Don't become a doctor #21 - haunted

When I was in medical school, a friend of mine asked me if I saw any ghosts in the hospital. No. I don't believe in ghosts. "It seems to me that doctors are always haunted by so many ghosts." I thought my friend was so very quirky, but she was so very correct. We are all haunted by ghosts.

My first ghost was a wonderful elderly lady s/p colon cancer resection and prolonged abdominal ileus. I placed an NG tube, like I'd done numerous times before, and she aspirated, went into respiratory failure, and ended up intubated. My next ghost was a woman with terrible breast cancer who suffered every moment that I kept her alive until her body failed. I have all these shadows hiding in the periphery of my vision: the colon cancer that we didn't find soon enough, the breast cancer that didn't respond to any treatment, the heart attack that happened the day after I did a complete physical, the elective orthopedic surgery who died on the table, the blood clot that I didn't prevent. And it would be nice if these shadows were just that, painful memories that hide in the darkness, but they are more than that. These shadows had names like Evelyn and Erik and Nancy and Steven. They had spouses and parents and children and friends. They had jobs and lives and purpose. And they haunt me because I took those things away from them.

In reality, I didn't kill them. Bad things happen. As long as a doctor is not incompetent or negligent, then there is always a chance that even the most benign circumstance could end badly. Life is not fair. In fact, I've written about this no less than twice already: Perfection and Guilty. And living with the choices you make, that takes some adult sized diapers sometimes, but it's not quite the same as knowing that you took part in an event that resulted in the death of a person. And you have to talk to that person's children or spouse, and tell them what happened. How do you do that without seeing the ghost over your shoulder? If you can't deal with the shadows of your mistakes having names and faces, then medicine may not be for you.

Don't become a doctor #20 - treating the source

​I am fond of telling people that all the advances of modern medicine account for maybe about 3% of the improvement in the health of the human condition. The other 97% of the betterment of humanity can be credited mainly to three things: clean drinking water, sewers, and immunizations. There are some other things too, like labor laws and pollution controls, but pretty much everything we do now in modern medicine is the equivalent of sprinkles atop an ice cream sundae. Your toilet has done more for the betterment of humanity than I ever will.

And really, the future of the improvement of the health of humanity doesn't lie in anything I can do or modify. If I wanted to make the biggest impact in the improvement of the health of humanity for the betterment of the general public, then I would institute universal basic income and mandatory pre-K through 12 education. I can do a lot of things right now: I can treat hypertension and diabetes, I can diagnose and treat complicated medical conditions, but I do not have a pill to treat poverty. I have no prescription for socioeconomic oppression.

Mrs B can't afford her medications. She has Medicare, yes, but she pays a monthly premium for a supplemental plan that only gets her out of pocket expenses down to $10-15 per prescription. How is that going to help her pay for the 8 pills I am prescribing? Best case scenario, that's $80 a month, but she only gets $800 from Social Security, and she spends $500 of that on rent. She literally cannot afford to be healthy. I see her every 3 months for what purpose? The diseases I am treating are not the principal problems of her life. Another $300 a month would make her far healthier than another diabetes medication. Having a blood pressure under 150/90 isn't going to get her electric bill paid. I asked her about it once. 

"I understand that you can't afford to do a lot of the things I'm recommending, but then why keep coming to these doctor appointments? You can save your copay." She was speechless for a moment, like that was even an option. The thought of NOT seeing the doctor is anathema to her. She wants to be healthy. She wants to do better. But she is swimming upstream without a paddle, and that paddle looks suspiciously like another $300 a month in her budget. I do a lot of counseling and education for her, because maybe she can keep up serious lifestyle changes, and maybe that will be an adequate replacement for lisinopril. 

I have a sickle cell patient who is frequently in the ER or hospital. She can't stay in school, can't hold down a job, can't have any semblance of a normal life because for her, a normal life involves spending on average 2 days a month in the hospital or ER. How is she supposed to better herself when she cannot access the tools by which people better themselves? Whenever I see her, I encourage her that she needs to work on avoiding triggers for a crisis. She needs to bundle up warm in the winter. She needs to stay really well hydrated in the summer. She needs to keep active, but not too active. She needs to wash her hands so she doesn't catch any colds. Her life is a constant vigilance to prevent her own body from betraying her. When does she have time for bettering herself, when all of her time and energy is put into avoiding being sick?

In America we always talk about pulling ourselves up by our bootstraps. But really, that assumes you have boots. If you don't have boots, then what? Forget boots, what if you don't have feet? We do not have equal standing in any respect. We do not have equal opportunity, equal adversity, or equal ability. If we do not share equally for the potential of success, then how can we expect people to be successful? So I don't spend much time with the successful. I spend most of my time with the losers on the battlefield of life: the injured, wounded, and crippled from chronic stress or poverty or oppression or injustice. They're the ones calling out for a medic.

The job of physician sometimes involves interfacing with a cold and uncaring world on behalf of someone unable to change their circumstance, and trying to make an improvement in a system that is fundamentally flawed. If you're not prepared to roll that rock up that hill, then think about something else. Because that is what I love about my job, that I get to fight for things that mean something, even if I'm not going to win.

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.

Don't become a doctor #18 - Meaning

When I am on the Internet, I often hear young people thinking about going into medicine because they are looking for meaning. This is a rather altruistic and noble vision, to pursue a career that benefits the world and humanity, and it is one that I held when I was younger, but it is sadly very naive, and very misleading.

Like many teenagers, I really struggled with the question of why do I exist and what is my purpose. It is really the first time we are aware that our lives can have a purpose. So I sought out a raison d'etre. I wanted a mission. Medicine really appealed to me because I could heal the sick, and the role of healer is full of meaning and purpose. If I could just put on the cloak of physician, then I too could have meaning, by extension.

However, the ugly truth is: a job is a job. There is nothing more or less meaningful about any job, and all jobs have meaning and purpose to someone. A plumber gives us running water and sanitary disposal of waste water. Without this, cholera would still be a worldwide killer. A janitor lets us have clean and safe facilities to use, whether at our work or places we visit. A chef prepares food for us for nourishment and pleasure. Every job offers some level of purpose. So the key is not finding a job full of meaning. Having a job full of meaning does not make YOU meaningful. It only gives you responsibilities and expectations.

In residency, I responded to a code for a lady in her 20's. I hadn't been phased by codes in a long time, but she was so young, and with so much life ahead. And somehow, I managed to bring this one back. Even though it was probably more luck than skill, it felt good. It felt like without me, she would be dead. I put everything I had into her case. And that good feeling, it lasted for about 15 minutes before I asked a terrible, terrible question of myself. "What if that was why I was put on this earth, to save that one person? What the fuck do I do with the rest of MY life?"

I know plenty of docs with amazing skills who have saved many more than I ever will, but they hate their lives and are going through the motions, locked into a profession that demands a lot of time and energy and dedication. I have avoided this by making sure I was able to answer to answer one simple question: is what I do meaningful to me? Do I love what I am doing? That is how you find meaning.

Don't become a doctor #17 - a checkered past

When I talk about the history of the United States, I use the word "we". We had a tragic history of slavery and institutional racism. We oppressed and slaughtered the indigenous people of this land. We fought difficult and deadly wars in Europe and Asia. But I wasn't a part of that, and neither were my parents who were immigrants to this country. I could not be more innocent to the checkered past of this country. But I was born here, and am an American, with all the positives and negatives that entails.

This is the part of being a doctor that people do not like to talk about. Being a doctor does not come with a clean white coat. It comes with a painful history. To take credit for all the amazing things done by physicians, we must also own all the terrible things we have done, and still do, and there are so many.

In the name of research, we have done things like the Tuskegee syphilis experiment, where we withheld treatment from participants for almost 30 years after penicillin was discovered to be effective. So egregious was this study that the government has forced any and all human research to be required to meet safety and practice standards, because we couldn't be trusted. And right they were, because we have also experimented on people in other countries, children, prisoners, and many other groups disadvantaged or with diminished ability to consent.

We have behaved like autocrats over the medical system, consistently devaluing and diminishing the roles and responsibilities of not only allied health professionals, but even the patient, to the point where we actually had to declare that a patient has the right to consent to treatment. Because we have, on so many occasions, fought this very point.

We have practiced our trade under the influence of business and industry, accepting benefits, gifts, and perks from all sorts of entities to influence the appropriate care of patients. There are no free lunches, but forget lunch. It was only 10 years ago that pharmaceutical reps could get a doctor vacations, trips, and outright money.

And still, we cheat patients, insurers, and Medicare out of money, to the point where President Obama's administration has stopped literal billions of dollars worth of fraud to Medicare. It's so bad, CMS has made a YouTube video about it.

So if you're coming into the profession of medicine, know that the ethical standard has now been set high, extremely high, because any less is not acceptable. And because we have done such a miserable job in the past of meeting any standard. If you're not willing to own the dark past of medicine and the failings of our peers, then you have no business enjoying the privileges of medicine.

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.

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?

Don't become a doctor #14 - Uncertainty

The first time anyone told me that something was unknowable was in science class when I learned about the Heisenberg Uncertainty Principle. You cannot know the exact momentum and position of an electron at the same time.

Well, surely, with better tools and more precise ways of measuring... "No, no, no, you don't get it!" My p-chem professor had crazy, uncombed hair and he had missed a button on his shirt. All the buttons were off, so it was hard to take his words seriously. "A thousand years in the future, with the best tools available, we will never know."

Medicine is not without its own uncertainty. And that doesn't sound so bad in an academic sense, but it's not very comforting to patients. How do you tell a patient that you don't know? I don't know what's causing your abdominal pain. I don't know if it's from your heart or if it's acid reflux. I don't know.

As a practicing physician, I've gotten used to it. The students seem to have a much harder time with it. As a resident, I worked with a group of students, and uncertainty was a problem...

"So, is it Buerger's Disease?"
"Excuse me?"
"The case from this week, Buerger's Disease, right?"
"Oh, the case. There's no answer. It's just an exercise."
"But we were supposed to think about Buerger's Disease."
"It's in the differential, but there are lots of possibilities."
"But it's really Buerger's."
"Well, there's no answer."
"How can there be no answer? It's Buerger's Disease!"

In medicine, there are lots of questions where we never get any answers: poorly differentiated tumors, diseases without any diagnostic tests, all sorts of situations without clarity. Sometimes we spend time and energy to try to find the answer. Sometimes we don't even bother. But the truth is that in medicine, there is uncertainty on all sides.

Don't Become a Doctor #13 - You know too much

There's a phrase in medicine: zebra hunting. When you hear the beating of hooves, think horses, not zebras. What this means is that common things occur commonly, and so when presented with a set of symptoms, look for the common disease first. Even an uncommon presentation of a common problem is more likely than a common presentation of an uncommon problem. If you go looking for the unlikely instead of the obvious, you are hunting zebras.

And that's all well and good until it's your own friends and family. With patients, you can play the odds, calculate the risk, give people choices. With family, you cannot help but assume the worst, because you have seen the worst. It's never a simple cold: it's pneumonia. It's never a headache: it's an intracranial hemorrhage.

You have seen too much. You have been exposed to the worst case scenario on a daily basis. You have seen breast cancer fungate. You have seen ischemic bowel. You have seen everything wrong that can happen to the human body, and the slightest hint of such a fate sets off all sorts of alarms. It is too great a risk to hope for the best.

Having all the knowledge and trying to use it on loved ones, it is paralyzing. It is an exercise in fear. It is reading NTSB safety reports while on a plane flying through turbulence. You can only see the worst possible outcome. And that is part of what it is to be a doctor.

Don't Become a Doctor #12 - Limited resources

One of the main principles of medical ethics is something called distributive justice. What it means is that resources should be allocated as fairly as possible, and when resources are limited, they should be aimed towards bringing the greatest benefit for all, not some.

When students think about distributive justice, they often call to mind health care expenditures and waiting lists for specialists. They think of MRI's and other expensive tests. It is a little detached, but the truth is that distributive justice is a harsh reality in medical care.

The easiest example is mass casualty situations. The first rule of triage is treat who you can save. If you can't save them, then don't waste your resources. It's cold, but it's society's competing interest.

But you don't have to have a mass casualty to find limitations in resources. I have been in a lot of tough situations as a resident. I've had a full ICU and patients needing a unit bed. I've had simultaneous codes. I've had three patients all go into respiratory failure at the same time. There are a lot of tough choices to be made there.

Now, most non-medical folks cringe to hear things like that. 'We need more nurses' or more financial support, or more beds, or whatever else. They mean well, but they miss the point. There will always be limits, but the most precious resource isn't any of those things. As a physician, I am the limited resource. My attention is a valuable commodity, and how I allocate it can be the difference in who lives and who dies. That is a tough call to make, and if you want to be a doctor, it's a call you'll have to make.

Don't become a doctor #11 - perfection

I was in an elevator one day, and I couldn't help but overhear two neurologists talking (elevator conversations are bad! Even when it's an elevator full of doctors! Don't make me call the HIPAA police!). The only part I caught was one saying, "The PCP really dropped the ball. It was textbook HSV encephalitis."

Just as an aside, herpes simplex virus (either the cold sore or the genital herpes variety) can rarely INFECT YOUR BRAIN, and if you manage to live through that, you'll usually suffer some major neurologic damage.

I was completely stunned at the boldness of the neurologist's statement. But I'm sure that this PCP doesn't need a couple neurologists beating him up. Probably doing a good enough job himself. I know I would.

In medical school, one of my professors told me something wise. "Ifinding, I'll bet you think you should be right 100% of the time, because when you're wrong, people suffer, and maybe die. But guess what? You'll never be right 100% of the time. No one can be. We're human. In fact, you only need to be right 60% of the time. That's what the USMLE says (182 out of 300 on Step 1). I think that the most admirable goal would be 90%. If you can be right 90% of the time, then you'll probably be the best doctor you know. And when you fuck up, then you can say to yourself that you're allowed to be wrong one in ten times."

That's a really easy concept when you're a student, and the only thing at risk are your grades. It's a lot harder when you're trying to decide if it's pericarditis on EKG or an MI. And after a while, you learn painfully that you will be wrong sometimes, and the best you can do is plan for the worst.

So if you can't deal with being wrong sometimes, then stay away from medicine. I long for the days when being wrong meant losing points on my boards. Now when I am wrong, people get hurt, and people die. There aren't many things in medicine that feel worse, but the truth of the matter is that it is unavoidable. No one is 100%. No one.

Don't Become a Doctor

I have been getting a LOT of links lately, and I appreciate the traffic, but I've come to realize that most of the links are for the 'Don't Become a Doctor' series, which I enjoy writing (I am still writing it), but I can see that there probably should be some sort of table of contents or main link page for ease of navigation and for the sake of links.

I just want to be absolutely crystal clear to the new readers out there, as I have gotten a lot of comments and mail about how pessimistic this series is, and how I must hate my job. I LOVE my job. I could write 40 posts on why someone should become a doctor. That's not the point of this series. Because you don't need help coming up with a list of reasons why being a doctor would be great.

To reiterate the purpose of these posts, I think that people spend a lot of time talking about the admirable qualities needed to be a doctor, and the motivations. We talk about the nobility and altruism of medicine, but rarely do we ever talk about the faults and shortcomings. So, I created this series as a guide, so that the eager pre-meds of the world can see the downsides too. And there are good sides, and it can be great, if it is what you want. But if all you are looking for is prestige and money and an easy life, I hope you might reconsider.

But please don't be too disheartened though. If anything I say actually discourages you from being a doctor, post a comment and let me know. I have no right to take your dreams away. I should be accountable for that. And if your dream truly is to be a doctor, I'll be more than happy to give you a litany of reasons why I think medicine is wonderful.

(1) The very worst in people
You only see the very worst of the world. Those are the folks that need our help.

(2) The doctor is OUT
it is very hard to be emotionally available for the people in your life, because you've learned so very well how to suppress it.

(3) There is no cure
We can't cure crap (literally and figuratively)

(4) A cruel mistress
It finds its way into every part of our lives, and continually pulls.

(5) Thou shalt not opine
Your professional opinion is not something to just throw around or wear on your sleeve.

(6) Laughing at the pain of others
What's the alternative? Go home and cry our eyes out every day?

(7) Thankless
All too often, I've taken exceptional care of someone, and been thanked with curses.

(8) Constant change
Some people like fields that are understandable and consistent. Medicine is not such a field.

(9) It's all your fault
Somewhere along the line, we decided as a society that the buck would stop at MD

(10) Hate me
If you want to be a doctor for the prestige and admiration, you're wasting your time.

(11) Perfection
No one is 100%. No one.

(12) Limited Resources
Distributive justice is a harsh reality.

(13) You know too much
You cannot help but assume the worst, because you have seen the worst.

(14) Uncertainty
In medicine, there is uncertainty on all sides.

(15) Guilty
Shouldn't someone be held accountable? And if I'm the patient's doctor, shouldn't it be me?

(16) I've got a secret
Patients have told me things, dark and secret things...

(17) A checkered past
Being a doctor does not come with a clear white coat.

(18) Meaning
the ugly truth is: a job is a job.

(19) Biased
He is still human, and still deserves to be treated like one.

(20) Treating the source
The diseases I am treating are not the principal problems of her life.

(21) Haunted
doctors are always haunted by so many ghosts.