Merry Christmas

Every Christmas is a little different, and my priest today made note that most likely, the story of Christmas in Luke’s gospel is invented. I’ll forgive Luke because he wrote one of the most beautiful pieces of prose ever, and even though I’m Catholic, the King James version is the best. Every year, I watch the Charlie Brown Christmas special just to hear Linus speak the words:

“And there were in the same country shepherds abiding in the field, keeping watch over their flock by night. And, lo, the angel of the Lord came upon them, and the glory of the Lord shone round about them; and they were sore afraid. And the angel said unto them, Fear not: for, behold, I bring you good tidings of great joy, which shall be to all people. For unto you is born this day in the city of David a Saviour, which is Christ the Lord. And this shall be a sign unto you; Ye shall find the babe wrapped in swaddling clothes, lying in a manger. And suddenly there was with the angel a multitude of the heavenly host praising God, and saying,
Glory to God in the highest,
and on earth peace, good will toward men.
“That’s what Christmas is all about, Charlie Brown.”

Theologically, Luke’s gospel is quite interesting. It takes place during the Roman census and involves a lot of fleeing, which seems very fine to us now, but was practically heresy at the time, for the Messiah was hoped to be a military king, a king of lands and armies, who would throw off the shackles of Rome.

But instead, he is a babe born to a carpenter and his wife. There is no room at the inn, so he is born in a barn. Luke is telling us that Jesus was not the champion of Israel to challenge the Roman oppression. He was not a king of the world, but a king of the heavens. He was out of place, and we can only find him if we look for him and search, and in the most bizarre of places sometimes.

And so, I find it a little simplistic when I see people praying to God for health or money or safety or happiness or luck or winning a game or whatever. In reality, I think that when we suffer, or we are abused or tortured or neglected or injured, we should be thankful. How lucky we are to be so tested. I have long believed that the trials and suffering of our lives are to test our spirit, and it is like gold in a crucible: in the fire we are purified. We should be thankful to suffer so.

I never pray for good fortune or happy things, or even good health. I do pray for my patients, but I don’t pray for them to get better. I don’t even pray that I do the right interventions or treatments. I simply pray that I may have the strength to do God’s work, whatever that may be. Because I can’t cure anyone, so let me at least do what I can, and let God do the rest. Penicillin can only do so much. There has to be something else.

What your coffee says about you

Whenever I want to get coffee, it's always a tough thing to coordinate with other people. Seems like getting a cup of coffee shouldn't be so hard, but in college I learned just how hard it could be to get a simple stupid cup of coffee.

Of course, Starbucks. You can't go to Starbucks. The pretentiousness isn't the problem. It's the corporate conglomerate nature of Bux, overpowering and outcompeting local small business, and taking money out of communities and draining the small towns. It is nothing short of evil.

Then, there's low brow coffee: Dunkin Donuts, Krispy Kreme, Tim Hortons. You can't drink these. It's simple, unpretentious, without sophistication or class.

There are a slew of smaller national chains: the deer one, the beanery, blah blah blah. You can't drink them, because supporting them would be complicit to the strategy of Starbucks, and the national chain philosophy of the destruction of small town America.

So then, you must find yourself at local small businesses who serve what can be accurately termed as terrible coffee. There are many of these kinds of places, but they tend to go out of business on a fairly routine basis because (1) their coffee is terrible, (2) they try to be pretentious but the hipsters who promote their types of establishments don't spend money, (3) they sell coffee at fair prices instead of coffee drinks at fairly unreasonable prices.

So, whenever I call someone to go grab a cup of coffee, we have to navigate this immense, geopolitical, socio-economic landscape to figure out just what the other person thinks about coffee, before we can even decide where. It's more complicated than trying to figure out who someone will vote for.

So, I called a friend of mine, and we went to get coffee, and we had this kind of a pitiful conversation:

her: So... where do you want to get coffee?
me: Well, anywhere is fine. Someplace close.
her: Well, Starbucks is close, but so is Place A and Place B.
me: Starbucks is fine. Let's do Bux.
her: Okay, Bux it is.
me: I could give a rats ass about where we get coffee, as long as it's warm and has a bathroom.
her: Oh thank God. There's nothing worse than trying to figure out where we can get coffee, and worrying about what your coffee says about you.

And for the record, I don't like Starbucks, not because of the corporate greed or whatever else, but because they burn their beans, and their roasts go far beyond 'bold' and are more like charcoal. If you drink the latte's, then I'm sure you could care less, but if you're a lover of coffee like me, then it becomes a problem. I prefer milder roasts, unflavored. People make the argument that the bolder roasts are more flavorful, but I'm sure these are also the people who order in Starbucks lingo, and think that my cup of Tim Hortons is swill. Well, it's tasty swill.

bleh

Usually, I'm a pretty Christmas guy. I enjoy the season, but not this year. I just can't get into the swing of the season. It feels a little hollow this year. Maybe it's the weather, maybe it's the weird life I've been living, but it all seems quite empty.

I miss being young, and all the wonderful joy of Christmas day, and surprises and presents and everything great, but now, Christmas lacks that innocence.

And it hurt this year that my Christmas card haul was only 8 cards, 3 of which were from schools or institutions. Shouldn't I have more cards? Why is it that I'm the only one who's capable of putting out Christmas cards?

Anyway, it's just another Christmas, and maybe that's a bad thing, but it just feels a little lacking is all.

The story of pharmacy girl

While I was on general medicine, there was a girl working with the pharmacy who I'll call pharmacy girl. She was very bright-eyed and cheerful, and had this ebullient personality which was so very attractive. I have to admit that I was smitten, and when I say smitten, I mean smitten with every possible negative connotation. I had some sort of bizarre, junior high, blushing cheeks and stammering speech infatuation that lasted a brief couple weeks, but then she was gone away to perform some other pharmacy related service, and I didn't see her again.

However, I thought about her and how she defied all of my previous stupid crushes. She wasn't haughty and dismissive. She wasn't emotionally unavailable. She smiled. She was friendly and outgoing. She was (dare I say it) somewhat normal.

So, I saw her again recently, and we talked for a bit while I was going over a chart, and we chatted pleasantly, and she had a negative left fourth finger test, and I thought to myself, "Ask her out. Give it a shot. Worst she can say is no." We seemed okay. We could have some chemistry. And so I scrounged up a little nerve.

Or I tried to find the nerve, and there was none there, so I said good-bye and left the hospital. And that is the end of the story of pharmacy girl.

Doesn't do anything for me

Trust me on this women. If you should meet someone who is a doctor, please avoid doing some specific things. If you don't have a steady job or aren't in school, then we have practically nothing in common, because I have been in school or in training every year of my life since preschool. At least pretend to have a job.

Most importantly though, do not tell me how cool it is to be a doctor. If you're trying to flirt with me, tell me about how wonderful a doctor I must be or some other contrived crap like that, but being a doctor is not cool. If you tell me how cool it is to be a doctor, then I will take that as implied consent to every disgusting medical story I have in my arsenal.

Because saying that being a doctor is cool is really no different from saying that it's cool to be a fireman. It's without any understanding of what it is to be a doctor.

WTF is wrong with me

So, I left the hospital at 6 PM, and I realized as I stepped out the door that I had no plans, nothing to do, nowhere to go. I stopped in the coffee shop near my house and did a little writing, but otherwise, went home. I didn't even eat dinner.

I didn't eat dinner because I've been feeling guilty about my weight and decided that I need to cut out about 700 calories from my diet. Sounds like a lot, but I take like 2600 kcal a day. So 700 is a drop in the bucket.

Anyway, I came home after 3 cups of coffee, watched some TV, goofed around on the comp, and now I'm going to bed. It's Friday though! C'mon! Shouldn't I be going out and doing something? Shouldn't I be living life to the fullest?

I need a life. I really, really, really need a life. I actually spent tonight listening to medical podcasts. MEDICAL PODCASTS! WTF.

Apparently, I'm a jerk

Patients LOVE me. I mean it. I'm not being facetious or pumping my ego. At least once a week, I have a patient talk me up, or try to get into my residency clinic. When I was still taking patients, I had to turn these people away out of fear that I'd be accused of poaching. Even today, a nurse told me that one of the patients I saw a month or two ago, this patient saw me in the hall, and the patient couldn't stop talking about me.

So, I was a little surprised to find out that apparently, I'm the jerk senior resident. I'm the guy that yells at the interns and is too critical. I'm always in a bad mood and never fun to work with. I make the interns work too hard. No one wants to work with me.

And as much as I'd like to deny it... it's TRUE! I'm a jerk! How dare I make the interns work, and demand that they meet a standard of excellence? I'm such an asshole. I am the Dr. Perry Cox of my institution (except I'm nice to patients). If you're an intern, let me tell you how to stay off my shit list.

1. Don't lie about your skills. Nothing pisses me off more than an intern misrepresenting his skills. I've had interns tell me they were experienced with central lines, only to find out that I was supervising their first attempt at a CVC. Not cool. I don't mind teaching a procedure, but I need to know that you don't know.
   
   
2. Don't complain about working. I've had interns complain and whine and bitch about doing FOUR OR FIVE admissions. Christ! Who the fuck complains about that? Compared to my intern year, these guys are getting off light. I've got absolutely no sympathy. If you didn't want to work hard, you should've become a janitor.
   
   
3. Mistakes are okay. Stupidity is not. Not knowing which antibiotic to use, that's okay. Not knowing which stress test to order, fine. Not being able to write an H&P, that's a big fucking problem.
   
   
4. Fucking up is okay. Being lazy is not. You're an intern. You'll make mistakes. That's FINE. What is not fine is not doing something because it is inconvenient. I have actually stood at bedside and made interns do rectal exams on patients when indicated, because not doing one when it's indicated is practically criminal. I've been so adamant about this that several interns think I have a butt fetish.
   
   
5. Don't help unless you know that your efforts will actually help. True story. I put in a central line, showing the intern how to do it. While I was sewing it down, he tried to clean up my sharps. I didn't notice. Then he gets paged away. I turn around and I can't find the guide wire. SHIT. SHIT SHIT SHIT SHIT SHIT SHIT. By the time he got back, I had a 911 page out to vascular surgery and super stat portable x ray.

I had a coworker in college. I was applying for a student supervisor position at the job, but he begged me not to do it. Why? "Ifinding, you're a good guy, and you would be awesome at supervisor, and I have no doubt that you'd get all kinds of stuff done, but it's a part time college job for beer money. You'd never let us be lazy. You take this too seriously."

I think the same is true now that I'm a senior resident. I demand a standard of excellence from my interns, and I'm not talking about technical proficiency. I'm talking about integrity, honestly, respect, humility, and compassion. These are requisites to being an excellent doctor. And if you're not interested in being an excellent doctor, I'm not interested in teaching you.

Coffee for two

In an effort to commune with the world and counteract my hermit tendencies, I have taken to camping out in coffee houses. This is, for the most part, entirely without point or purpose. I haven't yet met or talked to a single person who I didn't already know.

So, I'm not sure that this strategy is really an effective one, but I'm trying nonetheless, and I think the next step may be to join a gym or something like that. That may work, or it may just be another thing to waste my time.

But in the course of wasting my life in coffee shops, I've been privy to some interesting goings on. I've seen a lot of people studying, and most of them are studying medical things: students, pre-meds, residents, and even an attending or two. There seems to be a surprising amount of medicine going on in coffee shops.

Even funnier though is a conversation that I overheard between two girls about how to snag a doctor. It was absolutely ridiculous, and absurd in that they were surrounded by people in the medical field, in one way or another.

I've witnessed a few first dates (or half dates, depending on how you wish to view it). A lot of meetings from eHarmony or Match.com going off with several hitches and a few bricks. The world going by in coffee houses is a little bizarre in many ways, and the $2 cup of coffee is well worth the admission price to the show.

But it also points to the deficiencies in my life. Case in point, there is a pretty girl sitting not two tables away, typing away on her laptop, sipping her coffee, and here I am, doing the same thing, and I will pack up my computer and go home without another glance, and probably there was nothing there anyway, but still, how typical of me.

Concession

friend: C'mon, there are some single girls in the program, you know... we need to have something to gossip about.
me: No, I'm not interested. I thought about it, but no.
friend: Are you sure? That would be a good match, I think.
me: No. Really, I thought about it, and no. I don't think we match at all.
friend: You say that like there's a specific person...
me: You and I both know that you're referring to a specific person.
friend: Well, just for fun... to get the ball rolling!
me: How would going out with someone I'm not interested in be fun?
friend: You can't say then that you don't have opportunities.
me: Quite honestly, I think I have conceded defeat.

My social life has come to a somewhat of a screeching halt. I was dating a bit in my intern year, but not since then, and not without some opportunities, as my friend was apt to point out. I've actually had women had expressed this sort of vague interest in me.

The problem is that I was not interested at all in these women. And it's not entirely me trying to date thin, attractive, chesty, blond 19 year olds. It's just that I can't talk to these women. It's a one sided conversation. There's no spark, no chemistry.

The arguments that I should 'have fun' and date 'just to do something' have been made to me, several times by multiple people in fact. But I can't bring myself to do it. I can't see wasting two people's time and money on a venture destined for failure. And I've done the leg work. I've talked to these women, had some legitimate conversations, but all going nowhere.

Even worse for me is that there are girls who I am interested in, but for the most part, they want nothing to do with me for one reason or another. This is not necessarily for malicious reasons, mind you, but boyfriends, fiancés, husbands, lesbian, or (the most dreaded) a patient.

I used to believe quite honestly that this whole nice guy routine was an effort that would pay off in the end, but I see now that being a 'nice guy' has really very little to do with dating. I mean, of course, it has an affect, but there are a variety of factors conspiring against me. For your pleasure, I will list them.

1. I am Asian in the heart of the Midwest. I am, quite literally, the only Asian person whom most people around me know. I am a curio. I am not dating material for the same reason that you don't have a spot picked out for hanging up a Picasso: you've never considered the possibility of owning a Picasso. Similarly, women I've asked out display not contempt or disdain or even scorn, but surprise at the thought of an Asian boy asking her out. How can this be?
   
   
2. I am, essentially, a hermit by nature. I don't enjoy going to clubs or bars or large social gatherings. I hate meeting new people, and like most introverts, such events are draining rather than 'fun.' I'd rather work. And like most hermits, my friends are also hermits, and we connect infrequently. I have tried to expand my social circle. I have reconnected with some friends. But all in all, I still would rather sit at home reading a book than go clubbing.
   
   
3. I am seriously out of shape. I need to lose some weight, yo.
   
   
4. My standards just might be bordering on ridiculous. What I want in a woman is not a trophy wife. I want someone smart and intelligent (not the same thing...), classy and graceful, eccentric and funny, with interests and passions. Now if this woman were to be 19, blond, and chesty, I wouldn't complain at all. But I've met a lot of women who were physically stunning, and mentally vapid. That's not what I want.
   
   
5. I am tremendously shy. I am. What can I say. I've tried to be more 'open' but I'm pretty shy still.
   
   
6. Apparently, I come off as mean. This will be a whole nother post at some time.

So, for now at least, I've given up on romance. I have other things that I'm worrying about, and it's not that I'm all sobbing about it like in med school. I'm not all 'woe is me, I'll never find true love. Boo hoo!' bullshit. But my life does feel palpably empty, like something is missing, and I don't really know what to do about that.

Music to my ears

Lately, I've been going to a lot of classical music performances. Part of it is that I actually know some of the people performing, but lately, my musical tastes have changed... radically.

Anyone who knew me in college knew that I had no taste in music. None. Absolutely zero. I owned all three Backstreet Boys CD's. Oh, I would go to see local music and junk, but my CD collection was still an atrocity, a crime against music.

In medical school, I got into this weird alternative kick. I was listening to Puddle of Mudd, Hoobastank, Everclear... (you might note, still listening to crap). Then, I began to develop some taste. I got into emo. Dashboard Confessional. Guster. Jimmy Eat World. Get Up Kids. Saves the Day. The captains of emo.

And now, sort of out of the blue, I've been listening to jazz and classical music again, which I haven't listened to since I was a child forced to listen to classical music. But I actually enjoy it now...

It's weird how things can change without even trying. And yet, some things, no matter how hard I try, never seem to change at all.

The post where I lose all my credibility

I was contacted by a viral advertising company regarding the recent release of the St. Elsewhere Season One DVD. I was asked to put up a banner or a DVD review or a link or some such, as I had previously expressed that I liked St. Elsewhere on this blog.

My opinion of viral advertising is not a good one. I think that generating a fake grass roots kind of buzz is a little blah, and it is a big knock to my credibility if I am going to put up links and such for product placement. And I have just (only a few hours ago!) posted on how I think that doctors as a profession are selling out to big pharma.

But I have to admit, I liked St. Elsewhere. And maybe this is tincture of time painting a rosy picture on my memories, but I thought it was more truthful to the spirit of medicine, like Scrubs is, and like ER was when it started, or like M*A*S*H.

And I think that St. Elsewhere deserves a new audience, but maybe that's selfish of me. So anyway, here is the link that was provided to me for the St Elsewhere DVD. Feel free to follow as you like. You should know that I was offered a copy of the season 1 DVD gratis for my troubles. I have not yet decided to take them up on this offer. I realize that sounds trite.

The future of medicine

Bobby Labonte
uploaded by Mulsanne

Whenever the pharmaceutical reps come through, they throw all kinds of stuff at us: pens, paper, post-it's, stethoscope tags, pen lights, and more stuff always coming through. Doctors are given a lot of items.

And I don't take any of this stuff for the most part, because this picture encapsulates my fear. I think that this is the direction that physicians are moving, and eventually we'll be wearing white coats that will look remarkably like this.

So I don't take any pharmaceutical stuff like this. I'm not divested from big pharma. I still take the occasional free meal, and I go to a few dinners every now and then, but I don't accept any advertising material, because I don't want my future to look like this.

Gorgeous

I had someone say the funniest thing to me this weekend. One of my friends mentioned to me that I was such a good looking guy in high school. To which I say: wha? Did I miss something?

I guess that I've never really had such an image of myself. I've never thought of myself as attractive. How can one possibly be the judge of such things? It didn't help that I had this idea constantly thrown at me that I was one of the social outcasts, unworthy of popularity.

And now I find that I still think this, and I'm surprised if not shocked when people pay me compliments, because I think to myself how untrue their words must be. It can't possibly be reality. I can't be good looking. It's a lie.

It amazes me how the trauma of a few years of high school can still manage to affect my self-esteem, a decade after the fact. And how does one go about fixing something like this, if it can be fixed at all?

I was putting in a central line, and one of the nurses was standing next to me, helping me with some saline and other assorted things, and she said, "Dr. Ifinding, you smell nice today." Can it be possible that all these years I've been entirely and utterly wrong about myself? What a devastating thought that is.

High school memories

Over this Thanksgiving weekend, I got to see some friends from high school briefly. It was quite odd. It had been so long since I saw some of them that seeing them again was a little jarring. It felt good though, and it was wonderful to have some intelligent conversations and really talk.

But I realized that nothing had really changed from high school. The cool kids are still the cool kids, and I'm still decidedly not cool. And I don't mind that terribly, but it's not what you could call a badge of honor or anything. It's a little sad, really.

I remember what it was like to be that outcast, the pariah. High school was a really hard time for me, and I'm glad that it's done, and part of me is very sad that it still haunts me a little, that I'm still bitter about my life back then. I wish that I was beyond it all, but I'm not.

I found out a while back that someone had spread all kinds of bad things about me through high school, completely without my notice. And I couldn't figure out why it was that whole parts of the school wanted nothing to do with me, and it hurt, in a spectacular way that only a peer group can hurt you. So I stuck with my friends, and clung on for dear life until graduation.

I think back sometimes and wonder if I could've made things better for myself, and why can't I do those things now in my life. I just can't though. Some things are hard to change, and in the end, I'm still in that pariah mode.

Maybe high school would've been different if... well, there are too few hours in the day to waste any more time on thoughts like this. High school is over, thankfully, and as much as I wish it was different, it is done.

Don't become a doctor #10 - hate me

So, I was reading Waiter Rant's post about pharmaceutical meetings (nothing against waiter rant. It's a good blog), and I was really distressed at all the extremely negative comments about doctors. We're so rich, and privileged, and we take advantage of people, and we're evil and soulless. This kind of stuff really bothers me. And I said my peace, but I realize that trying to win an argument on someone else's blog comments is pretty hopeless.

Because if my goal was to make a lot of money, I picked the dumbest way to do it. If I wanted money, I'd get an MBA. I'd work at a firm. And I kind of resent the idea that I went into medicine to get mine, because it's such a ridiculous notion. Eleven years of education after high school! ELEVEN YEARS! $150,000 debt! My life has been on hold for so damn long. And this is the reward? Contempt and indignation?

And the comments keep ringing. We're rude. We're selfish. We're inconsiderate. We're in the pocket of drug companies. It hurts. It hurts because I spend so much of my time trying to be the exact opposite of these things.

What was the point of all this work, just to be taken for granted? Oh that's right. I'm here to help people. And I don't mean that tritely. Everyone in medicine, doctors and nurses and therapists, etc, we are in this because the idea of helping another human being is something that resonates. If it didn't, no one could do this. As I am fond of telling the students, we're worked too hard and suffered too long to do something we hate.

This is why I tell people that if you want to be a doctor for the prestige and admiration, you're wasting your time. Because all you need to do is look through waiter rant's comment section to see how you will be admired.

EDIT - The waiterrant website migrated, and comments were lost. Hopefully, you get the idea.

Code blue

The first code I ran, it was a nightmare. The patient was hypotensive because he was losing vast volumes of blood into his GI tract. I had three lines of a triple lumen running in wide open saline. I emptied the crash cart of atropine and epinephrine. 6 amps of bicarb. All in the first 10 minutes.

I turned to the unit supervisor, who looked back at me and told me, "Five more minutes, Dr IFinding." So I tried for 5 more minutes. And got nowhere. And that was that. And he was officially dead when I said he was dead. And I wrote in his chart "dead."

It's very surreal, calling a code. I say he's dead, and poof! He's dead. As if the words from my mouth have some sort of magic power. I go to talk with the family, and that's that. One time, I sat with the patient, watching each agonal breath, thinking to myself that I know that I called the code after 20 minutes. I know I gave a gallon of epi and vasopressin. I know that I couldn't get a pulse out of the patient using every trick and technique I had. But watching those agonal breaths...

It's a good reminder to me of the desperate primal urge to live. I remember a line in Crime and Punishment: "...if he had to live on some high rock, on such a narrow ledge that he'd only room to stand, and the ocean, everlasting darkness, everlasting solitude, everlasting tempest around him, if he had to remain standing on a square yard of space all his life, a thousand years, eternity, it were better to live so than to die at once! Only to live, to live and live! Life, whatever it may be!"

Sometimes, all we do is try to live. But sometimes all of nature and all our best intentions are not enough.

So, what are you going to do with the rest of your life?

It's about that time of year when the 4th year students are sending out their applications for residency. It's always interesting to find out what people are going to do with their lives, especially the students that I worked with, to see if my predictions were right.

I do alright. I usually bat about 0.400, which isn't too bad considering. The surgeons kind of stand out usually. The family practice folks stand out as well. The medicine nerds are pretty consistent. Anyway, around about now, advice comes as easily as toilet paper.

My advice to medical students is always the same: you have to love the pathology. People tell me all this shit about shift hours, good pay, no call, or radiology (nuff said), and all sorts of other things. Here's the thing though. 4 years of undergraduate education. 4 years of medical school. A minimum of 3 years of training. A potential career of 30+ years. We work too damn hard to do something we hate.

But if you love the pathology, you can do the job. You can make the hours work. You can make the time. But you can't learn to love a career you hate. So if you love treating hypertension, you'll be okay. If you love cutting out gallbladders, you'll be aces. If you love looking at CT scans of the abdomen, you'll do alright. If you love treating kids, then you'll be fine.

You are exceptionally fortunate that you can choose what you want to do, so why wouldn't you do something you love? Find what you love. Do it.

But if you're picking your career based on hours or shift work or pay, you'll never be happy, because you'll spend every moment you're at work wishing you were somewhere else. And that's fine if you're a high school dropout mopping floors or stripping at the titty bar. Then feel free to hate your job and life. But what a fantastic waste of your life if you put in 11 years of education and $100k+ of debt just to have the same satisfaction in your work as a high school dropout. Is it any wonder that the folks going into ER just for shift work end up burning out?

And here's more bad news: I know a lot of janitors and strippers who love their jobs.

Social calendar

So Sunday is The Simpsons. Monday is football, and sometimes pro wrestling. Tuesday is Veronica Mars, and Rescue Me when it's in season. Can't forget Dancing with the Stars. Wednesday? All about Lost. Thursday is relatively free. Friday, I have to admit that I have become attached to Avatar, the last Air bender. Saturday, more football. Sunday, repeat.

I talk to some of the other residents, and they tell me about their girlfriends, wives, children. They tell me about how wonderful it must be to be single. They have to take the kids to a doctor's appointment, or the wife wants a new car. They're shopping for a new place. Mothers-in-law.

The single life, right? What a dream. But for the most part, I watch a lot of bad television, cook, play around with my laptop and my digital cameras, and go to bed. It's a pretty boring life. I tried to get out and live a little. I was spending evenings in Starbucks, driving around to all sorts of local spots. I went to a lot of local sports events. A LOT. I was even going to some night spots and bars for a little while.

But when you're on your own, it's not exactly like there's a point. Sitting by yourself in Starbucks isn't really any different than sitting at home with a far cheaper cup of coffee. Going to see a baseball game has its own merits, but it's not like I'm meeting people. No matter where I go or what I'm doing, it's really not social. It's just being alone surrounded by a lot of people.

It's not that I'm so lonely. It's just that sometimes, I wish I had someone to talk to. Life feels a little empty without someone to share my life with in some way.

I'm not a real doctor

An actual conversation:

me: We've done a bunch of tests, and several of them are inconclusive. I'm very concerned that this might be a heart attack. I'm going to order some blood tests, and we will observe you overnight, and I will ask a cardiologist to see you in the morning.
patient: Well, you're wrong. I know it's not my heart.
me: Umm... okay. Can I ask how you know this?
patient: Don't be smart with me. I know my own body. This is not my heart.
me: Ma'am, you have diabetes, you have high blood pressure and high cholesterol. These are all risk factors for having a heart attack. Some of the tests have come back worrisome for a heart attack. It may not be a heart attack, but there is a very real possibility.
patient: Well, you don't know what you're talking about. This is not a heart attack, and I'm going home. You're just a resident. You don't know anything. You're not even a real doctor.
me: Ma'am, I admit a lot of patients to the hospital, but your case is concerning enough that I've already spoken with the cardiologist. I must urge you to reconsider.
patient: Screw you. You residents don't know what you're talking about. I want to talk to a real doctor.
me: Ma'am, I am a doctor, but I have already discussed this with two attending physicians, the attending internist and attending cardiologist.
patient: You probably lied to them and told them a bunch of lies so they'd agree with you. Or you didn't even speak to them. You're probably lying to me right now.
me: I'm not going to argue with you about this. This is a hospital, not a jail. If you want to leave, then please sign this form that states you understand that there is a very real risk of death if you leave against medical advice.
patient: I'm not signing anything! You're just doing this to cover your ass!
me: Fine, don't sign it. But you should understand that I think you're having a heart attack, and you may very well die from it, and if you leave, it is against medical advice.
patient: Whatever. I'm done with you.

The line "You're not a real doctor" is a common one that I get from irate patients, and this lady got to me, believe it or not. I am usually very cool in my patient interactions. My interns have seen patients and families scream at me. But this lady, I was pissed. Afterwards, I felt pretty bad. After all, she was frightened that she may be having a heart attack, and we all react very differently to terrible news.

People think empathy is being with a terminal patient or comforting a sorrowful family, but I think that the real challenge of empathy is understanding the belligerent patient. Because anyone can feel sorry for someone with terminal cancer. Not everyone can see from the perspective of someone yelling at you and cursing your name.

I am not a pediatrician

I was trying to get out of the hospital on time, when I was cornered by an irate family member of one of my patients. The family member was very angry that I'd ordered so many tests, and wanted me to cancel them. Specifically, the problematic test was an ultrasound of the lower extremity for DVT. One had been done only a few days ago at another facility.

I tried to reason with the family member. We didn't have the report. Ultrasonography is very technician dependent. The swelling in the leg had worsened, and was unilateral. There was significant concern of DVT. Still, the family member would have none of it, and accused me of wasting the patient's money ordering useless tests. It was like being a pediatrician, trying to reason with parents.

I am not one to get into an argument with patients' family. I canceled the test and walked away. No point in getting angry or raising my voice. And undoubtedly, some of you are saying, "Well, it WAS a useless test! You had an ultrasound done only a few days ago!" I don't order useless tests. I don't even order daily labs. I am a minimalist. But I felt very uncomfortable with a worsening extremity, and a strong clinical suspicion of DVT. But now we won't know.

I'm about to go to bed, but I can guarantee you that I'll be sleeping like a baby, because if my patient has a DVT, it ain't on me.

Reminiscence

I saw some people that I haven't seen since high school, and it was a little bizarre, and very uncomfortable. All that growth and personal discovery and becoming a man stuff, that all seemed to go in the shitter, and I felt like a pimply teenager again, with all the same uncertainties, fears...

And it's hard not to think about how it seems like everyone I know from back then has had so much personal growth. They're married, they have kids, they own homes and have jobs and all that stuff, and it seems like I've sacrificed so much going the route that I did.

And yes, I've got a BS. Yes, I've got an MD. Yes, I'm in residency and looking at a future in internal medicine. There's no way that I can deny that I am an adult, through and through.

A few years back, I met up with a girl whom I had not seen in nearly a decade. It was like old times, and we reminisced. We felt young again for a few hours, but all those feelings that I had for her back then, a silly, little crush that smoldered for ten years, those feelings hurt, and I felt miserable rather than happy.

Seeing all these people from my past, it ends up being a little painful, seeing all the things in my life that I've passed up.

The admitting resident

I was admitting patients the other day, and it was another great day in the history of emergency medicine.

Case 1: 54 year old female with diabetes and hypertension who complains of chest pain and difficulty breathing with diaphoresis. Exam has reproducible pain. Cardiac enzymes are normal. EKG shows... it shows... wait. There is no EKG. The emergency department hadn't done the most basic assessment of a cardiac patient.

me: So, you want me to admit this patient for...
ER doc: For chest pain. She's here for chest pain rule out.
me: And her cardiac enzymes are...
ER doc: they're all normal. Why are you-
me: The EKG?
ER doc: It's fine.
me: Are you psychic?
ER doc: huh?
me: because you didn't do an EKG.

So I was kind of harsh, but really, what if the patient had ST elevation MI, and she was sitting in the ER for a couple hours while I was getting to her, and she should've been in the cath lab? The ER doc and I both knew that he'd dropped the ball big time, and was lucky that she had a negative EKG, because if it was positive, he'd be presenting at the next M & M conference.

And this was how I began my night of admissions. I wish I could say that it got better from here, but there's a reason I numbered that first case.

Case 2: 30 y/o with HTN presenting with chest pain with difficulty breathing, diaphoresis, nausea. ER doc wants to admit him for rule out MI. SIGH! Okay, well, at least tell me about it. I'm assuming the cardiac enzymes are normal and the EKG was okay. But the ER doc didn't do them. After all, he's a 30 y/o with chest pain and low risk. Why bother?

Case 3: ER doc calls and doesn't know the patient's name, age, room, what the vitals are, what labs were done, or if they were done. The reason for admission is difficulty in breathing. That's all I got.

Case 4: Called to admit patient that by the time I come down, he's intubated. So I ask, "So, this is going to the unit?" Dead silence. He still thought I was going to admit!

Y'know, to any ER docs or people involved in emergency medicine, this right here is why the medicine resident is always pissed when you call for admission. Because this is not okay. This ain't kosher. And it's sad when patient safety relies exclusively on me doing the ER doc's work.

The ER was pretty busy, so I decided against ramming a pole up ER doc's ass, because that waiting room full of people is more punishment than I could ever mete out.

The idiot box

ER ruined it all. When I went to medical school, ER was in its prime. I remember in college, people would get together on Thursday nights to watch it. It was a social event, more so than Desperate Housewives could ever hope to be. It was big.

And as any doctor my age can tell you, it ruined the field of emergency medicine. There was a glut of ER applicants, and it quickly became highly competitive, a field that became a separate specialty relatively recently.

And as you might imagine, for every one emergency medicine applicant for residency, there were 10 bitter pre-meds that didn't get in, and missed on their chance to be Dr. Ross or Dr. Greene or Carter. It was a rough time getting into med school when I was applying, with the average rate being somewhere around 1 spot for every 8 or 9 applicants throughout the Midwest.

The problem is, as anyone that's worked in an ER can tell you, the show is nothing like a real ER. There is none of that drama and tension and romance and horror. ER is not real. The #1 question I was always asked was, "What's it like to work in the hospital. Is it like ER?" It was such an absurd question.

Now I see it again with Grey's Anatomy. It's so ridiculous. People watch it and think that life is really like that, as if being a doctor is somehow so automatically dramatic. And I'm always asked now if I watch Grey's Anatomy, and is it really like that to be a resident.

I think if you took a poll among doctors, we as a group tend towards Scrubs. When I saw this show, I felt a real connection. I didn't start watching until my clinicals, and after watching episodes on breaking bad news and patients dying and bad outcomes, I was instantly enthralled, because that was me. I was the person telling Mrs B that her cancer had returned. I was the one holding Mr H's hand when he found out that he needed a bypass surgery. I was the one offering tissues to the family of Ms S as they found out she'd died.

Through all the humor and flashbacks and weird characters, far more surreal than any of the other medical dramas, it actually ended up far more realistic. It didn't shy away from laughing at disease. It didn't hide from medicine destroying our personal lives. It was honest.

I would watch a show like ER and it would pick up on all the bad things in medicine. It was all codes and crash surgeries and everything horrible. But I could come home and watch Scrubs, and it was healing. It was like sitting in the resident lounge, talking about my patient that died and how she never got to finish her needlepoint of her favorite NASCAR driver's car, and getting a cheap laugh. JD would realize something, and I knew it too.

Nowadays, even Scrubs has departed from this coveted status. The only medical show I watch now is House, because I enjoy the diagnostic challenge. Honestly, Erdheim-Chester? C'mon. That's awesome. But if you were to ask me what TV shows a young and budding pre-med should watch, I'd say the early seasons of Scrubs, and maybe St. Elsewhere. That's what feels right to me.

ut aliquid fieri videatur

It's been a long time since I've done Latin, but the best I could come up with was "How something is seen being done." This phrase means doing something for the sake of appearing that action is being taken. Action for the sake of appearances. An example would be like after Columbine, there were all sorts of gun laws regarding youths, but truth be told, the laws did next to nothing. It was done just to show that the government was doing something.

One of the attendings I've worked with was real old skool, East Coast internal medicine, and occasionally pulled out obscure Latin, peppered with stories of Osler. That's East Coast medicine for you.

All the time in medicine, we do things not because they're necessary for care, but so that we can give the impression that we are doing something for the patient. Many patients don't feel like we're doing anything unless we're ordering tests or getting daily labwork. In fact, I often make it my job to tell patients that we are indeed taking care of them and not sitting around drinking coffee.

And I wonder sometimes if the show isn't for patients, but is for ourselves, so that we can go home at night, look at our handiwork, and say, "Look what I did today!"

Bettering myself

When I started medical school, I decided that I was going to reinvent myself, become a new me. I set some goals for myself, and I implemented a very ambitious plan to meet those goals. When setting goals, I always believed that it was best to set them high, so that even failure is really just a partial success. Easily achieved goals are worthless.

My goals were (1) to become popular, (2) to be engaged before graduation, (3) to have no fewer than 10 people with whom I would interact on a regular basis, (4) to have weekly social activities and no free weekends.

These were goals that I thought were quite reasonable and enjoyable. I was decidedly NOT popular in high school or college. I hadn't been on a date in a long time. My circle of friends had contracted from dozens to a handful. I spent most of my weekends doing laundry or cooking. I was disconnected from the rest of the world.

So, I seet my plan in motion. Over the course of medical school, I went to nearly every party. In the first month of medical school, I went to more parties than I'd attended in all of college. In the first two years of med school, I'd been drunk more times than my entire life before med school. I lost weight, a lot of weight, like 50 lbs. I worked out all the time. I was in the best shape of my life. I had scores of friends. I was invited to everything. I would meet with friends on nearly every day of the week.

I asked out so many women that for a while, I was utterly fearless. I had a big circle of friends. Other than the engaged thing, I achieved every goal I'd set out. My mission was a tremendous success, and I was utterly miserable.

And what I realized since then is that I went about trying to solve the problems in my life in the completely wrong way. I thought that by changing my trappings, I could change the person. I tried to be someone else, to change without growing. This is what the ancient Greeks would refer to as hubris.

Once I'd finished med school, I was able to look back and see some of the realities of my life. At first, I thought that it was just stuff about my love life, but after a while, I realized that the lessons I learned were more than just about love. I came upon some truths to life. And I thought I'd share what I've learned about life.

• Happiness comes from within, not from anything external. Something or someone can't make me happy.
  
• I must always be true to myself and accept who I am. I can't be happy unless I'm willing to be me.
  
• I cannot love others if I don't love myself.
  
• No one will love me if I'm not willing to love.
  
• I can't dictate the actions, perceptions, or emotions of others. I can't choose who will love me or hate me.
  
• There is no point in agonizing over that which I can't control.
  
• I cannot change who I am without growth.
  
• I cannot change other people unless they want to be changed.
  
• Doing something is NOT necessarily better than doing nothing.
  
• Life is measured in emotional content: not money or popularity or trips or parties or being social.
  
• I deserve love and happiness and everything good, as long as I'm willing to work for it.
  

This list required a lot of personal growth, but see? Growth is the only real way to change. And I needed to change, because that guy in med school, he may have been quite a guy, but he wasn't me, and I've left him behind.

Don't become a doctor #9 - it's all your fault

If you look in any medical chart, you'll see signatures and initials everywhere. Every test is initialed. Every study checked off. Every call to the doctor noted. This is all done for one reason: liability.

Somewhere along the line, we decided as a society that the buck would stop at MD, and so it is the doctor's responsibility to ensure that care is appropriate, and if malpractice does occur, the doctor is the one who is responsible.

This all sounds very reasonable until you consider a few circumstances. The doc is liable if a test is done and the report not sent, but the test is markedly abnormal. The doctor ordered the test, and should have followed up on the result.

The doc is liable if he orders a medication that is not administered over the course of a hospitalization. He ordered it, and should have ensured that it was given.

My point here is that there is only one person to blame for all these mistakes that happen, and that person, if you have MD after your name, is you.

Ouagadougou

VSEPR: Valence Shell Electron something something. Position? Pairing? I spent over an hour today trying to remember what VSEPR stood for, and I was a little embarrassed to come up so blank on something that I'd spent practically an entire semester of college studying. All that time, and now I can't tell you a thing about it, muchless what the letters stand for.

I have books full of medical information that is entirely lost to me. I was looking through a neuroanatomy text, thinking to myself that only a few years ago, I probably knew as much about the rubrospinal tract as any neuroscience grad student. Now, I don't know what it connects, and even less of a clue about what it does.

There are 16th century Chinese painters, eons of Japanese history, quantum mechanics and thermodynamics, linear algebra, linguistics, all these myriad pieces of information that are entirely lost to me, things I once knew so well. And even more frustrating is having to be reminded of things constantly. I need to cheat all the time with katakana. I keep a Korean dictionary on my coffee table. I need to be reminded every single time about what is the infield fly rule.

And what I've retained is entirely trivial sometimes. I remember that the capital of Burkina Faso (a small, land-locked West African nation), is Ouagadougou. I remember that the Battle of Antietam is the single bloodiest day in the history of the United States. I remember that it is known as the Battle of Sharpsburg in the South because the South liked to name battles after local towns and cities, while the North usually named battles for local creeks, rivers, and bodies of water.

There are times that I mourn all this lost information. I think about how sad it is that it's gone. There are things that have pushed this knowledge out, but it's not a replacement. It's not equivalent. Calculating PORT scores doesn't equal Kano Masanobu's paintings for the Ashikaga shoguns. Knowing the etiology of Diabetes Mellitus type 2 isn't the same as the Schrödinger equation.

But it's nice to realize that there are some precious things that I've held onto, like being able to escort a lady or a very basic waltz. I actually know the difference between a teaspoon and a dessert spoon. There are little things like this that bring a smile to my face, more so than VSEPR (I got it! Valence Shell Electron Pair Repulsion! It's a theory for predicting the geometry of bonding configurations for non-metals by estimating the repulsive forces of the valence shell electrons.) ever did.

Where were you?

There are certain things that are defining for a generation, defining for a whole society. One of my teachers in grade school told us about when he first heard about the Pearl Harbor attack, and where he was and what he was doing. Another of my teachers from England told us about VE Day.

When the Berlin Wall fell, I was sitting down to dinner with my mom and brother, and we'd watch the news during dinner. I was in the same spot during the LA riots. I was in gym class in high school when Michael Jordan retired. I was in school, like so many other kids, when I heard that the Challenger had exploded.

So now, five years later, I can tell you with deadly accuracy exactly where I was on September 11, 2001. I was sitting around in the student lounge of my medical school after a particularly annoying quiz. We'd finished early and were waiting for lectures to start. A few of us were playing euchre. My friends had been playing ping pong. One of the maintenance people ran in and told us to turn the TV on, and a few minutes after the fact, I learned about the first plane crash into the North tower. We watched just enough television to see the second crash, and then lectures started.

My professor made some offhand comment that we would need to learn to deal with adversity and that classes wouldn't be canceled. I was glad I invested in a cell phone, and I started calling everyone I knew who'd be around the WTC area.

After the lecture, I find out that one of the towers has collapsed. After another hour of lecture, another collapse. I call a med student friend of mine and she's been enlisted into the ER of a local hospital in NYC. But she has plenty of time to talk to me. No one's coming in. The ER is silent. I can hear over the phone, no buzz at all.

Instead of lunch, we all gather in front of the TV and watch the coverage. Several of us are darting in and out of the lounge trying to get better cell phone reception. Our afternoon lectures are canceled. There's no point in trying to teach us more. We're numb.

By the time I get home, they have footage of the exact moments the planes each crash into the towers. They have shots of people jumping to their deaths, preferring to die from suicide rather than burn to death. And they first realize that somewhere in the neighborhood of 400 firefighters are missing or dead. I watch as much CNN as I can stomach for the next 2-3 days, and then I can't watch anymore. I can barely watch cable news even today.

Turns out that everyone I knew in and around the WTC area were all okay. A friend who worked in the WTC didn't work in the towers, and my family was all far away. I visited Ground Zero about a year afterwards, and it was just a hole, and I felt numb. I still feel pretty numb, like it couldn't have happened.

And I still cry when I see those planes crashing into those beautiful buildings, that stood there for just a little longer than Ive been alive. It seems like they were there forever, and I can still remember going to the top three times in my life, and it's sad to know that I'll never see that view again.

Things that go bump in the night

Calvin: Help me (hic) get (hic) rid of (hic) these darn (hic) hic (hic) hiccups!
Hobbes: How?
Calvin: (hic) Scare me.
Hobbes: Our oceans are filled with garbage, we've created a hole in the ozone layer that's frying the planet, nuclear waste is piling up without any safe way to get rid of it...
Calvin: (hic) I mean surprise me (hic).
Hobbes: That doesn't?! Boy, you're cynical...

Last night, I had by far my worst nightmare in years. I wish that I could say that it was trolls or falling to my doom or something otherwise frightening, but it was me sitting in a big room taking the Boards. And I was doing bad. REAL bad. And I didn't finish. And I got my results instantly. And of course, I failed.

And then I lost my position. And then my girlfriend dumped me (waitaminute, I had a gf?), and everything was horrible.

Y'know, lately, whenever I have nightmares, they're not ghosts or things like that It's all stuff that is stuff that I wake up in the morning, and I'm not any less scared. The whole point of a nightmare should be that you wake up and feel safe. You shouldn't wake up in the morning and feel worse than you did in the dream!

Target rich environment

So, after years of dating misfortune, and after giving up on romance for the time, all of a sudden, I'm presented with the strangest situation. There are women who are interested in me. It makes no sense whatsoever. I mean, WTF?

One girl actually mentioned the words "I'm single" "I wish I wasn't" "Are you single?" and "It'd be nice if we weren't single" all within the span of a 3 minute conversation. The other girls were a little more tactful.

And I know, I know, I can see the irate e-mails from friends coming already. Why aren't I doing anything about this? I wish I had an excuse. I really don't. I just have a lot of stuff on my plate right now, and I just couldn't bring myself to follow through. Y'know, they're not my type. Or some other excuse. Do you have a good excuse I can use?

Screw you

When you're a resident, you discover the myriad ways that one person can screw another. And you might imagine that having a bad intern would be the worst possible fate, or maybe as an intern having a bad senior resident would be tops. Now, having a bad intern can generate a lot of extra work, but there is no screwjob worse than what one senior resident can do to another.

This extends to both same service or consults or transfers of care, or best yet the ER. In all circumstances, the worst that can happen is always the same: one senior resident screws another one over.

I've been called to the ER to admit patients who don't even have charts yet, or labs, or even an x-ray. I've been called to admit a patient for observation for chest pain without an EKG having been done. I've had fellow medicine residents hang onto pending admissions until I took over the admission pager, leaving me with the new admission.

And worst of all, I've had residents lie to me about a patient's condition. That's by far the most common and most horrifying reality of the incompetence of some senior residents. For your benefit, some examples.

"Oh, her blood pressure was low, but it responded well to fluids. She's stable now." The patient was in florid neutropenic sepsis, and expired about 6 hours after this statement.

"His last cardiac cath, they didn't need to do any stenting, so he looks pretty okay." They didn't stent because he had triple vessel AND left main disease. He was a cardiac cripple.

"His last admission BP was low as well, so it looks like this is normal for him." So normal in fact that the last admission they addressed that blood pressure with dopamine and levophed.

But by far, the thing that gets me angry the most isn't this gross malpractice that I've described, but it's laziness. That's what bugs me. I've had people dump tons of work on me, couched in the noblest of excuses: "My son has to go to the doctor's today" "I have a meeting I have to go to"

Boo fucking hoo. More than once, I've had someone dump work on me so that they could leave the hospital for something, and as a result, I had to spend extra time in the hospital cleaning up their mess. And some people would flatly refuse. But I say bring it on, because if I meet someone who is so lazy that they are willing to dump their work on me, then I'd rather do it then let them ever take care of one of my patients ever again. I have literally carted people out of the ER and straight up to the ICU without a thorough evaluation because the care they had received was so atrocious that even blind, I could do a better job.

My feeling is that one person's laziness doesn't excuse me from providing poor care, so I will always pick up the slack. And it's a small price to pay to find out what doctors aren't worthy of my trust or my time.

No good can come of it

I wish I knew what it was like to deliver good news. I wish that I knew what it was like to tell someone, "It's a boy!" or something good. All my news is bad. Even my good news is really just neutral. It's stuff like, "You didn't have a heart attack!" It's never very pleasant.

I saw an orthopedic surgeon once, and he encapsulated our experience very well: "I'm a nice guy, but you don't ever want to meet me." That pretty much describes my day. I'm damn good at what I do, but if you're seeing me, no good can come of it, only getting back to neutral.

And it only takes one day of telling some lady her husband is dead, telling a family their loved one is terminal, telling a husband that his wife had a massive MI, and I realized today that if I was a patient, I wouldn't want to talk to me, because what good can come of it?

It's been a while

"Hello, my name is Dr. I Finding. I was part of the code team called to see your husband. When I arrived at his room, he had been found unresponsive without a pulse. We put a monitor on him and we saw that his heart was in a dangerous rhythm, so we shocked him several times to get him out of it, but instead, it got worse. We gave him high doses of emergency medications to try to jump start his heart, but he did not respond to any of these.

"We also put a breathing tube down his throat to help him breathe, and we did CPR to pump his heart for him, and briefly, his heart was beating on its own, but it quickly gave out and we had to go back to CPR.

"Finally, we tried all the medications that we could, and all the other measures at our disposal, but we could not get his heart beating again, and he expired. We did everything we could. I'm so sorry for your loss."

I tell you, there is no worse feeling than telling some poor woman that the love of her life is dead. And even worse when she thanks you for it.

Wal Mart

Wal Mart, uploaded by Wearn.

So, it's finally happened. I went to Wal Mart. I bought things. I felt dirty afterwards, like I'd pissed all over the flag. I needed to take a shower. It felt yucky.

I really do believe that Wal Mart represents everything bad about America. It is the dominance of corporations and the homogenizing of the country, and reducing pay scales to "greeter" or "stocker" or "cashier."

But where else can you find notebooks for 10 cents and Spam for $1.50? What a cruel world.

Motherfuckers

Recently, I stumbled upon Save the Internet, a grass roots campaign to push for net neutrality. Net neutrality is an effort to prevent telecom companies from creating a tiered system where their data is routed faster, while other people's data takes the scenic route. It'd be as if only 18 wheelers were allowed in the interstates, and everyone else has to take surface roads.

It's shit like this that made me forsake the Republican Party. Please make your opinion known to your senator and stop the telecom companies from taking over the internet.

Okay, no more political stuff for a long time, I promise.

Teach nothing

I really love teaching. It's such a joy to participate in the education of others. It's so precious that at the same time you teach, you can't help but learn as well.

But then, sometimes you make an ass of yourself, like when you can't remember the diagnostic test for Goodpasture's Disease, or you miss the Q waves in the EKG. Doh.

Don't stop believin'

I was in the hospital the other day, and I heard a song on the radio. Don't you hate when you hear something on the radio, and it sticks in your mind? Then you have some random song stuck in your head and it slowly eats your soul.

There are some songs that are SO BAD about getting stuck in your head, and then you find yourself humming it at the nurses station in the afternoon, and one of the nurses looks at you funny and asks, "Are you humming 'It's Raining Men'?" and realizing that yes, indeed you were.

So for your own interest, here are the songs that always get me.
Journey - Don't Stop Believin'
Geri Halliwell's version of 'It's Raining Men'
Culture Club - Karma Chameleon
Backstreet Boys - As Long as You Love Me
Cardigans - Lovefool
Rick Springfield - Jessie's Girl
Total Eclipse of the Heart
Soft Cell's version of Tainted Love
Moody Blues - Wildest Dreams
When in Rome - The Promise
Alphaville - Forever Young
Peter Cetera - Glory of Love
Lou Bega - Mambo #5
Kelly Clarkson - Since U Been Gone
Guns and Roses - Sweet Child of Mine
Rihanna - SOS
N Sync - Tearing up my heart

No, I'm not a doctor

I don't like telling people that I'm a doctor. It's not because I'm humble or bashful. It's because I can't stand the questions! The first thing that people do when they find out I'm a doctor is to pester me with medical questions:

Can you feel something wrong in my knee?

Why did they use two different stitches?

I have this lump in my arm. What is it?

Stop, stop, stop, stop, STOP WITH THE MOTHERFUCKING QUESTIONS!! I don't want to answer your damn questions It's cancer, okay? Fever? Cancer. Sweating? Cancer. Leg pain? Cancer. The answer now is always cancer.

The worst was a stripper that had me do a joint exam. WTF.

Some of you may think, well, I went into medicine so people would seek my opinion. However, what you need to understand about free medical advice is that you get what you pay for. Without knowing anything about someone's medical history or doing a thorough H+P, I can't really give a decent opinion.

So stop asking me so many questions, unless you're in my clinic. Then ask away.

Ego dystonic

Part of what I love about internal medicine is tragedy. I've come to realize that I love flaws, injuries, cracks, holes in armor. It's like how everyone has a favorite Star Wars movie. Mine is The Empire Strikes Back. The movie ends with Luke's hand severed, Han Solo frozen in carbonite, and the Rebel Alliance fighting to stay alive. Everything is wrong; I like wrong.

And it's not that I want to fix things. I just want to know the tragedy of it all. I don't get any particular thrill fixing someone's blood pressure. I don't pat myself on the back over a glycohemoglobin of <7. I have a patient who's smart and attractive and in their 50's, and single. Whenever I see this patient, I think to myself, aren't you lonely? Isn't your life empty? What meaning do you find in life? I want to see their pain, their hurt.

I read the book Man's Search for Meaning recently, and in it he poses the scenario: if there was an ape being used to develop polio serum, and it is punctured again and again. It cannot comprehend the meaning of its suffering, but undeniably we can see a purpose to his pain.

"Is it not conceivable that there is still another dimension, a world beyond man's world; a world in which the question of an ultimate meaning of human suffering would find an answer?"

So sometimes I truly enjoy seeing the suffering of others, and not for some cheap masochism, but because it is in suffering that people often reveal their raison d'être, their will to exist. Because anyone can tolerate good times, but it is the pain and injustice that one is willing to tolerate that defines purpose.

Clinical acumen

The most common admission that we see on general medicine is chest pain, and at this point, I'm about 90% accurate on my calls. It's that 10% that presents so much trouble. And that's why I order enzymes even when I think I know. Because I'm just not sure.

It makes me think about those Pepcid Complete commercials where they show these 50-60 yr old folks with 'heartburn' and I'm thinking, "Umm... couldn't that be an MI?"

I'd like to think that I have that treasured 'clinical acumen' of an attending, where you can stare at a patient and walk away with some sort of quasi-impression of how sick someone really is.

The problem with this is that in order to develop this acumen, you've got to kill a lot of people. A lot. Because how do you know that someone's going to die if you don't kill a few people so you know what someone who's dying looks like? Seriously!

That's why residency is so nice sometimes. Every now and then when I kill a patient, it makes me think, and I try to put my finger on what I did wrong. Because I've done a lot of things wrong, and when I go home, at least I can tell myself that I'm working on developing my clinical acumen.

Working with nurses

There are a few nurses that I really enjoy working with. Most of the nurses in the hospital are okay, but there are 3 or 4 that are just a pleasure.

Blondie is a funny nurse. I always seem to see her around the hospital completely randomly, and she's always cheery and pleasant, and never fails to give me as much attitude as possible. But it's okay, because she's way hot.

Then there's Sarcasm, the best nurse ever to work with. She just drips sarcasm and biting cynicism. I was sitting at the nurses station, and I hear from one of the rooms, "Hey you! Ifinding! Get over here!"

I ran into the room expecting to find a patient coding but it was just Sarcasm, taking care of a comatose patient. "Your intern told me that I'm bossy! Can you believe that? WTF?"

But my favorite nurse is Done. Done is like having another intern. "Hey, Done, this patient is having diarrhea-"

"I'll get it done." Then I come back a few hours later to a chart full of orders that I supposedly gave, and Done is sitting reading the newspaper. "It's done."

Rules for interns

Reading through LVT's recent intern experiences, I realized that there are some basic rules for interns that everyone should know once they start. So, before you start on July 1, here's some basic house rules:

(1) DON'T FUCK YOUR PATIENTS! DON'T! DON'T DO IT! DO NOT FUCK YOUR PATIENTS!

(2) Become very familiar with IV and IM haldol. Your new best friend.

(3) If the nurse is freaking out, came down. All is right with the world. Would you freak out if the fire alarm goes off? No. Be glad that the system works.

(4) If the nurse is calm, be very very worried, because now you must ask yourself the following question: why is she paging me at 3AM if it's not a problem?

(5) House of God is required reading.

(6) The proper way to determine if your fellow interns are sane: ask them if they've read House of God. If they've read the book and do not immediately quote a law from the book, I would seriously question their sanity.

(7) If you have a competent senior resident, and he tells you to do something, YOU DO IT. I don't care how insane it seems.

(8) You can determine if your senior is competent using the same intern sanity test (rule #6).

(9) If you need to practice intubations or need a case for M&M conference, then ativan is your friend. If you like your patients alive, be careful with your ativan use.

(10) The greatest crime you can commit is not asking how to do something. That's fine. The greatest crime is asking how to do something twice. If you do this, your senior may freely hit you several times.

That's a pretty good start.

A new clutch

It's almost July, and the interns are pretty much independent now. They are, for the most part, ready to be seniors. It's strange to see these guys that one year ago could barely keep healthy people alive. I'm not really proud. They did most of the work themselves, but it's still nice to see them ready to take on the world as senior residents.

And it's more than a little scary that I'll have another July full of new interns, and more nightmares of trying to keep my patients alive despite my interns. It's more than a little ulcer provoking, and hopefully I'll have attendings that are understanding.

There's a starling that's nested in the tree outside my bedroom window, and every morning this Spring, I'd wake up hearing the chirping and peeping of the little chicks in its nest. And then a few weeks back, the chirping stopped. The chicks were all grown up and left the nest.

And then last week, new chirping. There was a new brood of chicks. And all I could think was, "Hey starling, I know how you feel."

Effort

I wish at times that I had the drive to be a superstar. I know that all my attendings think I'm good. I've already been offered jobs by some docs in the area. It's all extremely flattering. But I know that if I had more ambition, I could've willed myself into any field I wanted. GI? Card? I could do it, if I put myself to work.

My life, at its core, is a life lived on minimal effort. And I know why. I only put forth minimal effort because I save it up. There have been times in my life when breathing was something I had to force myself to do. And there are times when all the effort in the world was needed just to get out of bed.

So I never put the pedal to the floor anymore, just in case I need a little extra gas for a tough spot. And maybe that's timid of me, but I don't know how many times I can get roughed up without keeping something in the tank.

Discouragement

Recently, a reader posted a comment about my discouraging 'Don't become a doctor' series. And certainly, people are entitled to their opinions, and to some extent, I agree: there's no goal more rife with naysayers than pre-med.

But it reminded me of a story that a friend of mine Ghetto told me. Ghetto's dad was in a special forces unit during Vietnam. Ghetto was a smart guy, and looking for a way to get into college. The Montgomery GI bill seemed like a smart choice. Remember that I was in college after the first gulf war, and joining the military didn't seem like such a bad idea.

Rather than being proud of his son for considering a military career, Ghetto's dad was mortified. "Are you prepared to kill people, people whose only crime is living on a piece of land? Are you prepared to shoot and stab people because someone else told you to? Do you think you can murder women and children?"

Ghetto decided against enlisting. He went the old-fashioned route of climbing into educational debt. But it all ended happy.

The reason why I tell this story is that it speaks to my purpose. Those loaded questions that Ghetto's dad asked got to the heart of the matter pretty quickly. Ghetto did not have his heart in military service. It wasn't something that he wanted to do, and so when confronted, his resolve disappeared. Nothing against Ghetto. It just wasn't something that he wanted at the time. It was just a means to an end.

And I remember being a pre-med, and I remember talking to other pre-meds. So let's get rid of everyone for whom medicine is a means to an end. Let's take everyone who's looking to make tons of money, everyone who wants to work 9 to 5, everyone who only wants the prestige or some imaginary comfortable lifestyle, let's get rid of those folks first.

The ones that are left, let's show them that this job is tough, with a lot of pressures and demands. Because if their response is, "Oh, well that sounds sucky. I'll pass," then they'd have never made it through med school anyway.

One of my doctors put it quite well. I was getting my physical before starting med school, and he congratulated me on getting in.

"Everyone tells me it's really hard," I said tentatively.

"Oh, well, it's not so hard. If you love it, it's almost easy," he replied with a smile.

My politics

All this talk about immigration and a gay marriage ban amendment pisses me off, because it's so obviously a red herring, so obviously playing into the fears of people and the hot buttons of the ultra-religious. And let's be clear, the issue of illegal immigration has nothing to do with national security. If it was about terrorism, we should turn our attention to the Canadian border instead.

And it got me thinking about the Republican Party. I don't like writing about politics, because I'm not going to convince any of you to change your mind. No one ever changes their mind about politics or religion by arguing. But let me tell you about where I'm coming from at least.

My dad was surprised, shocked in fact, that I'm conservative. Even though he reads the New York Times every day, my dad is conservative. He couldn't believe that his college educated 20 something year old son was already jaded to the world and voting Republican. My mom takes it another step and is a card carrying Republican. She called me in 2004 to remind me to vote for Bush.

My parents are, in that way, typical for Asian immigrants. Most Asian immigrants of my parents' generation came to this country thinking that they could come here, get an education that was unavailable to them or job opportunities that were nonexistent. They love the Republican Party, because they cannot imagine working so hard, scratching out a living, putting two kids through college without a drop of debt, and supporting a bunch of people on handouts? Medicaid? Disability? It's utterly egregious.

Growing up with such influences, I had a strong Republican bias as well. It fit with my conception of government: minimalism, laissez-faire, etc. And when I was coming up in my political awareness, I leaned conservative. And I still do, but read that conservative, not Republican.

Because at the same time, I grew up very Catholic, and very aware that there is much in this world that is wrong that requires us to work very hard to change. There are people starving, people suffering, people requiring social change and justice.

And so, by college, I realized that I am what can be tritely called a centrist. I am one of those socially liberal but fiscally conservative voters, realizing quite acutely that the two party system no longer is able to describe my political ideology.

And until recently, that political view has led me to vote mostly Republican, because if there's one thing that this country needs, it's fiscal responsibility. And only recently did I realize how utterly misguided my voting has been. Because these nuts have been throwing away money like it's going out of style.

And I can't help but feel utterly detached from the entire political system, forced to choose between a party run by rabid fundamentalists who are wasting money and actually building bigger and more government, or a party that is rudderless and without vision or direction.

No cause for alarm

It was 12 hours before I had a meal. And that may not sound too alarming, but think of it this way: if you woke up at 6AM and then didn't eat until 6PM, that'd be a little weird, right? I did have a bowl of cereal, a handful of Doritos, and a rice crispies treat, in addition to some McDonald's. The way I add it all up, I've had about 1500 kcal today.

I'm getting kind of worried. I'm a big fatass. I normally eat 2500+ kcal. I literally could eat another whole meal. Why aren't I eating more? Normally, this is behavior that I've had when I'm depressed, but I'm not depressed! I feel pretty good!

Maybe this is my body finally saying that I eat too much.

Maslow's hierarchy is optional

Lately, I've taken a view that meals have become optional. I have grown fat, and could stand to cut back on the calories a little. I ate a handful of Doritos for dinner, and yesterday I didn't eat dinner at all.

Normally I'd be a little worried. After all, the last time that I took an optional view towards eating, I was acutely depressed and lost 10 lbs in a week because I was barely eating 1000 kcal a day. That was bad news, but I'm not depressed now. I feel pretty okay.

And I'm hungry too. I just don't have the enthusiasm for eating right now. I just don't feel very inspired. It seems like too much work, when I'd rather be sitting around watching baseball (I watched 3 baseball games on TV today...).

I did go to church today, for the first time since Easter. I've been on call or post-call every Sunday since Easter, so it's my first chance. It felt strange being back in church. It didn't feel very fulfilling, but part of the nice thing about being Catholic is that it's okay sometimes to show up just to fill a seat.

Maybe I am in a funk? I don't feel like it. I feel okay. Is this denial?

Back in the day

Sometimes, I marvel at the history of medicine. It's amazing to think that 50 years ago, antibiotics were new to the world. Only 30 years ago, coronary angioplasty was a revolutionary procedure. It's strange to think that only 20 years ago, the thought of using beta blockers in heart failure was an absolute contraindication.

It's one of the things I love about medicine. Things change, and things that we take for granted were only just discovered, and that in the history of the world, modern medicine is barely older than the personal computer.

But I have to admit, if I had to choose, I think the best time to be a doctor would've been the late 1800's and the turn of that century. I can think of no more seminal moment in the history of medicine than when Lister said: Hey, maybe we should clean these tools off?

I love the history of science, and it's drawn me to Neal Stephenson's Baroque Cycle. Because Boyle, Newton, Leibniz, Hooke, these gentlemen are known to me. And my accomplishments in life are along a road paved by men such as these.

Please shame yourself

I recently had the opportunity to talk to a few program directors and attendings who do candidate interviews both for fellowships and for residency positions, not to mention interviewing for faculty positions. And the question that I was most concerned about was the most infamous question in all of interviewing: what are your weaknesses?

This is the most patently ridiculous question that an interviewer could possibly ask, but I thought I might as well find out the motivation behind such a loaded question.

The answer almost uniformly was that it gives the candidate an opportunity to reveal some professional areas for growth. Another responded that it seemed like something valuable to learn about someone.

I read MB's post about it, and I have to say, I agree. It is such a ridiculously stupid question, because it is inviting a person at best to shame himself, and at worst to outright lie. The classic way to escape this question is to turn it into a strength: I'm too detail-oriented. I'm a workaholic. You get the idea, and if you've interviewed for med school, you've probably done this.

The people I talked to said this was a stupid answer, but hell, if everyone gives the same answer, then maybe people will stop asking it. But sometimes, I look at this question as a challenge. And the last time someone asked me this, my response was: I'm not the smartest candidate you'll interview, not by a longshot. I'm not the sharpest or the most qualified, but I'll be just as good a doctor if not better because if all you were looking for were the smartest and the sharpest, you wouldn't be interviewing me right now.

Reproductive success

My dad, he recommended to me that I obtain some additional advanced degrees, to which my reply was ppppppppppppblt. I'm already an MD with a hardcore science BS. The only thing left is a PhD, and I'll be damned if I'm going to do that. I've already earned my stripes.

My mother is much more tactful when it comes to the topic of career advancement. She wants me to do endocrinology, not because it is a good field, and one that is in demand, but for office hours. "There's not much call, and not a lot of hospital work, so you just have clinic hours, and then, you can make your own schedule! You should do that! Plenty of time off for life!" This is my mom's way of saying that it will give me the chance to meet some woman and impregnate her, perhaps several times.

And then, I got the most bizarre phone call. As you may know, there's been cases of mumps in the Midwest, and my mom called me to try to force me to get another MMR vaccine, to which I said pppppppppblt. I already had more than my fair share. However, she was determined to convince me. Finally, in exasperation, she said, "Maybe if you were married already..." and then gave up, and let me (her son, the doctor) figure it out for myself.

I had to go home and figure out what she was talking about. Epididymoorchitis occurs in >30% of adult male cases and can cause sterility, but rarely. That's my mom, always looking out for her reproductive success.

See ya

I spent some time hanging out with WC, saying my good-byes. He starts his residency soon in another state, and chances are I won't see him again for at least a year, if not longer. We had a couple drinks and enjoyed our time, but it always hurts saying good-bye.

I've had to say good-bye more times than I care to recall. I've left more friends behind than I can count. I hate good-byes, because they're painful. Good-bye should be enjoyable, like the ending of a good movie, and as the credits roll, I get to enjoy the denouement, and close it off. Now it can come in a DVD and sit on my shelf. I have digested it.

Parting with friends, it's never like that. It's never the three act play. My friends always seem to part in the middle of Act 3. I never feel any closure, and that lingering sentiment is probably what inspires me to write bizarre letters to my friends every now and then, because I'd like to know how the story ends.

So good-bye, WC. Stay good.

None for me

People wanted to go see the DaVinci Code, but I told them to go without me. I've already decided that I will boycott this movie. I'm a pretty open-minded guy. After all, I saw "Dogma" and enjoyed it.

But this DaVinci Code shit is too much. And to pass it off as real? That's just offensive. To say that there is any truth to this is actually blasphemous.

If this was about the prophet Mohammad, Dan Brown would have a bounty for his head. As it stands, we Catholics are too guilt-ridden to go about trying to execute anyone. But this is one trend that I'll pass on.

flashbacks and old scars

While I was on call the other day, I had a flashback to a few years ago. It was winter during med school, and I was trying to quit smoking, and I had some stuff happen in my life, and I was thrown into a tailspin. I couldn't sleep and found myself in my church parking lot at 5AM, waiting for morning mass, smoking half a pack of cigarettes.

And I went home and put on my game face, and no one was the wiser. I was bordering on suicidal ideation, and to the rest of the world, it was just another day. No one saw any reason for concern, as I was torn about whether I should go to the ER to get a psych eval.

And eventually, one of my friends noticed, and let me unload on him, and it felt wonderful to have someone there. And it's not often in life you have good friends like that in life.

And it's wonderful to remember that time of horrible depression in my life, and realize that I don't feel like that anymore. And it may not seem like much, but there is something wonderful about enjoying life, and when there is no joy, life can be so very painful.

I was talking to a psychiatrist a while back, and she noted that there are warning phrases people say when confronted with the issue of their suicidality, and the one that concerned her was when people would say something to the effect of: the only reason I haven't killed myself is because it's a sin.

That took me aback when I heard it, because that was how I operated for years. Every day was pretty much a wash, and I'd come home and think, "This sure would be easier if I could just kill myself, and get the next 50 years of pain out of the way."

And it's interesting to look back on all that emotional trauma, and see that everything's healed up, and the scars don't even show. And sometimes, I hear this specious garbage that life's struggles are like the story of Job, and that there are tough times, but it'll all turn out well in the end.

To them I say bullshit. The story of Job ends with him having a new family, new fortunes, but what about his wife and children, everyone he loved, all dead? The lesson is that we do not know what is in store for us in life, and that we must fight, constantly and continuously, and in the end hope that we find meaning in the struggle itself.

And maybe one day we can run our fingers over the scars, remember that time, and see that it was the struggle that made us strong.

Choices

As criticized as the Matrix: Reloaded was, there was actually quite a bit that was very sharp. Talking to some philosophy folk, they actually saw a lot in this movie, and the input was nice.

But the one thing I liked in the movie was when the Oracle was talking with Neo. He asks her if he has to make a choice and she says no. "you didn't come here to make the choice, you've already made it. You're here to understand why you made it."

And for most of us in medicine, that's a mouthful. Because I know that I chose to go into medicine a long time ago, all the way back in high school. And now that I'm a doctor, I've been spending a lot of time trying to understand the why behind that. I thought I knew when I first made that choice, but I really didn't.

Because I'm lonely, and I have no life, and I am tired all the time, and I think to myself why in the world did I decide to do this? And if I couldn't answer that question, I'd have quit years ago.

And it's hard to realize that why I went into medicine, all the stuff I love about medicine, that was all there back in high school. Everything I love about medicine now was there, lingering in the shadows, and it's taken me nearly a decade to discover it.

Why I'm nice to nurses

I'm always very pleasant and friendly with the nursing staff, and try to remember as many names as I can. This is for the two simple reasons: (1) I like to be friendly, and (2) I can get more done if the nurses are on my side. I like to brag (and some attendings have noticed) that I can get a lot of work done without a ton of effort because nursing and support staff find me approachable. It's akin to knowing a guy in the mailroom of a big company.

But for all my bragging, I'm not that efficient, and every now and then, I find myself in a strange situation like my last post-call day. I was writing some orders before I went home at about 7AM, and I was sitting at the nurses station. The nurse across from me was pitching a fit, having a little rhetorical conversation.

nurse: This lady's anxious like anything, and crazy too. How am I supposed to keep her from flipping out with 1mg po ativan? What kind of a useless order is this? What useless resident wrote this order anyway? I mean, c'mon, what a pushover dose. I hate when residents do this. They dump this shit on us and don't give us anything to fix it with. Who did this anyway?
me: Umm... is that the lady in room 5? [nurse nods] That useless resident would be me.

But we worked things out, and it all turned out positively. And that's why it's good to be friends with the nurses. Because she could've just as easily tore me a new asshole.

Antalgic gait

I was out with West Coast a while back, shopping for boots of all things. I'm not a boot guy, and WC's response to this was that I am a boot guy, if I would give it a chance. And so I did. I bought boots over the weekend. They go above the ankle and are leather soled. They are fancy, and I could probably wear them with my suit and stuff.

And so, I decided to try them out. And for the first hour, they were nice. I felt large and in charge, with an extra 3/4" of lift to make me feel on top of the world. However, that hour came and went quickly, and then it was nothing but pain. I haven't worn dress shoes for a day of hospital work in months. I usually wear Skechers or some other pseudosneaker.

And by the end of the day, the intern, my attending, and the nursing staff were all wondering if I'd twisted my ankle, I looked so awkward. But it was all worth it in the end. I went to the golf course, switched into my new golf shoes, and I was hitting for distance. It felt good. High and straight, the perfect swing.

So maybe a little pain in the end pays off. Come to think of it, this is an apt metaphor for the entirety of residency.

Compliments come from the stranges places

"You seem like a really personable person. That's a great quality to have. Y'know, it takes someone that's sincere and honest to be a good doctor. I'll bet your patients love you. You're going to be a fantastic doctor once you're done."

Take a guess who told me this. Student? Colleague? Attending? Fellow? Nurse? All good guesses. And I'd love to hear it from any of them. But those guesses would all be wrong.

The correct answer is stripper.

A well-deserved day off

"Ifinding, what's up with your blog? After reading it, I wanna run out into traffic." This is the subtle way my friends tell me that I've been a tad morose in my blog. I've been working a lot of days straight. My last day off was 3 weeks ago. It's been dragging me down.

So, it feels nice to finally have a day off again. I feel better, like there's a little hope in the world. I'm tired, as I slept only about 4 hours, but it's a good kind of tired, the tired after having fun.

Still, though, I know that there's so much missing in my life. And maybe those things will work themselves out, but for now, I think I'm content with a day off, so I can feel like a human again.

All things being equal

When I wrote this post about deaths in the hospital, a fellow blogger pointed me to a short story called "Zanduce at Second." It's about a baseball player for the Orioles who has managed to kill eleven people with errant foul balls. There's a wonderful line in it: eleven [deaths] isn't really worse than one for me, because one was enough by itself. It doesn't double with two.

I had a patient who was terminally weaned today. The patient was old and had risk factors. The patient had significant, severe disease. By all accounts, it was this person's time. Compare this to this young lady that I was following earlier. She was 30 something, young, without medical problems, and generally well until a vessel in her brain decided to explode.

If you look at things objectively, you'd say the younger patient is far more tragic. She was young and in the prime of her life, leaving behind a family with children, and the children she could've had. Her life was cut 40 some years short. It's awful.

But the thing I've learned is that you can't quantify tragedy. There's no yardstick for it. This old patient and the young lady, one is not more tragic, not more sad. It's all tragedy, and that's something that can't be added or subtracted. In such unequal circumstances, there's always equality in sadness.

May angels lead you in

I was driving into work yesterday, and I was listening to Jimmy Eat World, and the song, "May Angels Lead You In" came on. It's a great song. And I was suddenly bawling, in the parking lot of the hospital. I had to sit in my car for a couple minutes to compose myself.

Maybe it's all the tragic cases I've been seeing lately, with patients dying left and right. And I can't help but remember my aunt. There's just so much death out there, and sometimes it catches up with you. And I'm normally very good at compartmentalizing my feelings, locking them up in a little box and putting that box in the back of the fridge.But not this time.

Sympathy can be a dangerous thing sometimes. Because there are so many tears to shed, and if I were to cry for every sad case, I'd have no tears left to shed.

Don't become a doctor #8 - constant change

Today, we were talking about hypoglycemia, and if you talk to people who finished their training only a few years ago and you'll hear the words, "Hyperglycemia doesn't kill anyone. Better to be high than low." This has been dogma until recently, when several nice studies have shown that poorly controlled glucose in critical patients increase mortality up to 15%. Now, the thinking is the opposite. I've actually told patients that hypoglycemia is the price you pay for good glucose control.

Then, there's pulmonary artery catheters. 4 years ago, this was a bread and butter procedure for internal medicine residents. Now, I don't know any resident that's done more than one. Looking a little further back, there's beta blockers in heart failure, the use of thrombolytics, stenting versus CABG, anti-TTG Ab versus duodenal biopsy.

My point is that medicine is a field of constant change, and not little change. Big change. Talk to a doctor 15 years ago, and if you told him that you thought that his heart failure patient didn't need a Swann and should be on a beta blocker, he'd accuse you of malpractice (and 15 years ago, he'd have been right!).

Some people like fields that are understandable and consistent. Medicine is not such a field. If the thought of continually keeping up with the changing world of medicine scares you, then you'd best stay away.