Probation begins Tuesday.

I had almost forgotten that I had to go back to work. The week I was on leave to consider my decision was so nice and unrelated to medicine at all that I didnt even have much time to feel sorry for myself. There were birthday parties, ceremonies, days at the museum, even mundane things like getting my oil changed to take up my time. And then Tuesday begins my year of shit. Starting back in the ICU, so at least not working with any of the hospitalists who forced me to this course initially, but among people who had certain knowledge that I was finished rotating through that department.

I understand the rationale. If there are all these supposed concerns about my ability to treat critical situations, it makes sense for me to repeat my training in critical units. Nevermind the fact that those were some of my highest evaluations the first time around. I have accepted the fact that I am going to be eating a lot of shit sandwiches for the next year, and there is nothing I can do about it.

The program director and administration are still looking for ways to remind me how serious this case was, you know, in case I forgot somewhere along the way of them ending my career, or maybe in case I am not appearing appropriately contrite enough.

People portray doctors as being arrogant or uncaring. It hurts. A lot. You do your best day in and day out, and feel awful when things go wrong. And now someone is accusing you of having committed malpractice in your efforts. 

So why did I take the probation? Why havent I fought this harder, or "lawyered up" if I really feel I am being that unfairly treated or targeted? Because I dont have documentation to prove that I am being picked on, and it is easy for my accusers to say they have been concerned about my knowledge all along because residents make mistakes. And a single one here or there in an evaluation no matter how good can always be pulled out, and used to show in court that there were supposed doubts about my ability all along

It kicks the shit out of you. You lie awake at night wondering if you're going to lose everything you ever worked for. You cry. You think about quitting, but have to go on because you're in too deep not to. With this sword of Damocles hanging over your head, you still have to go to work every day, and do your best for the patients who still depend on you. Some days it's pretty damn hard NOT to start drinking.

And, deep down, you wonder: Am I really incompetent? You question your own judgment. Suddenly every headache patient needs a brain MRI. Every person you see is a time bomb. You start to view them as the enemy. People use the phrase "defensive medicine" in a derogatory fashion, meaning unnecessary testing doctors order to prevent themselves from being sued. But after something like this happens, you don't give a fuck how much money the "unnecessary" tests cost. You'll order anything to cover your ass.

And, regardless of the case's outcome, it will forever destroy the beliefs that once drove you to dream of being a doctor. Even if new reasons are found later on down the road, you will never trust or have the faith in your colleagues that you once did.

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...

One Mistake. That's all it took.

One mistake, and a committee came down to a split vote on outright dismissing me from the program, versus ultimately deciding to graciously allow me to continue, should I so choose, under probation. Demotion to r2 status with an extra year of residency. Guaranteed loss of the fellowship I spent months, if not years competing for. 

One mistake, and I reap a year of humiliation and condescencion. Having to tell all my friends I'm not moving, then explaining why. Having to work side by side among the current second years who will be talking about how badly I screwed up. Being made "the example" for the hospital. Having to stay in the same situation while everyone else moves forward.

One mistake, and one that more likely than not would have been treated more favorably had I not already been on remediation.

I have spent the last 6 months arriving at work, waiting for the day to end so I can go home, telling myself I could put up with any of it as long as I had my fellowship waiting for me at the end.

But now?

Do I really want to put myself through that? An extra year, to what purpose? I am burned out. I'm done. Even if I decide to graduate, I would be in medicine only as long as it takes to pay back my loans, and then I would quit and go back to enjoying my life again.

I should never have gone to medical school. But I guess that was just one mistake as well.

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 havent done a comics post in a while. Figured I would intersperse it with some personal thoughts. I think I am beginning to see the writing on the wall with my current relationship. Nothing is specifically wrong, it just seems that whatever I do will never be good enough. As per the excellent quote by @suuperstar in the last post, at a certain point you cant keep trying to change yourself especially when it doesnt seem appreciated or if the other person is willing to change for you. I like who I am, or at least I used to, and I dont want to lose that. Apparently relationships can fail simply from holding different viewpoints on life. Who knew?

I feel like this a lot at work lately...like somehow, I just dont get it. Like no matter what I do, it's not good enough, and even when I do something right, someone is there to point out how obvious the solution was and how I should have gotten it sooner. 

I know this too shall pass, but I wish that i didnt have personal and professional drama going on at the same time. I guess it's just because November is sweeps month, I am pulling stunts like this to garner ratings...

oh well, better than being canceled.

Spent 2 hours admitting a septic patient, trying to stabilize their rapidly failing heart rate, respiratory function and overall multiple complications in someone who was DNR

30 minutes after completing the admission, I am called down to pronounce the same patient.

Dammit.

Overnight, one of my patients went encephalopathic.

When you have liver disease, you dont break down certain metabolites as well as a normal person, and toxins like ammonia build up in your body. These can get carried through your bloodstream into your brain and make you act crazy and irrational. Liver patients, or rather patients with liver disease can decompensate quickly and for a variety of reasons.

So.

One of my patients became encephalopathic and during the night when nursing staff wasnt watching, slipped out of her room, walked clear across the hospital and climbed into bed with another patient. When he awoke, he was understandably disturbed at the stranger in his bed. He was even more disturbed when she promptly shat upon his sheets, got up and returned to her room.

And that is why you always read nursing notes.

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.

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.