"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.