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!