Crossed out

My attending likes to cross out things. He does so quite liberally. "This isn't right. There's a 3/6 holosystolic murmur at the apex." And then he'll line out the finding and rewrite it. The same goes for plans. "No, we're going to give vanco. He's from a nursing home and needs MRSA coverage." Line out.

I quite literally measure the quality of my notes by the number of times he crosses something out. He sees my notes nowadays as writes his little agree with above thing, and I feel good. It was a good note. Then I see the intern's note, and there are so many line outs that my attending's written his own note.

Just goes to show you something that I've loved about medicine. You can be the most knowledgeable person around, but it's meaningless if you don't have the skills of being a doctor.

Medical students that work with me know that everything I teach will never be on their tests, but they always have a good time, because I don't teach them how to pass a test. I teach them how to be doctors.

Fancy pens

Montblanc 146, uploaded by Wil Lau.

I don't take drug rep pens. I try to minimize my free items from drug reps, because I don't want my patients to think that I support a drug or therapy because they gave me free stuff.

So I use my own pens, and lately, I've been breaking out my fancy pens. And when I say fancy, I don't mean that they're nice. I mean fancy. I mean Cross and Mont Blanc and Waterman. I mean pens that cost $70, come in a fancy box, and have refills worth 20 lesser pens. In my pocket, at any given time, I'm carrying $100 in writing utinsels.

And as if that wasn't bad enough, I bought a new Waterman pen, ballpoint, retails $50. A little spur of the moment, but I've gotten in trouble only having 2 pens in my pocket. And most people don't notice. I mean, a pen's a pen.

But when you write for a living, and as an internist that's pretty much what I do, it's nice to do it with a little class. I used to think I was nuts to buy and use these fancy pens, but every now and then, I'll meet up with an attending, and the guy drives a beat up 10 year old Honda Civic hatchback, but he's got a Mont Blanc in his pocket. And that's when I know that I'm not the only one.

My junior is an idiot

My intern, he's an idiot. I mean, I've tried to be sympathetic and tell myself (on an almost hourly basis) that he's just starting, it's only October, but every day, he finds some way to amaze me with his tremendous stupidity. And I don't mean that in a jovial manner. I mean stupid, like when I found one of his charts, I was so angry that the nurses brought me coffee and tried to calm me down.

And the problem is that his deficits are not the deficits one should have as an intern. An intern should not know what to do or which antibiotic. He doesn't know what meds the patients are on. He doesn't know the labs. He's missed stuff like a hemoglobin of 7, a creatinine of 3.

He'll tell me that something was done yesterday, but it wasn't done. It wasn't even ordered. Or that a consultant recommended a medication, but the consultant made no mention of it. Essentially the problem is this: he cannot be trusted to report accurate information.

This would be fine, if he was a medical student. Then, I would see the patients and write my note and that would be the end of it. The problem is that you cannot manage a patient when you don't know the patient. Every day on rounds, I have to tell him something about his own patients.

And today, I couldn't believe it. One patient was off Lantus for 2 weeks. It was lost in an ICU transfer. But for 2 weeks, he's been telling me that he's taking care of her blood sugars, but he's done nothing. Worse than nothing in fact, because we've taken steps backwards. And it's my own fault for trusting him. I should've checked the accuchecks. I should've monitored the doses, but I just believed him. I had sicker patients to worry about.

Frankly, I'm ashamed. We've had multiple consultants on the case, and they must think we're morons. Internists that can't manage diabetes. I sent him home today and wrote all the orders to fix it.

Man in the moon

I spent a good twenty minutes staring at the moon tonight, and for the life of me, I can't see the rabbits.

In Korean myth, there are 2 rabbits on the moon making rice cakes.

And so it begins

I got my personalized Christmas cards in the mail yesterday. I ordered online from Hallmark. I wanted to get started early this year, as I'm planning on sending out at least 50 cards. In the last few years, I've been sending out 40 to 60 cards a year, and this year, I'm sending out professional contacts as well, so I'm thinking I'll likely be in the 70 to 90 range.

I love Christmas cards. It's nice to get them, but I like sending them, because I have a lot of friends out there, people that I've long since lost touch with. It's kind of sad really that I know so many people and it's been so long since I've talked to most of them.

And so I send people Christmas cards, kind of as a reminder that I still think about them and as a reminder to me about what people mean to me. Because I'm a pretty solitary guy. I went an entire month without one personal call on my cell phone. And every now and then, I need to remind myself that there are people out there that care for me, and people I care for.

"Thank you, doctor"

I had a patient die, and it's not the first time, and it wasn't my fault. I spent a lot of time with the patient's family throughout the hospitalization, and they kept thanking me and telling me they appreciated everything I did. I didn't really do all that much, really.

And I feel a little guilty, to be honest, that the family was so grateful. Be angry. Yell at me. Tell me I'm a son of a bitch. Hate me.

I'm not ashamed to say that I'm good at what I do, and when it comes to terminal patients, I do a damn good job. But I feel a little better when the family hates me or resents me, because it means that they don't blame the patient. Because I know what it's like to be angry at someone for being sick, and I'd much rather families hate me than sour their memories of a loved one.

Sudoku?

Holy shit, this is the best thing ever. Screw crossword puzzles.

Sudoku from the Daily Telegraph (UK)

Web sudoku, a vast puzzle library

Retroactive

Reading over my old blog, I was so much more... open. It wasn't all so heavy handed. Sorry about that. I'll try to do better.

I had a moment today, something that I thought I was past. Y'know, it's weird when you suddenly think of someone. I was thinking of this one girl, and I'd been carrying a torch for her for... well... years really. And part of moving somewhere that I only had a few friends around meant washing myself of all the little shit that I've accumulated in my life.

And suddenly today, I found myself thinking the strangest thoughts, like wondering what she was doing right then, or Googling her, or doing little shit like that. And it's like falling in a hole that's been cordoned off with police tape. It's just stupid.

Because if she came up to me today and confessed her undying love, I'd say no. No because she rejected me. No because she never thought of me. No because she was not there. No because she's not the person I dreamed that she might be. No because my heart deserves better than table scraps.

And I carry a torch for no one now, because no one ever did for me.

The trouble with juniors

Now that I've graduated from idiot to king of the idiots, I've come to realize that juniors come in a variety of flavors. There are those scared to commit to anything, like I was, and there are those that don't know what to do, and there are those who know what to do. It's kind of like what Rumsfeld once said: ... there are known knowns; there are things we know we know. We also know there are known unknowns; that is to say we know there are some things we do not know. But there are also unknown unknowns - the ones we don't know we don't know."

This was an oft criticized quote, but I thought it showed remarkable insight, and this one quote should preface every epistemology text. Anyway, the same is true with juniors, and all of us really. There are things that we know we know. And things we know we don't know. And by and large, we're comfortable with these things. The dangerous place becomes the realm of things that we don't know that we don't know.

That is what my experience of junior residents is. It is the continual exercise of, "Wait, hyponatremia has to be corrected slowly" or "You don't need levaquin and ceftriaxone for pneumonia" or "the patient needs to go to the cath lab right now." It is watching people display their blissful lack of knowledge.

This is my job. I've come to accept it. The frustrating thing becomes watching people defending their stupidity. "Well, the ER started these two medications" or "But she's getting better with what we're doing."

The most frustrating thing in life is trying to reason with someone who will not concede a position of ignorance.

Damning realizations

When you're looking into a career, you have to take something that you like, and try to think of what would make you leave that. For example, when I was younger, I loved to draw and write, and I wanted to be a comic artist, but I needed to interact with people, and the interaction with people is what I was willing to give up art for.

In college, I liked playing with chemicals, but I was pretty sure I wasn't going to do that for a living. I liked history a lot, but again, I wanted to work with people, and so I left that by the side to pursue medicine.

And now, I'm in internal medicine, and chomping at the bit to go into outpatient practice. But I realized that I like working with medical students. And I mean like like, as in I'd give up working with patients to work with students.

oops

Because now I'm in a bit of a pickle. I never thought I'd really want to go into academic medicine, and my CV shows that. But without medical students, this would just be a job. And I don't want a job; I want a profession.

I guess I took that whole docere (to teach) thing pretty seriously, because now that I've become a doctor, all I can think of myself as is a teacher.

Someone to lean on

I was feeling very insecure this weekend. I don't know what will come of my life. I don't know where it's heading. It's that same feeling I had trying to get into med school, or trying to get into residency. I don't know what will become of me.

And all I want in life is to have someone tell me that it'll be okay, someone to tell me that I'm a great doctor and a nice person, and I'll do wonderfully wherever I am or whatever I'm doing. I was going to call my friends and have them tell me that everything would be fine, and the world would be roses, but it's not the same as having someone invested in your life.

And part of the problem with my life is that I just want someone to lean on for a bit. I want someone to share the load for a while. I want someone to share my life. And there can be more problems and hardships, but there'd be someone to share that too.

Apologies

The problem with apologies is that they don't really feel good. Forgiveness feels good. To be forgiven, it's a wonderful thing. I remember breaking a collectible Peanuts glass from McDonald's (back in the day when McDonald's gave away things worth collecting), and my brother was mad, but my mom helped me clean up and told me that everything on this earth has its time, and we shouldn't blame ourselves too much when its time ends.

Apologies aren't as wonderful. It doesn't really make me feel any better. It's like alcohol on a cut. It sterilizes and is painful, and it's good in the end, but doesn't feel good. It can hurt worse than the injury that started things.

And part of the hard part about apologies is that it places the burden on you to forgive, and I have a hard time forgiving, because I don't hold things against people much. The things I have left unforgiven are few in number, but sore still. And maybe it would do me good to forgive and to let that chapter of my life close, but it's like a scar, and it's still there, and forgiving won't take that scar away.

Sometimes, life is what it is, and I guess that people should know that what has been done to me, what tragedies that were inflicted upon me, they are all forgiven. There's a saying that goes that you should write the bad things that are done to you in sand or in a flowing river, so that time will wipe it clean. Rest assured, the injuries done to me, they were written in sand and water.