As long as we're...

I was signing out my patients today and I told the on call resident that my patient had a case of the "As long as we're"s. I realize that no one else uses my jargon. My bad. But you all know what I mean. The classic example is cardiac. As long as we're doing a valve replacement, let's do a CABG. And as long as we're doing a CABG, let's do a carotid endarterectomy too.

However, CT surgery isn't the only offender. Too often, it's used to justify lines and other bedside procedures. As long as he's in the unit, let's get an a-line to monitor pressures while on pressors. As long as we're giving pressors, let's get a central line for access. As long as we're doing a central line, let's do an IJ because it's more sterile. As long as we're doing an IJ, let's do a Swann.

The truth about the hospital is that it's all about inertia. You have to surpass the threshold for activity, and once you have, then it's in for a penny, in for a pound. It scares me to think that so much of what I do is governed by the simple fact that I have to be in the hospital. Well, as long as I'm here...

Not my cup of tea

I realized pretty quickly that what I want to do with my life is outpatient medicine. I like longitudinal care. I like getting to know people and being involved with their care. I like seeing them while they're doing well. I like helping to keep people healthy.

I don't really like procedures much. I don't enjoy acute care. I absolutely hate codes and unstable situations. I don't like doing treatment that I know is most likely futile.

So, I've come to the realization that ICU medicine is the antithesis of what I want to do with my life. It's everything I don't want to do and everything I don't want to be. I might as well be a surgeon. It's so unappetizing to me that I thought about making myself DNR.

Maybe it'll make me a better doctor, but this critical care stuff is beating me down, and I'll be glad when I'm back in the office. Or maybe it's just that when you're alone, it's tough to see the point of buying a couple extra days for someone on death's door.

An ideal match

So, I met a woman that's a good match to me. She's smart, funny, demure, intelligent, witty, and pleasant. She's interested in the things I'm interested in and has a pleasant and cheerful outlook on life. She's great. The only problem (other than she's a patient)? She's 60 something.

And I guess that the only thing wrong with dating a 60 year old is the horrible social stigma of dating a woman that's more than twice my age and the fact that it's not where I see my life going, but it's not something I'm eager to pursue.

That doesn't seem very fair, y'know? I finally meet a girl that has everything I'm looking for, but she's as old as my mom. It seems like I can't get anything going when it comes to romance. It's all fruitless.

I really long for some human contact. I wish I had someone I could confide in, y'know? That's what's missing in my life, and at this point, I don't see that hole being filled anytime soon.

IV. The patient is the one with the disease

These days, most hospitals have instituted discharge planners, patient support staff, multi-disciplinary rounds, length of stay rounds, all in an effort to save money. And that's admirable, getting efficient hospital care. But what it means to me is on top of my senior and my attending, I have even more people questioning my clinical decisions. This person is an inappropriate admission. This other person doesn't have adequate nutrition. This one needs to go to ECF. I've got so many people riding my ass, I should install bleachers.

The nurses at least are somewhat sympathetic. We're in the trenches, and it's easy for other people to snipe when they're not the one telling the pt with intractible pain that she doesn't meet acute care criteria for admission and here's some vicodin.

And I appreciate the help sometimes. But it's hard not to be dragged down some by patients. It's hard not to feel miserable when you've got a rock garden going (doctor slang. Rocks don't move. A patient who's a rock is one that won't be leaving the hospital anytime soon). And it's only worse when 4 or 5 people who don't have to even lay eyes on the patient tell me the many ways I'm doing my job wrong. But one of the nurses reminded me, with a pat on the back: hey, the patient's the one with the disease.

Thank you, House of God. Your rules have kept me sane.

The things you miss

I had one heck of a call night. And then I was rounding post-call. I barely crawled out of the hospital. Every attending and resident that saw me could see that I had about 20 minutes before I collapsed in a heap. My attending kept trying to send me home, but there was so much to do, and I just couldn't let it go.

And when I got home, it was kind of strange. I felt fine. I watched a bunch of TV that I recorded and that was it. I cooked, cleaned a little, went to bed. It was like nothing had happened.

But since that call, I've had a weird feeling. I dunno what sparked this off, but I'm very lonely all of a sudden. I feel like I'm running on empty and that my life is incomplete, and I know why. I give out the same advice and it applies to me too: you need to separate your life and your career. For me, I have no such separation. My job is me. I don't do anything else. My life is otherwise empty.

It's not that I'm bored, and it's not that I don't have hobbies. It's just that at the end of the day, there's nothing in my life giving me any fulfillment. It's empty and meaningless. I actually look forward to the hospital because it's purposeful. It's more meaningful than playing on my gameboy and thinking about buying Pokemon Emerald and maybe a Nikon D70 while I'm in the store.

I'll admit, I enjoy what I do. I enjoy helping patients and trying to do what's right. But that's not my whole life, is it? I keep wishing that there was more to my life. I wish I had love and fulfillment. I wish I had something to push me forward other than earning a living. There's a time in life when all you're looking for is someone who gets you. That time for me is now.

Pay it forward

I recently saw the movie "Pay it Forward," and it's a nice movie because of the whole idea of it. It's this sort of think global, act local benevolent movement that's so in sync with the pacifist vegetarian whole grain view of the world. It's practically noble. The twist at the end is suitably cheesy and ruins the movie with its needless move for extra sympathy. Still it was a noble movie that had this bold vision of the bettering of humanity, one person at a time.

However, I think that the movie had it wrong. It's certainly noble to pay it forward, to do good deeds for others and certainly, the world would be a better place if we did that. I think that the true problem with life is that we too often pass on the shit in our lives. We have a terrible day at work, so we cut someone off on the highway, and that guy is rude to the drive thru cashier, who comes home angry to his girlfriend, whom he yells at, and she in turn goes to work the next day and ruins your day all over again.

The problem, you see, isn't with paying good deeds forward. It's that we've got to stop passing on the bad stuff too.

Why did I want to be a doctor?

My friend went through a lot of grief before settling on psychiatry for a profession. Third year of medical school is tough that way. You play around in all these various fields of medicine and while everything should be appealling and fun, it's all sucky and tiring and you wish you could just be a doorman. That's third year of medical school. And without fail, any good medical student finds himself questioning what ever possessed him to enroll in medical school, and now the $100k of debt means that the only two ways out of this sticky wicket are to die or to become a doctor.

And the true value of this exercise in self-deprication is to ask yourself the question: So, why did I want to do this? When you can answer that question, you're home free. You can look someone in the eye and say with a straight face that you really want to be a doctor.

For me, it's working with patients, educating them. I am their user's guide to the human body. I get to work with people and help them to understand themselves. I'm the guy that says you're going to be fine or you have 6 months to live. I'm the guy that people come to and ask if it's normal to have burning chest pain after eating pasta with 3 cups of coffee. People have switched from their long time family doctor to me because I answer their questions and I want to know who they are. It interests me that she's a molecular biologist or he's a janitor or that she loves meatloaf or that he runs 3 miles a day. That's what gets me up in the morning.

The problem is that the decisions we make about what we want to do with our lives, other people read shit into that. And no field is more fraught with this than psychiatry. Psychiatry is very cart before the horse. This lady is depressed, and she's depressed because she's a widow and she just retired from her job which was her only connection to other people. Now she spends all day at home with her needlepoint, waiting to die. She is fucking depressed. I say she needs a life. The psychiatrist says she has a chemical imbalance.

It's one thing to say someone has a blocked coronary artery and needs angioplasty. It's another thing to say that a person's grip on reality is all fucked up by a couple chemicals and proteins that are not doing what they're supposed to. But are the chemicals causing the depression or is the depression causing the chemicals to be all nuts?

Granted, people with psychosis need treatment, and a lot of it. But it's quite a big thing to say that I need to alter someone's perception of reality. That's why psychiatry is frowned upon. No other field of medicine questions reality, and supplies such a shitty answer as an imbalance of neurotransmitters.

But here's the deal. In any field of medicine, there are people who are in it to pay the bills, people looking to pay off their 6 digit educational debt, and there are people that honest to God love what they're doing. You'll meet them. You'll meet a radiologist that spends 30 minutes talking about Houndsfield units on CT. You'll find the internist that sits you down for an hour and is in love with hypertension. You'll stumble across the hematologist that is sad that you don't care about factor VII nearly as much as he does.

And happiness in medicine is as simple as realizing that something completely geeks you out, and for example, the idea of spending an hour talking about immunosuppresants for HIV sounds like something fun. When you find something like that in medicine, screw what other people think. You've answered your big question.


I've been listening to Nirvana lately. The advantage of a 6 disc in dash CD player is that you can put in all sorts of tunes. And while I was driving home from another nightmare day, I was rocking out to "Smells Like Teen Spirit." That song, such a breakthrough, and propelled Nirvana and the whole grunge movement, it's old. It was released in 1991. Holy crap. That was 14 years ago. I remember how it turned the music world on its head and made everyone take notice. Now, it's old.

The nurses around me, a lot of them are young, like real young. Some of the clinic nurses are 20. And I think about them, and all those 20 year olds, and they didn't have a Nirvana. They were all of 6 when it came out. They were watching Sesame Street (or maybe Barney). It makes me realize that I'm not young anymore. I'm old.

Sometimes, I wish I was young again. I wish that I could do it over, not to fix anything or to correct the injustices of my life. I just want to live like that again. I want to feel life. I want to grasp life in my fists again. I don't feel that anymore. I can't feel life. Where did it all go? And sometimes, in my car, driving to work to play doctor, I'll turn up Teen Spirit real loud and try to remember what it was like to be so young and so alive.