Authentic

How long does it take to know someone? How long does it take to be more than 'a doctor' and become 'my doctor'? I have a patient who I've seen for the past 7 years who tries his best to never see me. I have a patient who saw me one time 3 years ago, and he thinks the world of me.

I don't know what it is that I am doing. I don't actually know the recipe for good rapport. Is it listening? Is it patience? Is it time? Is it empathy? I do what I think is right, and is that it?

I know another doctor in town. She is a piece of shit. I have nothing but contempt for her. She is not incompetent. She is not fraudulent. She is lazy. She doesn't follow up on tests in a timely fashion. She doesn't educate her patients. She doesn't start meds when it's appropriate. She is careless and reckless because she cannot be bothered to do her job.

Being an internist requires a certain level of anal retentive behavior. It requires diligence and conscientiousness. It requires that you are, at least some sense, authentic. And maybe that's what people want from their doctor. That at the end of the day, they know that I gave a damn.

The Lord taketh away

Finding cancer is the worst. It never goes well. I remember one week in the hospital, I admitted 4 patients with new cancer diagnoses. There was the 80 year old with metastatic colon cancer with bowel obstruction. There was the family man with multiple myeloma. There was the young father with AIDS associated lymphoma. There was the college coed with AML. Everyone had a tragic story. Everyone had a bad hand to play.  

Last month, I found four cancers. Three of my patients thanked me, and I can't figure out why. Why are you thanking me? You have terminal pancreatic cancer. Why are you appreciative of my effort? You have metastatic breast cancer. This is not the time to thank me. This is not the time to be grateful. You should blame me. Why didn't I see this coming? Why didn't I stop this from happening? Don't thank me. Don't. You have every right to be wallow in self-pity. You have earned the right to be furious. Don't be grateful.

I realized that I really have no understanding of what it means to have cancer. I cannot understand why people are thanking me, as if there is anything to be thankful for. I am Job's messenger crying out 'All that you have and all that you love is lost, and I alone have escaped to tell you!'

And I watch as my patients rend their garments and worship, 'Naked I came from my mother's womb, and naked shall I return. The Lord giveth and the Lord taketh away. Blessed be the name of the Lord.' And much as I imagine Job's servant, I am dumbfounded.

Don't become a doctor #19 - biased

I have many gay patients. One travels over an hour to see me because he says I'm the only doctor who treats him like a person. One sees me because he has a crush on me. In real life, I've had gay men hit on me, so I have some basis for comparison. I don't do anything specifically to draw in gay patients. They just find their way to my practice.

In my heart, I have a lot of sympathy for my gay patients. It's a tough world out there, and being gay doesn't make it any easier, and especially now that there are so many doctors who let their faith and beliefs dictate the care they will provide. One of my gay patients told me how his previous doctor told him that he deserved to have HIV because of his sinful lifestyle. Wow. Yikes.

It's not my job to preach. It's not my call to say who is damned and who is saved. I don't get to look at a person and decide he is guilty or innocent. My job is to deliver medical care. And sometimes that means giving women birth control. And sometimes that means teaching a teenager about condoms. And sometimes that means talking to my pregnant patient about abortion. And sometimes that means that I see people who do things or believe things that I don't like. And that doesn't even cover gays. I like gay people. I can't believe we have devoted so much time and energy to trying to deny rights and freedoms to people who love each other.

I have a patient, he is a convicted rapist. He served his time, and now works a part time job and is 'retired'. He has several chronic medical conditions. His past doesn't mean that his diabetes doesn't need to be treated. He is still human, and still deserves to be treated like one.

If you cannot put your biases aside, and treat all people as deserving of medical care, and care for them without judgment, then you're probably best off staying away from medicine. You are not a priest. You job is to provide medical care appropriate to the patient, not your biases.

Indignation

There are some days where you discover what kind of doctor you are, and then some days where you discover what kind of person you are. I saw someone else's patient in the clinic for a sick visit, and her chart was a mess. Her medications were jumbled and erratic. Her diagnosis list was cluttered and with multiple duplicates. She had labs and diagnostic tests that were not reviewed. I managed to get a few things straightened out, her chronic medications sorted, and hopefully, she will do fine, but it's hard not to feel a little indignant.

In reality, what does indignation get you? Nothing. That smug feeling of self-satisfaction and superiority, it is comforting in the moment, but it does not give the patient a better outcome. It doesn't lower A1c. There is pride in your work, and it's good to have a sense of ownership and pride in what you do, but indignation? It is worth the paper it's written on.

There is always someone who will do a better job, and someone who will do worse. That never changes. Wanting to do better is great, but being better because you've pushed everyone else down doesn't actually improve anything.