Truly excellent post over at NY Emergency Med about diagnostic conundrums and corners that shouldn’t have been cut in the ED. This is the sort of thing I love!

We had a lecture by a palliative care doctor today, who amidst his talk threw in one particular anecdote that really hit home. I’m actually just going to tell the story and leave it at that; take from it what you will.

The doctor was taking care of a 30 year old Internal Medicine resident who had recently been diagnosed with metastatic cancer. The prognosis was very poor; neither of them knew that at the time, the resident had only 3 weeks to live.

The doc asked what the most important thing in his life was; what he had left to accomplish before he died. The resident thought a while, and then responded.

I’ve lived my entire life wanting to be a doctor. I worked hard in high school and college to get in to medical school, really missed out on a lot of friendships. Then in medical school I worked even harder, because I was where I had always wanted to be. My wife and I got married during residency, but because I was so busy, we never got to go on our honeymoon. I love her to death, but I haven’t had time to spend with her. That’s the one thing I want, more than anything, is to be able to go on our honeymoon before I die.

There was a glimmer of hope that chemo would stave off the cancer for a while longer, so the resident elected to undergo one last, fatal dose. The complications were too much for his system, and he died soon after, never having gone on his honeymoon.

Well, it’s struck again, the dreaded apathy.

It’s interesting, as I look back through my med school career. At first I remember being totally excited to learn, to understand, to really study our coursework. Anatomy, neurology, physiology… that was the stuff I loved in college, and being able to study it and apply it to other people? What an honor, what a privilege!

The grind slowly caught up with me. I studied too much, took the “work hard, play hard” mantra too much to heart. I would sit on the couch with a beer, a sleeping pill, the TV blaring, and my computer fired up simultaneously just to relax. I started making jokes that I used coffee as an upper in the morning and beer as a downer at night… but I wasn’t joking.

I finished Boards – god knows how – and thought to myself finally the long hours, the stress, the constant feeling that I should be doing something productive would stop.

3rd year rolls around and you realize that for all the studying you may have done during years 1 and 2, you still don’t know shit. Attendings pimp you on arcane knowledge from their specialty they’ve been practicing for 40 years and are shocked when you don’t know it. End-of-rotation exams are brutally hard and require you to diagnose, treat, and manage 100 patients in about 120 minutes.

On top of it all is the knowledge that everyone you work with… interns, residents, attendings… are all going to grade you subjectively on how well they thought you did. So you put on your smiley face, pretend like ophthalmology is the most awesome field EVER and go to work every morning, starting on average at 6AM and finishing around 5PM.

It is brutal, and exhausting, and sometimes honestly I wonder if it wasn’t a huge mistake to go to medical school. I’m not asking for sympathy here, by the way, but instead hoping that some of you nod to yourselves while reading this and go “yeah, I know where he’s coming from. I’ve thought the same thing to myself from time to time”.

Listen, sometimes you get that patient who comes along and just makes it all worthwhile. But sometimes you punish your body, mind, and soul for some asshole who treats you like crap and expects you to FIX EVERYTHING WRONG WITH ME even though he’s not fixable.

I’m a person too, folks. I like sleep, and food, and friends, and family. I’ve lost a lot of that these past 3 years… and sometimes the field of medicine just isn’t rewarding enough to make the sacrifice worthwhile.

I suppose the reason I write this now is that I have really, really been enjoying internal medicine- I like the diagnosis, the management, the primary care aspect. But I see my interns and residents getting no sleep every 5th day (and if you aren’t a meddie, imagine that for just one second. No sleep every 5th day for the next 4 years of your life… plus little sleep the rest of the time) and frankly, I don’t know if I want to do it.

So, here I am again, thinking about the decision between doing what I love and doing something where the lifestyle doesn’t suck. There’s a damn good reason people go into pathology, anesthesia, radiology, and dermatology. You work real people hours, and you get paid a decent salary.

After all this time and energy, don’t you think we deserve that?

Figure 1: A foolproof analysis of health vs. hospital stay.

As is obvious from the figure above, most some people who are admitted to the hospital are fairly sick on admission, starting at point (x) on the curve. We load them up with antibiotics, fluids, and vitamins, and usually by day two (y) we’ve made them better! Hooray! Everyone is happy, they go home and tell their family how great the doctors were, we go home and try to relax by drinking our livers into submission.

My concern today is patients who go from (y) to (z). You see, everyone most people some people in the hospital are sick, which means that it’s an ideal place to swap diseases. Think of it as day care, but for the elderly.

Problem is, the longer you stay, the more likely you are to catch something REALLY nasty, especially since you’ve got doctors, nurses, and techs walking around poking fingers into every orifice you knew you had, then forgetting to wash their hands, then repeating the same on the next patient.

Patients are always surprised when I try to kick them out (“but doctor, I’m still bleeding copious quantities of bright red blood from my ass!” or “but doctor, my body is rejecting my own heart and I can’t breathe without a ventilator!”)… but what they fail to realize is that if you weren’t sick when you came in, you sure as hell will be unless I can kick you out before you catch something. And let me tell you – hospital acquired illnesses are far worse than their community-based brethren. It’s the difference between 3-5 days of watery diarrhea and shitting out your own intestines†.

So please, folks. Don’t angle to stay in the hospital any longer than you absolutely have to. I know I, for one, do my best to not be there as much as possible††.

†C. Difficile in the House!
††That’s just a little joke, see.

I’ve been thinking about the practice of hiding information from patients (thanks to one of the comments in this post). In the link above, “hiding” information is looked at as a bad thing… lets come back to that idea in a moment.

To give a few examples:

12 year old child presents with new-onset seizures and a focal neurologic deficit.
65 year old man presents with recent lower back pain and difficulty urinating.
54 year old woman presents with difficulty swallowing and extreme emotional lability (laughing and crying within seconds of each other).

Each of these examples in a physician’s mind immediately raises the specter of a wholly unsavory diagnosis. The 12 year old probably has a brain tumor, the man has metastatic prostate cancer, and the woman has pseudobulbar variant ALS (Lou Gehrig’s disease). These are all really, really bad things to have.

What if I told you that the kid only had meningitis, the man just BPH and a pulled muscle, and the woman had a harmless psychiatric condition called conversion disorder†? Would it really be a good thing if I walked in the room and made a spot diagnosis without all the information? For the 45 minutes it takes to get the CT scan, the parents of that kid think their child is going to die. I certainly don’t want to be the person who does that to them.

All I’m really saying is that we aren’t doing it to hide information from you… we’re just trying to avoid giving bad news unless it’s due.

† I’m stretching that last one… unfortunately, she very likely has ALS.