Spoonfed

There's an intern that I've been working with, and every time he has a problem or question, he asks me. And normally, this is fine. But it gets absurd. He asks me what to do about home medications. He can't find the list of home meds. As if somehow I secretly know everyone's home meds.

But more concerning to me is that whenever something medically relevant arises, he asks for the answer. I do all the thinking, and that's not appropriate at all. Because the whole point of being an intern is to think. If you just want to get the opinion of your senior every time something comes up, you might as well quit residency and become a nurse. No disrespect to nurses, but the whole point of being the doctor is the responsibility.

I feel like I need to let him flounder a little. Not in a bad way. When I was an intern, my senior was busy cardioverting someone, and another patient was hypotensive. His words to me, "Take care of it." I had all of 36 days of being an intern under my belt. I learned. Sometimes, you have to jump out of the nest and try to fly.

Teach me

Having been a less than stellar intern, I find it very odd when interns now come up to me and ask me to teach them something. I'm used to medical students. In fact, I love teaching medical students. It's fun. It's just strange to think of myself as a repository for information.

I mean, honestly, it took me the better part of 6 months to figure out how to select an antibiotic. I mean, seriously, 6 months. 6 months of "My patient has a UTI. Can I give Bactrim?" or "My patient has pneumonia, should I give levaquin or ceftriaxone and azithromycin?" Even better, "My patient has MRSA. Should I start vancomycin?"

The fact that people come to me for information wows me every time. And I love to teach, I really do. I never thought I'd find something that I loved, but it's very strange finding something out about yourself.

The real truth about teaching though is that you have to know something really well. And it's surprising when you try to teach something to find out just how little you really know.

My first code

I recently ran my first code. I thought it would be horrible, but in actuality, it wasn't that bad. Of course, initially, it was miserable. I was ready to wet myself. However, after the first 5 minutes and the patient hadn't turned around, I realized something somewhat profound. This person, if I stopped right then and there, was dead. The only thing keeping the patient from being dead dead was the nurse pumping his chest and another bagging his lungs.

The thing about ICU that one of my attendings impressed on me is that you can't save everyone. Heck, you can't even save most. You do what you can with the tools given to you, and let God do the rest. The thing about the unit is that the only patients that get to the unit are ones that are dying. And if you're not dying, then you don't deserve the unit bed.

I feel better about codes now, and I've got a few under my belt. The shock of watching someone die, it goes away after a while. You do what you can with the tools you have.

HPI

This post is simply to inform you that I've established 2 ancillary blogs. One is History of present illness which is a fictional site, with storied inspired by patients (but not real stories, mind you. HIPAA and all, you know).

Merry X-Mas.

First names

In med school, I was taught to address patients formally. Mr or Mrs or Doctor or Sir or Ma'am or Father or Sister or whatever. It's a matter of establishing professional boundaries. I'm not there to make friends with my patients. I'm there to care for them, and that should be clear.

Sometimes, patients like to be called by first name, but for the most part, people appreciate the respect. But with some patients, things change. On my terminally ill patients, I can't help after a few weeks to start calling them by their first names. I've been seeing them for so long, and I've met all their family and friends, their spouses and children, their parents and best friends and siblings. I've talked to them all about matters of life and death.

It seems to me that after all that, I should be calling that person by first name, and they can call me by first name too, because you can't be that intimate and still stand on formalities.

The longest night of the year

It's officially Winter now, and the Winter solstice is gone days ago. The days can only get longer. Thank God. After my bout with seasonal affective disorder a few years back, I always dread November and December. It's the worst.

Seasonal affective disorder is a funny thing, because I always think that I'll do okay, but it's very much hit or miss whether the lack of sunlight will make me feel miserable, or whether I'll be fine.

A few years back, I had it bad. I was clinically depressed, and all of the sorrows and tortured issues of my life came flooding back to me, and I wanted to die. I just wanted everything to be over. I wanted to lose all the pain and heartache and self-pity. And one domino kept knocking down another. A girl rejected me. A friend abandoned me. A test was nearly too hard for me. And things just got worse and worse and worse, till I very sternly questioned what it was that made me get out of bed and bother to be alive.

And looking back on it now, it's strange to think that I was that depressed, because the things that bothered me back then, nothing's really changed now. Just a little perspective I guess. If I don't post before then, Merry Christmas.

All the king's horses

I admitted someone to the unit that when I saw her, she was alert and conversive and doing quite well other than the fact that her body was starving for oxygen. So, quite naturally, we intubated. Turns out she had sepsis. So, full court press. I poured fluids in this lady, threw pressor after pressor after pressor at her. I used everything in my arsenal to treat her. But the best pressure I got was 60's systolic, and on the vent with 100% FiO2, I had pO2's of 60 (these numbers are horrible, for you non-medical folks).

I had to talk to the relatives, try to tell them why this lady who is, undoubtedly, the strongest person they've ever known, why she is now as meek as a kitten, hanging on to life by cobwebs. I do the talk well, and that's the only thing I like about critical care. I do the talk surprisingly well, and people listen to me. But here's the deal, this skill is only valuable when I've already failed.

We weaned off pressors, and she expired. I went home in the morning, and I just wanted to throw up. I couldn't even get this lady 24 hours. I talked with my attending, and there were a few things we could've done, but in the end, it's just second guessing. It may have been that all the medicine from all the best doctors couldn't have made a difference.

I may not be a Republican, but I'm no Democrat

I've been hearing quite a lot of buzz about the NYC transit strike, which has really caught my interest, because after all I lived in NYC. And normally, I'm sympathetic to unions, but I gotta say, these guys blow my mind.

They get paid more than I do (and let's compare, I owe $130,000 for the privilege), they work less hours than I do, they have full health benefits, and a pension, and they get to retire at 55. If I retire at 55, it'll be thanks to several shady business ventures, or the lotto. And in this day and age, let's be honest, pensions are a pipe dream.

It's illegal for them to strike, by law. What an unfair law, you might say, but consider this: a lot of people in NYC live by the subways. When I lived in NYC, I had to take the train to school. Far more people use public transit to work at jobs that earn far less than what the transit workers are making. And even if the folks in NYC got to work, they depend on other New Yorkers to buy their sodas or newspapers or hot dogs or whatever.

This strike is actually threatening the livelihood of millions of New Yorkers who live paycheck to paycheck. And that's the thing that pisses me off the most. Strikes are supposed to be about standing up for the working poor. Instead, this strike is all about punishing them. I have no sympathy for the striking workers. In order to cling to unrealistic outdated labor practices, they've put people's lives at risk.

Fuck you, ActiveSync

To anyone contemplating buying a handheld, let me tell you, do NOT get a PocketPC product. Do yourself a favor and get a Palm OS product. I have had my battered Palm for the better part of 4 years and it's weathered a world of abuse in my pocket, and despie 2 new computers and 3 computer OS upgrades, it's still plugging along.

However, in the 2 years I've had my PocketPC device, it has now THREE TIMES decided on a whim to stop synchronizing with my computer, for no discernable reason, and I have now wasted 4 hours of my life trying to fix it, to no avail, and I give up. I will never use the blasted thing again. It has now been relegated to the status of paper weight.

Trust me when I tell you that PocketPC is shit and do not waste your money on it. I thank God that my educational account paid for this heap of shit and I didn't have to lay out any cash for it.

Not so happy holidays

Lately, the Religious Right has gone absolutely apeshit over the de-Christmasification of Christmas, and the use of Happy Holidays and Season's Greetings. For me, it's part of the reason why I don't consider myself Republican any longer.

I had a problem with the lack of Christmas in Christmas starting several years ago. The first year I did a lot of Christmas cards, it was either super religious cards, or else cards so secular that if not for the snowflakes, you wouldn't know they were Christmas cards at all.

But let's be honest with ourselves here. There wasn't much Christmas in Christmas to begin with. Christmas trees? Santa Claus? Candy canes and mistletoe? None of it has anything to do with the birth of Jesus. For the majority of the world, Christian or not, December 25th is a secular holiday first. And I'm at peace with that. I've divested myself of the trappings. I don't have a tree or decorations. I just do my cards and that's it. Sometimes, I get a poinsettia.

I think as long as we have Christmas in our hearts, that's all that matters. And that's why it's always nice to watch the Charlie Brown Christmas special, and hear Linus recite Luke 2:8-14. That's Christmas. And regardless of what other people do or say or write or whatever, in the end, Christmas is a celebration in our souls. God's not gonna freak cuz your card says "Happy Holidays."

Success boot camp

I saw a commercial on TV for Burlington Coat Factory, and it was a bunch of guys in Success Boot Camp, and what's the first lesson they shout out? "Don't lick your knife at a power lunch!" Hah!

People that know me know about my absolutely strange obsession with etiquette. I read Miss Manners all the time, and I've taken an active interest in all levels and rules of etiquette, to the point where I could probably, quite comfortably, function at a white tie event, with royalty and dignitaries. I could be upper crust.

However, people that know me also know that I love to wear shorts and t-shirts, I had a strange thing with flip-flops, and I answer my phone simply "Hey."

I can't help myself sometimes. I was raised this strange mix of white collar and blue collar. I went to private schools for the rich and elite of the world, the children of the people who make the world go round, but went home to a single parent mom who worked as a nurse and had multiple Spam recipes.

It's nice to know that at the drop of a hat, I could be in that world of formality and grace, and I'll admit that I look a little disdainfully on knife lickers, but I really am pretty blue collar at heart. I mean, I'm going into internal medicine. That's proof in the pudding.

Danish Butter Cookies

Danish Butter Cookies, uploaded by stickerbandit.

So, I decided to get some Danish butter cookies and candy canes for the nurses in the clinic and on some of my more loved floors of the hospital. Danish butter cookies are a bit of a family tradition. My mom would buy them every year around Christmas, and we all had our favorite shapes. I personally swear by the pretzel shape.

Anyway, we'd go to the store, or sometimes we'd go to Macy's and get them. And it came in a metal tin and we'd carefully eat one or two, trying to savor the enjoyment.

And so, I went shopping on Sunday practically everywhere. I went to 3 supermarkets, 2 specialty food stores, and finally, I found myself at Wal-Mart, the most evil store in America. Wal-Mart has single-handedly destroyed small business, got all of America buying everything in excess, and doing their best to ruin everything wonderful about this country.

And of course, Wal-Mart had the cookies, for $2 a tin. They're cheap quality, disappointing, and another precious memory from childhood ruined. Thanks for nothing, Wal-Mart. Of course, I bought 4 tins.

Breakfast memories

I was remembering this morning something very random. I was eating breakfast at a restaurant as the snow came down in torrents, and I remembered eating breakfast in Mexico. I was sitting out on the veranda with a friend, having a pleasant conversation over a simple breakfast and hot coffee, soaking in the beautiful weather, 70's and sunny, with tropical birds flying overhead. It was a beautiful morning, an excellent meal, pleasant company, and it's a precious slice of my life. It's one of my very fond memories of late.

And it makes eating bad scrambled eggs in a crappy restaurant, alone, in the middle of the Midwest, in a freak snowstorm, seem pretty shitty.

The last Christmas card push

Rather than take anyone off the list (oh, alright, I did take one person off the list), I've added 4 more. I'm nuts. So, I've got 4 more cards to write now. Yikes. I'm going to try to churn through them in the next few days. At least the bulk of the cards went out now, and the only ones I have left really are cards in desperate need of addresses, and some cards I've just been lazy about mailing. What kind of an excuse is that? A bad one.

It feels good to get back into the Christmas card spirit, and I'll admit, this year's not a personal best. I've only done around 40 some cards this year, whereas in years past I've gotten as high as 60. But I feel good about it. There's a certain... pleasure in dropping a big stack of cards into the mail.

The magic "Asians call tell each other apart" skill

I know nothing about the book or movie "Memoirs of a Geisha" other than the commercials I saw on TV, but I was a little curious when I saw the commercial, because everyone's Chinese. I dismissed it in my mind. Maybe the book's set in China or maybe this is about a Chinese girl in Japan. Who knows.

Well, of course, it's not. It's about Japanese people, in Japan, played by a cast of Chinese superstars. Now, maybe for white bread America who doesn't know Thailand from Taiwan this isn't a problem. But for me, I didn't even have to look at the screen to lose the feeling of Japan.

Their accents, so Chinese it's unmistakable. Their faces and even mannerisms from the 30 second spot, so very Chinese. It's too much. It's like watching Japanese animation dubbed into English. It has a certain lack of authenticity that is palpable. It's like a bulb that flickers in a movie theatre, never letting you forget that it's a movie.

Chinese is not Japanese, even if you dress Chinese in a kimono. Let me tell you, for the most part, it's relatively easy for Asians to tell each other apart.

Maybe I'll see the movie, but I'm not in a rush. It's hard to get excited about something that reminds you through the whole movie that it is fake.

The final 10 cards

I'm down to the last ten people on my Christmas card list. For some people, there's a system to doing cards. Some people save the best for last, and I've gotten touching cards from some friends about how I was their last card because they wanted to save me for the end. That's sweet. I have no such system.

A couple are family, and I usually save them till the end because they won't mind as much if they don't get a card. They know I love them, and don't need a card and a cheap sentiment (not so cheap this year with the amount I've spent at Hallmark) to validate our relationship. A few are really good friends, and I just haven't found the right words yet this year. And the last few are the tough ones.

The last few are people that I haven't been in touch with much at all. They're folks that have more or less evaporated from my existence, and it's hard to find the words to say, when more and more they're letters on a page rather than people I care for.

And it's a battle every year to decide whether I should just fill out the cards and be done with it, or whether it's time to take them off the list. And that's a hard call, because it's a lot to say that a person means so little to you that you can't spend the time to write even the most trite of sentiments on a piece of paper.

So it's going to be a tough week churning out the rest of the cards, and there's some value in this kind of catharsis, because in the end, Christmas cards to me are more than a chore. And I hate to think that for some of these cards, it's become just that.

Doctor's hours

I like to hang out with my friends as much as I can, but I've come to the realization that there is no schedule quite so hard to coordinate as trying to get a resident's schedule to conform to the working week of the rest of the world. The rest of the world doesn't work random nights or have to work 30 hour shifts. The rest of the world thinks a 50 hour work week is shit, whereas in medicine, we practically jumped for joy at the thought of only 80 hours a week.

I'm quickly realizing that the reason why so many doctor marriages fail is that the medical world just doesn't exist on the same temporal plane as the rest of the world. We don't have the time.

This has significantly dimmed my hopes for romance outside the hospital.

The wisdom of an older generation

I was talking to one of the Asian attendings in the hospital a few days back, and he was giving me the first generation perspective, where I was offering back the second generation perspective, and he pulled me aside in the hallway and leveled with me.

"These people in the Midwest, they're friendly. They seem nice, but don't be fooled into thinking you're one of them, because no matter how much you act like them, all they see is your skin and your eyes."

This isn't the first time that I've heard this. It's a rallying cry for first generation immigrants. I used to think that this was paranoia or misunderstanding, but as I've gotten older, I've realized that it's true. I'm not white. I'm not one of them.

Even though I love the Midwest, I'm thinking about the East or West Coast, somewhere where it's a little more normal to be Asian, because as much as I like to think that I'm just another guy, I'm the Asian guy. And it's not that people are trying to lynch me, but it's a very subtle recognition that I don't belong here.

Loved

My family visited for Thanksgiving, and my GI system has forgotten what it's like to eat nothing but Asian food. I'm gassy and my stomach is a mix of hungry and bloated. I haven't slept in my own bed in days, and I haven't had a moment of privacy except in the hospital of all places.

Still, I miss them now that they've left. I'm not a very communal person. I'm very hermit-like. So it's not my thing to hang out with random people. But family, family loves you, and it's always bearable to have family present. Family does little things like make your bed with hospital corners, or vaccuum, or make you dinner after a tough day in the hospital.

Family listens to your troubles and is always rooting for you. It feels nice to feel loved. There really is no substitute for that. My mom wants me to date and get a girlfriend, but I reserve the right still to be picky, because it's quite a wonderful thing, to be loved, and I don't want to waste that.

Thankful

I guess that Thanksgiving is supposed to be the time when we say what we're thankful for. And people in their blogs I'm sure wax philosophical about what thanks means and the ways which we give thanks. Here's what I'm thankful for: turkey, parents who feel the compulsive need to clean, having enough money that even the craziest black Friday sales aren't worth waking up for, not having to work on Thanksgiving, and svelte women that wear tight shirts. Thanks.

Transference

While I was reading another blogger's discussion about malpractice, I realized that there are certain things that are true about a lot of situations where people threaten litigation.

In my experience thus far in residency, the most common occurrence where litigation is threatened is the angry family, where no malpractice has been done. It's just an irate family, entirely unsatisfied with perhaps even the best of care.

I've had families where we diagnosed small cell lung cancer, and simply that piece of knowledge prompted the family to yell at me for 40 minutes, threaten to sue me personally, my residency, the hospital, and the nursing staff.

And this is just my observation, and probably not that generalizable, but the worst of them seem to be families with guilty consciences. Maybe they didn't love their father like they should've. Maybe they should've visited mom at the home more often. Maybe they shouldn't have yelled at their sister and called her a whore before she went into a coma.

And transference is a bitch, because it's so easy to shift all that guilt and self-loathing to the doctor. He's the lightning rod, and it's easy to dump on him. He should've done a better job, worked harder, developed godlike powers to miracle heal. And you know, sometimes, I don't mind.

So, I try to work with families and get them to understand things, because it's important for families to see, especially in terminal situations, that I am also in up to my armpits. Families need to see that someone else cares. Because for all of medical technology, we have little power over disease, and even less over life. I had one patient who just wanted to die at home, and I could not even give her that.

Most families are fine, despite the worst outcomes. I've had grim discussions with families who shed their tears and thanked me for telling them it was okay to pull the plug. And it's touching to see a patient's family who loves him enough to let him die.

But to those families who feel the relentless need to find fault with everyone involved, and blame doctors or nurses or the whole profession (excepting those where we have earned such blame), please realize this: what we can do with medicine, what we can offer is not playing catch in the backyard or teaching to ride a bike. We can't offer family vacations or Thanksgiving gatherings. We can't save everyone. We can't turn back time. We can't forgive you.

Feel free to yell at me all you wish, but please remember that all the yelling in the world won't make you feel whole inside. I know that for sure.

That holiday between Halloween and Christmas

I just wanted to wish you all a happy Turkey Day tomorrow, and mention one thing that's been bugging me, and it's been getting worse every year. People keep celebrating Christmas earlier and earlier, to the point now where the day after Halloween, everyone's got Christmas decorations up. It seems like no one remembers how to celebrate Thanksgiving.

First off, Thanksgiving is the best American food related holiday that we have. But more importantly, what it means. It's a chance for us every year to give thanks for what we have and spend some time with loved ones. It's an important day, and people are so eager to skip over to Christmas.

So if you're one of those store owners and you've been playing Christmas music in the malls and grocery stores this November, screw you, you bastards. You've made my shit list. Just because there are no catchy Thanksgiving songs doesn't mean that Christmas gets to come any earlier this year.

Happy turkey day!

Aaaaaaaaaaauauuuuuuggggghhh

Dammit, dammit, dammit, dammit, DAMMIT

I'm rich

I've discovered during my residency that there are several residents with wives and children (as in multiple offspring) and they seem to get by okay. Compare this to me, where I have a car payment, an apartment payment, and not much else. I'm rich.

Having made this realization, I've been a little more liberal with my spending. I'm so used to my medical school days where I never knew when the money was coming, or how much of it I'd get. I'd put everything on the credit card and pray that I had $5 to buy ramen noodles for the month.

There really is nothing quite so humiliating as medical school. It's a process of taking away a person's self-sustinence, pride, relaxation, and joy, and replacing these things with fear, inadequacy, and rejection. In some ways, it might be considered torture by the Geneva Convention.

I'm glad to be done with medical school and earning a steady paycheck. I've wasted quite a bit of money on things, but sometimes, things make you feel a little better about life, like buying that camera I said I'd buy myself when I was a doctor, or living in my own apartment alone again, and very comfortable.

Pimping

My current attending loves to pimp, and he's good at it, and I know most people would hate that, but I loved it. It was fantastic fun. it's so refreshing to be put on the hot seat again. I'm asked questions by other attendings, but it's more collegeal than instructional. Should we increase fluids? Did you check a TSH? It's nice to get something more basic. What's the most common peripheral neuropathy? What's the sensory innervation of the thumb? What are all the diagnostic criteria for type 2 diabetes?

Believe it or not, there is an art to pimping and an art to being pimped. And there are attendings where your admission of ignorance is welcomed, and others where it is an invitation to disaster.

Personally, I really enjoy being pimped by the right folks, because when done well, it feels more like a conversation than education, and I'm sure Socrates would be smiling up in Heaven, if not for all that hemlock business and not believing in God and all.

For your benefit, here is a treatice on the art of pimping, published in JAMA.

Target heart rate

So, I finally decided it was time to start working out again. My apartment complex has an exercise center that's actually pretty comprehensive. I was surprised, and felt a little sheepish that it's taken me this long to make use of it.

I got on the treadmill, and using my m4d d0ct0r sk1llz, figured out my target heart rate. For those of you that are curious, your maximum heart rate is 220 - age. Ideally, cardiovascular exercise should occur somewhere between 60 and 80% of your maximum heart rate. That's why stress tests aim for 85% maximum, and why a stress test that doesn't achieve at least somewhere close to 80% is worthless.

Anyway, my target HR was between 140 and 160, roughly. Well, I achieved and maintained that HR on the treadmill at the blazing speed of 3.5 MPH. I think the girl running at 7 MPH next to me must've worked pretty hard to contain her laughter. And this is why I don't go to gyms.

A girl's pen

I was out with one of my friends, and I was showing off my latest purchase, my new Waterman pen.

me: This is my new Waterman. $50. Worth every penny.
friend: ... dude, is this a girl's pen?
me: ... fuck you.

The art of medicine

There are some things that other doctors look for when they want to find a good doctor. And it's not that guy that bitches about his patients and has MD on his checks and credit cards and on his vanity license plate.

When I'm looking at other doctors, I'm looking for that guy who loves the pathology. He gets excited about hypertension. He dreams of gallbladders. He can give a 20 minute impromptu lecture on nephrolithiasis. He knows his shit and he knows it because he loves it.

He fears the white coat. He doesn't splash his doctor title around like a piece of fancy jewelry. He respects the meaning of it, what it means to patients. Just being a doctor means a lot, a fucking lot, to people and he takes that responsibility seriously.

But I think most importantly, he understands that there's a science to medicine, and then there's an art. Science is all about data and studies and biochemical markers, and that stuff is great. Fantastic. But the thing about medicine is that you don't treat test tubes and beakers. You treat people. And in any field where you work intimately with people's lives, there's an art to it far above what science can offer.

Because there's no textbook on how to deal with that confrontational patient who's fighting your every move because she's lost complete control of her life and she's grasping for any amount of control that she can get, even if it's refusing her morning labs. There's no multiple choice test that will teach you when a 96y/o demented lady should get a PEG tube and when she needs Hospice. There's no lecture that can prepare you for telling a patient's family that he's going to die, not in a month or a week or a couple years but today, this afternoon.

After I did my first family meeting where I was the doctor, I was the one delivering the bad news, I grew up that day. Understanding the biochemical mechanism of neosynephrine doesn't make it easier to tell some poor lady's husband that it's the only thing keeping her alive.

And I sat there for what seemed like 10 minutes, not saying a word, letting the patient's family cry and sob, letting them grieve, and I knew that 12 months before, I would've blabbered on incessantly, but that day, a voice inside my head said, "Shut the hell up. There's nothing you can say that will somehow make death more palatable."

And so I offered tissues and a shoulder to cry on, and I had the nurse titrate off the levophed and neo. And I'll be damned if I didn't feel like a doctor that day. Because any idiot can read the studies and order the tests, but there's no randomized, double-blind, placebo-controlled study that can teach you how to be a caring human being. And sometimes that hurts, but it's a good hurt.

And the only word of caution I offer is this: at some point, you will realize that you've nothing left to give. You've poured yourself empty. And that's good, because it's then that you'll realize that you're not in the practice of medicine to give yourself. You give medicine. That's the art.

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.

You must unlearn what you have learned

My friend, being the jerk that he is, corrected my golf swing. If you've ever seen my golf swing, you'd know that this is no easy task. My golf swing is entirely wrong. There's so much wrong that you can't really point out one thing to fix.

My friend is of course a natural and hit the ball 200 yds on his first time on the range. No one ever said life was fair. I took my piece of humble pie like a man. But the problem came when he tried to fix my swing. He made me move up on the ball, change my grip, fix my mechanics.

Now, I can't even remember how to swing my way. It's completely lost. But I'm no good at swinging the 'right' way, which means that the last few times I went to the range, the furthest ball I hit was 70 yds, and it rolled that far with a downslope and a tailwind.

But every now and then, you need to unlearn comfortable habits. You need to relearn and rediscover things, and find a new and different way, because it's exciting. It's exciting to hit a ball again. It's exciting to watch a ball sail high in the air, and it's utterly heartwrenching to miss on my swing and top off a ball.

I hate having to relearn how to swing, but it's nice to remember how wonderful it felt to be excited again.

Capped

I capped on admissions for the first time. It's a novel experience, knowing that I actually cannot admit any more patients. I'm not sure if it's scary or comforting. I do know that I'll probably live to regret it. I usually live to regret things.

Game day

I was cursing up a storm today watching football. I was dropping f-bombs like it was my job. I remember now why I try not to watch a lot of football. My blood pressure must be sky high right now. Oh well, that's life I guess.

But it made me remember when I was in college and how much I loved football back then. Oh, I guess I still love it, but it made such a difference being in college and surrounded by the environment, y'know?

I probably should have done something social today, but I just wasn't in the mood. I've been sitting on some replies to my online personal ads, I just feel kind of stalled out. I need a second wind on life.

As a note, if you're wondering where all the posts are coming from, I sit on posts for a couple days usually to edit them, etc.

First children

I was thinking about my friends the other day, and I came upon a disturbing realization: nearly all my friends are either the first child or an only child. All my best friends from high school and college are first kids. Only one or two of my med school friends are younger siblings. It's absolutely astounding.

I'm not sure why that is, since I don't know many only children. Most of my friends do indeed have a younger sibling, if not multiple younger siblings. Just seems like I've got many friends in the older sibling department. Maybe it's that older siblings tend to be the achievers and younger siblings tend to lay back and watch the world drift by. I don't know.

Similarly, I find myself very disturbed that I was talking to a single friend of mine, and the fact that I've had a total of 3 dates in the last 5 years is entirely non-representative of single doctors out there. With my doctor credentials, I really should be doing better. What am I doing wrong? Oh yes, working 70 hours a week, that's right.

I should note, I'm a younger sibling. -9/25/05

Do your fucking job

Nothing irritates me more than when I'm asked to do someone else's work. It is, far and away, the most aggravating thing imaginable, and the greatest offenders without comparison are the ER folks. And today was no exception. I was called to evaluate a patient in the ER who was hemodynamically stable, and all that was done was an EKG. There was not a physician eval completed, no labs were back, nothing. For all I knew, the guy could've had a troponin of 56.

So now, I'm taking an H+P from scratch. I am for all intents and purposes now an ER doc that can admit. The ER doc did his charting AFTER I did orders and dictated my H+P. At that point, why even bother? H+P trumps ER papers. All you can do is make me look bad, because what if a lab comes back now and you chart it? Now I've got to make extra special point in my H+P to note that this wasn't done and that wasn't done, just to guard against the possibility that you'll chart on it way late.

I told the ER to get my patient upstairs as fast as they could not because he was acute or urgent, but I didn't want my patient to stay in the ER if that was the level of shitty care he was going to get.

If you have anything to do with the ER, please remember two things. (1) If you're going to call for admit or consult on a patient, be sure to have your own paperwork done. (2) If you're going to call for admit or consult from cards and you haven't even got labs back yet, someone better be dying.

Male piggishness. Please skip this post.

I have lately found myself staring at breasts. I've had to be a little proactive about not making an ass of myself, but lately, it's been tough. It seems like it's not so easy when some of the nursing staff wear see-through shirts, or spaghetthi straps. This is not helpful, and mostly rather distracting. It's hard not to stare. I mean, honestly. When it's right out there, how can you not?

Even worse when the breasts are of a patient. When some college aged girl comes in needing me to do an exam, then it's my business to take a look. I'm not doing anything unethical or anything like that, but it's a chore to keep the libido in check.

I'm not sure why the new breast fascination. I mean, yes, I'm a guy, I like breasts, but why it's been so much trouble recently, I don't know. Maybe it's just that I've been thinking about being single for a while, and how I'd like to see a pair of breasts on a recreational basis that I don't have to examine and that I haven't had to pay a cover charge to see.

She wasn't there

I went to church today, and she wasn't there. Strangers on a train, I guess.

Weighing in

[Beware: this post is long and preachy]

First, it should be said that if you haven't contributed to the effort to help the people affected by Katrina, then you'd best read quietly and shut up. People unwilling to be part of the solution should avoid being part of the problem.

Now, over the last few years, I can't say I'm very fond of W. He is not the brightest man we've elected to the presidency. But I'm pretty annoyed at how he is being blamed for Katrina's aftermath. I wish to make the following 3 points.

(1) Working in health care and being inundated with courses and lectures on disaster management, I have learned one big lesson: disaster planning is local. When a hospital knows that it's gonna get fucked, it's ready to run independently (without outside power or water or help) for about 72 hours. That's because everyone who's ever run a hospital knows that it will take a minimum of 72 hours before any help may be expected.

The reasonable timetable for federal aid is usually at the week mark. The CDC and other agencies usually will take at least that long to come in force. That's reality. That's life. Big things don't just happen. And Katrina aid makes a bomb or contagious disease look like a stroll in the park.

That's why the most effective disaster planning is local. The closer you are to the problem, the quicker the response. So, local government is responsible for preparing and managing immediate disaster. And I'll give the New Orleans mayor some credit, it takes balls to call for the evacuation of a city.

But to say that the federal government and GWB are to blame for the poorly coordinated relief, that's just wrong. Sure, FEMA was stupid, but when you're handed a pile of shit, no matter how you pretty it up, it'll still be a pile of shit. State, regional, city, and even neighborhood recourses share as much blame as anyone else. Case and point, Memorial Medical Center's backup generators were in the basement. This was not the wisest move for a building that sits below sea level, in a town where most buildings don't have any basements at all.

That's just a microcosm of what I usually refer to as a cluster fuck. It's very similar to medical malpractice: one person making a mistake almost never kills someone. It takes several people making many mistakes to result in death. On a local, municipal, state, and federal level, it was one big cluster fuck of poor planning. If you think that one man could manage to do this, then you give GWB far more credit than he deserves.

(2) Let us consider that a good deal of the city of New Orleans is built below sea level and has such a horrible history of flooding that a whole system of levees and other measures to stop water had to be created by the Army Corps of Engineers. This city was destined to flood, and no matter how much you'd like to think you're safe, you cannot prevent disaster like this. You can only prepare. Nuff said.

(3) As much as I've already belittled the disaster response, there were some basic rules that were followed quite well, and it's easiest to think of it in the START model (Simple Triage And Rapid Treatment). Get rid of all the walking wounded (think Superdome folks). Get them to a safe location. Then assess those unable to leave. Medical supplies, food, all that other stuff is secondary to sorting the walking wounded from the rest. If you've done any mass casualty training, you know that the first priority, beyond anything else, is triage. Making sure that the walking wounded have food and medical supplies comes later.

Secondly, safety is paramount. Several hospitals and other locales came under gunfire. You cannot evacuate a location that is not safe for evacuation. If you've seen Black Hawk Down, you know what I mean. You cannot add more casualties to a casualty rich environment. If it wasn't safe to get folks out of hospitals and such because of gunfire and criminals, then the first priority becomes making the area safe for evacuation. I cannot find fault with putting military in the city to crack down on lawlessness, because you must make evacuation safe for evacuators. It's the medic principle. A medic is worth more than one soldier because a medic has the ability to save the lives of multiple soldiers. If you kill a medic, you can kill more than one person.

Don't get me wrong, I'm no fan of GWB, but let's get this right. Like any disaster, it begets disaster, and the common theme in all poor disaster response is that no one was in charge, or more aptly, no one was willing to take charge. Having run a few codes now, I know the value of having someone take point. The person in charge may not be the brightest or smartest or most capable, but at least someone is taking responsibility and making decisions. When no one steps up, then everyone loses. That's why nurses and respiratory therapists take ACLS training too. Someone's got to step up, and someone (anyone) is better than no one.

Docere

Docere is the Latin word from which the word doctor originates. It means to teach, as in documentary or doctrine. I've taken this to heart. I love teaching the medical students. It's a lot of fun for me, because it's more than just imparting knowledge. It's teaching someone how to think.

It's one of the things that gets me excited in the morning. It's actually fun for me. It's not a chore or anything. And part of it is that I want students to see what I see in internal medicine, but more of it is that I want students to see that there is so much more to medicine than just diagnosis and treatment. There's an art to it.

I'd love to teach professionally. I'd love to work at a med school and be a teacher and get paid for it. That sounds like a dream come true. There's one problem. I hate research. Hate. But it's tough to imagine not having med students around me. Maybe there's some school out there looking for someone to be grunt labor for them.

To the girl sitting in front of me

Hi. You were sitting in front of me in church today, and normally I'm not distracted in church, but I have to say, you were quite distracting, but in a good way. Not like the girl last week whose thong underwear was showing, or the girl who was next to her with the skirt that was far too short for church.

I have to admit, you're beautiful, and I don't mean that in a lustful, sexual way, but in all the best ways. You have that brunette hair that is just fetching and you have a gracefulness and allure that is pleasant to see.

There aren't a lot of us, people who go to church by themselves. It's hard to find the motivation to go to church when you're by yourself. It's not quite as intimidating as going to the movies by yourself or a restaurant, but it becomes more of a chore and less of something that should be redeeming.

So if I see you next week, and you're sitting by yourself again, I'll say hello, and maybe (in my little fantasy world, perhaps), we won't have to be two sad folks going to church by ourselves.

On prescribing coumadin

I was rounding with the cardiologists, and there was a patient with atrial fibrillation, new in onset, but the patient was 90 something years old, with severe dementia, bed bound, and cared for in a nursing home, where the patient needed help with all ADL's (activities of daily living: from dressing yourself and brushing your teeth to simple stuff like wiping your ass and chewing).

And the medical student couldn't understand why I was against starting coumadin (a blood thinner that would prevent strokes) in this patient. It works. It's effective. In this patient, where fall risk is nonexistent, it's even pretty safe. So we went to the cardiology fellow, and he was for coumadin as well. The student even felt a little vindicated.

Of course, the primary medicine service asked for Hospice to see the patient, and no coumadin was started. And that's why I went into medicine. Because the art of medicine is all about the simplest lesson in life: just because you can, doesn't mean you should.

Strip clubs

I'll admit, I go to the strip club every now and then, and it's not anything that I'm particularly proud (or ashamed) of. It's just something to do. And I guess that most go for the nudity. I mean, that is the intended purpose. But that's not really the draw for me. It's the illusion of intimacy. It's being around women, and not being a doctor.

And I know, I know, it's fake. It's not real. It's ego-stroking and playing to weaknesses. But sometimes, it's nice. It's nice to remember what it feels like to be close to another person. It's nice to feel a woman's skin when it's not behind a glove. It's nice to catch the hint of perfume. It's nice to remember what a woman smells like.

And I guess there are better ways to spend my money, on less morally objectionable habits, but it seems like every passing day, I find myself less and less connected to the rest of the world. So it's nice to feel close to a woman for a brief moment, even if it is fake, if only to be reassured that I am still a man.

You're nice

one of the nurses came up to me today to tell me that I'm a nice doctor, and all the nurses think so. It's nice to hear it sometimes.

Finally

So, it took me a year and 2 months, but I finally killed someone. Oops. And the old line is true: sometimes, the greater sin is that of omission rather than commision.

I should note, I'm fine. Really. I'm not crying myself to sleep. You know, you can't be perfect. You can't save everyone. You can't develop clinical acumen without seeing bad things happen sometimes. And am I going to jail or to court? No. Thanks for the concern, but I'm not the dead one. To quote House of God, the patient is the one with the disease. IF 9/7/05

"I wish I could do it over again"

Sometimes, I catch myself saying that I wish I was back in college, a little wiser, and could relive some of my youth, correct some indiscretions, prevent some tragedies, and shatter a couple kneecaps on folks very much deserving. It would be so nice to have that time over again with some of what I know now.

This is entirely wishful thinking. My God, I can't imagine how much it would suck to relive all that drama and torture, muchless trying to pass organic again. And P-chem, what a nightmare. And the angst and dilemmas and all that trash, it'd be Hell and a half to put myself through all that again. I don't really want to relive college. Sure, I wouldn't mind the free time and freedom from responsibility, but that's not really what I want.

I want to feel like I felt in college. I don't want youth back, but I want the feeling, the novelty. I want to feel things for the first time again. I want to hate like I hated back then, and love like I loved back then. I want to experience the things I should've experienced back then.

And I know, I can't go back. It's gone, and I'll never have it back except in memory, but that's what I'd like, to feel that again.

Why I wanted to be a doctor

When I wrote my essay for applying to medical school, I was convinced that I wanted to be a doctor in order to help people. And I'm sure that every other medical school personal statement read pretty much the same. I want to help people. And that was all fine and good before I went to medical school, but during med school, when I realized that I didn't go into medicine to help people, that was pretty disappointing.

The truth of the matter is that when I started the process to becoming a doctor, I didn't really see what it meant to be a doctor. I had a very romantic notion that being a doctor meant helping people. Never did I conceive of a day when I would wake up and say, "Damn, can't these people get sick on my off day?" And truth be told, I probably had a better idea of what it meant to be a doctor than 75% of applicants.

I thought medicine because it was intellectually stimulating, because it meant meeting new and different people and becoming involved in their lives, because it would be spiritually rewarding. And all these things have some truth to them, but really, it's not enough. I could say the same about a dozen different professions: teacher, doctor, priest, detective, researcher, psychologist, social worker, lawyer, even financial adviser.

And in med school, like so many other medical students, I discovered that my juvenile conceptions of why I wanted to be a doctor didn't hold water. They were romantic ideals and not motivating factors. They were concepts, but not desires. It sounded good on paper, but when the alarm went off in the morning, it wasn't enough to get me out of bed.

So I had to sit down and think about what I really wanted out of medicine, since I had $130,000 worth of motivation to finish med school, and the thought of going into radiology was repulsive to my vision of health care. And I realized that I wanted to be a doctor not for patients but for me.

One of the most selfish decisions you make in life is how you want to spend it, because ultimately the only person who enjoys that decision is you. And so I went into medicine for me. I wanted to be the person who says, "I think it's cancer." I wanted to be the person who patients go to in order to understand themselves. I wanted to be someone intimately involved in other people's lives because I enjoy it.

And part of that is helping people, and part of that is feeling good at the end of the day, and part of that is the intellectual stimulation. But diagnosis and treatment is really no different from doing tech support on computers, which I've done to death. You assess the machine, find the problem, attempt to remedy it. And I'm sure some people view medicine in the same vein that I view computer work. But it's the people I enjoy. If there were no people in it, I'd want nothing to do with medicine.

Because I love taking care of people, because it's what makes me feel good. Helping someone who's sick and helping them understand themselves, that's where the fun is. It's knowing that Mr. S is a scratch golfer, and whatever I do to him, he's got to golf. It's knowing that seeing me every 3 months is more valuable to Mrs. K than any of the meds I prescribe because she's lonely. No machine can give you that. And you can teach anything in the world, but teaching someone about himself, that's priceless.

Because there's no textbook on the cardiovascular system of Steve. That source of knowledge is me. And that's why I went into medicine.

Asian parents

I visited my dad this weekend, and I haven't seen him in a while, but hanging out with my dad reminds me that sometimes, having Asian parents can be trying. It's often said that you can never really get along with your parents until they treat you as an equal, and your relationship changes from person who runs your life into one of friendship. Once you're friends with your parents, that's the first time since childhood that you can really love your parents again.

With my mom, this is easy. She understands that I have my own life now, and every now and then, she'll say something like, "Oh, you're going to make more money if you specialize. You should do endocrine! I love my endocrinologist. He's really smart like you! And when are you going to give me grandchildren?" She doesn't tell me what to do anymore. She doesn't harp about paying my bills or any of that. She lets me live my life, and I love her for that.

My dad, he has a hard time with that. This weekend, he told me that I should pursue further academics, and I should get more advanced degrees. This is a little difficult, since the only more advanced degree than MD would be if I picked up a PhD. That won't happen. That I can deal with. Then he started telling me how to be a doctor. That's pretty much intolerable.

After going to school for 4 years of undergrad, another 4 years of med school, and now into my 2nd year of residency, I am familiar with how to be a doctor. And any advice of how to be a better doctor I'm not going to take from someone who isn't a doctor himself. He told me how to talk to patients. I've had classes, lectures, standardized patients, and real life experience on how to be a doctor. It's too much to bear sometimes, trying to have someone tell me what to do when I'm far more expert in the matter. He might as well have been telling me how to manage diabetes it was so far out of his realm of expertise.

Truth be told, my mom does something like this every now and then, but it's not motherly wisdom, but a nurse's perspective. "Be nice to the nurses, because we like nice doctors." It's her professional advice. And it's not an order or edict, but something a mom says, along the lines of eat healthy and don't get too stressed out.

I imagine that the hardest part of being a parent is the knowledge that at some point in time, your kids grow up, and they don't see you as their mentor anymore. They've found others who they now emulate and seek advice from. That must be tough, but it happens, and after that, you can't go back. It's a lesson in life that I've come to accept, but I'm sure that if I have kids, I'll probably do the same thing.

Observations

People make very astute observations about me, and sometimes, these things are nice to know, just for my own benefit. For example, one friend pointed out my tendency to correct myself with the phrase, "Wait, that's a lie." Another friend pointed out that I seem to have a rule for everything, and I do. Last weekend, someone pointed out that all my similes and metaphors are food-related.

The food thing, that's a little disturbing really, but the rules, that's something I've known about. I do have rules for everything, because it's how I deal with the world. To be fair, (1) they're not my rules but rules of etiquette or morality or behavior, etc that I adhere to, and (2) I don't enforce these rules on anyone but myself.

I can't help the rules. It's how I've learned to deal with a world that makes no sense. I make sense of it. I exert my personal guidelines upon myself, and let that serve as an example. And there's a lot of silly stuff that I do that I know no one will follow, but it's me.

I'm a virgin, and I don't believe in pre-marital sex, not for me at least. I don't think sex is something people take seriously. People should. I've yet to convince anyone to engage in abstinence, but it's not like I'm handing out pamphlets.

I say please and thank you for everything. It's such a common courtesy, but I am not a dictator. It is not my place to order people around without some respect. Along those lines, anytime anyone helps me with something, I personally thank them. I thank most every nurse taking care of my patients in the hospital. I thank the operator for connecting me. I thank my attendings for their help. I believe that when you ask for someone's help, you should acknowledge their effort.

I never raise my voice in anger. It's not for me to put my emotions onto other people. I try to keep a calm and steady voice. Anger is often misdirected, and thus, I have come to try to contain my anger till I can vent it in a controlled and benign manner.

I always address people properly, or as they would want to be addressed. Self-identification is a crucial element to how we perceive ourselves. I am a different person when I am Doctor IF as opposed to Mister IF.

Part and parcel to that, I try to learn everyone's name. Calling someone by name is a powerful thing. It shows that you value him as a person. It has to be one of the most influential actions you can do on a daily basis.

I've got tons more of stuff like this, everything from how to eat correctly to how to hold an umbrella. And I'm sure you think I'm nuts, and maybe I am. I'm guessing that 99% of this stuff goes entirely unnoticed, but I'm happy if 1% is managing to get through. And if you don't believe that such minor actions can have any meaningful effect, then I have a proposal:

Next week, every person you interact with, find out their name, call them by name every time you see them, and personally (that's face to face) thank them for helping you with whatever needed to be done.

And it's any wonder why nurses love me.

Stethoscopes

Digital things are nice sometimes, but there are times when it's overkill. One such place is physical diagnostics. Nowadays everything is digital. It's next to impossible to find a manual BP cuff, to the point where I'm thinking of carrying one in my coat. And the new rage is the digital stethoscope.

This stuff is ludicrous. And I say so as someone who owns 3 digital cameras and buys DVDs and CDs with some sort of unholy compulsion. Obviously, technology offers benefits, otherwise I'd be wasting my money. But it's not without its follies.

With cameras, everyone loves digital for the convenience, but truth be told, I'd rather shoot film. Film is an art. It takes skill and care and a thorough understanding of the medium. It captures a range of colors and shades that is unmatched by digital. Even the crappiest film picture rivals the best digital can offer.

Don't get me wrong, I've gone through 2 rolls of film in the last year, and I own 3 digital cameras. I've obviously been sold on digital, but it's no substitute for film. It'd be like trying to replace a Steinway grand piano with a Casio.

But when it comes to medical diagnostics, there is no replacement for analog. We've sold into this digital world, with automated BP cuffs and pulse monitors, but if you've ever worked with me, you should know that I trust these things like I trust a rabid coyote in a butcher shop.

You simply cannot replace the art of BP measurement with a machine. And similarly, I wouldn't trust a digital stethoscope, because it is simply taking sound, making it digital just to make it analog again.

Part of the wonder of medicine is interacting with people, and it makes me a little sad to think that we're coming up with more and more ways to distance ourselves.

Please understand me

The Kiersey Temperament sorter is one of those things that I do every year or two to see where I'm at. When I was in high school, I was a very strong ISTJ, which is very detail-oriented, probably the nerdiest of the personality types. Somewhere in college, I became an ISFJ, which was much more consistent with a career in medicine. The type is called the Protector and is common among general medicine practice.

Once I got into medical school, I had a subtle shift from ISFJ to INFJ, and right now, that sounds about right. I was trying to figure out my career choices in medicine and when I looked at the INFJ careers, it was my residency dilemma in grid form.

But reading through some of the stuff on INFJ's, I realize that other stuff hits home too more than just choice of career. I don't really believe that something as banal as a questionnaire has the power to explain my life, but it's a useful tool for introspection.

Some things really made sense, like my utter inability to take praise, or my ability to work well with people despite being horribly introverted. Or how I hate taking leadership positions, but when I do, I run a tight ship. But much like that crappy TV show "Crossing Over" it's easy to say these things and get people to identify.

The relationship stuff was pretty much right on. I have no interest in relationships that won't go anywhere, and I really do prize intimacy. What's the point of dating if it never goes anywhere? I'll admit that I've had opportunities, but it's a waste of time going out with someone if she's not someone you'd want to spend time with. There's sex I guess, but I'm a good little Catholic boy.

And besides, I'm not interested in sex as much as I am intimacy. I'd like to be close to someone. I feel like there's no one in my life who has ever known me intimately, and that's sad. And on bad days, I wonder if it'll ever happen. But like I've said, my outlook on life isn't as gloomy as it used to be, but it's hard not to feel alone sometimes, and that's not something you can overcome by yourself, y'know?

You can't go back

I met a 1st year medical student and it was very strange meeting someone who's so far back in the process I started what seems like a lifetime ago. I can barely remember being a 1st year, but what I do remember is with some fondness. I miss it.

Well, to be fair, I don't miss the stuff that happened as much as I miss the stuff that I thought would happen, if that makes any sense. I thought that med school would fix all the problems in my life, much like I thought high school and college would.

I thought that my life would enter a new phase and that things would be different, and I even tried to be different. I acted all extroverted and put myself out there, and expected some reward for my troubles. I got rewarded all right. My friends I'm sure recall with some chagrin that emotionally I did pretty badly in my 4 years of med school. And part of that was setting myself up for failure. My expectations were too high.

If you asked me the day before first year where I thought I'd be right now in my life, I honestly thought I'd be married by now. Really. Part of me still has a hard time believing that I'm so very far away from anything resembling marriage. I thought that I would find meaning and fulfillment, but that too seems rather intangible.

Maybe I'm too idealistic in this whole matter of my life. I have a lot of rules, as my friends enjoy to point out. Maybe too many rules. And I have to wonder if maybe not having so many rules would move things forward instead of stagnating.

Names

I think that I can manage to get more done in the hospital than most, and I'd like to say that it's my razor sharp clinical acumen, but in reality, it has next to nothing to do with my clinical skill. Because honestly, I'm not that good. My medical students were shocked to discover that their all-knowing senior resident only scored a 200 on his Step 1. One even asked me, "Two hundred and..." "No, exactly two hundred. Two zero zero."

I am, as one might say, not that smart. It goes without saying that I'm in the top 10% in this country, seeing as I've graduated college, obtained an advanced graduate degree, and am now training in a profession, and my IQ's prolly in the 130-140 range. But does this mean that I'm a smart doctor? Not really. I haven't made too many mistakes, and I have yet to kill anyone that wasn't already on the way out the door. But I'd have to say, there are better doctors out there.

But still I've managed to outperform a lot of these geniuses in the hospital setting and the simple reason is because I've bothered to learn people's names. I wish I was kidding. That's it. All it takes to be an outstanding doctor. That's my great secret.

It sounds so silly, but people actually feel a lot better when you address them in person, as an equal. When I was an intern, I'd track down the nurses for my patients, make sure they were squared away, find out what needed to be done from their end. I'd befriend the clerks and techs and respiratory therapists and it became easier and easier for me to do more and more difficult things, because I knew who to talk to in order to get stuff done.

And that's my great secret to being a good intern. Oh yes, and not killing people. That's important too.

So you wanna be a doctor

When I was an intern, I had a patient who, after extensive workup, had a simple fecal impaction. He was in need of manual disimpaction, which has to rank up there as one of the most humiliating jobs imaginable.

The matter of actually disimpacting someone isn't so bad. It's relatively simple. It's figuring out who's going to do it. And to be fair, I could've told the nurse to do it. Surgery was on board: I could've had the surgery residents do it. But I had some time in the afternoon, so I did it. I didn't get much, but a little rectal stimulation and some judicious enema use, and voila, one working colon.

And everyone around me asked me the same question: why did I do it, when I could've just dumped the work on someone else? It would've been quite easy for me to call surgery and say, "This is your domain. Do your worst." Or I could've told the nurse to do it. Wouldn't have made any friends, but wouldn't have had to do something that I'd rather forget. And honestly, I couldn't believe the attitude.

Y'know, I'm a doctor, and I'm taking care of patients, and they're my patients. They're my responsibility, and at some point in time, someone has to say that the line stops here, period. It's like heparin dosing. I track the PTT's, because while it's someone else's job to monitor that stuff, it's my name on the chart. It's my care.

Whenever I meet pre-meds, I try my best to discourage them, not because I am cynical or spiteful. It's because people go into medicine and don't have a clue what that means. They think it means sipping scotch neat at the country club and talking about how to improve your short game, or picking out which BMW to buy. Even worse, people go into medicine thinking that it's all about saving people or comforting the dying.

If you want to save people or comfort the dying, be a priest. Seriously. It's a better use of your time. Medicine is about dealing with shit. It's pulling stool from a grown man's rectum, or losing sleep at night trying to remember if you ordered a CT scan, or arguing with an HMO about getting a patient's MRI covered. It's messy work, and no amount of BMW's or scotch or people in the community kissing my ass is ever going to make it worthwhile.

The reason to go into medicine is because you love it. It's because seeing sick people and helping them deal with their illness is something that you enjoy doing. You can sit in a radiology suite, sip coffee all day in scrubs, earn $250k a year, and still hate your life. MD after your name won't fix that.

I knew I was in the right line of work when I had a patient of mine in the hospital, and I can't stand this patient in the clinic. One of my chronic pain med patients. But the patient needed surgery, so I stopped by, and we chatted for a while, and I realized that as much as I don't like taking care of this patient, it's my responsibility. If not me, then who?

When you are faced with the most unappealing jobs in life, like trying to manually disimpact someone, and can still go home and add up the day and come up in the black, you know you're there, because any number of people I know in medicine would've endlessly complained about such humiliating work, and I would not let one of those people take care of me.

If you believe in that sort of thing

The phrase I hear out of the mouth of so many people after they say the word 'fibromyalgia' is, "if you believe in that sort of thing." Not without justification, fibromyalgia has transcended simple diagnostic criteria and entered the realm of myth. People will walk into the office and tell me that their fibromyalgia is acting up, or that they know someone else who has fibromyalgia and that they benefited from     insert narcotic drug here    .

I really want to find the doctor who first started telling people they have fibromyalgia and beat him. While I agree, there are chronic pain syndromes, but to simply write it all off as fibromyalgia and call it a day, that's practically criminal. And even worse, to give out narcotics and call that treatment, that should be a capital offense.

If you ask me which camp I'm in, I ascribe to the 'there is no such thing as fibromyalgia' philosophy. There is a root cause always, whether it's osteoarthritis, hepatitis C, or any number of diseases that fuck one up. Half the time, I am willing to say that rather than having fibromyalgia, the patient has narcotic withdrawl symptoms. The best successes I've had with chronic pain patients are to introduce changes in living. I have yet to meet someone who is happy and well-adjusted and in chronic pain.

Part and parcel with my disbelief of fibromyalgia, I don't believe in OxyContin either. It has no therapeutic value. There is never a situation, except terminal cancer patients, where I would say go ahead, here's some oxycontin. I've written scripts for oxycontin 5 times.

Maybe I'm just not sympathetic, but from this side of the examining table, it's hard to figure out if someone has pain from some random disease or pain from being alive. Even worse, how can I tell if their pain is from too little pain medication or from being on too much pain medication? And only seldomly do I have a patient that has the insight to realize that they've traded one demon for another.

Dooced

Yet another blogger got dooced. I find this most amusing, not because of the fact that firing someone for expressing their opinions in a public forum is sheer evil, but because the person doing the firing is a writer for the NY Times and decided to write an article about it that borders on libel (not slander, as the Spider Man movie so accurately related).

I am obsessed with neologisms. I think they're intriguing, and being dooced is certainly one of those new fascinating words that seems so weird, but finds its use so aptly, now that blogging is so very common, and that blogging about work is even more so. Am I concerned? Certainly. I certainly don't want to be fired from my residency, since it's kind of hard to start a new residency after being fired from one. But really, it's not like I've done anything here that is out of bounds. I've resisted the urge to bitch about other residents and my program and other stuff like that, and I haven't divulged patient information.

I'm confident that even if people from my program found this, I wouldn't get fired for it. Of course, famous last words. This site ain't anonymous for nothing.

Overbooked

I have actively been turning patients away from my clinic. This is a crime. I've met fantastic people that I would love to see in my clinic, but I have to tell them the truth: I'm booked solid for the next 3 months. In fact, I'm double booked through most of my continuity clinics.

The true crime of this is that a lot of those bookings are patients that aggravate me. They don't listen to what I say and just rampantly ignore what I try to do to help them, but they show up and drone on interminably about how their lives suck and how I should prescribe more vicodin.

I feel like I should just tell them that it's because of them that I've been turning people away. It's because of them that I've had to refuse to take some wonderful people, and that, if they're so dissatisfied with me, they should find someone else. I just want to say to them: there are people who would love to have that double booked appointment that you can't stop complaining about, so if you wanna find some other doctor, go find one, because I've got other people waiting.

King of the idiots

As I'm fond of saying, I am no longer one of the idiots. Now that I'm a senior resident, I'm king of the idiots. My particular group of idiots are a nice group of folks, but wow, I have a hard time believing that I was that green when I started residency. Contrary to that, I hit the ground running as best as I could.

It's taken me a little while, but I actually feel like a senior resident now, and that's pretty funny. I mean, the difference a couple of days makes. Now the patients are sicker and I'm doing a whole lot more worrying. Still, I'm happy to say that my 'terns haven't killed anyone yet (not for lack of trying).

But the one thing I've realized as I've taken on my new role of senior idiot is that I really enjoy the teaching involved. I mean, it never occurred to me before, but I really do enjoy passing on knowledge, even if it's simple stuff. You know, doctor comes from docere which is Latin for teaching. Strange to say, it's the teaching and not the patient care that I really enjoy.

Oh, there's some stuff I like about patient care, but it's silly stuff. It's seeing my 49 year old hypertensive and managing his cholesterol and blood pressure medications. It's improving the exercise regimen of my 60 yr old diabetic. The thrill of seeing my name on a piece of paper has long since worn off. Now, what I really enjoy is seeing my patients and just talking to them and getting to know them.

I feel like I'm doing a pretty poor job as senior, but I'm trying my best. I hope that my interns are learning something.

Do the work

In some fields of medicine, it's all about skillz. Surgeons are all about skill. Radiologists are atuned to visual skill. Anesthesiologists have skills. Other fields of medicine, like internal medicine, don't have much in the way of procedural skill.

Medicine attracts detail-oriented perfectionists. It's all lists and tables and planning and proper medication selection. For lack of a better way to describe it, medicine attracts nerds. And it's because internal medicine is ultimately a specialty that demands planning.

And part of that is what attracts me to outpatient medicine. People think of planning when they think of placement, but the planning that intrigues me is stuff like what a patient needs over the next 3 years. This lady will need a pap and pelvic in 1 yr. This guy needs a colonoscopy in 10 years. This kid needs his cholesterol checked. This lady needs a glycohemoglobin every 3 months.

And it's funny to me that I still get a lot of pats on the back for doing nothing more than my job. It says so quite clearly in my contract what my job requirements are, and I've done them, and people think me a competent resident for it.

I have a very hard time taking a compliment from anyone, and part of it is because I don't feel that I've done anything worthy of praise. Y'know, all the time people are praised for doing their jobs. I don't get that. It's your job. It's what you're paid to do. Why should I take praise for doing my work? The way I grew up, I've always thought that praise is for exceptional work. When I do exceptional work, then I know enough to reward myself.

Diagnostic and Statistical Manual

When I did my psychiatry rotation in med school, the most valuable piece of advice I got from one of my attendings was while we were sitting in the conference room, talking about a tragic case of a little boy abused since the age of 5, neglected and physically assaulted, but thankfully no sexual abuse. He still carried horrible emotional scars despite being in a nurturing, safe environment at time of evaluation.

Me and the other medical student sat there flipping through the DSM, trying to pigeon hole this kid into a diagnosis. He lacked 1 criteria for post-traumatic stress disorder. He certainly lacked criteria for major depression. We presented the case to our attending over coffee. He watched us for about 5 minutes before becoming fed up.

"That book can't tell you anything about what your patient has. You're trying to diagnose with DSM, but it can't tell you that someone's depressed. It can't tell you someone is sick. It just tells you what to look for. Is that book going to offer any reassurance? 'You don't have PTSD because you don't have the necessary number of criteria met.' Ridiculous."

He took our DSM's away and asked us what this kid had. And that was when I realized the difference between cookbook medicine and clinical skill. After a certain amount of time, a doc's got to be able to look at someone and say, "You are sick." DSM is the psychiatric diagnostic equivalent of a Brother P Touch. Nice for labeling, but I wouldn't use it for much else.

A letter to an ex:

More in the series of painful letters never meant to be read by the intended recipient.

Ever since this all began, I've been in anguish. It's been torture for me to sit by while you sorted through your feelings, not saying no, but never really saying yes. But watching you tonight, watching you two pawing each other made me realize a lot of things.

I've been doing a lot of remembering, and really, I can't think of a time that you ever really opened up to me. I get all these cards and letters, but you never talk to me. You say things, but there's nothing behind it. I don't want your letters if you're not willing to share yourself with me. I've bared my soul to you. That's just not fair. I don't want your letters if you can't share with me who you are.

You say we're good friends, but I never see you, never talk to you. You're willing to hug everyone but I'm left standing around. I've never felt like a friend to you. I've always felt like an outsider, and it was stupid of me to think that I could have a relationship with you when you've never shown me a token of affection.

Half of my enjoyment of our relationship was finally feeling accepted by you, and that I was worthy of your affections, but that didn't last, did it. It was a battle just to see you, to hold your hand, to touch you. And now, it's like you're not in my life at all.

If you don't want to be friends, that's fine, but I don't like being treated like a second class friend, and that's how I've felt for a long time. You don't talk to me, you don't sit near me, you don't make eye contact, and I hate thinking that I have to compete for your friendship. That's not what being friends is about.

If this is how it's going to be, I'd rather never see you again. What's the point of this 'friendship' when we both know it's a joke. Let's call this what it is. You want to make this out to be all nice and pretty. Well, if this is friendship to you, I want no part of it.

And as far as our mutual friends go, you need not worry about me ruining your fun anymore. You can have them all. I've burnt longer bridges in my life.

A letter to a girl I knew:

More in the continuing series of painful letters never meant to be read.

Hey, I think it's great that we're friends and all, and I have a great time hanging out with you. But is that it? Call me crazy, but haven't we connected? Maybe just me... We could be like peas in a pod, but you're just not where I am. And I doubt you ever will be. And I've given up hoping. I think to myself that it'd be great or nice or special, but I'm thinking in that hazy dreamy way, the kind of thinking you do when it's raining outside, and you think of how you'd love to go outside and play, but if the rain stopped, you know you'd still be inside. It's not reality. It's not even a world of 'might have been's. It's all fantasy and conjecture. There's no truth to it.

I know that the proper course of action is bridge burning. It's the tried and true solution. And it wouldn't be because I hated you or resented you. It's be because every time I see you, I think, 'Maybe...' and every time I get a card or e-mail or phone call from you, I think, 'Maybe...' when there is no maybe, there is no possibility. There is no might. And the mind knows this, but the heart, it wants what it wants. And the only way to change its mind is to hate you, to resent you, to wish that I'd never met you. It's the only way to stop the wondering and the fantasies and the endless string of maybes. It's the easy way out, the model solution, but I can't bring myself to do it. And maybe I know that it'd be pointless. The maybes would still be there at night or in my dreams.

They wouldn't go anywhere. These feelings aren't the ones you can just chase off, because they're not lust or infatuation. It's not love either. I don't believe in love. You can't grasp it. You feel it like you smell cinnamon in an apple pie, and it blows away in the cold and wind. No, love is nothing to connection. Two people connecting, that's real. That's firm. You can't throw that away any more than you can throw away your parents.

So I guess it'll just be status quo, with me wondering if I'd ever had a chance, or if I was always out of focus. But I'm just festering, rotting away, waiting for something to happen when it never will. And I wonder what will happen when you finally find someone. Maybe that part of me will die, like I hope it will.

A letter to a once best friend:

Like I said previously, I thought I'd throw up some letters I've written here, letters that will never be sent to the desired recipient, but are interesting to read, in a jaded and painful way.

I can't believe you. Maybe you don't realize that you are the only friendship I have let survive in spite of betrayal. You say things like, "Does our friendship mean so little..." well maybe it would do you well to realize how close you were to not being a friend at all.

And you start off about her emotional state and whatever. What the hell am I supposed to do, huh? She was the one that rejected me. Somehow by listening to you, that's supposed to make everything better? I've tried to be the bigger person. I've tried to pretend that I was ready to move on, but guess what, I'm not. And if you think that I'm gonna feel sorry for her for rejecting me, and that 'my emotional state' isn't helping? Well, I don't give a damn.

I can't deal with other people's problems right now. I'm trying to piece together what's left of my life and trying to get back to even keel, and in case you haven't noticed, this isn't helping.

You can rush me all you want, and that's fine, but guess what, if I took what I've got on hand right now, I can come to pretty simple conclusions: you're a jerk and she's a bitch, and going behind my back was about the shittiest thing anyone's ever done to me. So there's your emotional resolution. So stop bothering me, leave me alone, and let me deal. I don't have time for your shit.

Going back to the well

For some reason that I don't get, being back around my old med school is making me itch to blog. Or maybe it's just using a real keyboard again instead of what my laptop claims is a keyboard. But I am brimming with the desire to blog. Creepy, no?

And I realized as I was driving today that I write a lot of letters to people that will never read them. I mean a LOT. You know, sometimes, it's nice to get your feelings about a person down on paper, so that you can vent all your frustrations without actualy hurting someone's feelings. So, they mostly sit in a pile in my room and maybe one day if I ever get drunk enough, I'll mail them all out, but probably not.

But I thought, since almost everyone that I write these letters to will never read this blog (I'd guess that most don't know it exists), I thought it'd be neat to put a few of them up. It's not like I haven't done so before. They're usually full of bitterness and shame and anger, and that's stuff I don't really ever show in life. It's the dark side of me that you never see.

Of course, I'm nowhere near those letters right now, so it'll have to wait for another day. For now, I plan on packing up, going home and drinking myself silly. What a nice day. Oh, and someone e-mailed me from one of my personal ads. How bizarre. A strange day today indeed.

Twin XL

Next time you go to Bed, Bath and Beyond, find the best sheets they have, the ones with the ridiculous 500 thread count and realize that it comes in twin, full, queen, and king, but no twin XL. That is because everyone knows that Twin XL is for pitiful college students and has no place in the real world. Except in my bedroom.

I still have a Twin XL. It's a pillowtop, so it's very comfortable, and it's a breeze to move. I even bought new sheets for it. I like it. But I know, it's for the kids. It's for college boys and girls, forced to accept the whimsy of some university dorm's conformist mattress.

I thought about replacing my twin XL now that I'm out of college. I'm a big boy now. A-D-U-L-T. Adults sleep in queens or fulls. Not this twin XL stuff. As a friend of mine so aptly put it, the twin XL is nice when you're the only one in your bed most of the time, but when there's a chance someone else might be in the bed, it's nice to have the room.

The thing is, I've been slumming on other people's beds lately, crashing on the charity of friends, and I don't know what to do with the bed. I had the same problem in hotels during interviews. I hover on the edge of the right side (the side where your right side is towards the edge of the bed) and I'm not entirely sure what to do with the rest of the space.

And yes, if someone came over, I could share the space, and I guess that's what a big bed is for really, but that's not something that I'll be doing anytime soon, for a variety of reasons. I'm still Mr. Good Catholic, for one thing.

The ridiculous part? I get better sleep on my sofa. Instead of moving towards more space, I'm going to less.