Don't become a doctor #16 - I've got a secret

Confidentiality is a legal requirement in medicine. There are only a few relationships where your conversations are protected by law: your spouse, your priest, your lawyer, and your doctor. We are entrusted with private information, and we have to protect it.

There are exceptions, instances where for the welfare of another person or the general public, we must disclose information, but otherwise, we are bound by professional duty and law to keep our information secret. Generally, this prohibition covers medical illnesses, medications, frailties, personal identifiers.

But that's just the tip of the iceberg. Patients have told me things, dark and secret things, long hidden, told to no one on the face of this earth but me. I have heard stories of rape and incest, physical and emotional abuse, spousal arguments, infidelity, greed, maliciousness and cruelty. I have had a husband and wife come in separately for STD screenings. I have had wives come in with injuries from their husbands. I have had patients tell me about being sexually abused as children.

When someone tells you a secret like these, you will not know how to feel. There will be anger and outrage, pity and sadness, compassion and anxiety. And as a doctor, you will want to fix the problem. But that is not what has been asked of you. You were asked to keep a secret, and that is all.

If you cannot live beneath the burden of all these secrets, then maybe medicine is not for you. But it is these secrets that make medicine into an art.

As as aside, if there is one thing that I hate, it is the abuse of children, and if it were possible to hate one particular form of child abuse more than others, it is child sexual abuse. Morality aside, the health consequences are staggering: insomnia, PTSD, eating disorders, sex disorders, anxiety, depression, substance abuse, anger and impulse control issues, headaches, chronic pain, fibromyalgia, chronic fatigue syndrome, irritable bowel syndrome, asthma, obesity have all shown higher rates in victims of child sexual abuse.

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Just a snapshot

One of the truly frustrating things about being a doctor is that it's hard to really understand someone's life. We only get to see little glimpses into a patient's life, like looking at a single frame of a movie and trying to tell its plot.

I had this experience recently with a patient. He is smart, pleasant, has a good job, and attractive (I'm not gay, but in my humble assessment). And he is single. I feel like if he is single, what are my chances? He has every advantage over me in the dating world, and he's striking out. Is he a jerk at home? Is there something else there?

I had another patient who is having marital issues because of his medical problems, and I don't get it. I found him to be really pleasant and engaging. I can't believe someone like him would have relationship issues over medical things.

It's tough to understand these situations, and I am picking relationship stuff because it's relevant to me, but I have no doubts that there are answers. It's just that I don't have them, and it's not my place to ask. But it's unsatisfying to go home and know that there is a whole side of a patient's life that I don't know and probably never will.

Cruel summer

This has been a hot summer, and as a result, we've seen sickle cell patients running into all kinds of trouble. Sickle cell is an annoying disease in that everything can set off a crisis. If it's too hot or too cold, too much exercise or not enough, dehydrated or drinking the wrong liquids... there are so many triggers and they're all common sorts of things.

Because sickle cell patients have been running into so much trouble, the nurses and physicians are complaining about them and their unbelievable consumption of opioids. I've seen some patients take in enough dilaudid to put down a horse. People accuse them all the time of drug seeking and inappropriate use.

The thing about having sickle cell disease though is that it is rife with chronic ischemic pain. That hurts. It also lowers life expectancy by decades with median age at time of death in the 40's. That sucks.

I hate giving out huge doses of opioids as much as the next guy, but pain is pain, and if I had sickle cell, then I'd want a little more dilaudid too.

Human lie detector

The show 'Lie to Me' is based on the idea of microexpressions, and if you can accurately see and interpret these findings, then you can be a human lie detector.

I seem to have a knack for this, as I am usually pretty good at spotting the liars, the folks who are outright dishonest about their history of medications usually. But they usually make it pretty easy when they tell me they need 6 xanax a day and oxycontin is the only medication that relieves their chronic back pain.

Knowing when someone lies to you is a remarkably depressing experience. It is one thing to be ignorant of what someone is doing, but to see the lies, that hurts. Still, one thing that people really have a hard time with is the manipulative patient who is actually in pain. I know that he's mean and demanding and wants dilaudid 4mg IV q2 hr, but he is s/p fasciotomy for necrotizing fasciitis. I think he deserves some pain medication, even if he is a jerk.

New design

I changed the site design in order to make use of a variety of features that Blogger offers. I am sorry if you liked the previous look better. I will be tweaking this from time to time until I like it. Hopefully, the sharing options and fixed width columns will make up for it.

Are you listening?

One of my patients was raving about me today to the staff. 'Oh Dr ifinding is the best doctor I've met! He really listens and treats me like a person!'

I think it has to be the saddest commentary on the profession of medicine that I was exceptional because I treated her like a human being. It's ridiculous, but we as a profession have really hurt ourselves. If we could just listen for a few seconds to what people tell us, then that would make all the difference. What earned me all this praise from this patient? She didn't want to take insulin more than once a day. That's it.

But there is a trick: she never said anything about concerns with insulin. That part I had to deduce. But is that really so hard to figure out?

backup plans

When you talk to doctors from my generation, we all had backup plans. I was talking to a colleague, and her plan was to get a PhD in neuroscience. My plan was to work in pharmaceutical development. I was even looking at jobs with a few pharmaceutical corporations, back when my med school app process wasn't going so well. A friend of mine actually got a Pharm D. Another friend pondered social work.

The thing we all appreciated is that being a physician is a privilege and an honor. It's not something you deserve. There was no 'game' or 'trick' to getting into medical school. The entirety of medical school admission can be summed up in one question: why should we let you be a doctor?

Don't become a doctor #15 - Guilty

Recently, I had a patient who died suddenly and unexpectedly after I had seen the patient in the morning for some muscle aches. I reviewed the case to see if there was anything I could have done to prevent it. Did I miss a lab result? Was there some sign that should have been picked up? Were appropriate protocols and guidelines performed? I was convinced I'd find something, some piece of evidence that would've shown that if I had paid more attention, this person would still be alive. It was preventable and avoidable... wasn't it?

One of the strange things about being a doctor is that, despite all the rhetoric about malpractice and liability, it's hard not to feel guilty when bad things happen. You can't walk away without a little blame. This happened on my watch. We go into medicine to help people, so when shit happens, it's hard not to feel responsible. This person trusted me to protect them from a bad outcome, but it happened, and I didn't even see it coming.

A lawyer friend of mine tells me that physicians are terrible in court because we want to take blame. But shouldn't it be my fault? Shouldn't someone be held accountable? And if I'm the patient's doctor, shouldn't it be me?

It took me a long time to figure out that one of my favorite aspects of adult medicine is that so much of it is lifestyle dependent. When something bad happens, I can go home at night and think to myself it may have been something I did, but it may also have been the patient's bacon cheeseburger lunches for 35 years. There is some amnesty in adult care.

If you are disturbed by the thought that your actions (or lack thereof) could hurt someone, or even kill them, then welcome to humanity. But in medicine, even when you are blameless, you may still find some guilt in your heart. And that is medicine. If it happened on my watch, shouldn't it be my fault?

Bachelor's in pre-med

I was reminiscing with a friend about the 'good old days' when we were both chemistry students. He's a chemistry professor now, and complains endlessly about pre-meds. He teaches one of those required pre-med courses.

Pre-meds (and medical students for that matter) are pretty high maintenance. 'Is that going to be on the test?' should be the pre-med motto. There's no learning for learning's sake: everything is goal directed. I need to ace biochem so I can rock the MCAT so I can get into Harvard Med so I can get a residency spot in derm so I can do cosmetic derm and rake in a seven figure salary. At no time is there any enjoyment of the process. It is facts and test material and hoops to jump through.

The pièce de résistance is that some schools offer a degree in pre-med. This is, in my opinion, ridiculous. When I was in college, I took all the tough science courses. I took all the sections for real science majors. This is because I wanted my degree to mean something, and feel like I'd accomplished something. I didn't want to spend four years earning a degree in 'pre' anything.

Learning about electron affinity, valence shells, and lattice structures may be entirely useless to me now, but that doesn't mean that it wasn't worth learning. Reading the Iliad was useless too, but I wouldn't give it up either.

EDIT 1/4/11
When I mention a degree in pre-med, I am referring specifically to a Bachelors in Pre-Medical Studies, which is an actual degree offered by some smaller colleges, but not at most universities.
I know that med school has a lot of requirements. I took them too. But part of life is enjoying the process. I enjoyed organic chem. It was fascinating. I took a geology class and loved it. I got a letter of recommendation from my Communications prof for one course that I got a B in. I took 3 or 4 classes that had nothing to do with my 'hard science' major because I wanted to learn. The point of education is to learn, not to earn a grade.
One of the hardest things to explain to pre-meds is that grades and MCATs aren't nearly as important as being a decent and honorable person. And if you can figure out how to convey that information truthfully to an interview committee, then there isn't a med school in the country that wouldn't accept you.

It's not my fault

Most of the diseases I see are lifestyle related. Diabetes, hypertension, cardiovascular disease, even colon cancer are all heavily influenced by lifestyle. Ultimately, most people earn their way into my care. So, it is pretty frustrating whenever I meet a patient who refuses to take responsibility for their health.

I met someone who took this to comical levels. He had an excuse for everything. No one wrote him prescriptions. He was blacklisted by local doctors. His PCP wrote for the wrong pills. He was never given appropriate dietary advice. He was never told french fries are bad for you. He was told his appointment was for 4 PM, not 3:20 PM. It was our fault. It was his doctor's fault. It was everyone else's fault.

The problem is that I just don't care. People spend so much time worrying about who is at fault, but the only thing I care about are the results. What difference does it make who is to blame? The only thing that matters is that his A1c is 13.6% and is LDL cholesterol is 171.

Your body is like your car: what you do at home has a whole lot more to do with how your car performs than anything a service station does.


I am convinced that the folks in Washington do not understand that primary care is currently an intensely unpopular choice of profession. There have been some massive shifts in popularity of some medical specialties, but the universal theme has been that primary care has waned.

People think it's all about debt burden, but it's not. It's nowhere near that simple. And if you want to prove it to yourself, look at the hospitalist vs the traditional internist. Finding traditional internists (folks who do both clinic and hospital work the same day) are a dying breed heading to extinction. In fact, primary care internists are harder to find in general. And it's no wonder.

Seeing hospital patients in the morning, doing clinic in the afternoons, call every 3 or 4 days, who wants that lifestyle? Compare that to the hospitalist, who is on one week, off the next. A week off is virtually unheard of in traditional practices, but it's the norm for hospitalist work. And hospitalist pays better too.

People fondly remember the days of doctors who do home visits, with a nostalgia entirely unwarranted, and I expect that in our lifetimes, patients will reflect on the days when their regular doctor would see them in the hospital too. But that is going the way of the dinosaurs.

And the true shame of it is that a lot of hospitalists burn out, even with the free time and the extra pay. And that's why I tell people to pick something that makes you happy, because money and lifestyle can't make you happy. It just gives you more time and resources to hate your life.

Match Day

Thursday (today) is the Match. Students found out on Monday whether they have a spot or not, and the unfortunate had to go through the Scramble on Tuesday and Wednesday, and today, everyone finds out their fate. It is a far more ominous day than any other day in medical school.

I have some patients who have children in medicine or are pre-meds, and they are pushing their kids towards subspecialty careers, which makes me sad as an internist. And the thing that I want to tell them so desperately is that there is no price tag on being happy with your job. I could've been paid far more than I'm earning now, but I love my current position, and I don't want more money. I'm happy now.

So, to all your MS4's out there, I hope you don't get what you want, but that you get what will make you happy. And those two may not be the same thing, but when it is, everything else falls into place.

The toll of medical school

My New Year's resolution this year was to get back to healthy living. I spend countless hours talking to people about improving diet and exercise, and ways to change lifestyle to improve health. And it's good advice, and some of my patients are quite successful. However, it's advice that I should probably heed.

Before I started my third year of medical school, I ate healthy. I bought fresh produce. Turkey was my favorite meat. I ran a few times a week. I worked out a lot. I was probably in the best shape of my life. Then came clinicals.

Since that fateful July 1st, my health has gone into a tailspin, because after a 30 hour call, I just didn't have the energy to do anything else, muchless exercise. And every year, I've gotten fatter and more complacent. So I have finally decided that it's time to change. And so I am returning to healthy living.

And I think to myself that medical school has taken a considerable toll on my life. I was physically great. I was mentally stable. I was doing quite well. And as much as I enjoy being a doctor now, it's with the knowledge that I spent so much time taking care of medicine that I forgot to take care of me.

Editorial notes

So, I should note a couple things. I've mostly been ignoring the purpose of tags on posts, but will actually start using them. I will be blogging in 4 main categories: patient care, medical school, first aid, personal life. First aid will be where I dispense unsolicited medical advice. I am hoping that I can start posting once a week, and giving myself some categories will certainly help with that.

EDIT - Make that 5 categories: patient care, medical school, first aid, personal life, and careers in medicine.

All apologies

One of my patients threw a fit. It was really disappointing because I had serious issues with this patient, but this person demanded a personal apology. I did it, and licked my wounds. Truth be told, I don't really care much.

One skill that I picked up in med school during my clinical years was that when it comes to patients, leave your ego at the door. I've had patients yell at me, call me names, disparage me to my face. I just sit there and take it in stride. It's not worth getting angry about.

So apologizing isn't really all that difficult. The only regret I have is that in medicine, the customer is not always right. And it seems like whenever I try to be a good doctor and order tests and medications appropriately, that's when I end up in trouble. And it would be so much easier to just order the needless test, give out the unneeded antibiotic.

But easy doesn't make it right. And the key in all things is whether I can go to bed with a clear conscience.

Empathy is such a simple skill

A lot of patients like me, not because I'm a good doctor or because I'm terribly friendly. I'm not even all that good at explaining things or 'shared decision making.' My one skill that has pleased my patients is simply that I try to be empathetic.

Many doctors advise caution about getting too emotionally involved with patients, and that it can suck you in, and it gets dangerous. And that's true. Empathy though is a very simple skill, and I think it's really a shame that doctors are so bad at it in general.

Empathy is trying to understand where someone is coming from. I saw someone today who was refusing tests and generally being quite difficult, but her life was spinning out of control with all sorts of new and scary diagnoses, and she was afraid to go further, afraid what the next test would bring.

I am not psychic. I found out by asking her. She told me that she didn't want anymore testing. Why? Because all the testing so far was not good. Well, if I was in her place, I'd be pretty scared to find out what the next test showed too. And I told her that.

I know it sounds trite, but the key to empathy is treating patients like people. Only a doctor could talk to someone about their dead wife, and then in the same breath ask about immunizations. It's no wonder that nurses are generally more appreciated than doctors, and view themselves as patient advocates. Doctors treat disease. Nurses treat people.

I saw a patient today and we talked about coffee for a while, and I think one of the nicest pleasures of being a doctor is meeting all sorts of interesting people. If I had to offer some advice to other docs, it would be that if you stop seeing people and start seeing diseases, it's time to retire.

Doctors say the darnedest things

When I was a student, we were encouraged to have a 'thick skin' because attendings, residents, interns, nurses, social workers, MA's, PT's, and custodians all tended to lash out verbally at medical students. And it didn't really matter how good you were, or nice, or helpful. Eventually, someone would chew you out for no reason other than you are a convenient person to yell at. People have more scruples about kicking a cat.

I remember the times this happened to me. I was publicly humiliated by one attending at a conference for asking the drug rep a question. One surgeon threatened to make me do M&M, since this patient's imminent death was all my fault. One day I was assigned to eight patients in the morning, and I couldn't see them all before rounds, and the resident told me that I was lazy and useless, and should seriously consider dropping out of medical school. I strongly recall one attending who spent 20 minutes on rounds screaming at one intern until she broke down crying.

So when I graduated medical school, I promised myself that I would not perpetuate this horrible rite of passage. I would be nice. And that's such a noble thing to say to oneself, but in reality, I was just as bad. As a resident, I made no less than two interns cry, and there are a few students who likely went home and blogged about what a jerk I was after getting dressed down by me.

The problem for me is that I expect a lot out of people. I expect 100% all the time. That is the effort that I gave as a student and resident. That is the level I want. But my 100% is not the same as other people's. And it's not like I had to miss my daughter's soccer game or my wife's birthday.

When I finished residency, I promised myself that I would try to be more understanding. Being nice is tough. When you're pissed off, it's hard to turn that into nice. But as long as you're willing to listen and try to understand, even the most withering criticisms can at least be constructive.


Don't get me wrong. I never want to go through the hell of med school again. One of my friends was thinking about a second career in medicine, and I honestly think that if I had to go through medical school and residency again, I would quit. It's too hard to do twice.

But there are some things about medical school that I miss terribly, because it's stuff that I can't get back. I remember my first perfectly done suture. It was a vertical mattress, and the tails were just right. I remember following a running suture during a vascular surgery. Afterward, the surgeon told me that he'd never let a med student touch a vessel he was working on, but he trusted me. I miss the excitement of seeing my first trauma, a 20 yr old female MVA, no LOC, FAST scan negative, c-spine cleared. I miss the novel sense of horror upon seeing an apple core lesion on CT abdomen.

But most of all, I miss that moment in medical school when I was not an internist. I wasn't sure what I wanted to do, but I knew that I was capable of anything. It was entirely within my power to pick my medical specialty.

There was a very similar moment that occurred in college. I remember it exactly. It was 6:54 PM and I was getting out of chemistry lab. It was twilight, and as I walked home from lab, I stopped at one particular tree about 40 yards from the chem building. At that moment, I could be whatever I wanted to be in life. I could be a lawyer, doctor, investment banker, veterinarian, librarian, computer programmer... All my life and education had led me to that one point in time where I could choose, differentiate. I was a stem cell.

That is what I miss about medical school. I don't miss the studying or the work. I miss being pluripotent.