New Wounds.

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

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

"Excuse me?"

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

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

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

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

"All the time?"

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

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

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

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

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

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

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

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

"Nowhere."

"Ugh.  Forget it.  We're leaving."

"Almost all of my patients have..."

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

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

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

"So even the older patients?"

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

"And it doesn't kill them?"

"Keeps a lot of people alive."

"AIDS?"

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

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

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

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

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

"The AIDS?"

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

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

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

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

"Sure, some of them."

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

"What?"

"The AIDS watch TV."

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

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

"Can I have your e-mail address?"

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

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

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

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

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

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

NY Med

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

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

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

Sepsis

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

Work for cheap in a great city.

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

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

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

Beep.

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

"Uh, yeah.  Thanks."

"Where'd you get that beeper?"

"I'm a doctor.  It's for work."

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

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

"The hospital gives out beepers?"

"To the doctors, yeah."

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

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

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

"No."

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

"No."

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

"Uh, yeah.  I guess so."

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

"I don't know.  Sorry."

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

"Great.  Good luck."

"Cool beeper though.  Really cool."

"Thanks."

The Urine Sample.

Clinic patient comes in with a plastic bag.

"I brought you a urine sample."

"What?  In the bag?"

"No."

"Okay, good."

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

"A glass?"

"Yeah."

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

"Well, I brought it just in case."

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

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

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

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

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

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

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

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

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

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

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

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

"No.  I'm saying you should dump it!"

"But it's a nice glass!"

"I Am Right" -- Dealing With Difficult Patients

I AM RIGHT:

DEALING WITH DIFFICULT PATIENTS
*          *          *

A LECTURE FOR RESIDENTS AND FELLOWS

BY AN ATTENDING WHO NEEDS A SMACK IN THE HEAD

*          *          *

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

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

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

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

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

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

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

Stories Untold, First In A Series?

I'm seeing a patient in clinic for the first time.

"So... are you taking any new medications?"

"Sure, I just started on one the other day."

"Really?  What medication?"

"[Prescription antifungal.]"

"And that was prescribed by...?"

"You guys."

"Um... who?"

"You.  The clinic.  I got a call the other day with my endoscopy results, and they said they were calling in the prescription, I should get it from the pharmacy, and it was very important I start taking it."

[I grab the chart.]

"Your endoscopy results?"

"Yes."

"You had an endoscopy here?"

"Yes."

"The only endoscopy I see in your file is eight months ago."

"Yep."

"Wait, let me make sure I'm following.  You had an endoscopy eight months ago.  They called you with the results a couple of days ago, and prescribed you this antifungal medication."

"Yes, that's right."

"And no one called about these results, I don't know, say, eight months ago?"

"Nope."

"The problem that caused you to have the endoscopy-- is it still bothering you?"

"Nope."

"Did you tell them that on the phone, by any chance?"

"Yep.  They said I should take the pills anyway."

"Did you happen to get the name of the person who called?"

"Nope."

"Bear with me-- I apologize for all of the questions.  I'm just trying to figure out whether for some reason they called you eight months late with your test results, or they called you with someone else's test results... but in either case, I think you can skip the medication."

"Really?"

"Yeah.  If you had a problem eight months ago, and it hasn't gotten worse, and the symptoms have gone away, I think we can safely say your body took care of it."

"Should I get another endoscopy?"

"If you don't have any symptoms..."

"I mean if they come back."

"Well, then... I'm tempted to say yes... but probably not here."

"Oh.  Okay."

"Yeah-- and next time someone calls you with test results from a test that happened, say, more than a season ago-- you can probably feel free to disregard.  Do yourself a favor, though-- call for the results next time-- don't wait to be called."

"Oh, I did-- I called seven times, and each time they said they didn't have them yet.  So I gave up.  I just figured this was how long it took."

"Know for next time-- it is not."