Break in the action

"I know who you are."

"Huh?"

"We know about your blog.  I think we'd prefer you stop posting for a while.  Not that there's necessarily anything revealing about what we've read -- I think it's the attitude more than the specifics, if that makes any sense.  And we know it's stylized for the blog, and different from you the person, but still.  We're not going to force you, and we're definitely not all on the same page about this, but if you wouldn't mind, maybe stop for a bit, if that's okay?"

Apologies for not sharing that news sooner, but I wanted it to settle for a bit.  I've been continuing to write, privately.  And maybe there's a way to share that more wisely, here or elsewhere.  And maybe there's a way to adjust what I've been writing here -- I'm having a conversation later this month about that, so there may be new posts then.  And maybe sooner, depending.  But for now, there's this post, until I take it down, which may be soon.  I don't know.

"I'm not sure if it's urine"

Sorry for the lack of posts. Was on vacation, somewhere with less Internet than I expected.  Of course, two weeks away and I came back to all sorts of fun messages from the fellow covering my pager. 

"One of your patients kept asking where you went on vacation and why doctors are allowed to take vacation when their patients are sick.  He called every day asking the same question."

Anyway... my first patient back in clinic:

"My body is leaking."

"Uh... from...?"

"You know, where I pee.  But it's not pee."

"Is it blood?"

"Oh, no, definitely not-- wait, are white blood cells clear? Because maybe it's those."

"No, it's clear?"

"Yeah."

"Then I think it's probably urine."

"No, my urine is more of a brownish."

"It's not yellow?"

"Well, I guess you could call it yellow."

"I think you're leaking urine.  Let me send you to a urologist.  Does this happen often?"

"Usually after I shower."

"Are you drying yourself off?"

"I guess."

"Are you sure this isn't just water from the shower?"

"Maybe?"

"Okay, why don't you try drying that area better and see if there is still wetness. If so, I'll have you see a urologist."

"Thanks, doc.  You know, this only started when you were out on vacation.  I tried calling and I got some other doctor I didn't know."

"Okay. I'll see you in six weeks."

Water Makes Poop

"I've been going to the bathroom too much, doc."

"Um, how often is too much?"

"Every day."

"I think that's okay."

"Not for me.  I don't like to go so often.  Is there a way to make less poop?"

"No.  I mean, everything that goes in has to come out."

"I think it's because I've been drinking too much water."

"No.  Water becomes urine."

"No, I think in me it becomes poop.  Because I don't really eat that much.  But I still poop a lot.  So it must be the water turning into poop."

"No."

"I think it does for me.  Maybe that's just how my body works."

"No."

"So you're saying if I eat less, I will poop less?"

"I guess.  But I'm not saying you should eat less.  You need to eat enough calories.  I don't want you to starve yourself because you don't like going to the bathroom."

"It would be nice to never have to go."

"I'm going to refer you to a gastroenterologist."

When An Arm Is Not An Arm

"Sorry to call you so late -- my arm is numb."

"Are your fingers blue?"

"No, they're normal."

"Is there any pain?"

"No."

"What do you mean by numb?"

"Well, I don't know.  It just feels funny.  It's my left arm.  Is it my heart?"

"Can you move your arm?"

"Yes."

"Where does the numb feeling start?"

"My fingers."

"From your fingers up?"

"No, from my fingers down."

"So it's not your arm, it's just your fingers?"

"Yes, but my fingers are attached to my arm."

"Yes, I know that.  But there's a difference between your arm and your fingers.  Did you do anything funny with your fingers recently?"

"No."

"Did you sleep funny?"

"No."

"Were you playing with a phone or a tablet?"

"Yes."

"With those fingers?"

"Yes, just before they got numb."

"How's the numbness now?"

"It's a little better.  It feels like it's going away.  Am I having a heart attack?"

"I don't think you are."

"Should I go to the ER?"

"If the numbness is going away, and it's just in your fingers, and you were just playing with your phone before they went numb, then, no, I don't think you need to go to the ER."

"What if I just want to make sure?"

"I'm not stopping you from going to the ER.  You know your own body."

"Okay, I'm going to go to the ER."

"Okay.  Thanks for calling."

A Recipe For A Urinary Tract Infection

Here is a recipe for a urinary tract infection.  It starts with a pot of boiling water.

"So, I wanted to try and figure out if there's something going on that's causing your husband to have repeated UTIs.  It may just be an unfortunate situation, because of his catheter use, but I want to make sure there's not something that we're ignoring."

"He does use a lot of catheters."

"Right, but you were trained by the nurse in how to do it correctly, yes?"

"Yes, she said I was doing it correctly."

"And you're using a fresh catheter every time."

"Yes, either from the package or after I clean them."

"I'm sorry -- you're cleaning catheters and then using them again?"

"No, I make sure to boil them."

"You boil them?"

"I put the catheter in a pot of boiling water, and then it is sterilized to use again."

"I think this may be the problem."

"But I do that with my jars for jelly and it's fine."

"There's bacteria on them."

"No, I boil them."

"OK, I'm not an expert in canning, but you need to not re-use catheters.  Use a new one -- fresh from the package -- every time."

"But catheters are so expensive."

"Hospital stays for UTIs are expensive too.  The catheters should be covered under Medicare."

"I need a prescription for more."

"That's not a problem."

"But they take up so much room."

"Yeah, there's nothing I can do about that.  Also, are you actually boiling used catheters in a pot you also use to cook with?"

"Yes, the pot I use for the jelly jars."

"What kind of jelly do you make?"

"Oh, all kinds.  Blueberry, strawberry, grape.  I can bring you a jar."

"No, please don't."

"I'm Hot"

"Hi, [Patient], this is [Anon Doc].  I got a message that you called."

"Yes.  I am feeling very hot!"

"Have you taken your temperature?"

"Yes, it's normal."

"Have you been feeling okay otherwise?"

"I guess so.  But my stomach is bothering me now.  I think because I am hot."

"Are you drinking enough fluid?"

"I don't know. Why am I so hot?"

"Have you been outside?"

"No, I've been inside."

"Is it too warm in your house?"

"Yes, the air conditioning is broken.  I called the repairman, but he isn't here yet."

"So it is hot in your house.  And therefore you are hot."

"Yes."

"And you called me... why?"

"Because I don't want to feel so hot."

"You're feeling hot because you're in a hot place.  Go somewhere with air conditioning and you'll feel better."

"But I have to wait for the repairman."

"Okay, this isn't a medical problem.  Keep hydrated.  You're hot because you're in a hot place.  Go to a cooler place."

"Can you prescribe me anything?"

"So you won't feel so hot?"

"Yeah."

"Air conditioning."

"Can you call it into the pharmacy?"

"No.  Go somewhere cooler.  Have a good day, and feel better."

Sleeping or Dead?

I walk into a patient's room, and he's sitting in the chair, slumped over, while his wife reads a magazine.

"He's just sleeping, right?"

"Oh, I don't know -- you're the doctor."


Probably not the best question for me to ask.  But, also, if you don't know if your loved one is sleeping or dead, perhaps you should check that instead of continuing to read a magazine.  In case you need some help telling the difference:

Is he moving?  Yes?  Sleeping.  No?  Maybe sleeping.

Does he respond when you call his name?  Yes?  Not dead.  No?  Could go either way.

Is he breathing?  Yes?  Sleeping.  No?  Dead.

Is his body cold to the touch?  No?  Probably sleeping.  Yes?  Probably dead.

Are his limbs stiff?  No?  Probably sleeping.  Yes?  Probably dead.

Does he smell funny?  No?  Probably sleeping.  Yes?  Could be either.

Has someone already declared him dead?  No?  Might be sleeping.  Yes?  Almost certainly dead.

Is there a coroner in the room?  Yes?  Probably dead.

Is someone asking him to fill out tomorrow's dinner menu?  Yes?  Could be either sleeping or dead.

"Is Someone Hurting You?"

"I'm noticing you have a bunch of bruises," I say to my fairly robust 92-year-old patient.  "I have to ask... has someone been hurting you?"

"Well...."

"You can tell me if something's going on, and we can try to help."

"Well...."

"Seriously, is someone hurting you?"

"When I was eight, there was this neighbor...."

"Um, we can talk about that if you want, but I actually meant more recently.  To cause these bruises...?"

"Oh, someone hurting me now?"

"Yeah."

"No, no one's hurting me.  I just fall a lot."

"You sure?  No one's getting frustrated and hitting you?"

"No!  I would hit back!"

"Okay, I just wanted to make sure."

"So you don't need to know what happened when I was eight?"

"Not unless you need to talk about it, in which case we can, or I can refer you to someone who you can talk to...."

"No, I'm okay."

"Okay, great.  Now let's talk about your medication list...."

Tell My Son. No, My Other Son. No, My Other Son.

"So, unfortunately the test results were as we expected, and you're going to need to see a specialist and figure out the best treatment."

"Would you mind giving my son a call and letting him know?  He's much savvier about this stuff than I am."

"Sure, but I think I spoke to your son the other day when he came to your last appointment, right?"

"No, that's my other son.  It would be great if you could give him a call, too, with the update."

"Okay, so I'll call that son, and I'll also call your other son."

"And my daughter."

"Can one of your sons update your daughter?"

"Well, one son isn't speaking to that daughter. And then I have another daughter who no one is speaking to, but it would be great if you could update her as well."

"I'm happy to talk to your family, but maybe if we could do it all on one conference call, or a family meeting if they're able to come in, or if one of them can be the point person -- it's just hard for me to take the time to call three or four different people with the same news.  I have a lot of patients."

"I was actually also going to ask you to call my brother.  He works in a pharmacy, so he's familiar with a lot of the medical terms."

"Like I said, it would be really great if I could call one person, and then they could tell everyone else the update.  If there's one child or sibling who can be the go-to person that I know to call, that would be the easiest thing."

"Right, except Janet isn't talking to Stu, and Stu isn't talking to Carol, and, really, they're only going to trust what they hear if it comes directly from the doctor. Oh, you need to call my boss, too, so I don't get penalized for taking today off for the appointment."

"I can definitely give you a note."

"No, he's going to think I forged the note, because of something in the past.  It would be much better if you called.  Also I need some refills that I was hoping you could call into the pharmacy."

"Do you have the list of prescriptions you need refills on?"

"I actually left that list with my cardiologist -- he said you could give his office a call and they would let you know."

"He couldn't refill them for you?"

"He said he'd rather leave it to the internist.  I also have an insurance issue -- they said the doctor can call and explain why I needed the scan in March, otherwise they weren't going to cover it."

"Okay, I can call the insurance company...."

"And if you could let my sister know after you've done that -- she's been handling a lot of my paperwork.  That would be great."

"I think I need a list of all of these names and numbers."

"My niece has all of that information.  I can't remember phone numbers anymore, but she said you can give her a call and she'll give you all of those details.  I don't want her knowing the medical stuff, though.  She's just dealing with the phone numbers.  And if you could minimize the test results when you talk to Janet, she's very squeamish with this stuff."

"Like I keep saying, one point person would be great."

"Oh, I almost forgot.  My brother had me take a picture of this mole he's got.  It's on my phone, he asked if I could show you."

"I really can't--"

"I don't need to know what it is, but I told him I'd have you give him a call--"

"I'm not--"

"Oh, also, my step-daughter, Sylvia -- her first language is Spanish.  So if there's some way you could get an interpreter on the phone when you call her.  Different father, she grew up in Mexico--"

"I don't think I can get--"

"Yeah, so I'll have the specialist call you once the results are in, and then you'll update my family?"

"He can--"

"Okay, great, thanks.  I really appreciate it."

Water Pills

"It's pretty hot out, so you should make sure you're drinking enough water."

"I don't like to drink water."

"Well, it's important.  You need to."

"Can't I just take a water pill instead?"

"You mean a diuretic?"

"Sure, whatever."

"I think you're misunderstanding what those kinds of pills do.  They make your body get rid of water.  They're the opposite of what you need when I'm telling you that you might be dehydrated.  You need to drink water."

"I thought those pills were just water in pill form."

"Think about whether that makes sense."

"I don't know.  They make everything into pills these days."

"A pill is not a substitute for drinking water.  Please drink water."

"Can I drink ice water instead?"

"Yes, ice water is fine.  Ice is just water in another form."

"I thought you said water doesn't come in other forms."

"I said it doesn't come in pills.  Ice water is fine."

"The rules are very confusing."

"I'm sorry.  Stay hydrated."

You Can Take My Personal Information And Stick It Where The Sun Don't Shine

"Doc, your 2:30 clinic patient is here...."

"Great, I'll come get him in a second."

"Just one problem."

"Yeah?"

"He won't fill out the forms."

"Can he read?"

"He says he doesn't want to give us his personal information."

"Like, his name and address?"

"Yeah.  And his insurance information.  You can't see him unless we are able to put his information into the system."

"So you want me to talk to him?"

"If you don't mind."

****

"Mr. Jackson, I'm [Anon Doc].  You made a 2:30 appointment?"

"Yeah, I don't feel well."

"The woman at the desk is telling me you won't give her your insurance card."

"I don't want you people knowing all my information."

"We just need the insurance information so that we get paid."

"I don't believe you."

"I don't know what you think we're doing with your insurance information, but if we can't bill your insurance company then we have to bill you directly.  And for that we need your address."

"I'm not giving you that either."

"Then I don't think I'm allowed to see you as a patient here -- you'll have to go to the emergency room and let them take a look."

"The wait's too long."

"I don't have a great solution for you.  What is your medical problem, just so I know?"

"I'm not telling you that either."

"What was your reason for making an appointment?"

"That's none of your business."

"But I'm the doctor.  It's hard to help you if you won't tell me what's wrong."

"Forget it.  I'm leaving."

"Okay, well, if whatever it is gets worse, you should go to the emergency room and they can help you."

"Screw you."

"But I Really Want The Surgery"

"So, I took a look at your blood results, and unfortunately I'm going to need to talk to the surgeon who's planning to perform your procedure next week -- I don't know that it's going to make sense to have the surgery until we figure out why your numbers are so abnormal."

"But I really want the surgery."

"Of course, but it's a non-urgent procedure, and if it has to wait a week or two, just so we make sure it's safe, I think we should do that."

"It's already on my calendar."

"I would think it would be.  Since it's scheduled for next week.  But I don't want you to end up in a situation where the surgery doesn't go well or there's a complication that could have been avoided.  Your platelets are really low, and I'm not sure why."

"But I want the surgery."

"I know.  And I want you to have the surgery.  But I want you to have it safely."

"Why are you telling me I can't get the surgery?"

"I'm trying to explain.  Your lab values were abnormal.  I want to repeat the labs and see if maybe there was an error, or something wrong with the sample.  But if these are the numbers, I think the risks of the surgery outweigh the benefits right now, and I'll want to talk to the surgeon and get his thoughts."

"He knows I want the surgery."

"Sure. But sometimes we need to push things back to be safe."

"Why can't someone else have their surgery pushed back if there isn't room on the schedule?"

"This isn't about the schedule.  I'm trying to explain why you may not be a good candidate for surgery right now, given the blood work.  But let's not get ahead of ourselves.  I'll take some more blood and see what the results show."

"Do you really think you should be taking so much blood from me right before I'm having surgery?"

"Okay, I'm going to have another doctor come in and explain this better."

Poop

"You mentioned fecal incontinence.  Describe what you mean."

"Every time I urinate, I also poop.  Even when I don't feel like I have to go."

"Every time you urinate, you poop?"

"Yes."

"Is it formed, or like diarrhea?"

"What do you mean formed?"

"Is it an actual solid piece of poop, or is it liquid?"

"I think I'd say solid."

"Like, how much are we talking about?"

"Like a small hot dog.  A pig in a blanket, without the blanket."

"Okay...."

"Like the size of a baby corn, I guess."

"Got it."

"Like maybe three jelly beans long."

"Okay, you can stop comparing it to food now."

"It's like the squiggle of toothpaste I put on the toothbrush."

"No more comparisons-- we're good."

"Like a cashew nut."

"Stop."

"Please Fill Your Antibiotic!"

I had a crazy week.  In which I meant to blog but I forgot.  So here I am.  Second-year fellow.  Which feels no different from first-year fellow, except for a tiny salary bump.

A patient comes in with a rash on his chest.  A fairly scary looking rash on his chest.

"How long has it looked like this?"

"Oh, it's definitely worse today than yesterday."

"And yesterday was the first day?"

"No, it's been about a week."

"And you're only coming in to see a doctor now?"

"No, I saw a doctor yesterday."

"Who did you see?"

"I went to the emergency room."

"The emergency room here?"

"No, a different emergency room."

"Which one?"

"I don't remember.  They gave me a prescription for an antibiotic.  They said it should make it better."

"How many doses have you taken."

"None.  I didn't fill the prescription yet."

"Why not?"

"I wanted to see if it would get better."

"You went to the hospital yesterday."

"Yes."

"They gave you an antibiotic and told you to take it."

"Yes."

"You did not take it.  The rash got worse.  You decided to come here and see another doctor."

"Yes."

"Why?"

"Because it did not get better."

"Take the antibiotic!"

"But I want to see if it gets better."

"Take the antibiotic and it will get better!  What did you think I would say?"

"I don't know."

"Take the antibiotic!  Go to the pharmacy.  Fill the prescription.  Take the antibiotic.  Then we'll see if it gets better.  It should get better."

"Maybe I wait one more day?"

"Why?  Take the antibiotic.  Can you not afford to fill the prescription?"

"No, I can."

"So why don't you want to?"

"I don't know."

"Will you promise me you'll fill the prescription and take the antibiotic?"

"Yes."

"Okay.  Feel better.  Goodbye."

Fellow Orientation

The new class of fellows is starting next week, so there are a few days of orientation this week, including a "party" yesterday afternoon in the office for the second-years to meet the new ones.

"Oh, this is nice," one of the new fellows said.  "Are there always snacks like this?"

"No.  Pretty much this is it.  And I think the cookies you're eating are leftover from last year's party."

"Oh."

"Also, I wouldn't actually eat them, because I'm pretty sure the fellow who took them out of the box and put them on this plate came right from clinic, and I didn't see her wash her hands."

"Oh."

"Generally, any food you see in the office has probably been touched by someone who has touched something you wouldn't want to put in your mouth."

"Oh."

"But, you know, I don't want to make you think this isn't a great fellowship."

"I was deciding between doing a fellowship and working at a medical start-up -- a concierge practice, sort of.  They had an on-site gym."

"Yeah, we have the stairs."

"They also catered lunch every day."

"There's a vending machine on the third floor.  It has Swedish Fish."

"But I figured, it was such a limited patient population.  I wanted to see a wider variety of issues, especially at this point in my career."

"Yeah, that's great.  Catered lunch, eh?  They still looking?"

"Ha.  I'm sure this job is a lot more interesting.  And at least you don't get paged in the middle of the night for medication refills."

"I actually just got paged at 3AM for a medication refill."

"Oh."

"The patient thought it was 3PM, not 3AM.  She apologized."

"Oh."

"No, at least she apologized."

"Maybe I'll go meet some of the other fellows."

"Okay."

Is 4 AM the night, or the morning?

I'm on this Sunday, so I tracked down the attending, just to check what time he would be coming in.  The typical thing on weekend shifts is you come in around 8 or 8:30, leisurely round on the patients, and are home by lunchtime.

"Hey, I'm on with you this Sunday.  Just wanted to check the plan."

"Great.  I get in around 4, so if you could pre-round before then, we can quickly go through the patients, and be out of there in a few hours."

"4 in the afternoon?"

"Ha, no."

"Oh.  With other attendings, it's been more like 8 or 9."

"Yeah, I like to have most of my day free.  I guess we can say 4:30, if you really want to sleep in."

"You must be a morning person."

"People tell me that, yeah.  I don't really sleep."

"Okay.  It's not daylight savings time this weekend, or anything like that, is it?"

"I don't think so."

"Okay.  So... 4:30...?"

"Yeah, and if you could pre-round by then, that would be great.  See you on Sunday!"

Oops

When all of your patients are doing okay, there isn't much to write about.  As I see more and more of my outpatients, more and more often, I've been noticing there's a big range of home health aide competence, from the ones who barely know their person's name to the ones who take notes, actually pay attention, and act in a warm, caring way toward the patient.  I think it's a pretty painful job, being a home health aide, especially to a demented person who doesn't have a non-demented spouse involved as well.  It's a lonely job, certainly.  And it's very easy to do it poorly, and hard to do it well.  If you are an aide, and you're bringing your person to the doctor's office, you should probably clean them a little bit first, brush their teeth, put fresh clothes on them -- or you seem like a bad aide.  If you ask questions, especially about medication dosing, you seem like a good aide.  If you wait in the waiting room, and act like the doctor's appointment is your time to make a call on your phone, you seem like a very bad aide.  If you bring a medication list, you seem like a very good aide.

Actually, it doesn't just apply to aides.  If you bring a medication list -- an accurate medication list -- to the doctor visit, you win.  The number of people who don't think that knowing what medicine you're taking is a good idea when you visit a doctor for the first time is really staggering.  If I could pass one health care related edict, I think it would be that people should be mandated to bring medication lists everywhere they go.  And if you've typed up a list of your medical conditions, surgeries, hospitalizations, names and phone numbers of the other doctors you see -- well, I want to give you a lollipop, because you are making your doctor's job a lot easier, and increasing the odds that you get decent medical care.

Also, if you're not the patient -- and you'd be surprised how often this happens -- if you're not the patient, I don't want to take your blood pressure, or weigh you, or answer your own medical questions.  Home health aide, if you need someone to listen to your cough, make an appointment with a doctor for yourself.  Spouse who is not my patient, please don't ask me to check your blood sugar.  And no one is getting a medication refill except the patient I'm actually seeing.  That means your sister, in another state, no -- I'm not calling in her refill, not even if you put her on speakerphone.

Who's On Tonight?

How you know you've been working in the hospital too long:

"Are you going to watch the Tony Awards?"

"I didn't know they were on."

"What are you talking about?  I e-mailed you about them."

"What?  No you didn't."

"Sure I did.  You wrote back and said OK, I didn't know.  But I told you, so now you should know.  Are you OK?"

"Oh."

"What?"

"That explains your e-mail.  I thought you were telling me Tony was on tonight."

"Who's Tony?"

"I figured he was a resident.  I didn't know.  That's why I said I didn't know.  I figured you were telling me Tony was on call tonight.  And that I should know who Tony is.  Even though I don't."

"No.  I was telling you the Tony Awards were on TV.  Do you want to come over and watch them?"

"Not really.  So who's on tonight if not Tony?"

"There is no Tony."

"Oh, yeah."

"I think you should come over."

Wrong Liver

"So, your father is scheduled for surgery tomorrow -- I don't know if the surgeon has been by yet to answer any last-minute questions, but if you have any concerns--"

"I just hope this goes better than last time he had surgery."

"What happened last time?"

"They removed the wrong liver."

"He only has one liver."

"Well now he does -- that's right."

"No, he only started with one liver.  There is only one liver."

"Now, sure.  They didn't even apologize."

"They couldn't have removed the wrong liver.  People have one liver.  And his liver wasn't removed."

"Not the remaining one, no -- I should hope not!"

"He did not have his liver removed."

"Not this one.  The other one."

"He only has one liver."

"Exactly, that's what I'm trying to tell you."

"No, there's something confusing here -- when you're born, you have one liver.  Just one."

"So then you know what he's gone through."

"I'm not talking about me.  I'm talking about everyone.  One liver.  There's no wrong one and right one.  There's just one."

"His was the wrong one."

"Okay, forget it -- that's not even the surgery we're talking about.  You know that he's having surgery on his left hip tomorrow, right?  The surgeon explained it."

"And how many hips will he have afterwards?"

The Diabetic 87-year-old who's 63 and not diabetic.

"Doc, we didn't see you yesterday."

"Yeah, I was off yesterday.  But someone should have stopped by -- there's always a doctor covering."

"Someone did, but we didn't like him."

"Why not?"

"He came in and thought our mother was 87 and diabetic."

"He must have had the wrong chart."

"No, he said that was in the chart.  He showed us."

"She's never been diabetic, right?"

"No."

"That's weird.  I don't know how that happened, but I'll check the chart and fix any mistakes I see."

"Also... you don't think she looks 87, do you?"

"Of course not... but it's hard to judge people's age when they're sick.  Everyone looks older than they really are."

"So how old do you think she looks?"

"That's not a fair question, because I know she's 63."

"But if you didn't know."

"I'd say she looks like an ill 63 year old, unfortunately."

"She used to look 40."

"She used to be 40."

"But you're sure she doesn't look 87."

"Yes."

"Good, because then there's no biological way I could be her son."

The Patient Advocate

Sorry for the gap in posting.  Was on vacation this week, with limited Internet access.  And no pager.  Fortunately.  Back for the holiday weekend.

"I'm told you wanted to transfer your mother?"

"Yeah, we were talking to the patient advocate and she told us we should."

"What?"

"We were telling the patient advocate that we were worried about our mother, and she said there are better hospitals in the area, and we might want to transfer her to one of them."

"The patient advocate said that?"

"Yep."

"Interesting.  So when did you want to transfer her?"

"Now."

"Did you talk to the other hospital about accepting the transfer?"

"No."

"Have you looked into an ambulance to get her there?"

"No."

"Is there a particular doctor you know over there?"

"No.  We were hoping you could take care of all of that for us."

"We can certainly work with the other hospital to arrange the transfer, but you need to contact a doctor over there and start the process."

"Do you have the phone number of a good doctor there, who would be better than you at treating her?"

"Honestly, I don't know anyone over there."

"I guess we can just ask the patient advocate."

"Okay."

The Physical Therapist Is A Fictional Character

A family asks to talk to a doctor.  I'm just a consultant on the patient, but I'm there, so I'm the one they get.

"Doc, we're frustrated because he's been here a week and still hasn't seen physical therapy."

"I do see that the order was put in five days ago.  I can put in a call to physical therapy and see why they haven't come yet, but I'm not sure what else I can do about that."

"That's not an answer."

"No, it's not, but let me give them a call and see if I can get them to come sooner than they might otherwise."

"It's been a week."

"I understand."

"Is there actually physical therapy, or is it just a lie you tell people, so we stop asking about it?"

"There is actually physical therapy.  I've met some of the physical therapists.  They are actual people."

"Hard to believe that."

"I understand that you're frustrated."

"When we asked the nurse, she said she'd never seen physical therapy come see a patient."

"I have to imagine she was joking."

"She didn't seem like she was joking."

"Then maybe someone misunderstood.  I don't know why physical therapy hasn't come yet.  I assume they're very busy.  But I don't know.  I will call them."

"You'd better do more than call them."

"I will talk to the physical therapy director."

"While you're at it, can you talk to the director of nursing and get us a new nurse?"

"I don't know that I can get you a new nurse.  If you're having a problem with your nurse, you can ask to speak to the nurse manager."

"More people to speak to?  This is ridiculous.  I want to speak to another doctor."

"I can have another doctor speak to you.  I'm not the primary doctor for your father, but I am familiar with his case.  That's why they had me talk to you.  I know you're frustrated.  You have a right to be frustrated.  Do you have any medical questions?"

"Yes.  Why does he need physical therapy when he's walking fine?"

"I thought you were upset he wasn't getting physical therapy."

"No, I'm upset that we were told we're entitled to physical therapy, and we're not getting it.  This is a different question, about why he would need physical therapy."

"Perhaps he doesn't, and that's why physical therapy hasn't come."

"If we're entitled to physical therapy, we want physical therapy.  If it's part of the package, we definitely want it."

"There's not a package.  Your father is supposed to get the treatment he needs."

"We also need some more of those toothbrushes that were in his room."

"You can ask the nurse for toothbrushes."

"We don't like the nurse."

"I don't have any toothbrushes."

"When is physical therapy coming?"

"I'm going to have you talk to a different doctor."

"I'd like to speak to the [p]resident"

I'm on call in the hospital and I get paged that a patient's family wants to talk to me about a patient I consulted on earlier.  I stop by the room.

"Are you the president?"

"Pardon?"

"Are you the president of the hospital?"

"No.  I'm the fellow who saw your mother earlier today."

"My wife has a brother who is a doctor, and he told me I should always make sure I speak to the president, because the president will be most familiar with the patient."

"I think you probably misheard.  He probably said resident."

"No, he said president."

"I think he said resident."

"Why would I want a resident of the hospital to know about my mother's condition?"

"Residents are the doctors who are most involved with the medical plan.  I was a resident until last year, and now I am a fellow.  The attendings are the doctors in charge of the decision-making.  That's just the hierarchy of the team.  The hospital president is not involved in patient care."

"He should be.  I want to speak to him, like my wife's brother said."

"I'm sure he said resident.  I can get the resident to stop by after rounds."

"The young woman we spoke to before?"

"Probably."

"She didn't seem like she was the president of anything."

"She wasn't the president, she was the resident."

"I'd rather wait for the president."

I Have Most of My Parts

96-year-old patient.  Female.  Complaining of stomach pain.

"I'm just going to see if there's any tenderness, okay?"

"I didn't know you were going to be touching me."

"I'm sorry, is that okay?"

"Yes, but I would have put on a little more makeup."

"Let me know if you feel anything."

"Oooh.  Yes, that hurts."

"And how about here?"

"Yes, that hurts too."

"I didn't see anything in your chart... have you had any surgeries in that area?"

"Surgery?  Like what?"

"Have you ever had any ovarian issues, have you had a hysterectomy, anything like that?"

"Well, I don't get my period anymore."

"No, I wouldn't expect that you would."

"And the doctor said I can't have any more children."

"Right, but is that because of any procedure you may have had, even if it was years and years ago?"

"Now that you mention it, I think they did take something out."

"Do you know what they took out?  Did you have a hysterectomy?"

"To be honest, I don't know.  I'm not really sure what's inside me anymore."

"Okay, I'm going to send you for a scan to see what's inside of you, and to make sure there's nothing concerning going on.  Obviously we don't want to look for problems at your age that it's better not to find, but I just want to see if we can figure out if there's a reason why you're so tender down there."

"You don't think that doctor was wrong and I'm pregnant."

"No, I don't."

"Okay, that's a relief."

Yes, I know that word.

"Doctor, I've been having terrible itching."

"Where is the itching?"

"My anus."

"Okay, how long has this been going on?"

"A while.  There is also some leakage."

"Oh."

"Yes, s*** is coming out.  I know that's not a medical word.  Do you know that word?"

"Yes."

"So you know what I mean when I say s*** is coming out of my anus?"

"Yes, I know what you mean."

"Because I don't know the medical word, but I wasn't sure if you would understand what I mean by s***."

"I understand what you are saying."

"Yes, it is leaking out of my anus."

"Okay."

"The s***."

"I got it.  I can give you a cream."

"To put in my anus?"

"To put on the skin, for the itching.  And I'm going to refer you to a gastroenterologist for the leakage.  I hope you feel better."

"I just feel like I'm always covered in s***."

"I'm sorry."

"You know what I'm talking about, right?  Even though that's not the medical word."

"Yes."

"Okay, I just wanted to make sure."

"Take care."

Opening Questions To Bad Conversations

"Do you know where the morgue is?"

"Wait, how many pills did you give him?"

"Does the patient have any family you think might be likely to sue?"

"Oh, so this was the patient you were talking about?"

"Did it always look like that?"

"Was there a patient in here earlier?"

"Do you know if she's an organ donor?"

"Is there a way we could get that cleaned up before it causes any more problems?"

"Has it smelled this bad for a while?"

"I'm sorry, your fever was what?"

"Did you see if the teeth are in the closet?"

"You don't happen to know if your father had any undocumented allergies, do you?"

"So no one had checked his pressure since... Tuesday?"

"Your malpractice insurance is all paid up, right?"

"Are you sure that was a doctor who works here?"

"Did you mark the leg that was supposed to be cut, or the one that wasn't?"

"Are you sure it always looked like that?"

"You went to the bathroom how many times?"

"You haven't gone to the bathroom in how many days?"

"Wait, can you say that again, but trying not to slur your words?"

"Is she always this difficult to rouse?"

"Did you ever follow up on that?"

"Did you notice that last time you saw her?"

"Do you think the med school would even want a body in this condition?"

"Do we have beds that can support that much weight?"

"Did I just step in what I think I stepped in?"

"Did all of that actually come out of your body?"

"Does anyone know where the crash cart disappeared to?"

"Oh, was I supposed to be running this code?"

Seeing Patients Is For Losers

"So, have you thought about what you want to do after fellowship?"

"Of course it depends on the jobs that are out there... but I think I want to find something that's mostly outpatient."

"Like, private practice?"

"Yeah, maybe."

"Ugh.  So you just want be a... clinician?"

"I find it more satisfying than inpatient-- you get to form actual relationships with your patients when they're not acutely ill...."

"No research?"

"I'm not opposed to research.  I just don't know that I'm passionate about it."

"So you really just want to see patients... in an office...?  That's so, I don't know... unambitious.  That's really why you went to medical school?"

"I guess so, yeah."

"Ugh.  Seeing patients is so annoying.  I can't believe that's really what you want to waste your time doing."

"I don't think it's so completely a waste."

"You know what I mean."

"Sort of."

"Well, whatever, I guess if I hear of anything ridiculous like that, anyone looking, I'll send you an e-mail."

"Thanks."

"You do realize we're probably hiring a whole bunch of people to do inpatient hospitalist stuff, right?  Mixed with research and some teaching?"

"Yeah, I heard about that."

"And you'd rather see patients."

"I think so, yeah."

"Whatever, it's your life."

Aside from the dementia...

"...so, aside from the dementia, your mother's doing pretty nicely, all things considered."

"Great.  I just wanted to ask if you could write a letter to her boss saying she's healthy enough to work."

"I'm sorry, what?"

"A short letter -- her boss wanted to see a doctor's note to just make sure she was OK to work."

"Your mother works??"

"Yeah, she's a secretary at a law firm."

"She's 88 and demented."

"Yeah, it's okay, she brings her aide."

"She brings her aide to work?  I'm sorry, does her aide do the work?"

"No, she just helps her."

"I'm sorry, I must be missing something.  Your mother doesn't recognize you.  She didn't realize this was a doctor's office.  I'm kind of floored to imagine she could do the job of a secretary."

"It's a low-volume desk."

"Still...."

"Look, I just need you to write a note saying she is physically healthy enough to go into the office, with her aide."

"I'll tell you, you are right that she is physically healthy enough to do that.  But she's not mentally equipped to still be working in any capacity that requires her to remember things."

"I think that's for her and her boss to figure out.  He just needs to know that she's not at risk of anything medically."

"I can write some kind of note saying she's physically healthy, but I can't write a note recommending she have a job in an office."

"That's okay.  The physically healthy part should be fine."

"I'm sorry, I have to ask-- why does her boss keep her on the payroll?"

"He's also 88.  He likes the company."

"Okay.  That's fine.  I'll write the note and be right back."

"I was wiping my mother, and..."

"I was wiping my mother, and..."

"Yeah?"

"...and I found, you know those plastic things they put on clothing to keep people from stealing them?"

"Like, an anti-theft tag?"

"Yeah, the long, plastic things, with the metal clip that attaches to the clothing...."

"Okay...."

"Yeah, I found one of those when I was wiping her."

"Like, coming from inside of her, or like she had sat on it or something like that?"

"No, definitely from inside her."

"Those things are not small, right?"

"No, about three inches.  And sharp on the edge."

"But no bleeding, and everything else normal?"

"Yes, everything fine."

"And you're sure she didn't sit on one, and it was just stuck on her?"

"Yes, I'm sure."

"So you're saying you think she swallowed one, and it passed through her?"

"I don't know!  Is that what you think?"

"There doesn't seem to be a lot of options if you're saying she passed it in her stool.  It had to come in from one end or the other."

"Oh, interesting."

"Did you recently remove something like that from any clothing in the house?"

"No, we don't steal clothing."

"I'm not accusing you of stealing clothing.  But it would have had to have come from somewhere."

"I don't know.  She never leaves the house."

"Well, if there was no bleeding and everything is normal, I wouldn't worry about it."

"I saved it.  But I accidentally left it at home.  Should I bring it next time?"

"That's okay.  I think you can throw it out."

"In the regular garbage?"

"I suppose."

"So you don't want to run any tests on it?"

"No.  If she's not having any problems, I think we can just chalk it up to an inexplicable accident, and cross our fingers that it doesn't happen again."

"You don't think it poisoned her?"

"Is she behaving strangely?"

"No."

"I think she'll be okay."

"If I find another one, what should I do?"

"If you find another one, you should look around the house for the source of these things."

"Do you think I need to call the plumber?"

"What?  What would the plumber have to do with this?"

"I don't want these things to stuff up the toilet."

"Okay, let's just try and pretend none of this happened, and move on to the next issue."

Refills for everyone

"My mom needs refills on a bunch of her meds."

"Okay, that's fine, let's go down the list and I can give you prescriptions."

"[drug]"

"Great."

"[drug]"

"Great."

"[drug]"

"Great."

"Percocet."

"Wait, why is she taking percocet?"

"Her last doctor prescribed and just kept refilling."

"How long ago?"

"Years, I think."

"How many is she taking?"

"I don't know.  She doesn't have any left." 

"How often is she taking Percocet?  I don't think she needs to be taking Percocet."

"Just in case.  When she has pain.  She's barely taking any."

"I think we should try and not have her taking Percocet."

"She doesn't take them, okay?"

"Then you don't need the refill.  What's next?"

"You can't just give her some in case?"

"You just said she's not taking them."

"Yeah, but sometimes I'll take them."

"What's the next drug on the list?"

"Just a few Percocet, in case of an emergency?"

"Look, I'm pretending I didn't hear what you said, because you're not my patient, and I'm not prescribing your mother this drug.  We can make this a bigger issue, or we can just move on to the next drug."

"Okay.  [drug]"

"Great."

"[drug]"

"Great."

"Oxycodone."

"Okay, I'm going to go get my attending.  Give me a minute.  Thanks."

"Young and Rich"

"So, Mrs. Patient, it was great to meet you, and I'll see you in six weeks for a follow-up... and hopefully everything is stable until then."

"It was nice to meet you too, doctor.  Oh, how I wish I was young and rich."

"I wish I was young and rich too."

"You are!"

"Medical school is expensive."

"You're a doctor.  I bet you make a million dollars a year."

"I'm a fellow.  I make a lot less than a million dollars a year.  And even after fellowship, I will make a lot less than a million dollars a year.  I'm not complaining, but, a million dollars, that's not what's going on here in the clinic for anyone."

"My cataract surgeon told me he makes a million dollars a year."

"Your cataract surgeon sounds awesome."

"No, he is great.  I can see now."

"I'm glad.  I'll see you in six weeks."

"You will be making a million dollars by then."

"I don't think so, but thanks."

"No, I will send you my friends."

"I appreciate it."

"They have good insurance."

"That's great."

"No, really.  Better than mine.  No co-pay."

"I'm glad.  I'll see you soon."

"Wait-- you know I have co-pay, right?  I have to tell you-- I can't pay my co-pay.  You can send me bill, and I will try to pay it, but I can't.  You still see me?"

"I really don't deal with the billing.  I'm just a fellow.  I see whoever shows up in my office, I promise."

"So you still see me?"

"I have no idea what the clinic does when people don't pay their co-pay, honestly.  If they let you in my office, I will see you, I promise."

"Yes!  Now I definitely send you all of my friends."

"Great.  Thanks."

Prostheses by Phone

"I wanted to know if you had the phone number of the prosthesis place."

"What place?"

"I wanted to order one."

"That's not how it works.  You need to talk to your surgeon, and he'll connect you with the people who can fit you for the prothesis, and do the training and rehab you'll need...."

"I thought I just call a number."

"And they send you a leg in the mail?"

"Yeah.  I thought maybe they'd want to know my height, so I was going to ask you to measure me."

"It's more complicated than that."

"So if I go to my nephew's wedding this weekend, I probably won't be able to walk?"

"No."

"Oh.  I didn't want everyone to know I had to have my leg amputated."

"Unfortunately, it's a longer process than that.  They're going to know."

"Could I maybe get a fake prosthesis, and just pretend it's real?"

"A fake fake leg?"

"Yeah, I guess."

"I wouldn't know where to send you for that.  Maybe a costume shop?  But you're still going to need the wheelchair."

"I can't just get a pair of crutches or something?"

"I don't think you'll be able to maneuver on them without a lot of physical therapy."

"I have a couple of hours free tomorrow."

"No, it's a longer process than that."

"And will insurance cover something like this?"

"The therapy?  It should."

"No, the costume shop."

"No."

"What if you write a note?"

"I don't think so.  Sorry."

"Do you think a costume shop would deliver?"

"I really don't know."

"Do I need a referral?"

"No."

"Maybe my surgeon can give me a spare leg he has in the office?"

"I guess you could ask."

"Great, thanks."

The Earring

"Hey," said one of my medical students.

"Hey.  What's going on?"

"I have a weird situation."

"Okay...."

"I lost an earring this morning.  It's my mother's earring, it's expensive.  I've looked everywhere... and I think I might have lost it while examining a patient."

"Okay...."

"I remember scratching my ear while I was in with Patient Jones.  And ever since then, I can't find the earring.  So I think I might have lost it in Patient Jones's room."

"You mean Patient Jones who just died, five minutes ago?"

"Yes, I mean Patient Jones who just died, five minutes ago."

"So you think it's in Patient Jones's room?"

"I think it may be in Patient Jones's bed.  I was wondering if you thought it would be okay for me to go in and take a look."

"While his family is there, with the body, saying goodbye?"

"Before they wheel him out, yeah.  Is that too weird?"

"It might be too weird."

"Maybe if there was a way we could ask the family to step outside for a moment, something medical we have to do, and I could take a quick look?"

"You're saying 'we' like I'm part of this plan."

"You won't help me?"

"What if you just go in and take a quick look and see if you see it?"

"But I want to be able to turn him over if I don't see it, maybe see if the earring slipped underneath him."

"I don't know."

"Come on, it's from my mother."

"I guess you can go in and ask the family if they happened to see an earring... if they seem composed...?"

"Will you go in with me?"

"I guess...?"

"Great.  Thanks.  I really appreciate it."

***

"Excuse me, Mrs. Jones?  This is going to sound like a ridiculous question, but did you happen to see a silver earring in your father's bed?"

"No.  Wait.  Actually, we did see something silver.  We weren't sure if it was a piece of medical equipment."

"No, it was my medical student's earring."

"Oh.  Well, here, here it is.  It does make more sense as an earring than a probe of some sort."

"No, no probes.  Thank you so much.  And, again, I'm so sorry for your loss."

The Leg.

"I was really sorry to have to call you this morning to tell you that your mother passed away.  I know we all expected this, but I'm sure it's still very difficult."

"Yeah, sure, do you want her leg?"

"I'm sorry, what?"

"Her leg.  The prosthesis.  We were thinking we'd donate it, if you guys want it."

"I mean... it was fit directly to your mother... I'll have to ask someone else if there's any use for a used prosthesis...."

"Do you have a form so we can get a tax deduction for it?"

"I don't have a form, no."

"It's probably still worth almost as much as it was new, right?  Do you know what she would have paid for it if not for the insurance?"

"No."

"Do you think you could find that out?"

"Uh...."

"We also thought we'd donate her walker, if that has any value."

"We could probably use the walker for patients who don't yet have their own...."

"Great, can the hospital pay us anything for that?"

"No...."

"And we pre-paid for another week of television service.  How does that work?  Do you give us back that money, or are we allowed to take the TV for a week?"

"I'm pretty sure you can't take the TV.  You can ask the billing office about getting the money back."

"Great, great.  Do people get buried with their teeth, or do you guys want those too?"

"We don't need her teeth."

"But could we get a tax deduction if we leave them here?"

"I don't think that's something we usually deal with...."

"Is she still getting lunch?  Because we're kind of hungry, and I guess we could all split it if it's going to come anyway."

"No, they stop serving meals after a patient dies."

"Okay, well, just in case they've already set up the tray-- we'll still take it."

"I'll let them know...?"

"If there's a way to take it to go, that would be even better."

"I don't think...."

"Also, I assume she didn't eat much of her breakfast-- do we get a credit on the account for that?"

"Her meals were covered in the overall cost of her stay."

"Oh, is she still being charged for the room until we leave?"

"I don't...."

"It's fine, we're going.  We left the teeth on the pillow.  Take care, doc."

"Sorry again for your--"

"Bye."

Getting Dumped

Sorry for almost a week since the last post.

Patient comes into clinic.  "So, how's the wound looking?  You've been seeing Dr. Dressing, right?"

"Sort of."

"What do you mean?"

"I've been trying to get another appointment, but he's refusing to see me."

"Refusing?"

"His secretary said that she wasn't allowed to make another appointment for me.  I saw him three times.  The wound was doing better.  So I want to see him again.  But they won't let me!"

"Do you have any idea why?"

"I don't know.  I had to cancel an appointment last-minute because the weather, but I can't imagine what else."

"And they didn't say?"

"The secretary said she couldn't talk about it."

"That's very strange."

"I know!  I was hoping you might able to call and get them to see me."

"I can call and see what's going on, but I can't promise that he'll see you.  I can try to get you a referral to someone else, though."

"I want to see Dr. Dressing.  He was making things better!"

"I'll see what's going on."

I give Dr. Dressing a call.  "Hi, this is a little awkward, but I heard from Patient Ulcer that your office won't schedule an appointment for him?"

"Yeah, he missed 11 different appointments.  I really can't deal with that in my practice."

"11 is a lot."

"No kidding."

"Do you know of someone else he might be able to see?"

"I actually referred him to my least-favorite colleague.  Patient Ulcer should see her instead."

"Okay, I'll pass along the name.  Thanks."

I call my patient.  "I spoke to Dr. Dressing.  He said you missed 11 appointments and he gave you another doctor's name.  Do you still have it?"

"I did not miss 11 appointments.  It was only 10."

'That's a lot of appointments to miss."

"I didn't feel like going to the doctor.  And what's the big deal?  I miss appointments with you all the time."

"I don't get paid based on how many patients I see."

"Then I'm just making your life easier by not showing up, aren't I?"

"Not really."

Hospital Visitation Policy

1. Visiting hours are 10AM-12PM and 2PM-8PM, unless you look like you know where you're going and don't stop at the security desk.  A visitor's badge is required, except it isn't.  Only two visitors per patient, except for people who don't ask about the two visitors per patient rule, in which case, one thousand visitors per patient are allowed at any given time.

2. No children are allowed to visit patients, especially adult children, because they are the most irritating visitors.

3. If you are sick, please only visit Mrs. Terrible in room 934.  It would be great if she caught something.

4. Do not bring outside food into the hospital, unless you value the health of your loved one, in which case you should bring enough outside food that he or she can skip our meals.  Also, you should probably bring outside food for yourself, because if you eat the cafeteria food, you will likely end up joining your loved one as a patient.

5. The bathrooms are only for patients and those who are lacking a sense of smell.

6. Hospitals are busy places and patients are often on the move.  If you arrive and your loved one is not in his room, it is probably because he died and we forgot to tell you.  If you see any of his belongings, there has been a mistake -- patient belongings are immediately removed from the room by thieves when the patient is taken for tests.

7. There is a lost-and-found in the backpacks of most of our hospital interns.  There, you can find chargers for every possible type of cell phone and mobile device, along with hundreds of pairs of dentures.  Feel free to browse.

8. Everyone you see in the hall is a doctor, and specifically the doctor who treats your loved one, so we will all be able to discuss every detail of his case, calmly and patiently, if you stop us while we're on the way to resuscitate his neighbor.

9. The people with mops and buckets are the most informed doctors of them all, and will be glad to tell you whether your loved one took his medication today, or give you an update about his currently-happening surgery, since they also have devices implanted in their brains that allow them to see into operating rooms six floors beneath them and telepathically communicate with the surgeons performing the procedure.

10. Yes, we do make extra lunches for family members.  You may eat as much as you like and we will be happy to bring you more.  We can even cater to your food allergies and entree preferences, since we are here to serve you, the visitor, even if it's at the expense of our patients' health.

11. Please only discuss interesting parts of your loved one's medical history while in the hallway or elevator.  We are tired of hearing about their diarrhea.

12. Discharge will always happen exactly when we planned it a week ago, even if there have been complications in the interim.  So, yes, please come to the hospital prepared to take your loved one home, especially if you haven't talked to his doctors in days and know he's on a ventilator.  We'll even send you home with a few extra lunches.

13. Your loved one's doctor works twenty-four hours a day, seven days a week, and spends most of his time lurking just around the corner, waiting for you to need something from him.  So, yes, please get very irritated if he can't be found in three minutes when it's midnight on a Sunday and you want to find out whether that cookie your loved one got on his meal tray three days ago was actually sugar-free, or the nurse was just saying that.

14. Wear your most expensive white outfit when you come visit, because there's no way you will ever accidentally touch anything dirty.  This is a hospital, after all.

Enjoy your visit, and please come back soon.

Dead. Or not.

TO: All
FROM: Anon Doc

Hey, I just noticed in the system that Patient XYZ is listed as deceased, but there's no note.  Does anyone know what happened?  I saw him two weeks ago and he looked good.  Thanks.

TO: Anon Doc
FROM: Attending

Oh, wow, I saw him that visit too.  He did look good.  I wonder what happened.  Do you mind calling his family?

TO: Attending
FROM: Anon Doc

Okay, I'll give them a call.  But it's weird there's no note, right?

TO: Anon Doc
FROM: Attending

Maybe the family called but didn't give any information.  Let me know.

TO: Attending
FROM: Anon Doc

I just called.  He answered the phone.  Not deceased.  I asked how he was doing.  He said he was fine.  Said I was just calling to confirm his next appointment.  Do you know how to change his status in the system from deceased to alive?  I'm not sure how to do it.

TO: Anon Doc
FROM: Attending

Not sure, sorry.  Glad he's alive.  Maybe ask the helpdesk.  Thanks.

Rehab: Acute vs. Subacute

"So, they tell me you're giving them a problem about going to rehab."

"No, no problem, they're telling me I don't qualify for acute rehab and they want to send me to some kind of nursing home."

"They want to send you to a subacute facility, yeah."

"I don't want to go to a nursing home."

"You won't be in the nursing home part."

"It's still a nursing home."

"It is."

"You told me I could do rehab in the hospital."

"I told you that if you qualified for acute rehab, you could do it here.  But you didn't qualify."

"Why not?  My insurance is good."

"Your insurance is fine.  It's because you're not able to do enough hours a day of rehab.  They wrote in the note that you've refused rehab for the past three days."

"I was tired."

"Right, but in order to get into acute rehab, you need to demonstrate an ability to do a certain amount of exercise.  And you haven't been.  It's an evaluation they have to do.  It's disappointing, I'm sure, but as long as you're trying your best, this is going to be a better fit."

"I can do exercise.  Just not when I'm tired."

"But if you're tired here, you're going to be tired there."

"No.  My wife said she would do the exercise if I couldn't, and then she would show me how to do it when I'm not tired."

"It is not beneficial for your wife to do the exercise."

"It sure is.  My wife is fat."

"Okay, but these exercises specifically are designed to strengthen you, not her.  You're the patient."

"She needs as much exercise as she can get."

"Everyone should exercise.  But we're talking about your rehab, not her exercise."

"If you make her do exercise, I'll do rehab."

"I don't know how these things are related.  You need to do rehab."

"If my wife gets to sit on her butt all day, I'm gonna do the same."

"You need to do rehab."

"And all she does is eat."

"We're talking about you, not your wife."

"Can she go to rehab with me?"

"Not unless she has a medical need."

"The system sucks."

"I'm sorry."

A Hamburger, Fries, and a Heart Attack

I stop in to check on one of my patients in the hospital.

"How are you feeling this morning?"

"Great!"

"Well, that's terrific.  You're in good spirits, for sure."

"The surgery team just came in and told me to eat whatever I want!  They said I should have someone bring me a burger and fries!  Can you bring me a burger and fries?"

"I can't at 8 in the morning... but also I'm not sure I should... or that anyone should.  You're sure they said burger and fries?"

"They said I needed more calories!"

"Right, but you don't need the salt and the fat... maybe they could get you some more Ensure?"

"That stuff is nasty."

"Maybe, but I don't know if they were looking at the whole picture.  Burger and fries may have just been their way of saying you need more nutrition.  I can take a look in the system at your labs and give the surgeon a call to check in...."

"Are you ruining my good news?"

"I think I might be.  I just don't want to see anything go wrong from a cardiac perspective.  I know the surgery team wants you strong for the procedure, but I'm just not sure those are the perfect dietary choices.  Besides, have you had a hamburger from the cafeteria?  They don't look good."

"I didn't want one from the cafeteria.  There's a McDonald's like three blocks away."

"I know.  And that's probably even worse."

"You are spoiling this great day, doc."

"I don't want to spoil it.  But I also want to make sure we don't inadvertently cause any problems.  I'll talk to your cardiologist and see if he can connect with the surgery team and make sure everyone's on the same page.  If they're cool with the burger-- I'll see what I can do."

"Bacon cheeseburger?"

"Unlikely."

"Worth a try though, right?"

"Absolutely."

"So the two of you are partners?"

I walk into the exam room with my attending, and introduce her to the patient.

"The two of us work together, and she's going to take a look at you, if that's okay."

"So the two of you are partners?"

"Sort of.  I'm in my fellowship, so I'm still being trained, and she's one of the attendings who supervises."

"So you both get paid for seeing me?"

"We both get paid regardless of whether we see you.  I get a salary.  It doesn't change based on whether I see you or not."

"So how do you split the profits on me?  50/50?  Or do you get more because you spent more time with me?"

"Like I said, I don't get anything for seeing you.  I get paid a salary.  It doesn't change based on how many patients I see or how much time I spend with them."

"So you want to spend as little time with me as you can and go see the patients who pay you?"

"No.  No patients pay me.  Medicare pays the hospital.  The hospital pays me a salary.  I spend as much time as I need to with you.  I have other patients waiting, but there's no monetary reason why I would spend less time with you."

"What if I paid you directly?"

"I get a salary.  Patients don't pay me."

"But would you spend more time with me if I paid you?"

"There's nothing I could do for you with more time.  I'm spending the right amount of time with you.  You paid into Medicare your entire working life.  Medicare pays the hospital.  If you have a co-payment, that is something you and Medicare deal with.  I don't deal with your money.  I don't know how much you pay, or who gets it.  Doesn't matter."

"Matters to me."

"Okay, but it doesn't matter to me."

"So if I pay you a little bit on the side, you can't give me a better medicine or something like that."

"I can't give you any medicine.  I can just write prescriptions.  The pharmacy gives you medicine."

"So if I pay the pharmacist, I can get better medicine?"

"No.  You get the medicine I prescribe, which is the medicine you need.  We're not holding back the good stuff for the people who pay more.  There's nothing better than what I'm giving you."

"That's not very reassuring."

"Medicine isn't perfect.  We're doing our best."

"You would do better if I gave you more money."

"I wish that was how it worked.  I would love to be able to charge patients for the good doctoring.  But it just doesn't work that way.  You're stuck with the best we can do, and we're stuck with our salaries."

"I thought doctors got rich."

"Some might, but fellows don't."

"So you're saying the women do?"

"No.  Fellow means someone still in training.  It has nothing to do with gender."

"That's confusing."

"Sometimes."

Hyperbolic Chambers

"...so I notice you still have your foot.  That's great."

"Yeah, the surgeon really wants to amputate, but a friend told me something about a hyperbolic chamber, so I think I'm going to try that first."

"You mean a hyperbaric chamber."

"Whatever, yeah, I guess.  They're good, right?"

"Honestly, I don't know a lot about hyperbaric chambers, and certainly I don't know the specifics about whether that's a reasonable plan for your foot.  I'd listen to what Dr. Surgeon says.  That's his expertise."

"He says he wants to amputate, or I could die of a septum infection."

"A septic infection."

"Yeah, yeah.  But I'm going to try this hyperbolic chamber thing.  Cause, you know, if I don't, I'd always wonder what if I could have saved my foot."

"Again, that's something to talk to Dr. Surgeon about."

"No, my friend got totally healed from the chamber thing.  He had this burn on his skin, and it was like a miracle."

"Okay.  Your issue is different from a burn.  You have a wound that isn't healing because of a lack of blood flow."

"Sure, but if it can do one thing, it can probably do lots of things."

"I don't know what it can or can't do, but, generally, that logic doesn't really work.  Some treatments are very good at very specific things, and not good at all at things that are not the same."

"No, if something works, it works."

"Well, like, you wouldn't take medicine that's great at treating infections if you had, say, high cholesterol."

"Why not?"

"Because different medicines do different things."

"No, no, if it's good, it's good.  And I'm telling you, you didn't see my friend, the hyperbolic chamber is an amazing thing."

"Hyperbaric chamber.  And I think you're being a little hyperbolic when you talk about it."

"What?"

"I was just trying to be funny.  Never mind."

"I don't get it.  You're not funny, doc."

"Yeah, don't worry about it.  Just, please, talk to your surgeon and make sure he's on the same page.  Septic infections are a real risk."

"I'm telling you, the chamber is going to heal this thing up.  Maybe fix my blood pressure too.  The oxygen, pressure, I think it's all related."

"It's good to be optimistic.  Make an appointment for six weeks and we'll see how you're doing."

"Either this will happen or that will happen"

"Doc, I just saw the cardiologist last week, and, I have to tell you, he wasn't very reassuring."

"No?  What did he say?"

"He looked at my EKG and basically put out his hands and said-- it could go either way.  Either you'll have a  heart attack-- or you won't."

"Did you give you any medication?"

"I don't know."

"No, it's a real question.  Did he put you on any medication?"

"He gave me some prescriptions, but I don't know what I did with them."

"I can check in the system and call them into the pharmacy if that would make it easier."

"I don't know-- is there even a point?  If I'm either going to have a heart attack or I won't, what's the point?"

"Well, everyone's either going to have a heart attack or they won't.  The point is to decrease the odds that you do, and increase the odds that you don't."

"Whatever, my life is over anyway."

"I'm wondering if it might benefit you to talk to someone about your health and your anxieties about it."

"I'm talking to you."

"I mean someone who might be able to prescribe you something to make you feel more relaxed.  Do you sleep well?"

"No."

"So maybe this would be useful."

"You mean a shrink?"

"A psychiatrist, or maybe a psychologist would be useful, just to have someone to talk to, even if you don't need medication."

"I'm not crazy."

"I'm not saying you're crazy."

"I wasn't worried until I went to the cardiologist.  He was just so matter of fact about it.  Either I will or I won't.  Either I'll live or I'll die.  No difference to him."

"I'm sure it mattered to him.  But even if it didn't, it matters to you and your family.  Not important if it matters to your doctors as long as we're giving you the best treatment."

"I'd rather see a cardiologist who didn't have such bad news to give me."

"I'm not sure I can change the news, but maybe it would be helpful if I referred you to a cardiologist who would be better at delivering it."

"Will I need to pay another co-payment?"

"Yes."

"Then I don't know.  I'm tired of sitting in doctor's offices."

"I understand.  Why don't I call in your prescriptions to the pharmacy, and set you up with a social worker, who can see if we can get you an appointment with a psychologist, just to see if that would be helpful."

"The psychologist is going to take another EKG?"

"Nope."

"Oh, okay."

Too Young

A patient's son calls me.

"I wanted to talk to you.  You saw my father for the first time on Monday."

"Yes, I did."

"He said you looked too young to be a doctor."

"He told me that too.  I'm not that young."

"How old are you?"

"[age]."

"That's young."

"I'm sorry.  That's how old I am."

"I don't think that makes you a good doctor."

"I don't think anyone's age makes them a good doctor or a bad doctor."

"He said you were still in training."

"Sure.  I'm a fellow."

"So you're not really a doctor?"

"No, I am a doctor."

"He said you weren't."

"I had this conversation with your father too."

"He said you barely even asked for a history."

"No, we spent a while trying to go through his history, but he was having trouble remembering it, because he has dementia.  It might have been helpful to have someone else at the appointment who had a better sense of his background, but if you want to go through that now, I can be better equipped next time I see him."

"Oh, there won't be a next time.  We don't want a doctor with so little experience."

"Okay, that's fine.  You're free to find a different doctor."

"You're not even going to defend yourself?"

"I'm not sure what you wish would have been done at the visit, but if you're more comfortable with an older doctor, there's no reason for me to try and change your mind."

"Yeah.  Too young."

"Okay.  Is that it?"

"Well, I was also wondering if you could refill my Oxycodone."

"You're not my patient."

"My father's last doctor did it."

"I'm sorry, sir.  I wish you and your father all the best."

President's Week

I meant to post this Monday, but it is not Monday anymore.

In honor of President's Day, here is a list of some of the answers my patients have given when asked who the President is:

Obama
Bush
That guy
Kennedy
You know who it is
Reagan
Some old guy
Washington
The black guy
Clinton
I can picture him
Nixon
You know, that guy on TV
Omaha
The one with the hat
The man who stands there
Why you asking me that?
You don't know the President?
Why don't you tell me?
I'm not listening to a doctor who doesn't know who the President is
The guy who won the election
George
I don't know, is his name Jackson?
Not me
Not you
No one?

IV Drug Use

Just going down a standard history...

"Any smoking or drinking?"

"No, not at all."

"So I'm sure no IV drug use?  Just have to check the box on the form...."

"Uh...."

"You use IV drugs?"

"Well, my husband does...."

"Your husband uses IV drugs?"

"Sure, we have an IV pole in the basement and everything."

"When I said IV drugs, I mean like heroin.  Illegal drugs."

"Oh, no, I was talking about antibiotics."

"Yeah, that's fine."

"I think it's vancomycin."

"Yeah, that's fine."

"Hmmm. That's a good question."

An elderly woman and her husband come to see me.  She's the patient.

ME: "So what brings you in today?"

WIFE: "Oh, we thought we were going to see my husband's doctor."

ME: "You come to this clinic too?  Who's your doctor?"

HUSBAND: "I don't know."

WIFE: "We've never been here before."

HUSBAND: "No, I think we have once."

WIFE: "No.  I don't know.  Wait, is this my appointment or yours?"

HUSBAND: "Mine.  No.  Yours."

ME: "So, the two of you live alone?"

WIFE: "No, we're married."

ME: "Yes, I meant do you have an aide who helps you?"

HUSBAND: "No, we're okay."

ME: "And what brings you in today?"

WIFE: "It's cold."

ME: "The weather?"

WIFE: "No.  In here."

ME: "Okay.  What medical problem brings you in?"

HUSBAND: "I'm not sure.  I think we had an appointment."

ME: "Okay.  Do you remember why you made the appointment?"

WIFE: "I was in the hospital."

ME: "Oh, recently?"

WIFE: "No, I don't think so."

ME: "Okay, no one lives with you to help you?"

HUSBAND: "No."

ME: "And what did the two of you do for a living?"

HUSBAND: "I was born here."

WIFE: "I'm not having a good memory day."

ME: "Do you know what medications you take?"

WIFE: "I think the pharmacy would know."

ME: "Which pharmacy do you use?"

HUSBAND: "I can't remember the name.  Can you?"

WIFE: "I'm not sure.  Maybe I have their card."

ME: "I'm just trying to figure out what brings you here today.  Do you have any pain?"

WIFE: "No."

HUSBAND: "I have some pain in my back sometimes."

ME: "Okay, but your wife is my patient."

HUSBAND: "Oh, sorry.  I forgot."

ME: "It's okay.  Do you mind if I ask both of you to draw a clock on a piece of paper?"

WIFE: "Should I start with the box?"

ME: "What box?"

WIFE: "The box for the clock."

ME: "If it's okay, I'm going to bring a social worker in.  I think there may be some services we can help arrange so you have some help around the house.  Do you find that you get confused at home?"

HUSBAND: "I don't know."

WIFE: "Sometimes when I'm on the toilet, he looks for me and can't find me."

HUSBAND: "When you're on the toilet, right?"

ME: "Do you mind if I listen to you breathe?"

HUSBAND: "No."

ME: "I was talking to your wife, because she's the patient right now."

HUSBAND: "Sorry, I forgot."

WIFE: "Did we come here to see you, or did you come here to see us?"

ME: "Do either of you know what year it is?"

WIFE: "This isn't a good day for me."

HUSBAND: "It's 19-something, right?"

ME: "I'm going to get the social worker and will be right back."

WIFE: "And then you'll check us in?"

ME: "Check you in where?"

WIFE: "I don't know."

HUSBAND: "She doesn't know."

ME: "Okay.  Great."

Yes, I See Your Badge

A woman approaches me at the nurse's station.

"Hi.  Are you the doctor dealing with my mother?"

"What's your mother's name?"

"You should know her name."

"I will if she's my patient.  Can you tell me who she is?"

"Look, do you see my badge?  I'm chief of [a department] at [other nearby hospital].  So don't think you're going to get away with anything."

"I'm not trying to get away with anything.  Who's your mother?"

"Jane Smith."

"Yes, she is my patient.  She's been my patient since Tuesday.  We've been trying to reach you."

"Well, I've been busy!  See my badge?  I'm a very busy person.  I don't just have time to talk at your convenience."

"I'm glad to meet you now."

"Give me a break.  I want to know what the plan is for my mother."

"The plan is to continue with the IV antibiotics, and plan for discharge once she becomes afebrile."

"So I could come back for her on Monday?"

"You know as well I do that depends on how she does over the weekend."

"I can't change my schedule last-minute.  I'm very busy."

"Yes, you said that."

"So we'll plan for discharge on Monday.  Give me your cell phone number and I'll call you Sunday night to confirm."

"Why don't I just call you once we know more about the plan for discharge."

"No.  Give me your cell phone number.  Look at my badge-- I'm very important."

"I can't give out my personal number.  It's against hospital policy."

"It is not."

"Maybe not at your hospital, but I'm not giving out my personal number to patient families.  I'm sorry.  You can call the nurse's station and they can page me if you need something."

"I'm not dealing with nurses."

"I'm sorry.  I have other patients I need to see.  If there's anything else you need, you can leave a note at the nurse's station.  It was nice to meet you."

15 Ways To Fill Out A Death Certificate

That shouldn't really be the title of this post, but I read somewhere that blog posts with numbers get more readers.  So there it is.  I get a call this morning from the medical examiner's office.

"One of your patients died last night?"

"What?  Who?  Why don't I know this?"

"You're listed as the doctor...."

Turns out it's a clinic patient that was assigned to me when fellowship started, but I've never seen him, or even spoken to him on the phone.  I pull up his record.  He was 102.

"...so we're going to need you to fill out the death certificate."

"I don't even know the patient."

"Well, we need you to fill it out.  Cause of death, everything...."

"Yeah, I don't know the cause of death.  I didn't even know he died."

"We can't do anything until you fill it out.  So you need to fill it out."

I call the patient's daughter.

"Hi, I'm calling from the clinic.  I was so sorry to hear about your father's death."

"He was 102.  It's okay."

"Yeah, I'm really sorry. .... Could you tell me how he died?"

"He was 102.  That's how he died."

"Uh, yeah... how did you find him?"

"He didn't wake up.  He was 102."

"So nothing happened."

"No, nothing specific happened."

"Okay.  Again, sorry for your loss.  I wish I'd gotten to meet him."

"We had a lot of trouble getting an appointment."

"Oh.  I'm sorry.  I don't do the scheduling.  I don't really know what to say.  I'm sorry."

"It's okay.  He was 102."

I call back the medical examiner.

"I don't have a cause of death.  He died in his sleep."

"So you want to just put something down?  You need to put down a clear sequence that led to his death."

"I don't have one."

"Should we just say homicide?"

"No.  It wasn't homicide."

"Because that one's easy and then I can go to lunch."

"No.  I'm pretty sure it wasn't homicide."

"But you're not certain."

"No, I'm not certain."

"There you go."

"Why don't I take another look at his chart and get back to you."

"You have half an hour.  This has to get done."

"Thanks.  Bye."

Dear Prudence, I Should Make The Nurses Brownies?

I've been sitting on this post longer than I meant to.  Twitter user H.C. sent me a tweet a bunch of days ago asking if I had an opinion about last week's Dear Prudence column on Slate.  The column featured a letter from a resident asking about how to deal with passive-aggressive nurses.  Her answer was to be nice, ask what you can do better, and perhaps make them some brownies.

A couple of times in the past, I've taken some criticism in the comments when I've written about nurses, criticism that was probably deserved.  Nurses have a hard, largely thankless job.  So do residents, but it's different. What nurses have to do requires a different skill set, and it's a skill set that doesn't get a lot of respect.

But I think the question was a little much, and Prudence's advice was a little much, too.

I don't think nurses have it out to get residents.  This resident sounds like she's having a rough time.  Her nurses are out for her, her program director is out for her, she's crying every day... I think she probably needs to talk someone more qualified to help her than an online advice columnist, as much as I like Slate and as much as I like much of the Internet....

But if there is an actual problem, I don't know that it's solved by being fake-nice and bringing people food.  Bring them food, sure, I guess, but the problem isn't that nurses want something from her.  The problem is that people who work in hospitals-- doctors, nurses, everyone else-- have a long list of things to do, and it's easy to seem brusque or rude when you're stressed, or even if you're not.

Also, just personally-- I don't actually want to eat any food that someone brings into the hospital, because the hospital is dirty, and once someone touches a brownie on that plate, I don't know if their hands were clean, or what else has touched these brownies, and so I don't want one.  And I definitely don't want to have to feel like I'm being rude if I don't take one, or have to make up an excuse that doesn't make me sound crazy.  So maybe instead of brownies, she can bring something individually packaged, that you don't have to eat with your hands.  Like a banana.

When your doctor tells you he's retiring... is he just trying to let you down easy?

New patient, a bunch of issues, hoping she might have some past records to check out, get a better sense of her history and any old scans or lab results...

"Sure, my former doctor probably has all of that, but he retired.  That's why I came here.  I needed to find a new doctor.  Oh, he was great.  I really liked him.  It's too bad he left the practice."

"Do you know if someone else was taking over for him?"

"I don't think so.  He said the office was closing.  I can give you the number, but I'm not sure he's still there."

***

So I call the number, and start to explain what I'm looking for.  The nurse interrupts--

"Oh, Dr. Jones?  No, he hasn't retired.  He's in the office-- hold on a second, let me put him on."

...

"Hi, this is Dr. Jones...."

"Yes, I'm a fellow at Mediocre Hospital.  I have a patient in clinic who says she saw you for many years, but she had to find a new doctor because you were retiring....  I was hoping to get some records if you had them...."

"Oh, yes, Mrs. Terrible, right?"

"Yeah...."

"Yeah, I have her records.  I can have my secretary fax them over.  She's really something."

"Well, I just met her today.  I'm just trying to get a handle on her history."

"Yeah, you'll see.  I'll definitely have those records sent over."

"And so you're not retired?"

"[laughs] No, no, not at all.  Retired from seeing her, for sure.  But most of my patients I can still handle."

"Uh, okay... great... can I give you a call if I have any questions?"

"I guess.  Good luck."