Am here in the hospital, on call overnight.

In theory, there is a cot for me to sleep on. In practice, there will be no sleeping. Partly because too many of the patients are going downhill fast, and partly because the cot is absolutely filthy. There's either chocolate pudding on the sheets or... something that isn't chocolate pudding. And I'm going to insist it's chocolate pudding. Please let it be chocolate pudding. Or whatever, I'm not sleeping on it anyway.

Two families are here overnight, two patients who may or may not make it to the morning. One family understands what's going on, the other doesn't. The lesson here, drugs are bad news. In the private hospital, so many of the patients we see are there because of bad luck, twists of fate, illnesses beyond their control-- cancer they didn't do anything to cause, etc. In the public hospital, it was alcoholics when I was on regular floors, and in the ICU it's drug addicts. Normal 35-year-olds don't go into cardiac arrest. Normal 35-year-olds don't have liver enzymes off the chart. Under normal wear and tear, the body takes years to fail. 35-year-olds, even morbidly obese smokers, can still be doing okay. By 50, they may not be, and by 65 they almost certainly aren't, but at 35 the body can take a lot. Not if you smoke crack. Sorry. Forget about bringing kids to prisons to scare them into behaving-- bring them to the ICU and show them what these people have done to themselves. I do know some doctors who smoke, and don't understand how they can do it. I know doctors who drink, and don't understand how they can do it. But not even a moron could be a doctor and see the patients I've seen this week and decide that heroin or crack are safe enough to try even just once. You may as well throw yourself off a bridge.

In other news, my mother is trying to set me up with her friend's daughter's best friend (I think that's the connection), who just found out she'll be starting here as an intern this summer. We just became Facebook friends. So that's a start, right?

"You're going to need to call the medical examiner," said the woman in the Office of Decedent Affairs (a very restrained name they've given to the Death Office).

I have seven patients who are still alive, six notes to write, orders to enter-- so calling the medical examiner to find out if she wants to investigate the extremely un-mysterious circumstances of my patient's death went to the bottom of my list.

Three hours later, the woman calls me back. "Have you talked to the medical examiner yet?"

"No, I haven't had a chance."

"Well, we can't move the body until you do, and unless you call them in the next fifteen minutes, we're going to be wheeling another patient into that room and she can lie there, right next to the corpse."

So I called. And, of course, the medical examiner had no interest in a guy who died of a massive heart attack ("no murder, no intrigue, no interest"). But transport didn't get there to move the body for two more hours anyway, so we had a patient in the hall for half the afternoon, while a corpse was waiting in her room for removal.

First day in the ICU. I have a patient who looks like an elephant. 500 pounds, thick, wrinkled skin, legs like tree trunks. Besides just the health consequences of being that big, there are problems beyond that-- there's a limit to what we can do to treat him. He doesn't fit in the CT scanner. He needs a scan, but we can't give it to him. X-rays aren't revealing because he has so much soft tissue. We can't get much of a read with the echocardiogram-- it can't penetrate all the fat. He's in the hospital with a problem that should have been found early and treated-- but he has so much skin and so much of it is hidden from view, folded over itself, that problems can fester without being identified. He can't really clean himself, he's barely mobile, and we can't really get to the bottom of things because we can't give him the diagnostic tests he needs. Beyond that, there are psych issues-- it's pretty hard to get as large as he is without psych issues. He's going to die here-- hopefully not this visit, but unfortunately if it's not this, it will be something else, and probably soon.

The ICU is terribly sad. After months on the outpatient service and on normal hospital floors, it's been easy to forget just how sick a lot of patients are. There are rapid responses every day here. People die. They don't get better and leave. But, oddly enough, from the doctor's perspective, in a lot of ways this is a better rotation than normal floors. They put better nurses here, there are more fellows, more attendings here for more hours, you're not as alone. Fewer patients, fewer notes to write. Shorter hours, even. Although the overnights will not be much fun. At all.

"A few weeks ago I felt a terrible pain in my chest, but it eventually went away so I decided not to go to the doctor. You think my heart is ok?"

Well, if it's not, it's too late for us to do anything about it now! If you think you're having a heart attack, seek medical attention while it's happening, not a few weeks later, after the damage has been done and the best we can do is an EKG to see if anything shows up. This woman probably didn't have a heart attack-- my best guess from her more detailed description is that she ate something that didn't sit well-- but still, it's not terribly useful to tell me about things that happened weeks ago and went away.

We had a two-hour lecture this morning... about diarrhea. Complete with slide show.

Seriously, there are days this feels like a pretty lousy profession. All we do is deal in people's yuck. Their discharges, and pustules, and mucus, and blood, and vomit, and bile, and poop. Oh boy. If you have something disgusting going on with your body, you come see me, and I have to look at it, and think about it, and revisit it in my nightmares. No one ever comes to us with pleasant problems to solve. There are very few clean illnesses. And, in fact, the 'clean' illnesses are usually the worst ones. Neurological issues, degenerative diseases, etc. From a patient's perspective, you want the messy ones. Or at least some of them. The messy ones we can sometimes solve. You have blood, we have stitches. You have poop, we have medicine. You have something we can't see? You might be in trouble. But it can get really stinky and gross, very very quickly. I have a weak stomach. I get woozy. It's not the best trait for a doctor, I know. Diarrhea is really disgusting.

Sorry for the delay in new posts. Outpatient service, combined with the family stuff-- just haven't had much to say. Should change as the schedule does-- I start in the ICU this weekend. Every 4th night overnight. Can't wait.

No, I'm serious. Part of me can't wait. Outpatient is boring. If I had a life, maybe it wouldn't be. But I don't, so it is.

Forgot to mention another reason for the slowdown. I was seeing someone. Another intern. I liked her. Thought she liked me. She broke it off yesterday, said she didn't have time for a relationship, thought I'd figure out soon enough that she wasn't worth my time. It's weird, to be a doctor you need some degree of confidence on the academic side, some degree of accomplishment, drive, motivation. On the social side? Not so much. She thought I'd figure out it wasn't worth my time? That's a cop-out. I can decide for myself whether something's worth my time or not. But what can I do? We a few nice weeks. I almost felt like an adult, with a job and a relationship-- not really anything in the extra-curricular department, but still, almost a life. Now, back to the ICU and back to the job being the only thing I've got going. So I figured I ought to return to the blog, right? Posting every day in April, I'll make that a promise.

I had a patient in clinic today, crazy high blood pressure. "It's because I walked all the way from the parking lot," she said. People don't understand blood pressure. "It's high because I'm nervous." / "It's high because I just ate lunch." / "It's high because I have to go to the bathroom." I've heard all of them. They don't make sense. We have this strange compulsion to be able to explain things. It's fine if you have knowledge. Smart people can make educated guesses and sometimes they're right. But if you have no background, no understanding of how the body works-- like most of the patients in clinic-- you're just about never going to make any sense, no matter how much you think you do. A patient came in earlier in the month, ended up hospitalized with anemia. She comes back for a follow-up today, she isn't taking her iron supplements. "Why not?" "I'm drinking tea. The Internet said tea is good for anemia." "Your iron is still really low." "I didn't drink the tea today." "Please take the pills." "I don't need them." "No, you do. I promise, you do. I'm the doctor. Please listen to me. I know what I'm talking about." Trust me, trust your doctor. Not blindly, of course. We're human. But the easy stuff? We do know things. Medication, we're pretty good at. We tell you that you need something, you probably do. Ask questions, fine. I'm happy to explain, to a point. But take the pill. Please. Just take it. Don't worry about it, don't stress-- just take it, be happy, and get on with your life. Patient recovering from surgery comes in, "I'm in terrible pain." "Taking the pain pills?" "No, I don't like taking medicine." Medicine's all I got. I gave you the pain pills to take away the pain. You don't want them, it's your choice, I guess-- but then you can't complain about the pain. I gave you an answer. You're just choosing to ignore it. And then you blame me for not making you better. Ugh.

I haven't posted in a week because I've been dealing with a family medical issue, and have been realizing what a tremendous ordeal it is to be on the patient side of things-- or at least the family side of things. And that even when you're a doctor, even when you're part of the system-- it still doesn't necessarily make things much easier.

My dad had a routine medical procedure performed a couple of weeks ago-- the details don't matter-- and was still feeling some pain at the wound site this past Monday, so he went to the doctor, was sent for an ultrasound, and they discovered a small leak in a blood vessel-- an unusual but not unheard-of complication from the procedure. He was sent to a vascular surgeon for a simple injection-- the standard treatment-- and somehow everything went awry.

From what I was able to gather, the surgeon was in a bit of a rush, a packed day of patients, and should have realized that this particular leak-- due to size and placement-- was not a good candidate for the injection, and he should have scheduled a very minor outpatient surgery to deal with the problem. Instead, he decided to go ahead with the injection, and it immediately caused a blood clot, stopping flow to my dad's entire leg and causing him to need to be rushed into emergency surgery to save the limb.

If this wasn't enough-- while in the recovery room from this surgery, after my mom had gone home, thinking everything was okay-- they discovered my dad was rapidly losing blood, and had to go back in and do a second surgery-- the surgeon (same guy who had botched the injection) had ineffectively tied off a vein in the first surgery-- the tie came loose-- and they had to repair that, and in the process replace 4 units of blood he lost.

Fortunately, this surgery seems to have gone well, with no further complications, and as of this morning, he's out of the hospital-- albeit in pain and with restricted activity for the next 6 weeks-- and doing well.

Beyond questioning the actual competence of the doctor-- the botched injection and improperly tied-off vein in the surgery-- what truly disappointed mewas the lack of communication and accountability throughout the process. When my dad was rushed into the second surgery, my mom received a phone call saying he needed another procedure-- was not told the extent of the problem, nor what had happened in the first surgery to make this one necessary-- and was promised she would be called with an update. She wasn't, and was up the entire night assuming the worst. At the same time, throughout the hospital stay, I was unable to get anyone on the phone to tell me anything, despite being a doctor, despite having attendings here call on my behalf, despite trying to explain that I merely wanted the information about what was going on, and wasn't trying to blame the surgeon.

Immediately after the injection, the surgeon's first priority became protecting himself-- from any criticism, from any accountability, from any possibility of blame-- by making it impossible to get any information from him. The morning after the second surgery, after trying unsuccessfully to get him on the phone, I sent him an e-mail-- explaining I was my dad's health care proxy, I wanted to talk to him about what had happened, I was disappointed my family was not kept in the loop overnight to know what was going on and whether my dad was alive or dead, I wanted to know the risks going forward, the treatment plan. 12 hours later I received a response saying he does not communicate with patients via e-mail and that his first priority is patient care and not "coddling the family." Again I tried calling and could not reach him-- it was not until I got the head of the resident program at my hospital to place a call that I was able to get a response, and that response was severely lacking.

The lesson learned-- and I've changed a lot of details here, so I don't want to get into the medicine specifically-- the lesson learned for me as a doctor has been about communication. Problems get worse when families aren't kept in the loop. They don't always know how you best like to communicate, they don't always know the questions to ask, they don't necessarily how to reach you, and it shouldn't be their responsibility, it should be ours. Having seen how anxious my mom became, how out of the loop I felt even as a doctor-- I realize that even on the medicine side (as opposed to surgery), it's on me to reach out, it's on me to share promptly and completely, and not to always put "call patient's family" at the bottom of the list. Better to over-communicate than under-communicate. Better to assure them you're on their side instead of fighting against them and treating them as a nuisance. I will communicate more, after this. I will learn a lesson even if that surgeon won't.

We had a workshop this afternoon about dealing with alcoholism-- identifying patients who may be alcoholics, guiding them toward treatment, etc. A recovering alcoholic spoke to the group, told us the lies he would tell his doctor, told us some signs to watch out for...

It's interesting to think about where the line is between what a doctor is expected to do and what he isn't, and a lot of it depends on the context. During my inpatient rotations, I've seen a lot of alcoholics come into the hospital, with all sorts of problems-- and never once did I see anyone talk to them about treatment. We treated the immediate medical issue, released the patient, and, as often as not, I'd see the same patient back again, after another drunken fall or other consequence of the alcohol. In the inpatient setting, the focus is on fixing and releasing.

But in the outpatient clinic, we do talk about treatment, we talk about addiction, and therapy, and I've heard people mention AA. The difference, I think, speaks a little bit to why I'm drawn to outpatient care more than inpatient. I don't just want to deal with the acute problems, I want to help the patients have better lives. I want to fix the big picture as much as the small. Not that the things they're coming to the ER with are small. But I don't know how to better articulate the difference.

Also, I think one of my friends is an alcoholic.

Okay, let me try and correct some faulty patient assumptions. These are all from one patient-- ONE CRAZY PATIENT-- in clinic today.

1. We don't prescribe medication based on body weight. I can see you're a small woman. That doesn't mean you should be cutting your antibiotics in half. I'm giving you the right dosage. You don't have to keep questioning it.

2. You're not allergic to water. You need to keep yourself hydrated. It's important. I don't know who told you you're allergic to water. It wasn't a doctor. You're not. Your body is mostly water. Drink more water.

3. Even though your blood work came back fine three years ago, I still have to do it again. Things change. That's the whole point. You didn't have these symptoms three years ago. You do now. So I have to check. A blood test isn't like an IQ test. I'm not just testing for blood type. It's important.

4. Just because you and your husband sleep in the same bed doesn't mean you should take his medication. In fact, sleeping in the same bed has nothing to do with sharing his medication. "But I already have all of his germs" is not a sensible reason to take his medication. At all.

5. Your bowel movements don't change your weight by ten pounds. You aren't ten pounds heavier than last visit because you haven't gone to the bathroom in two days. Sorry. Not correct.

6. You can eat all the vegetables you want. The pesticides will not hurt you. And even if they will, they won't hurt you more than your diet of red meat and ice cream does.

7. Headaches are not caused by the sun.

8. Your blood pressure has nothing to do with which bra you happen to be wearing. "My blood pressure is always higher when I wear this bra" is not a comment grounded in any sort of logic at all, and when you tell me this, I have no idea how to respond without laughing at you.

9. Just because I don't have a vagina doesn't mean I can't tell you what's "normal down there." The symptom you are complaining about is not normal. It's not "normal for you" or "not a problem" just because you think it is. And even though I don't have one myself, I am a doctor, and so I know things.

10. Just because the "dye" they use in an angiogram is pronounced the same way as the word "die" does not mean it is going to kill you. They don't call it "dye" because you're going to "die" from it. They call it dye because it is dye. I don't know why you don't understand this, especially since your first name is also a word, and it doesn't mean you are what that word is. Good grief.

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.