Even with three months left, it really isn't too late to learn!
THE
NEW
DOCTOR
Hooray! The new doctor is here! The new doctor is here!
Unfortunately, this is something only heard on corny television shows and in movies. In reality, there are no grand celebrations and there are no red carpets. Sure, some hospitals may have a lame welcome party for the new blood coming in each year, but that is basically all you get. The doctors on staff may smile and say hello the first day, but the next day you are on your own. “Good to have you with us” is what they say, but “Get your ass to work” is what they mean. This is usually capped off by putting you on-call your first weekend on the job. On-call is the despised responsibility of being at the whim and mercy of patients as well as the emergency department. In fact, my first night on call was a classic example of what's in store for new physicians.
It was my first week in practice and I was raw as could be. I was called to the ER because a patient, who had no primary care doctor, had a fever. This was no big deal except for the fact that he had had a kidney transplant in the past. Not knowing how to “turf him” to a specialist yet, I went in and did the job. To turf someone means to pass off the patient to another physician more capable than you are or who should be doing the job instead of you. I didn't know any better, so I worked my ass off for hours. I tried to remember everything I'd ever been taught about long-term transplant effects and problems. I called the transplant center at the teaching hospital in the next state and got their advice. They were nice enough to go over everything – what I knew and what I'd never known – with me. After finishing up and tying the loose ends into a nice package, I decided to call our local nephrologist (kidney doctor) and alert her of the admission. I figured she could stay in bed and come in and consult in the morning. I was still, at that time in my life, very considerate.
“Did you take care of renal transplant patients where you trained!” she yelled.
“No.”
“Then what makes you think you can take care of them now!”
“I don't know. I did call the transplant center and they … “
“I'm coming in,” she interrupted and hung up on me.
The ER doctor turned pale when I told him that the nephrologist was on her way. “Oh, boy,” he muttered as he walked away scratching his head. Now I knew why he called me in the first place to admit the patient! I convinced myself that I wasn't scared of her, but did find myself sneaking out the back exit a short time later anyway. I didn't need to be berated again in person on my first call night.
All in all, though, it was an important lesson and I learned it well: Some doctors are nice and some are pricks – the key to surviving medicine is determining who is who. In fact, to this day, I still don't speak to this nephrologist, and I can confidently say it hasn't made my life any worse. She is still a witch and now I am mocking her in print. It's sweet justice for me.
Every doctor goes through similar rites of passage on the road to becoming a real physician. Each doctor's experience is unique, and obviously, it is not all bad. For most doctors it is an exciting new step in life; a huge threshold to cross. Leaving residency for a new position in a new location is a breath of fresh air. More importantly, you finally feel that you are somebody; that you made it in life. You look forward to proving your worth. You know you are smart and well-trained and you want to show it to all the other doctors in town. You want to make a difference in the world and be part of that medical “club.” But you are still the new kid on the block, and don't know yet what you don't know, as my first on-call experience showed.
As a new doctor, you have a unique set of insecurities. You wonder to yourself whether you really are good enough. You are unsure of your decisions. Do you know enough to be independent? You ask yourself, “Oh my God, no one is going to check on me?” When you talk to other doctors, you are nervous because you question whether they are scrutinizing you or not. The truth is they are. It takes time to feel comfortable with the new kid on the block. You are a rookie to them and the only way to build their trust is to work with them over many years. The same thing is true with the nurses you meet. Until you prove your worth to them they will deem you incompetent. If they like you they will try to “train” you to be the doctor they want to work with: pleasant, responsive, and open to their suggestions. If they don't like you they conspire with other nurses to make your life a living hell.
Even patients get in on this training process. Initially, every new doctor gets to see lots and lots of new patients. New doctors are always very popular. Unfortunately, lots and lots of these patients are doctor shoppers looking for a new miracle worker or a narcotic supplier. Like flies attracted to fresh stool, these patients block up your schedule for months until you get wise to the whole game and send them back to wherever they came. It's all part of the initiation.
With time, things do get a lot better. Call is easier as compared to the hell you went through in residency. You have on average over $100,000 in student loans so you can use the income. You even have extra money to spend on yourself and even on your family … and spend you will! The patients seem a lot nicer. In fact, you start to question why Old Dr. Hibbard was so bitter when he retired and left you his practice. With time you get more comfortable in your new role as real doctor. Until then, however, you are a blank canvas waiting to be filled up with open abscesses, pelvic exams gone wrong, vomit in your face, legs that fall off, and kids that punch you in your crotch. It is these experiences, as well as some of the others depicted in the following stories, which become the foundation of your medical career.
No one ever said it was going to be easy.
Starting out in practice is not so easy. The learning curve is high and the confidence level is low because you are finally on your own. I was seeing a patient new to my practice one early autumn morning.
Mr. Raymond was a very nice older gentleman and seemed happy to see me. I am a female family practitioner and Mr. Raymond was not only very jovial, but a little flirtatious. This didn't bother me as he really was harmless or so I thought.
He had a very complicated medical history and since he was transferring to me, I wanted to impress him with my skill. Don't we all put on a little show when someone comes to us because their other physician let them down in some manner? I really spent a tremendous amount of time obtaining a complete history which included everything from diabetes to heart disease with a little touch of COPD. I delved into the past treatment of each ailment and even impressed myself with my thoroughness. I thought to myself,
“I'm pretty good at this.”
When it came to his exam I was determined to be perfect, but time was not on my side. I didn't have him fully undress because it wasn't set up as a complete physical. As I was trained, I started at the top and worked my way down to his toes. Nothing seemed to be that unusual until I got to his extremities.
As stated earlier, this man was a diabetic and I wanted to see if he had good circulation in his lower limbs. When I got to his pedal pulses, I found none in his left foot. I must admit, this part of the exam is not my strength, but I really couldn't feel anything. I quickly replayed his history to remind myself if he had told me about any peripheral vascular disease. He didn't. I think.
“Any problems with your left leg?” I asked. “No, Doc. Why, is there a problem?” he replied.
This is where it got tricky. I had to admit that either he had a compromised leg or I just couldn't feel pedal pulses very well.
This was not the best way to build up confidence in your new patient. I shared my dilemma with him. At that point he kindly offered to remove his sock.
Chatting nonchalantly all along, the sock comes off with a little effort and then so does his entire calf! I let out a little girly scream and Mr. Raymond burst out laughing and proceeds to yell,
“I GOTCHA!”
The fact that he neglected to inform me of his left below-the-
knee amputation was a slight oversight on both our parts. He stated that he makes a point of doing it to all the new young female doctors he meets and they fall for it every time. Needless to say, Mr. Raymond soon became my new favorite patient and I now always have my diabetics take their off socks during the exam.
Clues That You Are NOT Getting Your Patient, John Squatter, Out of the Hospital Today
10 The satellite guy for Direct TV is hooking up a unit outside John's window.
9 You receive an invitation for a 4th of July party (3 months away) with directions to the hospital and, more specifically, John's room.
8 You try to enter the room but it is locked and a new doorbell has been installed.
7 You see a sign above the door, “Welcome to John's Place.”
6 John's family has begun to move in their own furniture.
5 Like a squirrel, John has begun hoarding food and other stuff into piles around the room.
4 Preprinted envelope stickers for John Squatter have arrived from the Disabled Veterans of Any War charity.
3 Color samples of drapery and linens are left around the room by the interior decorator John has recently hired.
2 AMWAY has begun meeting in the room and John has reached “Triple Diamond” by selling to the nurses.
1 Telemarketers keep interrupting your exam to ask if John Squatter would be interested in changing long distance plans.
JUST CAN't GET PREGNANT
While working in a small community in Kansas, an established patient came in for an office visit for lower abdominal pain. She was a married, 31-year-old white female who was obese and not very sharp. She also had buck teeth that were an unusual shade of yellow. During the history and physical, I asked if there was a possibility she could be pregnant to rule out this being a possible cause of her abdominal pain. She replied “No.“
“Oh,” I said, “then you're on the pill?”
“No,” she said.
“Oh,” I said “then you have had your tubes tied or your husband has been fixed?”
“No,” she replied, “I just can't get pregnant and my husband and I have been trying for the last five years.”
Noticing she was upset with this, I told her that there was a chance that it might be her husband who is not able to produce children.
“No,” she said, “all of his friends have tried and it didn't work either, so I know it is me.”
During my first year in private practice, I had a 20-year-old woman come to see me for a localized left breast infection. I initially put her on antibiotics and requested that she follow up with me in three days.
Three days later she came back in. The examination of her left breast showed not only was the infection spreading, but now there was a fluctuant mass there as well. I incised and drained the area and sent away for the appropriate cultures.
A few days later the results came back showing some type of bizarre anaerobic microbe that could not have possibly gotten there by any natural means. Something smelled funny. The next time I saw the patient I confronted her with the culture results. After a moment she broke down and started crying. She stated that she worked as a tech in the microbiology department of the local hospital. She desperately wanted some time off so she picked up a sample culture, scraped up some of the growth, put it in a TB syringe and injected into her left nipple area. The mystery was solved as we now had the reason for the impossible culture and a new method of getting worker's comp.
It was my first year in practice. She was new to the area. Her husband was in the military and they had just moved back to the states from the Orient. Her migraines were tortuous and she couldn't take it anymore. She needed something but nothing seemed to work.
She looked like she was going into labor her pain was so bad.
Joanne was a young and attractive woman. She was in her late twenties and already had a hysterectomy for chronic abdominal pain. Hmm, that seemed weird. I tried everything for her head. All the new migraine medications didn't touch them. The shots, nasal spray, and pills were like water to Joanne. Then it hit me. Maybe there was an estrogen component to her exacerbations. We tried adjusting her hormone therapy but wouldn't you know it, she kept coming in for narcotics. That was the one constant medicine that would make her headaches go away.
Something was always fishy to me about Joanne. Her symptoms were so overdramatic that each time was like an Oscar performance. Add to this that I could never get her records from the military doctors from overseas and my suspicions continued to grow.
I finally sent her to a neurologist who started the process all over again MRIs, triptans, and even different types of birth control pills weren't the answer. Unfortunately, the neurologist never got to the bottom of the story either. Even though he started from scratch in the whole process, he ended up in the same dead end that I did.
Pretty soon Joanne started working both of us for her severe migraines and need for more and more narcotics. Whenever we hesitated she would either get very angry or make us feel guilty as hell for not finding an answer to her ordeal.
At some point, both the neurologist and I had had enough and we got a little tougher on Joanne. We said that she needed to get her medications from only one source. Unfortunately, the neurologist pointed her back my way as her source. That sucked. As I continued to try to regulate Joanne's use (or abuse?), she suddenly disappeared. Trust me, I didn't try to find her. It was not until months later that my OB-GYN colleague was calling me and questioning about Joanne and her new abdominal pain. I had no idea why she would be going to an OB-GYN as she no longer had reproductive organs. Anyway, I passed along my stories of her migraines and her need for narcotics and we ended the conversation there.
Months later I was admitting a patient in the ED when I heard violent screaming. The EMTs were scurrying by the ambulance entrance. I saw them race the stretcher past me like the issue was life threatening. I caught a glimpse of the poor patient and it turned out to be Joanne. Again, she looked like she was going into labor her pain was so bad. None of the ED staff even moved. I saw the ED doc who was completely indifferent to the loud shrieks and she stated that Joanne had been making the rounds more frequently to get narcotics. Our little friend had now exhausted the last route of getting painkillers (that being the generous ED) since they were immune to her act. For me, it was surreal to see the EMTs running like chickens I with their heads cut off and ED staff not even getting up. Only a narc seeker has that ability to produce this type of reaction.
I never saw Joanne again. I don't believe she goes to our ED anymore or any other local doctor. She probably has moved, and unless she has detoxed, I recommend you think twice about giving narcotics to an overdramatic actress whose past is buried in the Orient.
PAUL THE POPPER
Don't you ever find yourself popping those bubble wrapping papers? It can be quite addicting. I just love them. In some small way it relieves stress. This Munchausen has a similar addiction. He's a 30-year-old student that loves to travel. His hobbies include skiing, singing in the choir, and putting a needle in his chest. Actually, the first two are made up.
“Paul the Popper” came into the hospital complaining of chest pain and shortness of breath. A heart attack you say? How naïve. The X-rays show that his right lung had a pneumothorax or was punctured.
Paul had undergone many chest-tube insertions in his life for this problem because, as luck would have it, he kept getting spontaneous pneumo-thoraces. He had been seen in three different cities (at least) for this before. This time the physicians decided not to put in a chest-tube immediately as they felt the lung would reinflate on its own. Unfortunately, a recheck on the next X-ray showed that the lung was even smaller. The funny thing, however, was that something else was in the lung cavity as well. Wouldn't you know it, Paul had gotten a hypodermic needle stuck in his chest!
Talk about your bad days.
When they confronted Paul, he was incensed. “This hospital should be ashamed of itself for leaving
needles recklessly around the patient's bed!”
This didn't stop our heroes from doing their job and taking Paul to the operating room to remove his needle, as well as part of his lung. Heck, a 30-year-old doesn't need all that much lung tissue anyway.
“Paul the Popper,” with enough prompting, finally admitted to his hobby of dropping a lung for fun. Yes, Paul was a Munchausen, but must all patients be given a label? They are so much more than one diagnosis. Our friend Paul was also caught stealing narcotics.
At that point the hospital I team took [out his chest-tube and discharged him on his second postoperative day. It seems Paul was bigger than his Munchausen Syndrome. He was also a narc-seeker. Goodbye Paul, and we hope you find another city to float around in. Don't forget your needles.
Ann Thorac Surg2001;72:281-83.
LANGUAGE PROBLEMS
In the ongoing effort to save money, our 100 member medical group changed transcription services. It now goes through the Internet to India where it is transcribed and sent back within hours. No doubt we are contributing to a host of slave labor, but the cost was too good to pass up. Unfortunately, there is something lost in the translation as this next example will demonstrate.
One of my partners had wanted to dictate just how horrific his patient's car accident was and included the statement,
“The patient then had to be extricated with the jaws of life.”
You and I, of course, can picture the frantic paramedics cutting through the rooftop to reach this surely critical patient.
When the dictation came back and was proofread (which now we really have to do!), the above line was interpreted as,
“The patient then had to be educated on the joys of life.”
The Placebo Chronicles: Strange but True Tales From the Doctors' Lounge Page 12