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)

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.