A patient in clinic this afternoon didn't like me. I don't know, sometimes you don't click. He was this big guy, mid-50s, seemed to want a doctor who looked older, more imposing. He made a few jokes about how young I am, and then got annoyed when I asked about his eating habits (he's overweight, elevated blood pressure, history of high cholesterol). One of my supervising doctors popped in to grab a file, and the patient starts making a fuss to her. "I want a new doctor. This guy is incompetent." My supervisor brushed him off, and that just made him more annoyed. He walked into the hallway and started yelling after her-- "He's not qualified to be a doctor. He shouldn't be a doctor. He should be a train conductor."

And of course I didn't really know what to do-- I didn't want to argue with him, but I felt like I should try to reason with him and get him out of the hallway. But, gosh-- train conductor? So specific, and a little baffling. He didn't say I should be a high school student, or, I don't know, a waiter, or something else relatively menial. A train conductor. Why did he think I should be a train conductor? I'd be a terrible train conductor. I was running 25 minutes late-- and I didn't even really know the way to the examining room I was supposed to use. Those are both terrible characteristics for a train conductor. I don't know why I've been overthinking this-- it just seemed so oddly specific. Then again, my patient was probably crazy, so I really shouldn't be considering his career advice as if he has any idea what he was talking about.

Two extremes on the patient spectrum. The ones who want control over their medical care, and the ones who don't. We talk a lot about making sure patients give informed consent, that we don't just bully them into signing off on risky procedures or letting us do anything they don't understand. But we don't talk about the flip side-- and it's just as important-- patients who assume we're going to do what we need to do, and that if we're asking them whether they want something, it must mean they actually have a choice, and it's okay for them to say no. I feel like we're trained to soften things-- "we need to go in and do so-and-so procedure, it will really help you, here are the risks...." But you soften it too much, and a scared patient can be like, "that sounds risky, I don't want that." And then what? Do they realize they're refusing treatment they need to save their life, or do they think they're just making the safer choice between doing something scary and not doing anything at all?

I covered someone's shift on the floors today and had to deal with a patient who needs a cardiac procedure, the cardiology fellow went in, explained it, and the patient-- scared and not very knowledgeable-- said no. And so the fellow left the room, didn't move forward with it for now-- but did the patient really know what she was doing? I went back in, asked the patient if there's anyone she can call, she called her husband, and he basically yelled at her through the phone and said she has to have this thing, and she had me get the fellow back, and she gave her consent. Some would say she was bullied into it-- although if her family bullies her into it, at least we're not the ones who get sued-- but in this case, hey, she needs it, her husband got through to her in a way the doctors couldn't. Is that a bad thing? Unless this woman wants to die-- and she didn't, she was just scared-- she needed the procedure. And didn't understand the choice she was making, because we soft-pedaled how urgent this was, all to pretend she has a choice and needed to give consent. But consent means nothing to a confused and scared patient who thinks we're saying there's an option not to have an invasive procedure.

Yet if I were to argue we need a broader view of consent-- asking something like, "do you want us to do everything we need to do, in our best medical judgment, to save your life?" and not asking about every pill and every treatment option-- I'd be shot down instantly-- that's not really consent, patients have a choice.... We're doctors, they assume we know things, they assume if we need to do something to help them, we're going to do it, whether they "consent" or not. At least some patients. Problem is knowing which ones.

I had a patient today in the clinic, she comes in, I'm taking her history, I ask her what medication she takes, and she names some bizarre diet drug. I Google it while I'm talking to her, and the first link is to some article saying it's a pyramid scheme. So I asked her, why are you taking this drug?

"It helps me lose weight."

"Oh. How much weight have you lost?"

"I used to be 165 pounds. I was down to 110 pounds."

I look at her. She isn't 110 pounds, or anything close. "What do you weigh now?"

"115 pounds."

I look at her chart. "The scale said you weigh 152 pounds."

"Yes, it is my clothing. It is heavy. At home, I weigh 115 pounds."

"I'm not sure your scale at home is working correctly. Your clothes don't weigh 40 pounds."

"Yes, I weigh 115 pounds."

"I'm not sure you do."

"Yes, I do."

I decided it was better to move on at that point....

Patient in clinic today had some sort of issue that was making her very, very warm -- and for whatever reason she was wearing a very heavy sweater to the visit. She's sweating, having trouble getting through the exam-- I wanted to tell her she can take the sweater off, it's a doctor's office, it's okay, I'd rather she be comfortable than suffering, and we need to get through the exam... but I didn't. I couldn't get past the idea that I'm opening myself up to some sort of insane sexual misconduct lawsuit if I tell a female patient she's allowed to take her sweater off. If she was there with some sort of problem that required me to do a breast exam, or something like that, obviously I would do the exam. I've probably seen fifty vaginas in the past six months, it's not like this isn't a normal part of my job. But somehow the vague-ness of it -- I don't care if she took off her sweater, I didn't need her to take it off for any medical reason, it just seemed like she would definitely feel better if she did, and there was no reason not to -- it just made me feel awkward and uncomfortable. I don't know, being a doctor is strange sometimes-- we have a real power over our patients, we say things and they have authority behind them. If I tell one of my friends he shouldn't eat at Burger King because it's bad for you, he doesn't feel compelled to listen or give my opinion any weight-- but if I tell a patient, it has weight. They may not listen, but they'll feel bad if they don't listen. By virtue of wearing the white coat, I have authority. I'm still not used to it. I still find myself talking to patients sometimes like I'm a peer and not a professional. More than once, I've made a comment that's probably too casual when we're talking about running some blood work. Like, "I hope they don't find [whatever]." As a fellow human being, I hope they don't. As a doctor, am I supposed to acknowledge hope, and uncertainty? Shouldn't I say something like "there's an x% chance they'll find [whatever]," or say nothing at all, and wait until they find what they're going to find, and not scare the patient needlessly? I don't know. They don't train us (much) in actual patient interaction. We're expected to pick it up, to know things automatically. I still don't know if I should have told that patient to take her sweater off or not. And there's really no one to ask.

I had a homeless patient come into the clinic today. Strangely enough, he's probably the brightest, most diligent patient I've had in weeks. Keeps his appointments, takes his medication, tries to exercise and eat healthy... he just doesn't have a home. He's basically choosing to be homeless-- he's employable, probably, but doesn't want a job. He has friends, but doesn't want to impose on them. He doesn't mind living on the street, he claims. He reads newspapers that people throw in the trash, he collects cans to earn a little bit of money, he gets free meals from soup kitchens, he showers every couple of days at a friend's apartment, he washes his clothes, shaves-- he doesn't look homeless, or at least not as homeless as you'd expect a homeless person would look. And he has all of his medical records neatly organized in a folder, gave a concise history, was in good spirits, and actually asked a lot of smart questions about how to keep himself healthy and manage the medical conditions he has. He almost made me think being homeless wouldn't be so bad.

And then I remembered I hate sleeping outside. So there goes that.

I spent Valentine's Day alone and President's Day in the hospital, covering someone's shift even though I had the day off. I was a summer camp counselor a whole bunch of summers ago and we each had a few nights a week we were "off" and allowed to go into the nearest town twenty-five miles away and drink beer and eat pizza for three hours until the shuttle came back to pick us up-- everyone looked forward to their nights off, an escape from the camp, from sitting on the bunk porch waiting for kids who couldn't fall asleep to come bother you. But I liked being at camp, I didn't mind covering people on my nights off, and it was easier to stay in and go to sleep early than to go out, pretend I liked my fellow counselors, and be tired the next morning. There are times I think I'm a very different person from who I was back in high school and college, and then there are times I realize I'm exactly the same. I'm still the guy who's happy to cover other people's shifts, who's content to be at work when the alternative means I have to try and meet new people or miss a few hours of sleep. The analogy isn't perfect-- the alternative to covering a shift wasn't hanging out at a bar with people I didn't like (although I guess it could have been), and I could have just stayed home and slept-- but in my head it's kind of the same. If I can use work as an excuse not to push myself to find something social to do-- if I can pretend I'm busy by covering other people's shifts so that I don't have to be alone or find strangers to hang out with-- I will. And that's why I spent Valentine's Day alone, and why I spent President's Day in the hospital, and why I'll probably spend this weekend covering someone else's shift-- she's begging on our internal message board for someone to cover so she can go to a wedding, and why not? What else am I doing? It's a good thing, right? It makes me a nice guy, a good resident? And keeps me from having to dwell on the truth that there is nothing else in my life besides this job.

I had a patient in clinic today ask me way too many personal questions. We're trained to deflect personal questions. They're patients, not friends. It's about them, not us. But it's hard not to feel rude if they ask something direct and you try to evade. "Where do you live?" "Not too far." "Do you have a girlfriend?" "We're here to talk about your problems, not mine." "But I have a granddaughter...." "Does she have diabetes too? Because that's really what we should focus on. Your diabetes."

I had a 296-pound 21-year-old guy come in because he's having foot pain. He didn't seem to understand that the pain will go away if he loses weight. "You should try and lose two pounds a week," I said. "I don't have a scale." "You should buy one." "I don't have any money." "Then you should save some money you spend on food, and use it to buy a scale." Okay, I didn't say that, but I wanted to. I seem to see three kinds of problems in clinic. Genital problems, drug and alcohol problems, and problems caused by obesity. I don't know which ones are my favorite. They're all pretty terrible. I guess obesity-related problems are my favorite, because at least I have some answers and usually there's a way to help, or at least hope to help. And I hate looking at diseased genitals, I really do.

I had a patient today, overweight, long-time smoker, really not taking good care of his health at all, hadn't seen a doctor for years but came in today with stomach pain, worried it was appendicitis but actually turned out to be gas.

"You really should try and quit smoking," I said. "I can give you information about smoking cessation classes, or we could try a nicotine patch...."

"I've never tried to quit. But don't worry, I go outside when I smoke."

"Uh... well, that's good for anyone else in the house, but it's not any better for you...."

"Oh, I live alone."

"Then why do you go outside to smoke?"

"I have two birds, and I don't want to expose them to it."

"Well, that's great for the birds. But, still, not good for you."

"I cook for the birds every day. Organic bird feed, pesticide-free, healthy stuff, they love it."

"But what are you eating?"

"McDonalds, Burger King..."

"You should try and treat yourself as well as you treat your birds."

"I'm too tired after cooking for the birds to worry about myself."

"Maybe you should think about what will happen to the birds if you get sick and can't take care of them."

"I don't take care of them. They take care of me."

"Then they should tell you to stop smoking."

"They do."

So... psych consultation, or what?

Had a patient today who insisted that because she had a clean mammogram eight years ago, it means she's fine and doesn't need another one. Do dentists have this problem? Do patients insist that their teeth were clean a year ago and so there's no way they need another cleaning? She was telling me that before that mammogram, it had been eight years since the previous one, and she was fine last time so that must mean that she doesn't need them so often. And this logic made sense to her. I could not convince her otherwise. She did say she was willing to take a look at the information about a colonoscopy, but couldn't commit to it until she showed her friend. "Is your friend a doctor?" "No, but he knows things." Medical things? I doubt it. Who's she asking for advice about whether she needs a colonoscopy? With whom is she talking about her colon?

There's an intern, married, who keeps saying she wants to set me up but hasn't found the right person yet. No kidding. I haven't found the right person either. I don't know why married people think that because they met the one person for them, it means they're an expert on relationships. We wouldn't accept that on the professional side of their careers-- if you diagnose one case of pancreatic cancer, it doesn't make you an authority. It just makes you lucky.

So much more luck goes into this job than I expected coming in. Luck as far as who your residents are, who your patients are, what happens to your patients under your watch versus what happens when you're not on call, which patients get assigned to you, which files are on top of the stack in the morning. Already there are interns who have a reputation for being terrible. The program director warns us that our reputations matter. You get one chance to make an impression, and if it's the wrong impression, then you're the lousy intern who's never going to be trusted to make decisions, who's not going to get good evaluations, who's not going to get fellowship interviews, who's going to be stuck in an ultimately unsatisfying medical career. Most of the people who write our evaluations don't spend enough time with us to make judgments of their own. The attendings admit that. They ask around, see what everyone else thinks of us, and that's what they write. But the interns with the bad reputations-- it's not always their fault. You have one complicated case and a patient has a bad outcome-- and suddenly you're known as the one who killed that patient. You accidentally piss off a family and they go complain to the attending about you and you're the "difficult personality" who needs to be monitored. You forget to follow up on one lab result and you're the scatterbrained moron who can't be trusted to do his work. There is no margin for error. It just takes one bad outcome. Other jobs, people can fail. As doctors, we can't. And even though the cost of failure is often absolutely incredibly high, still, it's a standard no one can meet.

I had a full day of clinic today, saw eight patients. Had to refer one of them to gynecology-- she didn't know she was pregnant. Three months along, and she had no idea. No clue. At least I got to give her (arguably) good news. We don't get to give good news very often.

Just to address the comments on the last post -- my friend and the nurse -- he asked her out, she politely declined, he thinks it's crazy awkward now even though it really isn't, so he acts weird around her, regrets ever taking a chance, and she seems to feel pretty bad about it.

I had a patient yesterday, young girl but not that young, mid-20s-- we were talking, and in the middle of the visit, all of a sudden she asks if she can have a female doctor instead. I didn't think I'd done anything wrong-- turns out I hadn't-- but I sheepishly went and told the attending who was supervising, and she went in to talk to the patient. Fifteen minutes later she comes back out and tells me she hopes I wasn't beating myself about anything-- the patient is about to get married, and had some questions about how the baby-making process works-- where it grows, how it happens, what it feels like, what to do to help make sure it's a boy (??)-- and felt more comfortable asking a woman. After my post earlier this week about the lack of health literacy among patients... I feel like this went even deeper than that-- this patient literally did not know where a baby comes out. Shouldn't this come up at some point before people turn 25? Did she not see Knocked Up?

The e-mail lists have been passing around an article this week (here's a link) about a guy in medical school who posted a picture on Facebook posing with his anatomy lab cadaver, smiling and holding two thumbs up (his, not the cadaver's). The reaction is of course the right one-- it's beyond unprofessional to take a picture with your anatomy lab cadaver, it's disrespectful to the deceased and his family, to say it's in poor taste is a huge understatement-- but anyone who thinks it's an isolated incident is fooling himself. By necessity, after the first couple of days of anatomy lab, first year of medical school, you have to sort of block out the fact that you're in a room filled with dead people. We're forced to cut into the bodies, dissect them, examine them-- they cease to be people. They're lab specimens. And we were there three hours a day. So of course people end up letting their guard down, people make jokes-- not always tasteful jokes. Obviously there's a line, and certainly taking a picture, with you smiling and standing over the cadaver, and posting it on Facebook-- well, that seems to unambiguously cross the line-- but it's not as if everyone else is behaving in a way that the families of the deceased would be thrilled about.

What I think is amusing about the article is part of the school's intended response:

"The medical school will also develop a social media policy, a set of guidelines that will lay out for students what is appropriate and not appropriate to post on social networking sites."

Something goes wrong? Develop a policy. Of course. Because that will fix everything.

All high school students should be forced to take a basic health care class-- not just the sex ed classes most kids get, but something that teaches everyone a little bit about medical tests and medication and what cancer is and what MRIs can show and what constitutes good nutrition. The lack of knowledge among so many of my patients is astounding-- but when I think about it, it's not like my family knows any more than this. Educated people, uneducated people, it doesn't matter all that much. No one knows anything.

I had a patient today who didn't know what a stethoscope was.

I had another patient who came in the other day with a tumor the size of an eggplant. It's metastatic cancer, growing quickly, he probably has a couple of months left. But this must have been noticeable for at least the past six months, if not longer. And yet no doctor visit until now. When one side of your body has something growing that makes it twice the size it used to be and it's turning purple and it's lumpy-- go to a doctor! I see how people can ignore something that seems like a cold, I see how people can ignore a general feeling of malaise for a little while-- they shouldn't, but I can see how it happens. Big lumpy growths, I don't understand. Not normal. Go seek medical attention.

People convince themselves nothing can possibly be wrong with them. Or they just don't know. I asked one woman, in her 70s, when her last mammogram was. "Oh, I never had any problems," she said. Yeah, but when was your last mammogram? "Oh, I never went, I never had any problems." Sure, you don't have any problems, until you do. I've had patients who tell me they've never been to a dentist-- let alone had a colonoscopy when they're supposed to. We need some basic preventative care education-- what you need to do to best help yourself, what you can do to make some real impact in your chance of staying alive a little longer. You find things early, we can sometimes fix them. You wait until blood is pouring out of your ears, it's probably too late!

We had a team dinner last night after work that I wish I had something to say about. See, it's not that the program doesn't try to forge social connections and give us all the chance to be friends-- we had orientation activities that were social, there are weekly happy hours, we're divided into "teams" that have occasional dinners like this one, there's going to be an overnight retreat in a few months-- but it's hard to force these things especially when the workplace itself is not that friendly day-to-day just because of the nature of the work. We all have different patients, we all spend most of our day either with those patients or in front of a computer entering orders and writing notes. The interaction with other interns is minimal-- sometimes there are two interns to a resident, in which case you're in the same call room as the other intern most of the day, but you're each working on your own things, and basically competing for your resident's attention (or competing to avoid your resident's attention, depending on the resident...), not really hanging out and getting to know each other. And it's tough to become too close to a resident, because he or she is your boss-- and that goes quadruple for an attending. We don't really have direct colleagues-- and even if you become friendly with someone on one cycle, two or four weeks later, you're both onto a different unit in the schedule and won't see each other for six months. The people I've found I become friendliest with during each schedule chunk are the ones I sign out to or sign in from-- the night float folks, when I'm on days, or the day team, when I was on nights. Because you're chatting for 10 minutes, twice a day, about the patients, and it's actually like a conversation. Then you go the rest of the day staring into patient charts and feeling stressed and on your own.

Anyway, the other piece of it-- which isn't the program's fault at all-- is that so many of us are at completely different life stages. It was sort of nice that of the ten people at this team dinner, five of us are single, and so we were there alone and had the chance to talk and get to know each other a little better. But even so, two of the five of us are more than a decade older than the rest, medicine is a second career, and they're single and 40-- which is a different place than single and 27. And of the other five, three are married and brought their spouses (none are doctors-- we hear about doctors marrying other doctors, and of course it happens, but what really seems to happen is doctors date other doctors, or doctors marry and divorce other doctors, because the number of actual doctor-doctor marriages in the hospital, at least among the resident and fellow population, is much smaller than it first seems-- although maybe a lot of them meet down the road as attendings or in private practice, because there do seem to be a fair number of attending-attending marriages), one brought her boyfriend (a resident on another team), and one was on like a first date-- she (rightly) claimed she has no time to date, so when a thing like this came about, she figured she'd invite a guy she'd been e-mailing on Match.com for weeks to come along. Which of course was awkward and weird-- the rest of us know each other or at least know the spouse we came with, and then there's this guy who doesn't even know his own date, and we're in someone's house having dinner, and the host (an attending) is worried this guy is going to steal things, and the joke was that he was some psych patient she picked up on the ward-- which maybe he was.

The spouses didn't have jobs that sounded more interesting than this one, they all seemed to wish they were doctors (they shouldn't), but, hey, I guess the grass is always greener on the other side. Am doing nothing with my two-day weekend-- it's so soon after my lazy vacation that I almost don't feel entitled to be lazy again, but what else can I do. I'm invited to an intern's place to watch some Pro Bowl football thing-- I don't like football but I'll probably go anyway.

"Oh, don't worry about making mistakes," said the attending. "It's not like any of the clinic patients would ever be savvy enough to figure it out. You think someone who's here illegally and doesn't even speak English is going to find a lawyer and sue us?"

Ah, yes. The reason it's okay to make mistakes is because the clinic patients probably won't sue us. Unquestionably the right way to think about our job. Patients who can afford lawyers? Be careful. Patients who can't? Eh, what's the difference, who cares if you get the diagnosis right, maybe we should let the surgeons experiment on them too, while we're at it.

I seriously think I'm going to tell my friends to pretend they're lawyers whenever they go to the doctor. You tell a doctor you're a lawyer, and maybe they won't just pick the sterile instrument off the floor if they accidentally drop it. Maybe they'll get a new one, a clean one, one that won't cause an infection. Maybe they'll double-check the prescription. Maybe they'll order the right tests. Maybe they won't. But at least they'll think twice.

I had a patient come in to clinic today complaining of depression. I think. She brought her boyfriend to be her translator. But that makes it difficult to be sure the boyfriend isn't a contributing factor. How do you ask "does your boyfriend abuse you?" when the boyfriend is the translator? I asked him to leave the room, and called the translator phone instead. He seemed insulted. He probably had a right to be. She gave no indication he's abusing her. I had no reason to suspect. But why have the doubt? The translator today was not putting 100% into the job. She was probably watching TV or something while translating. Even my terrible Spanish was enough to know she wasn't quite right. I don't know where they find the translators, who these people are. It's a work-from-home job, I'm sure it doesn't pay that well, I feel like these people have two or three phone lines and switch off between whatever rings. They do some translating, and then when we're done, they're also the phone psychics and on the sex hotlines. Same people, no doubt. Medical translation and phone sex. Heck, there's probably about the same amount of talk about genitalia on each of those lines. Although we may get a little more graphic.

One day back from vacation and I get a clinic patient with a butt rash. It's the exception that proves the rule: I've written before that whenever it's a young guy coming to the clinic, it's because there's something wrong with his penis. There is no other reason an uninsured guy under the age of 50 goes to a free clinic to see a doctor. Except, apparently, for a rash on his butt.

At first I thought he was a test patient-- they've said that they will sprinkle test patients into clinic throughout the year, so our progress can be evaluated. The test patients are prepped with answers to all of our possible questions, and armed with a checklist to mark us against ("did the doctor do a complete and thorough physical examination?" / "did the doctor wash his hands?" / "did the doctor explain the possible side effects of the medication?"). It's sort of fun to know that somewhere along the line, we'll get a couple of fake patients. It's like trying to figure out which section on the SAT is the experimental one, which won't count. Anyway, this guy just seemed so textbook-- he was too quick with all of his answers, and much too excited to be sharing. "I just got out of a relationship, and I'm concerned my girlfriend may have been cheating on me, and could have given me a sexually transmitted disease. I had gonorrhea a few years ago, but it was effectively treated with medication." Thanks. And he was just a little too clinical with a couple of answers. "We use protection approximately 75% of the time." Are you keeping a log?

So when I went to talk to the supervisor before going back to examine the patient, I told him I thought this might be a test patient, and handed him the file. He laughed. "Trust me, you will never have a test patient with a butt rash." Oh. Well, I guess that makes sense.

Went back in, examined his rash, and sent him off with some cream that will hopefully clear it up. I understand why outpatient medicine gets looked down upon by the specialists-- it doesn't take a genius to deal with butt rashes-- but, hey, I helped him, I don't have to worry that he's going to die overnight, and I got to leave the office before 5. Is it worth looking at butt rashes to get out in time for dinner? I don't know, but it might be.

I'm sorry for the break in posting.

I stayed at my parents' house longer than I expected I would, and just got back. Getting ready to go back to work tomorrow. And since my parents still live in the past, Internet access was spotty. I don't know why I spent a week with them. It's too long. Even though I didn't get to see them over the holidays. It's still too long. But given the choice of being alone in my apartment or tagging along on their pointless days, I chose them. You'd think they'd be happy that I'm a doctor. You'd think any parents would be satisfied that their kid is a doctor. All throughout high school and college that's all they wanted for me, that's all they kept pushing-- do something with your life, become a professional, make sure you have a career. And now that I've done it, they're still not happy. "You need a wife, you need a family...." Well, it's not like I'm not trying, and it's not like you need to remind me. And, frankly, it's not like becoming a doctor isn't what has made the other piece of it so difficult. I asked someone out right before vacation, someone else in the hospital. She said she doesn't want to date another resident because she knows what the schedule is like. So if I can't even get someone at the hospital to understand, how in the world can I have a chance with someone in the real world? The schedule is crazy, there's no way someone with a normal job wants to deal with this. It's one thing if you're already in a relationship, but to start something when you're working 80 hours a week? I'm exhausted most of the time, I'm irritable, I'm not myself. Although if I'm always feeling like I'm not myself maybe I just don't know who "myself" is anymore. Maybe I'm becoming this person I don't want to be. This person who's going to end up alone and miserable. I kept snapping at my parents. I don't know why they even tolerated me being around for a week. I was obnoxious. I was mean. I don't want to be like that, but it's the knee-jerk reaction. I'm trying to be an adult, I'm trying to figure out what an adult life ought to look like. But it's hard. And all I can really do is keep getting up and going to work and hope it figures itself out eventually.

In the morning I start two months of outpatient service, which should be considerably less stressful than the past few months have been. I might actually have free weekends. Which would be great if I had something to do, but since I hardly even know my friends anymore and the only people I talk to are other residents, I don't know why I even need the days off. Maybe I'll do research so I can get a good fellowship. That's the smart thing to do, right? Spend my days off in the library just to fill the hours, pretending I'm doing it for the right reasons?

Going to sleep early tonight, to bank a few extra hours just in case. Awesome.

Vacation is going well. I am sleeping a lot. Catching up on the backlog of TV shows on my DVR. Explaining to friends that even though I have officially been a doctor for six months, I still can't write them prescriptions until I pass Step 3 of the boards, and even then, I'm going to require an actual doctor's visit.

It's kind of nice to go a week without being called "doctor," without having to ask anyone if they moved their bowels today, without having to find a vein, and without having to check lab results. So much of what we do is tedious, dull, mindless work. Interrupted only occasionally by moments of excitement or reward. I guess that's any job though.

I don't think I've talked about this before, but the doctor/nurse divide is weird. One of my intern friends called me the other night and said there's a nurse he likes, and in theory wants to ask her out, but doesn't think he should. It would be awkward, he's like her superior... he doesn't feel comfortable doing anything. And maybe he's right. But the whole dynamic is weird. They call us doctor, and we call them by their names-- and sometimes not even. At one of the hospitals, there's this strange custom where the nurses all go by Miss or Mister and their first names. So I'm Dr. Lastname and they're Miss Jenny or Mister Steve. It's bizarre. Miss Jenny sounds like a kindergarten teacher. Maybe. And some of the residents use these names when they talk about the nurses to each other, like-- "did you give the order to Miss Amber?" "did you tell Miss Jeanette?" Are we children? I feel like we're colleagues, and we should all just call each other by our first names. Like colleagues do. Patients can call us Dr. Whatever, but I don't feel like I need the nurses to treat me like a superior, and I also don't want to treat them like they're my nursery school teacher.

Back to my DVR.

After today's shift is finished, I will be on vacation for my assigned two week block. It's great to have vacation right after everyone I know who isn't a doctor has already taken vacation for the holidays and is back at work without any time to hang out.

I have big plans to sleep, visit my family, and read at least a couple of books that aren't about diagnosing and treating medical conditions. I will also clean my apartment and buy more ketchup, which I've been trying to find time to do for the past three weeks but instead I end up taking tomato paste and mixing it with maple syrup to get a sort of ketchup-like slurry that approximates the taste pretty well.

The past couple of weeks haven't been too bad. I like the people on my team, which I'm starting to realize makes all the difference. It's like any other job-- you like the people you're working with, it makes the days a lot easier. Sort of.

More later.

I walked into a patient's room today, and with the curtain wide open, no blanket over him, no clothing over him-- he was cleaning his penis.

His roommate was watching, riveted.

This is why you don't want to be in a hospital. Ever.

I asked him if he wanted a minute to cover himself up before we talked.

He said no, not necessary.

I asked him if he could please cover himself up.

He said he was just cleaning himself.

I said that's fine, but I wanted his full attention while we talked.

He didn't look up.

I got my resident to deal with him instead. :)

I got home a couple of hours ago, and just got a call from the resident on night float. They hardly ever call-- and it never means something good. Some piece of information is either lost or confusing, or something terrible is happening with a patient and they need to know if there was anything relevant that happened during the day.

This call wasn't a good one.

One of my patients died. Unexpectedly, I guess. If the death of a 90-year-old with multiple cancers, a feeding tube, and a blood infection can be called unexpected. It's just that we didn't expect him to die today. He looked better today. His family went home. He talked about getting out of the hospital.

We should have sent him home as soon as he came in. We should have called hospice and let him die at home. We shouldn't have poked and prodded and given him more pain than he already had. Instead, we tortured him for a week and then he died, in the hospital, alone. Instead of in his own bed, surrounded by people who loved him.

They come, we treat. That's the default. They come, we treat. To send someone home because there's hardly anything we can do isn't how it usually works. As long as hardly anything means maybe something, we do it. If they ask for treatment, we treat. Even if we know it's probably not going to make anything better. So maybe we gave him an extra day. Maybe. Maybe we cost him a week. I don't know. He wasn't going to make it another two months, for sure. And he was in pain. But he was alert, and talking... he was alive. Until he wasn't.

I tell people I don't want to spend my life dealing with death and they ask me why the heck I went to medical school. I want to deal with life. Living patients. People who get better. People who leave the hospital, and not just in a bag. People with years ahead of them, not days. Death is depressing. To be surrounded by it is unceasingly sad.

The resident called the family. The family thanked the resident for his help, said they were relieved that at least his suffering was over. But what were they really thanking us for? We did nothing. There was nothing for us to do. Too often, there's nothing for us to do, and yet we find something to keep the patient there, in the hospital, just one more day. One day too many. One day too many.

I went into a patient's room yesterday to check on him, I pull back the curtain--

And his girlfriend is in the hospital bed with him, naked from the waist up. I immediately closed the curtain, apologized for interrupting, and told him to let me know when they're ready for me. I hear some rustling, he yells out "okay" and I open the curtain back up--

And the girlfriend is pulling up her pants, over leopard-skin underwear.

The patient seems to be feeling better. :)

Happy New Year.

I celebrated by going to sleep at 10:00. Which means I just woke up, 6 and a half hours later, and I think trying to get that last 90 minutes of sleep is going to be a futile effort.

I've been trying to come up with some New Years resolutions, but they're not ready yet. I'm hoping for something more than "do a better job at this doctor thing" and "do a better job at this life thing". We'll see what happens.

My patients finished off the year by simultaneously going downhill all at once. We have one who seems to have acquired a nickname. "The Cadaver." As in, "how's the cadaver looking today?" His blood pressure spiked, so we called a cardiology consult. The doctor came to see him when none of us were in the room, so he went to the nurse's station to make sure this was the right patient, and this was his baseline status-- he said he was worried something had happened to him between the call and when he got there, because he couldn't imagine we were calling a consult on someone who looked like he was already dead. We were like, no, that's what he looks like, and he's looked like this for a week and he's still here. The cardiologist had no recommendations, and said next time if we could refer him the living instead, he would appreciate it.

Which brings me to a weird practice that goes on in the private hospital-- specialist consults.

The way it seems to work is that whichever resident or attending wants the patient to see a specialist just calls whichever specialist they want, there's no system, there's no process-- so if you're a smart gastroenterologist, you just need to befriend all of the residents, make sure you get your contact info in their phones, and you'll get all the referrals and make money. See, the specialists aren't on salary-- they get paid per patient, they get paid per consult. And the way they get new patients, at least at the beginning, is to get hospital referrals-- they see the patient in the hospital and then the patient comes back as an outpatient. If all the residents know cardiologist X, and haven't met cardiologist Y, cardiologist X will get every referral, because it's like cardiologist Y doesn't exist. He has an office down the hall, he would love to see patients-- but it's not about availability, or competence, or a particular sub-specialty, it's just about who the resident likes and wants to send business to.

It's kind of absurd. You could have two neurologists, one who's awesome with stroke patients and one who's awesome with movement disorders, but unless the resident knows that, knows both of them, and doesn't have anything against one of them, one of them might get all of the business. It puts pressure on the specialists to be oddly and extraordinarily polite to us-- they are economically incentivized to be friendly-- they need us to send them business.

But it shouldn't work this way. The specialist you get should be the one who can get there fastest, or the one who will best serve you, not the one who's friendliest with your resident.

It's like you have to be a schmoozer and a salesman besides just being a good doctor. And the potential for corruption is enormous-- if I'm a specialist, what if I tell the residents that I'll give them a kickback for every patient they send me, under the table. Because what's the difference to them, they just need the consult-- and this way they get the consult and I get the business. I'm sure there's a rule against this. There must be. But if no one enforces it, the potential for abuse is obvious.

I guess that's enough on my soapbox for this morning. Maybe 2010 will bring an end to illness and accidents, and then I can sleep more.