Because we don't do that treatment.  We're happy to release you to go elsewhere for your care."

"...no, I'd rather just stay here, and do that treatment here, like we talked about."

"We did not talk about that, sorry.  Not happening, no matter how many times you mention it."

"...but I've barely even mentioned it."

"Nope, that's not true."

"...and when I did mention it, you said we could do it."

"Nope, did not say that."

"...maybe we should talk about it tomorrow."

"Great.  I'll see you tomorrow."

Ten Years

"I have this pain in my chest.  When I breathe.  I think I need an MRI."

"And how long have you had this pain."

"Ten years.  When can I get the MRI?"

"You don't need an MRI."

"How are you going to figure out if the pain is dangerous."

"If the pain was dangerous, you'd be dead by now."

"That's not funny."

"I didn't mean it to be funny.  You've had it for ten years.  Anything that's going to kill you would have already killed you.  Dangerous pain doesn't stick around for ten years.  Especially dangerous pain that doesn't seem to interfere with any of your normal activities."

"It keeps me from doing this--"

He then smacked himself in the chest, really hard.

"Why would you ever do that?"

"I don't know.  What if I wanted to.  I can't because it hurts."

"Maybe it hurts because you're hitting yourself in the chest."

"You're no better than the other doctors."

"Oh, you've seen other doctors about this?"

"Yeah.  One of them said it was anxiety."

"Okay, maybe it's anxiety."

"The other thirteen said it was nothing."

"Okay, maybe it's nothing."

"You just said it was anxiety."

"Fine, it's anxiety.  I think we're finished."

"Wait, I have this other pain--"

"How many doctors have you seen about it."

"The same fourteen."

"And how many were concerned about it?"

"One, but I think he's a quack."

"Okay, we're finished."

It gets to me, sometimes

I'm not saying that life seems miserable, because it doesn't.

I'm not saying that people can't be happy-- that I can't be happy-- because I can be, and I often am, and I know people who are, often or even just about always.

But it's hard to be around illness all day.  Hopelessness.  Poor prognoses.  Death.  Sadness.  Pain.  You get used to it, and in some ways that's a good thing, because if you didn't get used to it, you wouldn't be able to get anything done.  But in some ways, it's a bad thing, because you start to see the world through that lens, and you forget that there are lots of people out there who aren't sick, who aren't sad, who aren't in the hospital.  That there are lots of people out there living their lives and enjoying them, and not waiting for the next shoe to drop.  People who aren't professional patients.  People who aren't just biding their time until their diagnoses come to get them.

Yes, we will all die, and most of us will get sick before then.  It is inevitable.  And that's why it's hard to talk yourself out of thinking about it.  It's not accurate to say it may not happen to you, because it will happen to everyone.  It's not accurate to say you can prevent it.  You can try and live a healthy life, and act responsibly, see doctors, get screenings, live carefully... but you're still only tweaking the odds a little bit.  Healthy, responsible people get terrible illnesses too.  Things that they did nothing to bring on.  People die young.  People die old.  People die.  And even people who don't die often live in pain and with disabilities, limitations, and struggles.

Everyone has struggles, whether health-related or not.  Everyone has worries, everyone has problems, everyone has their own issues they're forced to deal with.  Even people who seem to have it all, from the outside, usually don't.

And it's so easy to dwell on that side of things, to reduce it all to pointlessness.  What's the difference, if we're all going to die?  What's the point if you can't control your fate, and you could be struck down at any moment?  Why even try if any happiness you achieve might all be taken away?

But where does all of that get you, if, at least right now, you're okay?  Intellectually, I know it gets me nowhere.  I know that happiness is possible, that life can be satisfying and rewarding, that relationships can be satisfying and rewarding, that the day to day can be satisfying and rewarding.

Not everyone loves what they do, but some people do.  Not everyone has a rich, full existence, filled with friends they care about and who care about them, activities that bring them joy, families, things to look forward to, meaning-- but some people do.  Not every day can be perfect-- every day isn't perfect for anyone.  Not every day can be happy, not every moment can be filled with something worth filling it with, but that doesn't mean none of them can.

There are days I don't remember what about this path was supposed to bring me joy, what about this path was supposed to motivate me to be excited to wake up in the morning.  I hate those days.  I hate the way those days make me feel, about myself and about my life.  But I'm also tired of feeling guilty for having those days.  I'm tired of feeling guilty or ashamed for feeling sad, for feeling like I'm failing if I succumb to those kinds of thoughts sometimes.  Because it's not every day, and it's not every moment, and there is happiness, and there is joy.

I just wish it was easier to grab it sometimes.  Easier to remember how to grab it when I most want to find it.

It sounds silly, but I've thought about writing down the things that make me happy.  In the moment, the things that make me smile, that make me feel good about the world and about the path I'm on.  So I can look at that list when I need to, and remember that sometimes all it takes is a cookie to feel okay about the world.  Or an e-mail from a friend.  Or crossing something off the to-do list.  It's not big things.  It doesn't need to be big things.   It's small things.  And I think it's just when eight, nine, twelve hours pass without any of those small things that the whole world starts to look a little bleaker than I'd like.

I know a lot of people have disappointment, and don't get the positive feedback they're craving.  I know a lot of people suffer a heck of a lot more than I ever have.  I know I have control over my own life and what I spend my time doing and how I feel about it.  I'm just saying that sometimes, when everyone around you will be lucky to make it through the month, it's hard to remember that life can be about more than the road to eventual suffering.

Hospitals need ball pits and bounce castles.  For the doctors.

Misaligned Incentives

We've been told to try and get our patients discharged before 11AM.

In fact-- we've been promised CUPCAKES if our team gets the most patients discharged before 11AM.

(This is not sufficient incentive to do anything, by the way.)

See, the hospital wants patients out early so they can get as many new patients admitted as early as possible, to start making money on them. Patients about to be discharged don't have procedures the day of discharge, so there's no money to make. Earlier they leave, the better.

But as soon as someone like me discharges a patient, we have room to get a new one-- and the last thing we want is to get four or five or six new patients in a day, and have to deal with all of those admissions notes.

So, in a perfect world, from my point of view, I want to discharge my patients late in the day, so there isn't time for me to get new ones. Since I'm not allowed to be given new admissions after 4:00 (they go to a different service), my goal is to keep all of my patients until 4:00, and then discharge them afterwards.

Of course, then I end up getting overnight admissions... which still take time the next morning... but not as much time, because someone has done some of the work for me overnight.

If the hospital wanted to align incentives, perhaps they could pass along some of the money they would gain along to residents like me... you want to pay me $200 for everyone I discharge before 11AM, suddenly you would see a lot more early discharges. $100, even. Maybe $75.

But for a chance at cupcakes? No thanks. I'll buy a cupcake if I want a cupcake.

(But I won't buy it from the kiosk in the lobby, because the kiosk in the lobby just got closed by the health department. Would you feel comfortable being a patient in a hospital that can't keep its lobby kiosk sanitary enough to remain open? Hint: YOU SHOULDN'T.)

"This is just to make money, isn't it?"

"Sir, I saw you refused your MRI."

"Yeah, I don't need it."

"I think you do. We need to see what's going on."

"You're just doing it to make money."

"Sir, I get a salary. It doesn't matter how many tests I run, how many procedures I do, I don't get any more or less money. I'm a resident. They pay me the same thing, no matter what."

"If I die, you probably get a bonus."

"I don't. And I don't know why the hospital would want you to die, anyway. If you die, they can't make any more money off of you."

"See, I knew it was about the money."

"It's not about the money. I was just trying to tell you why it's not in our interest for you to die."

"Well, I'm not letting you scam me with the MRI. Those things probably aren't any better than your eyes."

"I assure you, the machine picks up things our eyes can't possibly see. I can't see inside your skull."

"You can look up my nose."

"Still won't be able to see what the MRI can see."

"I'm not letting you charge me for it."

"Your insurance company pays anyway--"

"And then they'll raise my rates--"

"You're on Medicare. It's the government--"

"Then they'll raise my taxes."

"They might. But you still need the MRI."

"Nope."

"You're only hurting yourself."

"And that's just what you people want."

"Nope."

"I know the truth."

Teeth

"...I've also been having a problem with my teeth."

"Um, you should really see a dentist. To be honest, they don't teach us much about teeth in medical school. So you should really see a dentist."

"Oh, but can you look?"

"I guess I can look in your mouth, but, really, a dentist is the person to go to. I can see if there's anything that looks like you need to see a specialist, anything medical that looks like it's going on, but any problems with your teeth, please, please, make an appointment with a dentist, or we can set you up with the dental clinic."

"Oh, but they really hurt."

"Okay, I can take a quick look and see if it seems like there's an obvious infection or something that even I can see is wrong."

She opens her mouth.

And pulls out a complete pair of dentures.

Uppers and lowers.

And tries to put them in my hand.

"Okay, this is definitely an issue for a dentist. I'm really sorry, they don't teach us dentures. I'll give you the number for the dental clinic."

"Maybe you x-ray them?"

"The dentures?"

"Yes, see if they are broken?"

"I'm sorry. That's not what we use x-rays for."

"Maybe just this once?"

"I'm sorry. You need to see a dentist."

Elevator

Someone grabs me as I'm walking past:

"Can I take the service elevator?"

"No, sorry. That's for emergency use."

"But the wait for the regular elevator is so long."

"I'm sorry. Even doctors have to take the regular elevators. We can't tie up the service elevator with non-urgent needs."

"But I really want to get out of here."

"I'm sorry, I know. It's a pain, but you need to wait for the regular elevator."

He walks past. A couple of seconds later, I realize, turn around, and yell down the hall--

"Wait-- sir! You're a patient! You need to return to your room-- you haven't been discharged!"

Option A or Option B

"Looking at your test results, there are two options here. The first is that the medication isn't working. The second is that you're not taking it."

"I think we should go with the second."

"That's what I thought."

"Follow up in two weeks? No, I can't, I'm moving to Siberia."

Spent over an hour with a patient today. Went through the list of her problems, came up with a medication plan, set out a list of tests she needs to come back for, specialists for her to visit, a comprehensive plan to address her issues... felt like a successful visit... until the very end, when I handed her the prescriptions for the medications, and the slips to take to get the tests she needs... "So you'll do all of this and I'll see you back here in two weeks?"

"Oh, no, I can't come back in two weeks."

"Okay... when can you come back?"

"Never. I'm moving to Siberia [not Siberia, but may as well be] next Monday."

"So you're not even going to be able to get these tests done by then..."

"No, no time."

"And the refills on the prescriptions... you're going to have to go to another doctor, in Siberia, because these won't work halfway across the world..."

"Sure, yeah. I mean, not right away, but I'll try to find someone."

"So this whole visit was just sort of an exercise, in a way, because you can't actually follow this plan we just put together..."

"Yes."

"Why didn't you tell me you were moving to Siberia?"

"I didn't think it mattered."

"Well, bring a medication list, and try and see a doctor there. Good luck."

"Thanks."

How much do you protect your colleagues?

Patient comes into clinic. Has a medication list (AMAZING). Is on a mess of medications. A mess. Three pills for the same problem, nothing for another problem, two that interact, at least three he shouldn't be on, a couple that should be replaced with better alternatives. So I talk to my attending and we decide to clean up the med list, get him on the right set of pills... and he asks the very legitimate question: WHY SO MANY CHANGES?

And the very legitimate follow-up-- "Did my last doctor screw up?"

Now, fortunately, there doesn't seem to be anything bad that happened because of the less-than-optimal medication regimen. So, fortunately, his questioning is more out of curiosity than any real demand for answers.

It's true that I don't even know if I have an answer for him. I don't know if he's taking the medications he was told to take, and only the ones he was told to take. I don't know if he brought his full med list to his last visit. I don't know if he's still ordering refills on things he should have stopped, until the refills on the prescriptions run out. I don't know if he might have described different symptoms in the past. I don't know if other doctors know more than I do or have had different experiences with different medications.

But I do have a strong feeling that, yes, someone probably screwed up, or at least failed to think about the full medication list. So do you tell that to the patient, or do you glide past the question, and decide that since you don't know for sure, and there don't seem to be any repercussions, the more responsible thing to do is to not throw another doctor under the bus?

My pregnant, virgin daughter

"My daughter hasn't gotten her period yet. I want to make sure she isn't pregnant."

"She's ten years old."

"So?"

"[Daughter], are you sexually active?"

"No. I keep telling her, ew, that's gross."

"I don't think she's pregnant. Especially since she has never had her period."

"But she's getting fat. I want to see if it's a baby."

"I think it's probably just normal weight gain."

"Are you gonna do the test or not?"

"I can do the test, I'm just telling you I don't think she's pregnant."

"Well, do the test-- and do one on me too, while you're at it."

"You think you're pregnant?"

"Who knows, I just figure it's one co-payment instead of two."

When Residents Get Pregnant

Okay, guess what? If you're around doctors all day, and you're pregnant, even if you think you're keeping it a secret, IT'S NOT A SECRET.

I have a co-resident who has spent the past two weeks thinking she hasn't been announcing her pregnancy in big flashing neon lights.

"Oh, I'm so tired!"

"Oh, my acid reflux is really acting up!"

"Oh, it smells terrible in here!"

"Oh, I'm sorry I keep running to the bathroom-- must be something I ate!"

"Oh, no, I've given up drinking for lent!"

"Oh, I have this doctor's appointment next week I really can't miss, so I need someone to switch shifts with me. What kind of doctor? Oh, you know, the regular kind!"

And no one wants to be the person who says, hey, it's okay, you can stop pretending-- we know. Everyone knows. The patients probably know by now. You're pregnant, fine, big deal, congratulations.

Instead, we're all walking on eggshells around here, no one acknowledging the very obvious and perhaps soon to be large elephant in the room.

It's not that I care if she's pregnant or not.

But it's always nice to have something to talk about.

"No, no caffeine, just coffee"

"I've been having trouble sleeping."

"Are you having any caffeine in the evenings?"

"No."

"So no coffee?"

"Oh, of course I have coffee."

"Decaffeinated?"

"No, regular."

"Then you're having caffeine."

"Oh, I never thought of it that way."

"How much coffee are you drinking?"

"I have a big cup in the morning..."

"Okay..."

"Then three in the afternoon, and three or four more later in the evening."

"Okay, I think we know why you're having trouble sleeping."

"I thought it might be the tea."

"Oh, how much tea are you drinking?"

"A big mug. Right before bed."

"Yeah, that could be the problem too."

"And I have Coke with breakfast."

"That's not very healthy."

"I know. People tell me I shouldn't do that."

"You need to stop with all of the Coke, coffee, and tea. Switch to water."

"I don't like water. My water isn't so good. I don't think it's safe."

"But you use it for the coffee and tea, don't you?"

"Oh, I never thought of that."

"Well, you can always get a water filter, or bottled water."

"I hate the idea of being one of those people who's always drinking water."

"I don't know what kind of people you mean."

"Those hippie-dippie people."

"Do you like the idea of sleeping?"

"Yes."

"Then you should drink water. Any more problems you came here to talk about?"

"Just my diarrhea."

"Yeah, stop with the coffee."