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

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

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

"I'm so sorry."

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

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

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

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

"So if we removed the organs ourselves--"

"No, no--"

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

"No, no, definitely not--"

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

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

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

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

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

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

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

I Want The Extra Strong Multivitamins

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

"Excuse me-- the what?"

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

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

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

"Those are the real thing."

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

"Vitamins should not cost you that much."

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

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

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

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

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

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

-----

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

"What do you mean?"

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

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

"How many vitamins is he buying?"

"150 dollars worth."

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

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

"So he's crazy."

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

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

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

-----

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

"Wow, they must be good."

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

"Oh, great.  Thanks, doc."

"Sure."

"I used to be a little boy too!"

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

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

"I'm older than you think."

"No, you're a little boy."

"I used to be a little boy."

"Yeah?  So did I!"

Boards II

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

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

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

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

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

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

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

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

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

"And she smelled funny."

"I never even met her."

"Good for you."

Bored of Boards

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

So many multiple choice questions.

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

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

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

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

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

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

"Okay... how blurry?"

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

"That's a female medical student."

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

"Yes, she's a female."

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

"That's a coat rack."

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

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

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

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

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

"We'll have him stand close."

"Great."

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

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

"Yeah."

"But that didn't happen--"

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

"Did you call to follow up?"

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

"Because he didn't call you back?"

"Yeah."

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

"When you say it like that..."

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

"But he didn't call me back."

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

"Okay, great!"

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

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

"Not even if you need it?"

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

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

"He should have called me back."

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

"So what do I do now?"

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

"Will this one call me back?"

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

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

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

"He should still call me back."

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

"Someone's Been Urinating On Me."

"Someone's been urinating on me."

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

"No."

"You're wearing diapers."

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

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

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

"Okay."

"Thank you."

"You're welcome."


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

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

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

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

"I am."

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

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

"Hmmm.  We wanted a full doctor."

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

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

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

"You look young."

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

"We wanted a doctor with experience."

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

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

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

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

"I'm sorry you feel that way."

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

"I'm not sure."

"We'll try."

"Good luck."

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

"Great.  Thanks."

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

"They do that at the front."

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

"Nope."