There’s always an element of mystery about a hospital.

Patients will enter with a vague sense of uncertainy and unease, a nagging certainty that something is wrong but they dont know what. Having moved beyond their problem solving abilities, they turn to an authority, the physician. For some, the answers come easily: You have disease/condition x, the treatment is drug y which you have seen on tv, take it for 2 weeks and then you will be cured.

For others the suspense drags on: muttering in the hallways outside the patients room, increasing numbers of specialty consultants, treatment changes day after day. Oftentimes a mere 10 minutes to speak with the physician, hoping to obtain the medical equivalent of a facebook status update-Bob’s weakness is improving, Jack’s liver needs to be replaced, want to share your lab results with friends and family?

And through it all, the doctor is seen as the man behind the curtain, the conductor of a veritable symphony of nurses, techs, equipment and labs. After all, solving mysteries is what we do, isn’t it. CSI: You. Feeling weak? check the blood. Vomiting? scan the belly. Fevers? get a lumbar puncture and start some vancomycin. In internal medicine, the deepest satisfaction often comes from solving the mystery of you. Many treatment are simple enough once we have an idea of what’s going on. 

Coming in to the hospital every day, wondering what you will see, when you will figure it out, can it be beaten; it can be exciting for quite a while. But eventually all heart attacks, all strokes, all tumors look the same. The answer to diabetes is always better sugar control, the eventual outcome of cirrhosis is always poor. So how do you keep the magic/mystery alive?

By focusing in on the details. Yes, every heart attack gets treated with aspirin, but Cindy’s ischemia was caused by cocaine, Ethel’s by clogged arteries from an all bacon diet, and Ricky’s by being shot. Identifying and treating the condition makes you a good doctor. Remembering the person makes you a great one.

Which one am I? Which will I become? 

I guess there are a few mysteries left to unravel after all.

I will fight this. At least, I will try to fight it. There isnt much I can do, but I will go down swinging.

Should I make it through, I will add another tattoo to the collection.

Should they win, I will stick around only until I can pay off my loans. And accept that I wasted 13 years of my life on something I wasnt meant to do.

And they thought I had an “attitude problem” before…

I wish this comic was less true. But for many families, being involved doesnt mean weighing the options and heeding the advice our education has given us, but dictating care according to what they think the patient wants or needs.

I find myself dreading my upcoming wards month…I dont want any difficult families. I cant afford to have anyone evaluate me as anything less than perfect. The human body was not meant to undergo these levels of stress for this long. And yet, here I am still plugging away, still hoping against hope that despite all evidence to the contrary, something, anything, will turn out right. I guess that is the difference between hope and faith…with faith, you dont have this kind of anguish, you simply know. With hope, you keep waiting for something to be snatched away.

I dont know why I keep recording this whole episode. Is it for you, or for me? If I make it through this, is it something I really want to remember? Will I one day look back on these posts and tell myself, oh right medicine isnt always easy, but you have been here before…or will I reread this and be like, this was your tipping point, when you had all you could stand and left a career that was doing nothing but breaking your spirit

I dont want to know the future, I just wish I didnt have to keep anticipating it.

I dont know why I never put anything personal on here anymore. It’s not like I am trying to do anymore about protecting my identity. Maybe it’s just that life has been so busy that sitting in front of a computer for another hour just to sit down and complain that i have too much to do doesnt seem worth it. Easier to go swimming, or yoga, or something active with my limited free time.

Residency has been bad the last couple months. Mostly because I have been made the whipping boy in this hospitalists versus residents atmosphere. Someone not get their scheduled med? Josh’s fault. Pt septic on wrong antibiotic? Probably Josh. Someone three counties over broke a hip and died from fat embolus? Get Josh’s lawyer on the line.

It’s not really that bad, but the snowball effect sure makes it seem that way. So in my final year of residency when everything is supposed to be sunshine, lollipops, and unicorn farts, what am I doing?

getting in early, writing all my notes, and then looking for procedures to do so I can minimize the amount of time I have to spend around all these toxic personalities until 5pm when I can go home. The upside it that it means even better pt care since I can hide in pts rooms to avoid the hospitalists…they will never find me there. I have already managed to do about 4 paracentesis and 3 central lines in 2 weeks. maybe i will throw a thora or two in for the hell of it.

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.

“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.