Ethical Dilemma of the Week

"Hi, I think my brother-in-law, [Patient], told you I'd be calling."

"Yes, he said you were a doctor and wanted to discuss his condition."

"Yeah, I want to know if we're at the end yet."

"Excuse me?"

"I want to know how close we are to the end."

"Um, your brother-in-law is not in great shape, that's absolutely correct.  But I don't believe he is actively dying.  We're having him come in for surgery next week, and while I don't think he's going to be playing golf anytime soon, with rehab and probably a wheelchair at least for the short term, I think he'll be okay."

"I don't think my sister is capable of taking care of him."

"She seems to be doing okay, from what I've seen."

"Well, what I want to know is whether it's time for her to just leave him in the emergency room and let the state take care of him."

"I'm sorry, what?"

"You know, they're not legally married.  So I told her, she has no legal responsibility for him.  If she gets tired of dealing with him, I told her she can just drop him off at the hospital and never come back."

"She seems to be doing okay.  I'm sure they'd love the situation to be better, but we're hopeful he can have some kind of recovery and even if it's a limited quality of life, mentally he's okay, and whether or not they're married, she doesn't seem like she would want to just leave him to die on his own."

"I know, and I'm trying to convince her otherwise.  I was hoping you might be able to talk some sense into her."

"Wait, you want me to convince her to leave him in the ER and walk away?"

"Yes, exactly.  I appreciate it, thanks."

"No, I don't think that's the best option given his situation."

"For him or for her?"

"For either of them!"

"You know you'd still get paid by insurance, right?"

"Why am I in pain? My surgery was LAPAROSCOPIC!"

Patient calls me.  "Doc, I'm feeling really terrible today.  In so much pain.  Couldn't go to work.  Really feeling awful."

"Okay, one second, let me take a look at your chart..."

"Sure, sure.  Really, I'm just totally wiped out."

"Have you taken your temperature?"

"Yeah, it's normal."

"Okay, I'm looking at your chart.  Uh, you had your gall bladder removed yesterday?"

"Yeah."

"Were you feeling like this before the surgery?"

"No, no, I was feeling okay."

"Yeah, you're feeling like this because you had surgery yesterday."

"No, doc.  It was laparoscopic."

"Okay..."

"The surgeon said it would be nothing.  He didn't say anything about pain."

"Even laparoscopic surgery is surgery.  You had the procedure yesterday.  It's normal to be feeling terrible.  Have you been taking the pain medication?"

"No, I don't like to take stuff like that."

"Then it's not surprising you have pain!"

"I think he botched the surgery.  It was laparoscopic.  I'm supposed to be fine."

"You had the surgery yesterday.  This pain is normal."

"If this is normal, I'll tell you one thing-- I'm never having my gall bladder removed again."

"That's right, you're not."

"Okay, write that down in my chart."

"Uh... okay...."

"You know, the ambulance service."

My pager buzzes.  I call back.

"This is Dr. [Me].  I'm covering this weekend for your doctor.  I got a message that you called."

"Yes, I'm calling about my husband.  I need you to send an ambulance for him."

"Okay, if your husband needs an ambulance, you need to call 911.  I'm the doctor on call, I can't dispatch an ambulance."

"No, if I call 911, they're going to take him to [Local, Terrible Hospital].  I want him to go [My Slightly Less Local, Slightly Less Terrible Hospital]."

"Can you drive him, or call a taxi?"

"Oh, he can't get into a car!  He's barely even breathing!"

"Um, you need to call 911 if this is an emergency."

"No."

"No, you really do need to call 911 if this is an emergency.  I want you to hang up with me and call 911.  Then you can call back if you still need to ask me any questions."

"No, it's not an emergency.  He's been barely breathing for weeks.  I just think it's getting slower now and I want him to be seen.  And not at [Local, Terrible Hospital], because my aunt died there."

"I'm sorry."

"Oh, it was thirty years ago."

"Okay.  What is your husband's name?  Let me quickly look him up in the computer."

"[Name.]  With a [silent letter]."

"Can you spell that?"

"You need me to do everything?  You're the doctor!"

"Please, ma'am, just spell your husband's name for me so I can look him up in the computer."

"[Name]."

"Okay.  Your husband is on the hospice service.  You should call the hospice nurse.  Do you have that phone number?"

"All the hospice nurse does is give him painkillers!"

"Yes, they're trying to make him comfortable."

"I need you to send an ambulance to get him to your hospital.  That is why I called.  You are not being helpful."

"I am trying to be helpful, but this is not an ambulance dispatch service.  Your husband is on hospice.  You need to either call the hospice nurse, or you can call 911.  But, looking at your husband's chart, I'm not sure it makes sense for him to go to the hospital.  The last note from your doctor seems to indicate the goals of care are to make him comfortable."

"He's not comfortable."

"Yes, you should call the hospice nurse."

"I want an ambulance here in 15 minutes."

"Okay, I am going to see if I can get a social worker to call you back, and you can discuss your case with him or her.  I think a social worker may be able to provide more help, since I don't know your husband, and, even if you want to get him here, I'm not sure how to arrange private ambulance services."

"Not private ambulance.  I'm not paying for an ambulance.  You need to send one!"

"Do you know how to check your husband's vital signs?"

"No, I'm not the doctor!  You tell me his vital signs."

"I'm not there.  I can't check his vital signs.  Look, I want to help, but the best way I can is to have you call 911, or the hospice nurse, or let me find a social worker to get in touch with you."

"Well, don't have the social worker call between 12 and 2, because I'll be out at lunch and my husband can't answer the phone."

While I have you on the phone... do I need to put my father in a nursing home?

...so the biggest difference so far between residency and fellowship is that I have actual patients, I am their doctor, and I'm seeing for the first time what it means to be accessible to patients and able to be reached whenever they have a question.  I call back a woman who called the answering service and said she had a medication question regarding her father.

"Hi, doctor.  I don't mean to take up your time, but I was just wondering... I got my father's pills confused and I'm not sure which is the pink one and which is the white one.  I was hoping you could tell me."

"Oh.  That's really a better question for the pharmacist who dispensed the medication.  I don't actually know what the pills look like.  But if you call the pharmacist, he should have your records and be able to look at the actual pills and tell you which is which."

"The pink ones are bigger."

"Okay, that's great.  But I don't know what the pills look like.  So you'll need to call the pharmacist.  If the pharmacist needs to get in touch with me, or you have trouble reaching him, you can give me a call back."

"Great.  Oh, just one more quick thing while I have you on the phone."

"Sure."

"Do I need to put my father in a nursing home?"

"What?"

"Well, I don't imagine his situation is going to get much better, and I'm having a rough time taking care of him."

"This is definitely a discussion you should have with the social worker you and your mother met with in the hospital-- there might be some services your father can qualify for.  Or she may have some other ideas."

"No, but, just generally, is my father the kind of person who should be in a nursing home?"

"This might be a longer discussion than we should have on the phone right now--"

"No, I have time."

"Yes, but I think this should be something we look at over time, and we can talk at your father's next appointment about what services he might need, and what the best situation might be for him, now and in the future."

"Do you have any nursing home recommendations?"

"I don't, but the social worker would be the best person for you to talk to about this.  You have her card, right?"

"Yes, could you transfer me to her?"

"I'm not in the hospital right now-- I'm calling you back from home.  So if you call the number on the card, you should be able to reach her."

"I don't have the card in front of me right now-- it's in my purse downstairs.  Could you give me the number again?"

"I actually don't have the number-- I'm at home.  If you can't find the card, call again tomorrow during business hours and I can get that to you."

"I can't call during business hours.  I'm at work."

"Okay, that's fine.  I will call you tomorrow with that number."

"You can't just tell me now?"

"I don't have the number right now."

"And you can't transfer me?"

"I'm sorry, I'm not in the hospital right now."

"Wait, one more thing-- are you sure you don't know which is the pink pill and which is the white one?  I'd hate to bother the pharmacist."

"Urgent Question For Doctor"

I got an urgent page from a patient.  I call back the first chance I have, about ten minutes after I get the message.

"I got the message you called-- I'm sorry it took a few minutes."

"That's okay.  I have an urgent question."

"Okay, what's going on?"

"I wanted to know how Medicare will be affected if Obama becomes President."

"That's your urgent question."

"Yes."

"For your doctor to answer."

"Yes."

"Obama is already the President."

"Oh.  Is he?  The election already happened?"

"No, he got elected in the previous election."

"Oh.  And how is my Medicare doing?"

"It's okay."

"Is something going to change?"

"No.  Are you feeling okay?"

"For now."

"Are you taking all of your medication?"

"Yes.  When I remember."

"Are you still living alone."

"Yes."

"I'm going to give your daughter a call, is that okay?"

"Yes."

"For now on, only tell the answering service your message is urgent if it is a medical question.  I'm not the right person to answer questions about your health insurance, okay?"

"Okay."

"I'll see you at your next appointment."

Irregular periods and premature ejacularies.

"I don't think the medicine you prescribed last time is agreeing with me."

"No?  What have you been feeling?"

"Well, I've been dizzy and lightheaded and haven't had much of an appetite."

"Okay, those are all potential side effects."

"I've also been having headaches and irregular periods."

"You've had something that seemed like a menstrual period?"

"If that's what I said."

"You're 77 years old.  You were having bleeding?"

"Bleeding?  No.  Dizzy, lightheaded, loss of appetite, headaches--"

"You're just reading off the list of side effects.  I have that list too.  Are you actually experiencing these things or you just don't want to take the medication?"

"No, I've had headaches, irregular periods, premature ejacularies, dry mouth--"

"I'm sorry, premature what?"

"Ejacularies.  I think that's what they're called."

"You're a 77-year-old woman.  And you're telling me you're having premature ejaculation?"

"I don't know.  Whatever I said."

"You don't want to take this drug."

"No.  I don't need it."

"So you're telling me you're having all of the listed side effects."

"Yes."

"Why don't you want to take this drug?"

"It's expensive!"

"Oh.  Do you want me to prescribe you a similar drug, that has a generic alternative?"

"Okay."

"Great.  Do let me know if you're actually having either a menstrual period or some sort of ejaculation, because then we may have to call the record books."

"Okay, thanks."

"Nope, you should actually take your pills EVERY day."

"Your blood pressure's really high.  Are you sure you're taking your medicine?"

"Yep.  Every time I feel it acting up, I take a pill."

"Every time you feel what acting up?"

"My blood pressure."

"And what does that feel like?"

"You know, like a sensation in my blood vessels."

"What kind of sensation?"

"Like a pressure, sort of."

"Okay, that's not good.  You realize you're supposed to take the pills every day, right?  We talked about that last time."

"Yeah, yeah, that's what you said, but I don't want to overmedicate.  So I just take it when I feel something.  Otherwise I don't need it."

"No, you do."

"I don't like taking something every day."

"Yeah, but you need it."

"I just want something that can treat the problem when I have it.  Like Tylenol, or vitamins."

"Vitamins?"

"Yeah, when I eat something unhealthy, I take a vitamin afterwards, to balance it out."

"That's not how nutrition works."

"No, it works for me."

"No, it doesn't."

"I just don't like the way medicine feels.  I don't want to take too much."

"This is a very low dose."

"Can I cut the pills in half?"

"No, it's a very low dose."

"I'm going to cut the pills in half."

"If you're going to do that, I'll give you a larger dose."

"Oh, you can give me a larger dose and I can just cut them in half?"

"Uh, I guess.  If that means you'll take them.  Sure."

"Great.  I mean, I'm not going to take it every day, but I'll take it more if it's only half."

"He's an organ donor-- so where should we drop off the organs?"

I get paged by the son of one of my patients early this morning, a 94-year-old man in declining health, on hospice.  I call back--

"I wanted to let you know-- my father passed away during the night.  His aide woke up and checked on him, and he had stopped breathing."

"I'm so sorry."

"Thanks.  We haven't called the funeral home yet, because I wanted to find out-- I know he was an organ donor.  So I was wondering how we handle that process."

"Um, you should go ahead and call the funeral home, it's okay."

"No, he really wanted to help others who could use his organs."

"That's a very noble thing, and it's great that he made those wishes clear.  I wish more people would do that. Unfortunately, we can't use organs once the patient has been dead for any amount of time-- organs lose their function very quickly, so harvesting normally happens when the patient is brain dead but blood is still circulating.  So it's not practical to harvest organs from home, it's really when people die in a hospital setting."

"So if we removed the organs ourselves--"

"No, no--"

"No, I'm not saying we did that.  I'm just asking if we should."

"No, no, definitely not--"

"But you're saying we should have brought him in as soon as he died--"

"No, no, I think your father is very lucky he died at home, in his sleep, peacefully."

"But if he had died in the hospital, you could have used his organs?"

"Honestly-- and fortunately for your father, since he lived a long life-- he was past the age where we are able to use the organs.  I'm not an expert in this area, but it's not generally practical to transplant organs from people over age 50 or 60.  The organs tend not to be in good enough condition for transplant, even if they're still working quite well in their original owner."

"So I just want to be sure-- you do not want any of his organs.  We should not do anything, or bring anything to the hospital."

"No, but it's a lovely gesture.  Please give the rest of your family my deepest condolences."

"Oh, I also wanted to know if we needed to schedule an autopsy--"

I Want The Extra Strong Multivitamins

"...I also need a prescription for the extra strong multivitamins."

"Excuse me-- the what?"

"The extra strong multivitamins.  Not the ones you get over the counter.  The prescription strength."

"I'm sorry, sir-- I'm not aware of any such thing.  If you want a vitamin, just buy one over the counter."

"Don't even pretend to tell me the over the counter ones are as good as the real thing."

"Those are the real thing."

"I'm willing to pay-- up to $150 a month for the good vitamins."

"Vitamins should not cost you that much."

"The pharmacist was giving me the good ones, for $150 a month.  I just need a new prescription."

"Wait, the pharmacist was selling you some kind of vitamin for $150 a month?"

"Yeah-- they were helping, too.  I don't want to have to go back to the regular kind."

"Sir, your pharmacist is either a drug dealer or a scam artist.  He's stealing your money.  I don't know what he's selling you, but if it's vitamins, he is ripping you off."

"No, not my pharmacist.  Stop giving me the run-around."

"I'm not.  What's the phone number of your pharmacy?  I'll give them a call."

-----

"Hi, I'm Dr. __________, calling about a patient of mine, Mr. ___________.  He's asking me for some kind of prescription, telling me you're selling him vitamins for $150/month.  What are you selling him?"

"What do you mean?"

"What are you charging him $150/month for?  I know what vitamins cost."

"No, I don't think you understand how many vitamins he's buying."

"How many vitamins is he buying?"

"150 dollars worth."

"So, hundreds and hundreds of vitamins every month."

"Yes.  I get them from the back.  He doesn't like the ones on the shelf.  Same kind, I just get the bottles from the back room."

"So he's crazy."

"Yes.  Just write him some bogus prescription and I'll take care of it."

"I don't want him wasting his money."

"Well, I'm not just going to give him the vitamins for free."

-----

"Okay, I'm going to write you a prescription, but these are really strong, and you can only take 1 a day, okay?"

"Wow, they must be good."

"Yep.  And, even better, a hundred of them should only cost you like ten bucks.  If they cost more, tell the pharmacist to give me a call and I'll give him the information about the discount code.  Don't let him charge you $150.  You get my special $10 rate."

"Oh, great.  Thanks, doc."

"Sure."

"I used to be a little boy too!"

I go in to see my new 101-year-old patient.

"You're my doctor?  You look like a little boy!"

"I'm older than you think."

"No, you're a little boy."

"I used to be a little boy."

"Yeah?  So did I!"

Boards II

I guess no one was interested in my fake boards question.
And now that the boards are over, I'm not interested either.

Are there any universally-liked doctors?  Is anyone able to seem competent and pleasant to all of their patients, and not just some of them?  I would hope there could be, but I have yet to have any proof.  For everyone who tells me they miss the previous fellow, or they love the attending who's been dealing with them (and don't know why now they have to see inexperienced me, who takes twice as long and doesn't know about that terrible medical problem they had in the past that isn't in the chart), I get someone else who thinks their previous doctor in the clinic was terrible and wants me to agree.

"I never even met Dr. Johnson-- she graduated from fellowship right as I was starting."

"Well, she was terrible.  Never seemed to have any appointments available."

"That's not her fault.  We're only in clinic a couple of days a week."

"And her name wasn't on her white coat."

"Again, not her fault.  They don't give us coats with our names on them."

"And she wouldn't give me her cell phone number."

"I'm not going to give you that either."

"And she smelled funny."

"I never even met her."

"Good for you."

Bored of Boards

All anyone wants to talk about is the internal medicine boards.  I've been dodging a handful of phone calls and text messages from former and current colleagues who I imagine want to wish me luck but I'm afraid in doing so will happen to ask a question I don't know the answer to and make me freak out about which of the  two dozen heart murmurs we need to know the details of haven't quite stuck.

So many multiple choice questions.

As with everything that has come before, you end up building up such an anticipation about how much life will be when this test is done / when this rotation is done / when this year is done... but then you get to the end and, too quickly, there's a new next badness to replace the one you've completed.

Patient comes in with nausea, vomiting, nystagmus, ipsilateral Horner syndrome, ipsilateral palate and vocal cord weakness, and "crossed" sensory loss.  You correctly identify that he is suffering from lateral medullary syndrome, but before you can tell him, you instantly become unresponsive, apneic, and have no pupillary function.  Is an EEG required for your diagnosis of brain death, what kind of stroke caused the problem with your patient, and whose responsibility will it be to tell him once you have been wheeled to the morgue?

(A) Yes, hemorrhagic, neurology fellow
(B) Yes, vertebral, neurology attending
(C) No, hemorrhagic, resident called in to replace you
(D) No, vertebral, risk management officer

"You're Female, You're Male... You I'm Not So Sure."

"So, you're having trouble with your eyes."

"I am.  For a long time.  Things are blurry."

"Okay... how blurry?"

"Well, you, you I can tell, you're male.  From your voice, and your short hair.  That one over there is a female.  The one in the corner, maybe a male, maybe a female, I'm not really sure."

"That's a female medical student."

"Oh, good for her.  You sure it's a female?"

"Yes, she's a female."

"And that other one, by the door, that's a male."

"That's a coat rack."

"Yeah, I thought it was a skinny one."

"I think we're going to have you see an ophthalmologist."

"Oh, I saw one of them years ago."

"We're going to have you see one again."

"I don't know if I'll be able to see him.  If he stands close."

"We'll have him stand close."

"Great."

"I assumed I was fine, since no one dragged me, kicking and screaming, into surgery."

"So, I see in your chart that you were supposed to follow up with a gastroenterologist a few months ago, have an MRI, and potentially surgery."

"Yeah."

"But that didn't happen--"

"Yeah, I saw the doctor, he said I needed surgery, but then he never called back to schedule it."

"Did you call to follow up?"

"I called once, but didn't get a call back.  I figured the doctor decided I didn't need the surgery after all."

"Because he didn't call you back?"

"Yeah."

"But you didn't pursue it-- you just assumed that he secretly decided you didn't need surgery, and thought the best plan of action would be not to tell you that."

"When you say it like that..."

"I apologize on behalf of that doctor that he didn't call you back.  Of course he should have called you back. But that doesn't mean you didn't need surgery."

"But he didn't call me back."

"No one's going to make you have surgery."

"Okay, great!"

"No, it's not great!  You're the one in charge of your own health.  Just because a doctor doesn't hound you to do something doesn't mean that if there's a problem, it's going to go away.  You're the one who ultimately is going to deal with the consequences, so it's in your best interest to take ownership and follow up.  I'm not saying the doctor doesn't care if you live or you die, but we have lots of patients, things fall through the cracks-- it's unfortunate, but inevitable.  You have to be your own advocate.  You have to follow up.  Someone tells you that you need surgery, you need to call back and schedule it.  Or at least call back until you get to speak to the doctor and hear him tell you he changed his mind, and explain why.  It is your health."

"But I didn't want the surgery anyway."

"Not even if you need it?"

"No, I want it if I need it."

"No one's going to force you.  That's not what doctors do, or at least not what they do anymore.  You need to take ownership."

"He should have called me back."

"Yes, absolutely.  But your body doesn't care!  If something's wrong with you, it's still a problem even if the doctor doesn't call you back.  Your blood test results are really not good.  There is really something wrong.  And, yes, of course your doctor should call you back, but you have twelve different doctors, and not everyone looks at every test result, and it's frustrating, sure-- but you have to be the one looking out for yourself."

"So what do I do now?"

"I'm going to give you a referral to a different gastroenterologist, and I want you to make an appointment, and go see him, and then we'll go from there."

"Will this one call me back?"

"I don't know.  But it doesn't matter.  If he doesn't call you back, you call him back.  Call him back until his secretary puts him on the phone.  Pretend it's a matter of life or death.  Because it might be!"

"It's his job to call me back."

"It's his job to do surgery.  You'd rather he be good at doing surgery than be good at calling you back, I promise."

"He should still call me back."

"Absolutely.  And I shouldn't be two hours behind on my clinic appointments, but I am.  I will call you in a week.  I will write a note to myself to do that.  But if I don't-- call the clinic next week and ask to speak to me.  It's okay.  You're allowed to do that."

"Someone's Been Urinating On Me."

"Someone's been urinating on me."

"Um, do you think it might be you?"

"No."

"You're wearing diapers."

"I don't know how those got there."

"I think, unfortunately, it's because you're having trouble with your bladder."

"Well, you'd better tell the person who's been urinating on me to stop."

"Okay."

"Thank you."

"You're welcome."


There are days it seems terribly frightening to think about getting old.

"Oh, no, we wanted a full doctor."

"So, I see it's your first time at the clinic."

"Yes.  You're not the doctor, are you?"

"I am."

"Oh.  We came here because we were told there were some very good doctors here, very experienced."

"There are.  I'm new.  I'm one of the fellows."

"Hmmm.  We wanted a full doctor."

"I'm a full doctor.  I'm just relatively new at it.  But I assure you, as a fellow I am consulting with more experienced doctors about your case, and in fact one of those doctors will be in to see you after I finish.  They make sure you're getting the right care."

"We just-- well, we would have kept going where we going if we thought we would get someone who hasn't even finished medical school yet."

"No, I finished medical school.  And residency.  I'm three years out of medical school.  I'm a full doctor.  Licensed and everything."

"You look young."

"I am younger than some of the other doctors here, sure."

"We wanted a doctor with experience."

"I can't force you to be my patient, but I can tell you that with a fellow it's like you get two opinions for the price of one, since I will be consulting with one of the more senior doctors during each of your visits."

"Why can't we just have the more senior doctor and you can watch?"

"That's not how they do it here."

"I think we probably made a mistake to come here."

"I'm sorry you feel that way."

"If we call again, can they assign us to an older doctor?"

"I'm not sure."

"We'll try."

"Good luck."

"You seem nice.  Maybe we'll see you in a few years, once you finish medical school."

"Great.  Thanks."

"Have a nice day.  Can you validate parking?"

"They do that at the front."

"Oh, I thought maybe they have you do that, since you're new."

"Nope."

New Wounds.

"So, like the surgeon talked to you about, you need to be vigilant about the wound where they did your husband's toe amputation in order to avoid further problems.  He could end up with a very real risk of losing his foot."

"Wait, wait, wait-- I thought we just had to watch for new wounds.  I didn't realize this wound counted too."

"Excuse me?"

"I thought the amputation meant that this whole part was over, and that we were just worried about new wounds that could lead to problems, not old ones.  I thought the amputation meant we got to restart fresh."

"Unfortunately, the foot doesn't know if something is an old wound or a new wound.  Any wound can lead to problems, given the blood flow situation.  We're going to have to monitor this very closely and with a great deal of care in order to minimize the chances of future problems."

"No one said there was going to be a wound where the toe was amputated."

"I'm sorry if the surgeon wasn't clear-- but anytime they're doing surgery, they're making a cut, there's always going to be a risk afterwards.  There was a lot of dead tissue there, this is an open wound right now, the dressing has to be changed--"

"All the time?"

"All the time.  Yes.  This is a wound, and we need to try and provide the best possible conditions for it to heal, or else it's going to potentially lead to further problems."

"I just wish someone had told me this wound still counted, because I'm not sure I would have gone along with the amputation."

"Without the amputation, he had an infection that might have killed him."

"Might have.  No one was ever able to tell me for sure."

"Let's just keep this wound clean and try to protect the foot as much as possible."

"Wounds on the other foot don't count, do they?"

"Count for what?  For losing the foot they're not on?  No.  For developing into a life-threatening infection?  Sure."

"Just tell me-- which parts of the body are we allowed not to worry about?  Where is he allowed to have a wound that we don't have to watch?"

"Nowhere."

"Ugh.  Forget it.  We're leaving."

"Almost all of my patients have..."

"Yeah, this month has been really interesting.  Almost all of my patients have had AIDS."

"Wow.  I wouldn't think it would be so common."

"Yeah, it seems like once people reach a certain age-- they all have AIDS."

"So even the older patients?"

"Especially the older patients.  Some of them have had AIDS for years."

"And it doesn't kill them?"

"Keeps a lot of people alive."

"AIDS?"

"Yeah, AIDS.  Although the treatment can really vary.  Some people-- wonderful.  Others are very angry with their AIDS."

"I'd be angry if I had AIDS."

"I'd be more frustrated and disappointed than angry, I think."

"And you're saying that even the elderly can go for years--"

"Definitely.  Years and years with their AIDS, absolutely.  Becomes like part of the family."

"The AIDS?"

"Yes, the AIDS.  You know, most of the time, it's AIDS from overseas."

"They go to a foreign country and get AIDS?"

"No, no, they get the AIDS here. But originally."

"Well, yeah, they say AIDS started in Africa."

"Sure, some of them."

"And sometimes the AIDS-- terrific, really great.  But, you know, sometimes the AIDS just sit around and watch TV all day."

"What?"

"The AIDS watch TV."

"Oh-- wait-- do you mean aides?  Like, home health aides?"

"Of course.  What did you think we were talking about?" 

"Can I have your e-mail address?"

I've had a couple of clinic patients ask for my e-mail address.  I gave it to one of them, whose son is a doctor, and who had an e-mail relationship with the previous fellow in the clinic.  I didn't give it to the other one, partly because the day after I gave the e-mail address to the first patient, she sent me three long e-mails, and I found myself concerned about setting up a situation where I'm receiving e-mails that I don't have time to read and answer promptly.

I'm not sure what to do about it, as a general rule.  There doesn't seem to be a policy, at least not one that I can figure out.  The attending I asked said it's up to me.  Some fellows do it, some don't.  The issue that some doctors in practice have with e-mail is (1) it's not compensated, and (2) liability issues, if you don't reply instantly and something needs to be urgently done about the patient's condition.  I think the biggest issue is time.  There aren't enough hours in the day to have an e-mail relationship with every patient.  And the barriers to someone sending an e-mail feel like they're a lot lower than picking up the phone.  There's an expectation that if you call a doctor, they might not get back to you for a few hours, or until the end of the day.  That expectation doesn't hold with e-mail, even if a doctor may not actually be checking e-mail for hours in the middle of the day.

On the other hand, who wants to tell patients they can't contact you via e-mail, if e-mail is their preferred method.  In other professions, no one would tell a customer they can't send an e-mail if they have a quick question.

It's hard to tell tone over e-mail.  It's hard to ask follow-up questions, since you may end up in a days-long back and forth.  It's hard to give any advice more specific than, "you should come in just to be sure," which isn't advice that requires an e-mail relationship.

I don't want to e-mail with patients, if there's a choice.  There are systems in place to speak to a doctor on call 24 hours a day.  There are other ways to ask questions.  And yet that feels like a bad attitude, or at least an attitude that doesn't reflect the reality of how people communicate.  We can use the Internet without question for so many transactions and relationships-- even many that used to be in person-- grocery shopping, etc.  It can't possibly be the case that in the future people won't be e-mailing with doctors.  So why does it feel like such an imposition?  Why does it feel out of bounds, like a form of communication that is too direct, too easy to abuse, too personal?

We're on the hook for so many hours of the day.  To be able to go home and not be on the hook-- yes, there can be phone calls, and messages through the answering service, but it's different, somehow-- doesn't just feel like a relief but like a necessity.  People's health issues are important, usually require full attention, and can't be effectively dealt with in the same way you scroll through Facebook posts.  You can't half-answer a question and hope it turns out OK.  A patient e-mails saying he's feeling x, y, z symptoms and you can't necessarily just flag the message and say you'll deal with it tomorrow.  I don't want the responsibility of having to be fully engaged 24/7 with every patient.  It sounds bad to say that, but I don't know any other way to express it.

NY Med

I got out of the blogging rhythm this week.  Sorry about that.  Will try and get back into it.  I just watched a show on ABC called NY Med.  I don't know why I want to spend downtime watching exactly what I do all day, but I know someone from med school who knows someone who knows someone who's in it, or something like that, so I figured I would check it out.

This week's episode-- I think it aired on Tuesday-- had the healthiest-looking guy having a liver transplant that I have ever seen.  Do they give the patients makeup?  This guy did not look like a transplant patient.  I don't know if I can watch any more episodes of the show.  It made everything look too easy.  Everyone had a good outcome, nurses seemed like they had brains, no one messed up, it seemed like there were hardly any patients, even the homeless people seemed jolly and harmless.  I don't know if they left all of the terribleness out in editing, or the hospital only agreed to let them air stuff that reflected well on them, but where were the patients lingering on stretchers in the hallway because everyone forgot about them?  Where were the broken computers?  Where were the attendings yelling at residents for no good reason?

I'll probably give it one more episode, since the preview showed that next week, Dr. Oz will get a colonoscopy on camera.  That seems like fun.  I've always wondered what Dr. Oz looked like on the inside.

Sepsis

I just read a frighteningly well-written New York Times article about a 12-year-old boy who died of sepsis despite going to an ER at a reasonably early point in the process. The article raises all sorts of questions about information sharing and what happens to test results.  It's also a reminder of how high the stakes are.  Most jobs people have, for better or worse, are not one inadvertent oversight away from tragedy (and a New York Times article).  No one in the article is being accused of anything sinister, but, unfortunately, it doesn't take doing something actively evil to contribute to a terrible result.  Certainly a compelling, terrifying read.  Gosh.