How do you know?

Perhaps the most common question I receive on this blog is a simple one: how did you know you should be a doctor? Well, I have written no less than 4 times on that subject, and posted a litany of reasons why to avoid medicine.

But the truth of the matter is that there is no way to know for sure. Is there any way to know for sure about any career decision until you've already made it? What I can tell you is this: all the reasons YOU think you would be a good doctor are bullshit. Total 100% crap. Because I had the same thoughts, and it just wasn't true.

I want to help people. I'm compassionate. I care. I had a grandfather who was really sick. Blah blah blah. This is all trite garbage, and doesn't cut to the heart of the matter.

In high school, I decided that I would consider being a doctor. Instantly, my teachers were enthusiastic. They thought I'd be an excellent doctor, as did a few college professors and a boss or two. What did they know? They didn't see my transcript. They didn't read my admissions essay. They knew nothing about my motivations.

In truth, being a good doctor is not one quality, but a myriad. It is compassion, but it's also conviction, empathy, faith, indignation, professionalism, perseverance, reverence, charity, dedication, hope, intelligence, skepticism, forgiveness, anger, and so much more. It is a whole subset of skills and traits that you don't know you have at the tender age of 18.

I realize now that all those encouraging words from my teachers and superiors, it was because they could see in me things that I could not see in myself. I wanted to become a doctor because I thought it would change me, make me different. They saw that the other than some coursework and a stethoscope, I didn't need to change a thing.

I needed that

I saw a patient today, and had some bad news. We talked about what we can do and how to approach it, but ultimately, things are getting worse, and we'll have to see if we can turn things around or not.

As I finished up, he said to me, "Dr ifinding, you gave me all kinds of news today that I didn't want to hear, but I'm glad you were the one telling me."

Thanks, dude. You have no idea how much I needed that.

Quality improvement

Our length of stay is too long. That means on average, we are keeping people in the hospital longer than we should, given their diagnosis. But we will be penalized for bounce backs, which is where a patient is readmitted within a month. So, we need to get people out earlier and ensure they don't come back. Our A1c's are too high. We are not keeping diabetes well enough in check. Our blood pressures are not well enough controlled. We are not getting enough yearly mammograms.

Quality improvement can be frustrating at times, because there are so many places where a quality standard is being imposed, either now or in the future, and many of these standards have no evidence whatsoever that they actually improve patient outcomes.

So let's be honest here. These goals are not to improve quality. They are to save cost. There's nothing wrong with that. We waste a lot of money in health care and trimming our expenditures is reasonable for any business. But I resent the idea that I am not delivering quality care because I don't hit some arbitrary target, or document something so some quality maven can review it.

A few years ago, I had a patient with HTN and diabetes who was passing out frequently. So I changed his meds so SBP was >140 and A1c was >8.0, and he hasn't passed out since. I think he would say that he's getting quality care.

Liar

I have a patient who is a liar. He is telling me a story to get pain medications. I don't have any proof he is a liar. He has no incriminating evidence that I can find. There is no labwork that I can do to prove his pain one way or the other. Without evidence, I am inclined to give him the pain meds. I am willing to play this game. All he must do is play the game with me.

Instead, the staff catch him with secret pain meds not prescribed by me, and eating meals from the cafeteria when he swears that he can't keep anything down. All he has to do is play along, and even that, he can't do.

And that is the sad fact about addicts. He has me beat, and still, he cannot stop himself from ruining it.

Leukemia is an asshole

I am currently reading 'The Emperor of All Maladies' by S. Mukherjee, MD. It is a biography of cancer. I got 20 pages into the book before I had to put it down and walk away for a while. It is tough to read. Only last week I had a patient die from acute leukemia, so it hit close to home, but this book struck a nerve with leukemia. I hate leukemia.

I do not hate diabetes or hypertension. In fact, I love them. If you remember the movie 'Backdraft' there's a nice quote: "the only way to truly kill it is to love it a little." There is a certain love of the pathologic. When I see something going wrong, I know what it is. I know why it does the things it does. I do love it a little.

But acute leukemia I hate with a burning passion. If leukemia was a man, I would kick him in the crotch several times, and then let him get up, and kick him again in the crotch, and then pee on him. THAT is how much I hate leukemia. I hate leukemia because it is totally unfair. It picks on little kids. It strikes hard. It is relentlessly fast. It is cruel. It doesn't care if you've been a good person. It wants you to suffer, and it makes you suffer in all sorts of horrible ways. It is an asshole.

You would be right to say that this is not unique to leukemia. Certainly, sepsis is similar in its tenacity. But with sepsis, it only asks for a cure. If you can treat with the appropriate antibiotic, then the cure is delivered. All I must do is keep the patient alive long enough for the foreign pathogen to be removed.

Acute leukemia is entirely different. In order to kill it, you must also try to kill your patient. You must play a game of chicken: if you swerve, leukemia wins and your patient dies, but if you stay straight, you may kill leukemia but also kill your patient in the process. All the odds are already stacked against you, but instead of other cancers where you think and plan, you must act now. So you destroy what remains of the bone marrow. You pour toxic substances throughout the patient's system. You push the patient to the very edge of death, and sometimes over. And in the end, all that buys you is a 20% shot at being alive after 5 years?

Fuck you, leukemia.

(Of course, prognosis for acute leukemias vary by many, many factors)