Medicine is never an easy field. People accuse doctors of not doing enough, or doing too much.

There are no easy answers. We’re caught between doing what’s best, without putting the patient through too much, and doing what’s needed to protect ourselves from legal action.

Let’s take Mrs. Seasons. She’s a nice 78 year-old lady I saw in the ER. Earlier this month she hurt her back. So she saw her primary care physician, who correctly diagnosed her with a muscle strain. He gave her a muscle relaxant and Tylenol #3. A few hours after she took the medications she became confused and sleepy, so her family panciked and brought her to the emergency room. 

The odds are that all she had was confusion due to Tylenol #3. So do nothing. It’s most likely and least expensive. BUT maybe she had a transient ischemic attack (mini-stroke). If I don’t correctly diagnose that, and she has a big stroke, then they could sue. So let’s order a brain MRI, head & neck MRA, and echocardiogram. That’s a few thousand dollars in tests. Or maybe she had a seizure, and needs to be started on seizure medications. So lets order an EEG, too. Another $500.

Perhaps it was a metabolic event, with her blood sugar getting too low. So I’ll order some labs. That’ll be another $500-$1000 depending on how much I order.

This is the dilemma your doctor faces each day, many times over. None of us come to work saying “Oh boy! I can’t wait to drive up the cost of health care today!” But we’re faced with finding an (at times) impossible balance.

We don’t get a 2nd chance, either. If we guess wrong we run the risk of getting sued. Another doctor is always willing to make a living as an expert witness and testify that we are incompetent.

And yet, with this sword of Damocles hanging over our heads, I and thousands of other doctors do this every day. And try to do the best we can, within the limits of human fallibility.

It’s been a rough month.

Lately, I feel like I have been sliding into a bit of a funk for no good reason. Let me preface by saying what follows is (probably) unjustified bitching from someone who is well aware he has good health, a loving family, a host of supportive friends, a caring girlfriend, a job that I (usually) enjoy and all in all, no real reason to be feeling like shit lately

That said, I am beginning to feel like the hospitalists have all been ganging up on me and turned me into the hospitals whipping boy. It doesnt matter how many difficult diagnoses I catch, or studies I order creating my differential, I never really get any feedback for positive things. But the moment I forget to order something or am not aware of every lab that is back instantly, the hospitalist saunters around with a “I am concerned about your performance, it seems you lack motivation, or clinical judgement, or whatever the complaint du jour is of my abilities.” 

It didnt help that during my most recent wards month I was saddled with a difficult intern who would copy paste notes, not follow up on labs, and in general was just slow moving and disorganized. So in attempting to work with said intern, and eventually just doing the interns work so I could get out in a timely fashion, certain things that may not have slipped my attention otherwise did. Now nobody died or got sicker as a result of these decisions, but I cant be everywhere and do everything at once, and being blamed for things that are essentially beyond my control is not fun for anyone. 

I never seem to hear these complaints during subspecialty months, but the second I am saddled with a hospitalist, I apparently turn into the worst resident ever.

Now I like to think I am well aware of my faults and limitations, have good insight and in general try to constantly improve myself and take all feedback and or criticism into consideration. But I have finally reach a point of learned helplessness, where it seems that no matter what I do, I end up with a average to mediocre evaluation which results in the equivalent of being called into the principals office to discuss concerns with the program director.

And because our program tends to be very hospitalists vs residents, it always comes down to my word against theirs, so extenuating circumstances such as personality conflicts or any sort of positive improvements or efforts dont come into play, just a lecture that i should be performing at a higher level, i managed to get into fellowship and where is all that potential i apparently was showing back when the housestaff didnt hate me.

At this point I am so tired of playing the game. I just want to sign my contract for fellowship and get the heck out of this program, this environment, and this state. It’s time for a change of pace, and to bring back the happy carefree person I feel like I used to be.

And for icing on the cake, while I am finally back on GI, my attending is the program director who rejected me (although thank goodness I matched to a program that will train me better anyway) and the fellow is our former chief resident, who we all disliked for being two-faced. However, at least I like what I am learning and anything I go through now will only help prepare me better for fellowship next year

I just wish I could catch a break.

One of the things it’s hardest to get used to about #residency is never knowing what happens to most of the patients. I switch rotations, or they switch services, and there’s no system to know what the result is.

Not that I want an endless daily report on everyone I’ve ever treated, but sometimes, a couple of days or weeks or months later, a patient crosses your mind, and you don’t remember the name, and you don’t have anyone to ask, and so you just never know.

Maybe you see them again, months later– it happens, more than you think it would– and they’re back on your service, so you end up seeing how they’re doing– but, usually, you never have a clue.

You’re such an important part of someone’s life often for such a very short time. It surprises me sometimes when I realize I care. When someone happens to have some quality that reminds me of someone in my family, or is in a situation I can empathize with, or we just have that little connection that makes it feel like more than just ticking the boxes each day and writing the note.

But, far too often, it just feels like an academic exercise. I wonder what’s wrong, I wonder what the plan is, I wonder if they’ll get better. The same way someone might wonder how their science fair experiment will turn out. Oh, look, giving a sedative does exactly the opposite of what I would have expected! Interesting! Hope to remember that next time. Maybe I should write it down…

I walk into the ER and notice a young couple at opposite sides of the room, neither one looking at the other, eyes downcast, the man occasionally reaching for his genitalia, the woman nursing a black eye. Seems like a fairly straightforward case and I find myself wondering why I got the call from the ED doc to admit to medicine.

Turns out the couple had been celebrating an occasion, lets say an anniversary just for the hell of it. At the fancy restaurant, the woman decided to slip under the table to give her beau an appetizer before the main course, as it were.

Of note, her past medical history is significant for seizures which have been well controlled on anti-convulsant medication. Of more significance, she opted not to take her medication this evening as she knew she was planning to have alcohol and was worried about possible interactions.

So there she is, fellating her companion when all of a sudden she begins to seize.

Kindly reread the above sentence.

The man, on the receiving end of a ooh, ooh, OW reaction, does some quick thinking and calculations and realizes that he is poorly positioned to be involved in her seizure. After trying once or twice to forcibly remove her head, he does the only thing he can think of to save his member and punches her right in the face. At which point he then goes to obtain assistance for his significant other with what had to be an elaborately concocted cover story.

End tally:

1 male with a lacerated member

1 female with post ictal confusion, remembering only that she went to a restaurant and is somehow now in an emergency room with a black eye

So, my questions to the modern gentleman

1.Does this qualify as the only acceptable excuse for hitting a woman?

2. What are your odds of the male counterpart of this dynamic duo suffering PTSD-no honey, lets just cuddle tonight, no BJ’s necessary

“I started feeling the pain right after I ate lunch. So I think it was the sandwich.”

“You had a significant heart attack. The fact that you were eating a sandwich just prior is a coincidence.”

“Well, I think the sandwich caused it.”

“You have a completely blocked vessel leading to your left ventricle.”

“It’s the sandwich.”

“The sandwich is not blocking your vessel.”

“What if I didn’t chew it completely?”

“Food doesn’t get swallowed into your blood vessels. There’s medication we can give you to help your heart, but I need you to understand, this is a problem that’s been building over the course of years.”

“I did not have a problem until I ate the sandwich.”

“You didn’t have any symptoms, but the blockage was building. Your heart was not in good shape– and now, post-event, it’s in worse shape. Which is why we need to start you on medication.”

“I don’t care what you say, it was caused by the sandwich.”

“That’s fine if you think it was caused by the sandwich. Even if it was, it doesn’t change what we have to do going forward. You need to change your diet–”

“Of course. No more sandwiches.”

“Well, it’s more than that.”

“No– it’s the sandwich.”

“Fine. No more sandwiches. Your heart attack was caused by a sandwich. And I’m writing you a prescription for three anti-sandwich pills that will help counter the effects of past sandwiches.”

“But if I don’t eat anymore sandwiches, I shouldn’t take the pills?”

“No, you need to take the pills either way.”

…

“Then how is this helping with the sandwich problem?”

Dr. J: “This is Dr. J, returning a page.”

John: “Hi, this is John Anydude. You saw my girlfriend a few weeks ago for a left arm injury? She had a lot of trouble using her arm? I was with her at the appointment?”

Dr. J: “What can I do for you?”

John: “Well, she’s getting a lot better, like you said she would and, um, I…”

Dr. J: “Yes?”

Mike: “Is there anything that might, like slow down her recovery? Not a lot, ’cause she’s my girlfriend and all, but maybe just make it take longer?”

Dr. J: “Um, we’re trying to get her better.”

John: “Yeah, but she can use the arm for almost everything now, and when it was really weak she had me come in the shower to shampoo her hair for her, and that sort of got things going if you know what I mean…”

Dr J: I see you’ve lost almost 15 pounds since your last visit– that’s great! You’re sticking to the diet we talked about?

Eaty McEaterson: Yep. But, doctor, I don’t think this is healthy for me.”

Dr J: What do you mean? Your blood pressure is lower, eating healthier and losing weight is going to be good for your heart failure and diabetes, it’ll help your back pain, you’re really doing great, I’m very proud of you.”

Pt:But my foot’s been hurting, and I think its because of the weight loss.”

Dr J: ???

Pt:It used to be cushioned with all of this fat. Now that I’m losing weight, there’s less cushioning, and when I walk, it’s really the foot that’s feeling the weight, without that cushion. I feel it all over. The fat made things soft. Now everything hurts

Dr J: That makes no medical sense, let me take a look and maybe I can get some xrays if you have a sprain or fracture or something

Pt: But now there is less fat to absorb the radiation and I am at a higher risk for cancer

Dr J: *curls up into little ball and cries*

What you say: “I take my pills almost every day.”
What we hear: “I almost never take my pills, and probably don’t even know where they are– if I even filled the prescription to begin with.”

What you say: “I think I followed up with the specialist, yeah.”
What we hear: “I did not follow up with anyone, and only now remember that I was supposed to.”

What you say: “You told me not to eat anything before I came in, so, yeah, I basically didn’t eat anything.”
What we hear: “I had breakfast, but I ate it quickly.”

What you say: “I probably don’t exercise as much as I should.”
What we hear: “The walk from the parking structure to the clinic is the longest walk I’ve taken since my last visit.”

What you say: “Do I need to get that test done today, or can it wait?”
What we hear: “Am I actually going to drop dead on the way out of the clinic, or can I forget all about this, forever and ever?”

What you say: “But what I really want to talk about is this other symptom that I’ve been having for the past twenty years, unchanged.”
What we hear: “Here is an irrelevant distraction I’m going to mention, that’s been going on so long that if it were important, it would have killed me already.”

What you say: “And I read online that–”
What we hear: “I am now going to prove that I have access to the Internet.”

What you say: “No, that’s okay, I’ll call for a follow-up appointment.”
What we hear: “Goodbye, forever.”

Doctors are a lot like mutants…there are a lot of us out there among you, we each have our own special abilities, we feel like no one but others in our situation can understand what we have been through and we are feared and distrusted by a lot of the general public who seems to think we have abilities beyond human ken

Sadly the resemblance ends there or I would be liquifying stuff with my mind all day long. Of course just like Professor X’s gifted, we all went through a special school where we learned to develop our burgeoning abilities as well. For some of us the mystique didnt last and we left for greener pastures. The learning process managed to turn others of us into beasts, although we manage to retain some of our human nature. The rest of us may have remained unchanged on the outside, but the havoc within us could lead to screaming banshees at any moment and magneto could…you know what? I think I lost my metaphor somewhere, let me know if you see it around.

More to the point, July 1st is the medical new year.  Medical interns begin their journeys into the real world of clinical medicine, journeys that started during medical school but become much more real when they sign their own orders in a chart. This is the first week for all these new interns. So New interns, I was once in your shoes, and will be again when I start fellowship next year. Here are a couple things to keep in mind:

1.Embrace your fear.  You have good reason to be scared.   You are directly responsible for the lives of others.  These others are very sick, or they wouldn’t be in a hospital.  But remember that you aren’t alone.  Your colleagues can and will help you, and you can help them.  Support each other.  

2.Never be afraid to ask for help, but when you call, have your information in hand; anticipate questions.  If you don’t know what to do about a cardiac dysrhythmia, make sure you have an EKG and have ordered some labs before you call the cardiac fellow.  It will save you time and embarrassment, and will get the patient help more quickly.

3. Sleep when you can.  Sleepiness harms both you and the patient.  I cannot emphasize enough the value of sleep.  Go to bed early, nap if you can.  If you’re too tired to drive home, don’t

4.There is not a single tone on your pager that will not make you hate all humanity at 3 in the morning. Sorry.

5. You now  live behind a magic curtain of people’s expectations and perceptions. You are more than just you now, you are a symbol…like Batman, or Captain America. Try to live up to it, but give yourself some secret identity time too.

-Dr J, superhero at large.