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."

When Notes Go Rogue (Part III)

"Hey, I'm not sure we've met.  I'm the fellow covering a bunch of your patients this month."

"Yeah.  What do you need?"

"I'm not sure if you're just writing draft notes and then going back to change them once you've seen the patients, but I've noticed a bunch of them haven't really been matching up to what's going on when I go see them."

"I don't know, they're fine."

"I'm not trying to cause a problem, I just wanted to check and see if I'm just reading them before they're finished, or you're going back and changing them... like Mr. Patient the other day, where it said he refused a procedure, but he'd already had the procedure."

"Maybe I mistyped, I don't know.  I'm busy.  I can go in and edit that one, I guess.  Who's that-- Mr...?"

"Mr. Patient."

"With the big family?"

"No, the other guy."

"Oh, okay.  You can point him out."

"I just worry that I'm going to make a mistake, if I'm relying on notes that aren't necessarily updated."

"So don't rely on them."

"Yeah, but they're in the system."

"I don't know what you're asking me to do.  If you don't like my notes, you're seeing the patients anyway.  Don't worry about it."

"If you could just double-check that you're not pressing the wrong button, to save your drafts as finalized notes, that might just make it easier for the team."

"I'll be more engaged, sorry.  I've been busy."

"Okay, I just wanted to make sure."

"Yeah, yeah, I'll check them over."

***

"What is up with the cardiologist?"

"What do you mean?"

"I mean he's actually here, and it's the afternoon.  So weird."

When Notes Go Rogue (Part II)

"Have you noticed the cardiologist's notes?"

"Yeah, he does them early."

"No, I mean, they're not correct."

"What do you mean?"

"They do not reflect reality."

"Huh?"

"I don't think he is seeing the patients.  What he is writing in his notes is either cut and pasted from a previous note, or in some cases seems to be completely invented."

"Then you probably shouldn't rely on them."

"No kidding.  But I wanted to know what to do about them."

"What I just said.  Don't rely on them."

"But shouldn't we say something?"

"To an attending?  No."

"Why not?"

"Because he's an attending."

"But he's writing notes on patients he's not seeing."

"You don't know that."

"Either he's writing notes on patients he's not seeing, or all of his patients are crazy, even the ones who aren't."

"Okay, so there's another explanation.  You can't start accusing attendings of things."

"I just thought it might make sense to mention it to someone, in case, I don't know, someone reads his notes and makes a treatment decision based on them."

"Well, like I just said, you shouldn't rely on his notes.  What else do you want me to say?"

"That he shouldn't be making up notes on patients he isn't seeing, and, presumably, falsely billing for consults he isn't doing."

"Come on, I'm not the hospital police."

"I just don't think it's right.  Or sensible.  Or without risk to the patient and the hospital."

"I guess it just means you should make sure your notes are extra good."

"I guess it does."

"Have you seen the patient in 1206 yet?"

"Yes."

"Really?"

"No.  See, it's confusing if I say I saw someone I haven't, isn't it?"

"Sure, but you're a fellow, not an attending."

"Okay, I'm going to go see the patient in 1206 now."

"Great.  Thanks."

When Notes Go Rogue

I round on my patients pretty early in the morning.

So I was surprised to see that three of them already had cardiology notes in the system before I saw them.

Patient 1 was "feeling better."

Patient 2 was "feeling better."

Patient 3 had refused a paracentesis.

So I went to see them.


Patient 1:

"So, I saw that you're feeling better."

"Me?  No.  Chest pain."

"But you saw the cardiologist this morning and he said you were feeling better then?"

"No.  The cardiologist?  Today?  Nope.  Haven't seen him."

"You're sure?"

"Yep.  And this pain?  Since last night."

"The cardiologist should definitely see you then."

"If you say so."

"And you're sure he hasn't?"

"Yep."


Patient 2:

"So, I saw that you're feeling better."

"Yep, definitely."

"Great.  And you saw the cardiologist this morning."

"Nope."

"You're sure?"

"Yep.  I haven't seen a cardiologist at all, I don't think."

"No, you saw him yesterday, didn't you?  Tall guy, mustache, gray hair?"

"Nope."

"You're sure."

"Yep."


Patient 3:

"Did I hear that you refused a test?"

"No."

"Something called a paracentesis?"

"Yeah, I had that yesterday afternoon.  Do you have the results?"

"I have to check... but, uh, I was told you refused it."

"No, I didn't refuse anything that I was supposed to have."

"Did you see the cardiologist this morning?"

"This early?  No."

"Okay.  I'll check on the test results."

Falling

"Doc, I have a question.  When I fall, why do I always fall backwards?"

"How often are you falling?"

"Oh, all the time.  But always backwards.  Is there a reason?"

"There probably is, but I'm more worried about why you're falling in general than the direction of your falls specifically.  I think I should probably do a fuller examination and see how your balance is, and what's making you fall."

"I never fall forwards."

"Okay..."

"And usually it happens when I've been drinking."

"Oh.  That may be part of the problem.  How much are you drinking?"

"Hard to say.  It varies."

"Give me an estimate."

"A few glasses of wine a day?"

"That is too much."

"But I've always enjoyed a glass of wine."

"A glass may be okay.  Maybe.  A few is too many.  Not good.  Definitely contributing to falling, and probably to other problems as well."

"I don't drive when I'm drinking."

"Well, that's certainly good for everyone else on the road, but that doesn't make the drinking not a problem.  I think you need to significantly cut back."

"And then I'll only fall forwards?"

"No, hopefully you won't fall at all.  I still want to do some balance testing."

"Also, I heard you should just let yourself fall naturally instead of trying to brace your fall.  Is that true?"

"No."

"Why not?"

"It's better to fracture your wrist or your arm than your hip or your head.  So you should brace your fall."

"Even if I'm falling backwards?"

"Especially if you're falling backwards.  You don't want to hit your head if there's a way to avoid it."

"My head's hard."

"Yes, but easily damaged."

"Did I ask you why I always fall backwards?"

"Yes, that's how we started this conversation."

"Oh."

Inauguration Day

"I'm going to ask you some questions just to see how your memory is.  Do you know what year it is?"

"Twenty-six."

"You mean two thousand six?"

"No."

"Do you know what month it is?"

"Tuesday."

"Okay.  Who's the President?"

"It's Obama.  You should know that."

"I do know.  I was seeing if you knew."

"I don't know what kind of doctor you are that doesn't know who the President is."

"I know the President.  I was seeing if you knew."

"I don't want a doctor who isn't smart enough to know the President.  How did you become a doctor without knowing something like that?"

"I know who the President is.  I just wanted to test your memory."

"No.  Stupid questions."

"I'm sorry you feel that way.  Can I ask you to draw a clock on this piece of paper?"

"I'm not doing any more of your job.  If you want to see a clock, you can make one yourself."

"Okay.  Can you tell me what brought you here today?"

"A car.  Ugh, this is ridiculous.  I drove a car."

"And who's the President?"

"I told you.  It's the guy with the hat!"

"What's his name?"

"He doesn't have a name!  Oh, you are a stupid doctor."

"No, that's normal for me."

"So, did you have any fever?"

"Well, one time in the night I had low-grade fever, but I took Tylenol and it went away."

"What was the low-grade fever?"

"101.9."

"That's not so low."

"No, it's normal for me."

"It's not normal for anyone."

"I get it every night.  It's normal."

"Not normal.  We need to figure out if there's an infection, or what's causing the fever."

"I had blankets on me."

"That doesn't cause a fever."

"For me it does."

"Nope.  And it was still a fever, even if Tylenol lowers it."

"No, I think if it were a serious fever, one dose Tylenol wouldn't work."

"That's not true.  If Tylenol doesn't take your fever down, there's a serious problem.  But just because your fever goes down after taking it doesn't mean it's not a fever and we don't need to figure out what's causing it."

"No, doctor, like I said, this is normal for me.  I shouldn't have even said anything."

"It's important to tell a doctor when you have a fever."

"No, because now you think something is wrong."

"Something is probably wrong."

"No, I'll let you know if I get a fever over 103 that a bunch of Tylenol won't take care of."

"At that point, you shouldn't let me know-- you should let the morgue know."

"Now you're just being overdramatic."

"Yes, but you're being underdramatic.  Let's get some blood work done."

"No, I don't want to get blood work.  My last blood test showed my hemoglobin was six and a half, so I don't really want to give up any more blood."

How much am I supposed to be able to care if the patient doesn't?

"Sorry to call you at home so late-- your blood work just came back.  Your potassium level is 6.8.  I'm not certain of the cause, but I need you to come to the ER right away so we can redraw the labs, see if that value is real, and treat you if it is."

"I'm already in my pajamas, doc."

"I know, and I'm sorry.  I wish your appointment had been earlier in the day, and we would have had these labs back sooner.  But given the value-- and there are some other things in there that are concerning-- you need to get here tonight.  I don't feel comfortable having you wait until the morning."

"I can't get all the way to the ER."

"I know, it's a hassle.  But it doesn't have to be here.  If it's easier, you can go to the closest hospital, call 911, that's fine, and if you end up admitted, we can worry about transfer tomorrow if that makes sense.  I just want you to be seen tonight and not risk being at home."

"I'm feeling fine, doc."

"But you're not fine.  Your labs are very alarming.  I want them redrawn and I want you in a setting where you can be treated, because a potassium level that high can cause real problems, quickly.  Cardiac arrest-- your heart could stop functioning."

"Oh, come on, I'd have a higher fever--"

"No, you wouldn't.  I don't mean to be alarming you, and I'm not trying to say that in every case something terrible would happen if you waited until tomorrow--"

"Well, tomorrow's really no good for me--"

"What I'm saying is that we're not going to wait until tomorrow.  The prudent thing to do-- the only thing to do, unfortunately-- is to come in tonight.  Let's be safe here.  I don't want to play games."

"I'm really tired, doc."

"I know.  And I wish these labs had come back normal, but they didn't.  And I have to tell you to come in tonight, because if you don't, you're taking a real risk, and unfortunately it's not a risk that you should be comfortable taking.  I don't know how else to say this.  It's potentially life-or-death important, or I wouldn't have called you at home this late, and I wouldn't be trying this hard to convince you to come in."

"I'll deal with it later."

"No, you should either have someone drive you to an ER, or you can call 911 and have an ambulance bring you in.  That will get you to the head of the line and we can figure out what's going on."

"I'm not coming in tonight."

"That's not a legitimate decision to make."

"My heart is beating fine."

"There wouldn't necessarily be any warning if something were to happen.  We don't know what the potassium level was before, or where it's going.  Did you eat anything since you had the blood drawn?"

"Yeah, I had a piece of chicken and some spinach."

"Spinach has a lot of potassium.  Normally it wouldn't be a concern, but with your level that high--"

"Now you're just trying to scare me."

"I know that's how it sounds, but I don't want to regret not having you seen tonight.  And you shouldn't want to risk that.  It is better to be safe than sorry, I promise you.  Tell me what else to say.  You need to come to the hospital.  I don't know how to say it any other way.  You are at risk of death if we don't treat this."

"I'm fine.  I'm not going to die."

"Look, call 911, they'll redraw the labs, and if it's nothing, you can go right back home."

"I already brushed my teeth."

"That's fine. You need to get this checked out tonight.  You need to come in.  I can call 911 for you, if you let me.  I'll take care of it."

"You just want to make money."

"I don't get paid based on whether you come in.  You can go to any hospital, or if there's a clinic that can check your blood this late, that's fine too.  But you can't leave this untreated until the morning.  I have to document that I've explained the risks to you.  You could have a fatal event during the night given these lab results.  This is a medical emergency.  Something could definitely happen, and I'm not just saying that."

"I play Bingo in the morning."

"Your life should be more important than Bingo.  You need to be seen by a doctor.  I'm going to call your daughter and make sure she's aware of your situation and my strong, urgent recommendation.  I can't keep going in circles with you."

"My daughter always wants me to go to the hospital anyway.  I'm not listening to her."

"I'm sure she's only trying to be cautious.  And I have to call her if you won't agree to come in."

"I want to live my life, not be stuck in a hospital."

"I want that for you too.  But sometimes you need to get things checked out, to be safe."

"I'm going to sleep.  Goodbye."

"You can call 911 at any point in the--"

[click]

"Why'd You Kick Him Out of Office?"

"Do you know what year it is?"

"Uh... I don't remember."

"What month?"

"...Tuesday?"

"Who's the President?"

"Bush."

"Well... you're close.  Bush was the last President, but who's the President now?"

"Wait, you kicked him out of office?"

"No, there's a different President, it's not Bush."

"Why'd you kick him out of office??"

"I didn't do anything, I promise.  I'm just trying to see how your memory is."

"My memory is fine-- now why did you go and kick Bush out of office?  What did he do to you?"

"He didn't do anything to me.  So you don't know who the current President is?"

"It's still Bush.  Where I live, it's Bush."

"No, the President is Barack Obama."

"I knew he was running.  I didn't know he won.  Why'd you kick Bush out of office?"

"His term was up.  He couldn't be President anymore."

"That doesn't matter."

"Yes, it does."

"Maybe to you and whoever you were working with to kick him out of office.  Not to me."

"Okay, I want to move on to listening to your lungs.  Is that okay?"

"Why?"

"I want to see how you're breathing."

"Okay, but only for a minute."

"Okay..."

"I still don't know why you kicked him out of office."

Fever

A patient calls the call center this weekend... I call back:

"Hi, this is [Anon Doc] returning your call."

"Yes, my wife isn't feeling well."

"I'm sorry to hear that.  What's going on?"

"She's been out of it since last night.  Very tired.  Not hungry."

"Any temperature?"

"Yeah.  A hundred and seven."

"Excuse me?"

"A hundred and seven, since last night."

"I'm sorry, is she in the room you're in right now?"

"Yes."

"And she's breathing okay?"

"Yes.  [I hear him say:] You're okay, honey, right?  [I hear her say something in response.]  Yeah, she said she's feeling a lot better than last night."

"I think you need to call an ambulance, and I think you should do that as soon as you get off the phone with me."

"You think it's that bad?"

"I don't know what's going on.  But her fever should not be 107.  Ever."

"Did I say 107?"

"Yes."

"Oh.  I meant 97."

"Oh.  That makes a difference."

"Oh, okay."

"If her temperature is 97, and she's just tired, I think you can probably hold off until tomorrow and come in to the clinic if she still isn't feeling well."

"Oh, okay."

"If anything changes-- if she gets a high fever, if she starts having trouble breathing, anything like that, then you need to call 911.  And call me back if she starts feeling worse again.  But otherwise just plan to come in tomorrow, okay?"

"Okay, thanks."

"But You're Married!"

My 94-year-old patient with dementia.

"Marry me, doc."

"But you're married!"

"You're married?"

"No, you're married."

"You're married."

"No, not me.  I'm not married.  You're married."

"To you?"

"No, to your husband, Bob."

"Do you know Bob?"

"I've met Bob, yes."

"You're married to Bob?"

"No, you're married to Bob."

"But I thought I was married to you."

"Nope, I'm not married.  But you're married to Bob."

"Do I like Bob?"

"Yes, you seem to like Bob."

"Oh.  But before I was married to Bob I was married to you?"

"No..."

"Before I was married to Bob, you were married to Bob?"

"No..."

"How did we start talking about Bob?"

"I don't remember."

"Neither do I."

"Yes, he's been like that for a while."

I was called to do a consult on a patient in the hospital.  I walk in, and there's a private-hire aide sitting next to the patient's bed, doing a crossword puzzle.

It all seems a little too casual, as I take a quick look at the patient, and the patient is very clearly not alive.

"Oh, he's been like this all morning," says the aide.

"Yeah, he's not breathing."

"Yeah, all morning like this.  I don't know what's wrong."

"He's not alive."

"Oh, I'm going to go fill up the water pitcher.  Let me know what you think."

"He doesn't need water.  He's dead.  That's what 'not breathing' means."

"Yeah, you take a look.  I'll get him some water."

She leaves with the water pitcher.  She comes back-- by this time, I've brought another doctor in with me.

"Oh, another doctor too?  He is okay?"

"No, he's not okay!  He is not alive anymore."

"So you think it's not good?"

"It's as not good as these things get, unfortunately.  He is dead."

"Yes, I was concerned when he was looking like this before.  Should I give him some water?"

"No.  Stop with the water!  He is deceased.  Does he have any family to call?"

"They said they're planning to come visit Friday.  He still be in the hospital?"

"No.  There is no one for them to visit on Friday.  I don't think you're getting this.  He is dead."

"Yeah, he was not sleeping well.  But today, he sleep good."

"He's not sleeping.  He's dead."

"Okay, you do some tests, and let me know."

Flu Shot

"Did you get a flu shot?"

"No, that's not for me."

"The flu could be a bad thing for you-- I don't want to see you get sick if it could be avoided."

"No, last time I had the flu shot, I got the flu."

"Well, it's not 100%."

"No, the shot gave me the flu."

"I think you should really consider getting the shot."

"Doesn't work for people like me."

"What do you mean, people like you?"

"You know, people like me."

"I'm not sure what you mean."

"People who don't have the flu."

"Yeah, you don't have the flu now.  I'm worried you might get it."

"Why, do you have the flu?"

"No..."

"So I'll be fine."

"But you're around other people aside from me."

"I'm sure I'll be fine."

"I still think you should really consider getting the shot."

"I heard you can die from it."

"I don't think you heard that."

"Well, I just don't want it."

"As you can see, I'm not forcing you to get it.  But I think you should.  You don't want to get the flu."

"I'm sure I'll be fine."

"I hope so."

Bereavement, sort of.

"So, [patient], the wound on your foot is not looking good at all-- when's the last time you saw the vascular surgeon?"

"Oh, I saw him last week.  He said we'll watch it, but he's worried he's going to have to do an amputation."

"I'm sorry to hear that-- I'm sure that's not easy news to get."

"Yeah, I thought it would get better, especially after he did the bereavement."

"Excuse me?"

"He did a bereavement on the wound, so I thought that would help."

"I'm sorry, explain to me what he did to the wound?"

"He cut off some of the dead skin.  He said he was doing a bereavement for the skin."

"Oh, okay.  You mean a debridement.  He removed the dead tissue."

"Yes, a bereavement."

"It's called a debridement."

"Same thing."

"Anyway, I'm sorry.  When's your next appointment with him?"

"Two weeks, unless I get a fever over 105."

"Could he maybe have said one hundred point five, not a hundred and five?"

"Oh, maybe.  I don't remember."

"Okay, well, if you get a fever over 100.5, give his office a call just to check."

"Okay, I'll do that."

"Great."

"Of course he needs a doctor...!"

I have a patient whose daughter is also a doctor (an actual medical doctor!), and she's very involved in her father's care.  Which is fine, except when it's weird.  I call her with some lab results...

"So... the labs came back.  Everything's basically looking fine, but I'd like to start him on [drug A] -- I think he'll benefit from it."

"You'll send me the lab results?"

"Of course."

"Okay, let me take a look and I'll call you back once I have all the information."

"Sure, fine."

***

"So I looked at the lab results.  You think [drug A] is better than [drug B]?"

"Yeah, we tend to give [drug A]."

"Well, I think we should do [drug B]."

"I'd rather check with my attending first, if that's okay."

"Sure, call me back."

***

"Uh, I guess we can try [drug B], that's fine."

"What dosage were you thinking?"

"[Dosage]."

"Yeah, me too.  So I can just call that in for my father, that's great."

"Uh... you don't want me to call it in?"

"No, no, I like to manage all of his meds."

"Okay..."

"And if you could do [these three tests] next time you see him..."

"Sure..."

"I'll e-mail you a reminder before his next visit."

"Okay..."

"Great.  My father and I think we like you."

"Uh, thanks, but I'm not really doing much-- you seem to have it all under control.  Not even really sure why you need me, to be honest."

"Oh, well, he obviously needs a doctor!"

Please Have a Seat in the Waiting Room. Please?

I had to cover a shift reading chest x-rays in the hospital.  It's usually a fairly chill evening, as compared to covering patients on a ward.  You sit in a room, interpret x-rays, and write notes.  A woman runs into the office, frantic.

"Yes, my son just had a chest x-ray and I need you to read it.  Quickly."

"Sorry, uh, you're..."

"I'm a doctor.  Not here, but I'm a doctor.  My son is very sick.  I need you to read his x-ray."

"I'm sorry, I read them as they come up in the system, there's a queue.  If you want to wait in the room outside, I can let you know after I've read it, and you can go talk to your son's doctor about it..."

"No!  You're going to read it right now."

"I'm sorry... like I said, you can take a seat in the room outside, and I'll come get you after I've read it.  As a doctor, I'm sure you understand the protocol.  Who's your son's physician here?"

"He came in through the ER, I don't remember the doctor's name.  But I need you to read it right now.  He might be very sick."

"There's an order in the system, I assure you that it'll be read very soon-- I just can't have you in here while I'm working.  As a doctor, I'm sure you understand."

"As a doctor, I understand that you have to read my son's x-ray right now."

"Okay, you know what, this isn't how it's supposed to work, but let me just pull it up and take a look, okay?"

"That's what I've been telling you to do!"

"Fine, fine.  [I look at the x-ray.]  Okay, well, it looks like [small finding, nothing of an emergency nature], now if you can go back to the ER, the report will be in the system in a few minutes, and you can talk to your son's doctor about next steps."

[frantic] "He's gonna die???  Is he gonna die???"

"No.  I'm sorry... where are you a doctor?"

"At [local university that doesn't have a hospital]."

"Wait, what kind of doctor are you?"

"I'm a professor of linguistics."

"What?"

"I have a phD in linguistics from [prominent university]."

"Okay, please go back and speak to your son's doctor.  The report will be in the system in a few minutes.  I hope he feels better."

"So he's not going to die?"

"Probably not today."