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."