Intake

Based on several new patient encounters over the last few weeks, I’m making an intake form for all new patients requesting narcotics.  It will look something like this:

1.   Are you taking cocaine right now?

2.   No? Good. Okay.

3.   Why have you fired your last 3 doctors or been fired from their practice?

4.   Are you expecting narcotics today, as in, right now?

5.   Because I am not going to give them to you without a little more information.

6.   What exactly is your pain?

7.   What, besides Vicodin, are you doing for your pain?

8.   Ok, what, besides medications, are you doing for your pain?

9.   Are you taking methamphetamine right now?

10. No? Good. Okay.

11. Are you willing to submit to a drug test?

12. Why aren’t you able to pee today?

13. If you had to choose among the Percocet, the Xanax, and the Soma you currently want to take all at once, which would you pick?

14a. Is it cool if I call your previous doctor before our next visit?

14b. Please list the names of the doctors you have received prescriptions from in the last 2 months:

1)_________________________

2)_________________________

3)_________________________

4)_________________________

5)_________________________

6)_________________________

15. Many people seem to have nicknames for their medications. What do you like to call your pain pills? (e.g. oxies, vikes, etc.)

16. After leaving jail last month and having been off narcotics for a year, why did you then immediately resume taking 8 oxycodone 30’s a day? Are you sure you’re taking them? Because you do not appear to be dead.

17. In the past month, how many times has your cat knocked your Vicodin into the toilet? (0-5) (5-10) (>10)

18. In the past month, how many times has your cat knocked your Ciprofloxacin into the toilet? (For statistical purposes only)

It will be printed on pleasing pink paper with a marbled background and smell like candy canes.  I’m super excited.

The Other Shoe Dropping

Wait for it...

When I saw the schedule at first, I was glad she was coming in.  She’d be the last patient of the day.  We could figure out how her blood pressure had been, since somehow she hadn’t followed-up since a month ago when she’d been at 200/100.  We gave some clonidine in the office, then I started some meds for home. She was supposed to see me the next week but didn’t.  Then she had a stroke.

What?  Holy f*cking shit.  She had a stroke.  The scheduler wrote that in with a couple exclamation points so we would know it was important.  “Here for f/u HTN: Pt had a stroke!!” She is 49.  What the hell just happened to this 49-year-old?  How did I let this happen? 

We have a paper charting system.  We have a completely incomprehensible scheduling system that somehow involves a computer but which I have no access to.  If someone cancels an appointment no one tells me.  These are excuses, I know.  I should have put her on some kind of list so I’d remember to call her if I didn’t see her the next week.

A lot of times I’ve thought about when the other shoe might drop.  When I will blow it big-time and miss something or make a fatal error.  Back when I was a resident, hoping to get into a car accident each morning as I drove to work so I could get some rest in a hospital bed, losing my job didn’t sound so bad.  I’m sure I could find something else to do with my time.  Like, I don’t know, hang out with my kids.

Now I’m more ambivalent.  I think I actually like this crazy job and would be a little sad to let it go.  But that’s all a moot point next to the utterly sickening, kick-you-in-the-gut feeling that you’ve let someone down in a big way.  In a life-and-limb- altering way.

There were still 7 other people to talk to about their various manifestations of candidiasis before I saw her.  Obviously candida matters but it’s hard to really focus on it when obtrusive thoughts keep leaping into your brain.  “Do you have itching?” I just nearly killed someone.  “Yes.” I am going to lose my job. “I think it would be helpful to do a pelvic exam.” She can’t walk because of me.

When I walked into the room she smiled at me meekly.  Her kids were there with her.  “I am so sorry this happened to you.”  What else do you say?  Turns out she’d checked her blood pressure daily after I saw her last.  It was 130/70 or thereabouts each time.  She didn’t see the cardiologist I referred her to because her paperwork didn’t go through.  She forgot to come back to see me.  Then she had a stroke.  I asked her about drug use, about symptoms of pheochromocytoma.  No, and no.  And her blood pressure was normal the morning of the stroke.

What the hell?  This doesn’t make any sense.  Why?

I sent her home with a giant jug to collect her urine for 24 hours.  When she left I finally got my hands on the discharge summary.  Utox on admission positive for cocaine.  She admitted regular use to the neurosurgeon.  So now I’m vindicated by blow.  But she refuses to talk to me about it. 

So I’ve failed her, but in a different way than I thought.  I failed to gain her trust.  Or maybe to kick her kids out of the room so she’d give me a straight answer.  I get to keep my job.   Does she get back her left arm?

I guess we’ll have to wait and see.

Impostor

For Planck, and the Physics-ian

I love it when I have a patient who talks to me about Physics. “Quantum physics, now that’s really just another explanation for the soul,” he added.  I nodded my head.   “I never felt like I got enough Physics in College,” I lamented to him.  “Me neither,” he replied, and went on to outline some recent findings about Neutrinos that travel faster than the speed of light.  My curiosity, long suppressed by trying to cram More Facts into my head, awakened.  I remembered the wide-eyed wonder of the world split open, looked at through a hundred different glasses, tiny colored pieces of light falling together into a giant Mandelbrot set.  Philosophy, poetry, Chemistry.  Always feeling the truth is out there for the honest seekers.  Physics.  I love it when patients talk to me about Physics.

Except that I don’t.  Because there’s someone in front of me who might be as smart as me.  He likely has the internet at his house.  He knows about his meds and doses.  He tells me he wants a higher dose of testosterone.  I assume they make it in a higher dose, but I don’t know.  I’ve never prescribed that medication before.

There are a lot of things I don’t know, actually.  Turns out I can’t ever spell amitriptyline without looking it up.   I’m pretty honest about what I know and what I don’t know, to the extent I can still manage to keep my patient’s confidence and my colleague’s respect.  It’s such a balancing act, though. 

And some day soon they’re all going to find out that I had to look up cervical radiculopathy treatment.

In medical school I complained to my classmates when a test was difficult, expecting them to commiserate.  They didn’t.   I felt stupid.  Turned out I did better than most of them. But I didn’t know about the game we were all playing, called “Act like you know what the f*ck you’re doing.”  If you don’t know the answer, don’t tell people that, of course.  What was I thinking?

So I learned.  And when I was an intern it was approximately the opposite.  I held on to my doubts, and folks told me I was doing great.  I smiled and nodded, and panicked on the inside.  One day soon they would realize I don’t know anything and fire me.  Then I’d be done.

But I wasn’t done yet.  I finished the whole darned residency.  And here I am.

Today I printed off the ASCCP guidelines.  Again.  Because not only do I not remember them, also I lost the copies I had.

Also, which one is Diovan?  And what’s the highest dose of that?  And how do I know if someone has Sjogren’s syndrome?  And why does this 15 day old kid have conjunctivitis?  And what do I do about galactorrhea?  And is it ok to take Trazodone and amitriptyline and gabapentin together?  And OverActive Bladder.  Is that even a thing?  (Still not convinced).  By the end of the day I had 6 AAFP articles pulled up and 2 up-to-date articles all on my desktop. 

Soon everyone will know what a fake I am.  They’ll figure out I really don’t know much of anything.  Really I’m just a dork with a 12-year-old’s sense of humor who guessed enough questions right on enough tests and showed up to work enough times to pass just under the radar.  Am I even sure I’m not still in high school?

This is why I hate the sophisticated patient.  He’ll only unravel this web of lies quicker than the others.  Then I’ll have to get a job faxing things.  And I still have loans, people.

This is called “impostor syndrome.”  I thought I was the only one who had it.  Nah, turns out.  Some of the smartest doctors I know complain about it on Facebook.

If it says it on Facebook, it must be true.  There are a lot of impostors out there.

Leaving the Room

Sure enough.  There was a lump in his throat.  We had talked about it, and I was already worried he might have an abscess.  Of course, maybe he just had a uvula. It’s amazing what folks will find in their throats when they are looking for the first time.

I got out the light and I looked.   It wasn’t his tonsils, or the spot where the tonsils would be if he had any.  Instead it was behind the base of the tongue, pinkish, and floppy.  “I have no idea what that is,” I said, using the following words:  “Well, sure enough, you have a lump.  You know, it’s hard to see it well and so it’s hard to know exactly what it is.  Actually it could be lots of things like an abscess or some other kind of swelling.  And there are lots of ways to look at it.  Like I could refer you to a specialist, or we could do a CT scan, or someone can look with a camera.” 

“Sure,” the 20-year-old looked at me with wide eyes.

“And we’ll have to figure out how to do that, since you don’t have insurance.”

“Uh-huh,” he looked worried. 

“Let me go talk to some folks about that,”  I said.  Then I left the room. 

Leaving the room is one thing I really miss about being a resident.  There’s so much pressure in the room, to know the dose of everything, to be confident in your assessment, to draw detailed anatomical diagrams of disease processes.  Sometimes you just want to leave to take a breath, to think.  To ask someone else what they think. 

Now, I do not “look like a doctor.”  You might not pick me out of a lineup.  I’m not a tall, grey-haired man.  Nor do I always “look old enough to be a doctor.”  Depending on whether or not the Beastie is screaming for milk at night or T.P. has croup, or if GB forgets to get into bed before he is somnambulant and I have to wake up at 2:30am and drag him off the hardwood floor into the bedroom, the age I appear to be might vary by 10 years the next morning.  If I’m feeling well-rested and refreshed, chances are my patients will politely ask more than once if I am actually a doctor or maybe just got lost on the way to P.E. class.  If, on the other hand I’ve aged overnight from a mere 90 minutes of interrupted half-sleep followed by checking on the respiratory status of 2 or more of my family members, funny thing, no one asks me my age.

I’m always conscious of how credible I might appear, though.  And every time I think about coloring the 15 or so grey hairs on my right hairline, I think again.  I’m going to need all the credibility I can get.

So when I show up to work looking like a barista AND I need to ask someone else for help, it probably undermines my credibility as a doctor.   But what’s best for the patient always comes first.  So I left the room.  And I found the Dinosaur. 

He was busy, “but I’m always busy.”  He shuffled with me back to the patient’s room.  He walked in and greeted the patient by name.  Wait, I hadn’t told him the patient’s name.   “I know this guy.  I’ve known his family for years.”  He got out the light and looked into his throat. 

“You’ve had your tonsils out of course, so they would be inflamed but there’s nothing there.  That swelling at the base of your tongue is probably a lingual tonsil.  It will get better.  No abscess there.”  He smiled at me.

“Thank you,” I said, as he left the room. 

“Anytime.”

“Well, so I guess that’s it.  Want to come back the next time I’m here and we’ll make sure it’s getting better?”

“OK,”  he smiled, fair game.

I wrote out his slip.

“You know, I think the Dinosaur delivered me,” he said as we walked out together.

See, this is why I want to be a family doctor.  Someday, maybe I’ll get it together enough to know a family like this.  Someday I’ll have seen enough tongues and throats and rashes and variances that I can look and reassure and then ask about Aunt Matilda.  I’ll see the kids I deliver grow up to have kids of their own.  Then one day I’ll need to go to the doctor for some problems of my own.

And if she needs to leave the room for a minute in the middle of it all, I’ll let her.  I’ll probably be relieved.

Weekend notes (week 3)

Bed catches baby. I'm still falling.

Had my first call all on my own over the weekend.  Well, actually wasn't all on my own because I was supervising a resident.  It went as follows: couplets discharged home: 1. Term NSVD: 1.  Breech PPROM transferred out for higher level of care: 1.  Babies delivered by bed: 1.  In some ways it felt very natural.  Babies have been being born for the history of humankind despite our attempts to manage the process.  It's a little weird being the attending.  Now I was the one responsible for ensuring a patient was stable for transfer.  I was the one reading the strip (all were good this time).  I had to choose how much to interfere with the resident's delivery and thought process.  She was very gracious. 

I spent a few hours at home, and actually got a good nap in the afternoon with the kids.  But every time there was something going on I felt I needed to be there.  Get this: I spent 10pm to 1am waiting for a lady to deliver, which I was certain was going to happen at any moment.  And then she delivered in the bed while we were across the hall.  So, I guess I was right.  About the imminence, anyway.

Today is Tuesday, 2 weeks from when I saw my first patient here.  Went out with the other newbies to one of those restaurants with a funny Asian play-on-words name.  We talked about where we were from, what our partners did, how we feel supervising residents.  It was a great start.  I need that.  I feel so lost sometimes in such a new place without any anchor.  I used to think I was a solid person in myself.  No more.  I feel like a flighty rabbit, or chicken.  Or piece of paper blown around in the wind.  Or hamster.  Something anyway.  I know I need to cut back on coffee.  I know.  But there's an emptiness I'm trying to fill with constant moving about. Searching facebook. Email. Overanalyzing emails. Texting. Running in and out of clinic rooms. Calling the internet company incessantly.

I feel best when I'm running or hiking.  I need to do that, and not drink coffee anymore.  Right.  Will get right on that.

Week 2

This morning I’m in the hospital.  I will be here occasionally in this job.  It is large and daunting but I have found the cafeteria.  It’s not busy this morning apparently and the guy I’m supposed to follow around isn’t here yet.  In fact I may have awoken him with my 6:56am call.  There’s free wireless though so I can do facebook and pretend I’m somewhere familiar. 

Last week was remarkable for the presence of a Day Off.  This is a marvelous phenomenon which apparently exists in the real world of real doctors.  In it, you do not work on that day.  Except probably you spend the whole day unpacking boxes and go for a 4-mile run while the kids are sleeping.  But that turns out to be lovely.  And then when you go back to work the next day it is Friday and so it is only One Day Before the Weekend and you can do anything for one day.  Even if one of the patients requests you get a second opinion from a doctor who "looks older than you do."

Even if you discover in clinic that there are no ortho supplies.  Or crutches.  And you had to send a poor little girl hopping to the ER holding on to her mother’s arm.  That is unfortunate.  You can think about that on your day off.  Actually, maybe you shouldn't.  But you probably will anyway.  Hmmm.

**********

Here are some things I thought about, 10 minutes too late, today.  First impressions matter.  As you meet people while touring a hospital, probably don’t comment on people’s impressively western outfits, or tell them about your previous experiences with mentally ill nephrologists, or let them know about your fringe activities in the medical field.  Probably don’t  try to pronounce their name unless it’s John Smith.

But then I had my first delivery of the likely many to come.  One nice thing about babies is that they all come out in the same one of two ways no matter where you work.   And almost all mothers think at the last minute that they can’t do it.  And then they do.  Lovely little boy.  The thing is that in every hospital all the forms are different and the protocols are different and the delivery tables are set up differently and you’re never supposed to put the laps in the same place.  But whatever.  Babies.

Bless the babies.

Day 4

Well.  I survived the first day of patients.  And the second.  Here is what I learned.  There are many rashes in this world that exist, and which I cannot identify.  Getting an atlas out does help me to generate an impressive differential diagnosis, but not necessarily the correct diagnosis.  When in doubt, I tend to dictate an impressively long note.

Sent a lady for induction for pre-eclampsia.  It was the correct decision.  It felt very, very weird to make that decision.  I felt the absence of an attending like a phantom limb.

Suddenly, I can understand why folks would want to be a PA or NP.  I could be content to fill that role the rest of my life.  I kind of wanted to be a senior resident forever, only be paid enough to support my family.  And maybe have a little autonomy from time to time, whenever I wanted it.  And then have an attending whenever I needed that. 

Once, on our eighth-grade class trip, my friend Bug sent several postcards in the mail without an address or stamp.  We gave her crap about it for years.  Yesterday I gave 2 people prescriptions without a name.  Or phone number.  Or birth date.  Just the medicines, and my signature.  Like, here's a blank check for metformin.

Precepted the resident OB patients in the afternoon yesterday.  That was cool.  Signed a note above the resident's signature, out of habit.  As if they were in fact co-signing my note.  Additionally used perhaps the oldest OB ultrasound still in regular use in the developed world to do an AFI with the resident.  Took my brain several minutes to distinguish amniotic fluid from uterine wall and/or intestines.  Machine is size of mini-cooper, color of emesis.

Today was more of same but less rashes.  Long long notes and diagnostic waffling.  Why is it so difficult for me to make decisions?  I know I'm always like this, actually, but it hasn't been much of a problem before.  Now it's a problem.

I'll tell you what's not a problem:  babies.  Babies can come see me any time of day.  I like them folks.  And I think that 3-month old I saw today liked me, too, a little bit.  She'll never know I was the one ordering the shots.

Day 3

A Brand-New Doctor

First day as a real doctor seeing real patients.  F***.  Why does this scare me so much?  Sort of mini-flipping out.  Had to read Up-to-date summaries in advance of every problem on the list.  Which meant I got up an hour earlier than I needed to.  This is not normal, certainly. All I see in my mind is a graph of y = 1/x.  This is an approximation of how much you remember of what you learned in medical school, where y = stuff you know and x  = time.  I know I don't remember anything about being a doctor.  How do people even do this job?  Also, I'm doing it with a new system of insurances, charts, computers and people.  It's like moving to another country. 

Should I drink coffee?  Would that just make matters worse?  I would either be a. more enthusiastic and forget about my panic or b. have a panic attack.

Tough to decide.  I'll give it another 90 seconds.

Today feels like a day of reckoninng.  What if I went to the wrong residency and I didn't really learn what medicine was all about?  What if my brain has developed an abnormal lesion or metabolic syndrome in the 3 months since I last worked as a doctor, which has caused me to be incapable of this job?  It feels like it, anyway.

Ok.  Calm.  Down.  When I walk in the room, it will still just be me and the patient.  I can still smile at them and do my best to take care of what they need.  Even if I need to look everything up.

OK.  Going to look for coffee.

Day 1

First Day of Work

First day of work.  Headed in.  Once again, didn’t have time to unload the car completely.  More specifically, the roof of the car.  At least this time it’s bikes and not a lawn mower. 

In a way I feel like it’s my first day as an adult.  Sure, I’ve been getting a paycheck for over 17 years.  Sure, I have 2 kids and I’ve been married for 7 years.  Sure, I’ve owned a house, traveled independently, finished a graduate degree and post-graduate education.  Sure, I’m 30 in 2 months.

But for the first time I’m starting the job I trained for.  Literally fought for.  Stayed up all night on multiple occasions for.  Almost lost my marriage for.  And I feel…unsettled.  

Not like when you wonder if you've made the right decision.  I purposely no longer wonder that.  It's a moot point, anymore.

Nervous, like when you get up to give a speech you should have spent another hour preparing.  Like when you're in England and you're not sure which way to hold your fork.  Like taking your drivers license test for the first time, and you almost hit the car next to you while backing out, and he passed you anyway.  And now you're on your own.