"So the two of you are partners?"

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

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

"So the two of you are partners?"

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

"So you both get paid for seeing me?"

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

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

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

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

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

"What if I paid you directly?"

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

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

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

"Matters to me."

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

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

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

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

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

"That's not very reassuring."

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

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

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

"I thought doctors got rich."

"Some might, but fellows don't."

"So you're saying the women do?"

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

"That's confusing."

"Sometimes."

Hyperbolic Chambers

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

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

"You mean a hyperbaric chamber."

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

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

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

"A septic infection."

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

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

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

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

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

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

"No, if something works, it works."

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

"Why not?"

"Because different medicines do different things."

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

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

"What?"

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

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

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

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

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

"Either this will happen or that will happen"

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

"No?  What did he say?"

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

"Did you give you any medication?"

"I don't know."

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

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

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

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

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

"Whatever, my life is over anyway."

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

"I'm talking to you."

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

"No."

"So maybe this would be useful."

"You mean a shrink?"

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

"I'm not crazy."

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

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

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

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

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

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

"Yes."

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

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

"The psychologist is going to take another EKG?"

"Nope."

"Oh, okay."

Too Young

A patient's son calls me.

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

"Yes, I did."

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

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

"How old are you?"

"[age]."

"That's young."

"I'm sorry.  That's how old I am."

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

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

"He said you were still in training."

"Sure.  I'm a fellow."

"So you're not really a doctor?"

"No, I am a doctor."

"He said you weren't."

"I had this conversation with your father too."

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

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

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

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

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

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

"Yeah.  Too young."

"Okay.  Is that it?"

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

"You're not my patient."

"My father's last doctor did it."

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

President's Week

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

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

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

IV Drug Use

Just going down a standard history...

"Any smoking or drinking?"

"No, not at all."

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

"Uh...."

"You use IV drugs?"

"Well, my husband does...."

"Your husband uses IV drugs?"

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

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

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

"Yeah, that's fine."

"I think it's vancomycin."

"Yeah, that's fine."

"Hmmm. That's a good question."

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

ME: "So what brings you in today?"

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

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

HUSBAND: "I don't know."

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

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

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

HUSBAND: "Mine.  No.  Yours."

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

WIFE: "No, we're married."

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

HUSBAND: "No, we're okay."

ME: "And what brings you in today?"

WIFE: "It's cold."

ME: "The weather?"

WIFE: "No.  In here."

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

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

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

WIFE: "I was in the hospital."

ME: "Oh, recently?"

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

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

HUSBAND: "No."

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

HUSBAND: "I was born here."

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

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

WIFE: "I think the pharmacy would know."

ME: "Which pharmacy do you use?"

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

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

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

WIFE: "No."

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

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

HUSBAND: "Oh, sorry.  I forgot."

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

WIFE: "Should I start with the box?"

ME: "What box?"

WIFE: "The box for the clock."

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

HUSBAND: "I don't know."

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

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

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

HUSBAND: "No."

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

HUSBAND: "Sorry, I forgot."

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

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

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

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

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

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

ME: "Check you in where?"

WIFE: "I don't know."

HUSBAND: "She doesn't know."

ME: "Okay.  Great."

Yes, I See Your Badge

A woman approaches me at the nurse's station.

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

"What's your mother's name?"

"You should know her name."

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

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

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

"Jane Smith."

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

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

"I'm glad to meet you now."

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

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

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

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

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

"Yes, you said that."

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

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

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

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

"It is not."

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

"I'm not dealing with nurses."

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

15 Ways To Fill Out A Death Certificate

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

"One of your patients died last night?"

"What?  Who?  Why don't I know this?"

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

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

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

"I don't even know the patient."

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

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

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

I call the patient's daughter.

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

"He was 102.  It's okay."

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

"He was 102.  That's how he died."

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

"He didn't wake up.  He was 102."

"So nothing happened."

"No, nothing specific happened."

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

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

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

"It's okay.  He was 102."

I call back the medical examiner.

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

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

"I don't have one."

"Should we just say homicide?"

"No.  It wasn't homicide."

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

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

"But you're not certain."

"No, I'm not certain."

"There you go."

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

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

"Thanks.  Bye."

Dear Prudence, I Should Make The Nurses Brownies?

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

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

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

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

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

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

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

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

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

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

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

***

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

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

...

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

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

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

"Yeah...."

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

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

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

"And so you're not retired?"

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

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

"I guess.  Good luck."

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."