Scapula

Me: "My scapula hurts."

Husband: "Where's the scapula?"

Me: "Are you serious? How do you not know that?"

Husband: "Um, non-doctors don't know where the scapula is."

Me: "Yes, they do!"

Husband: "No, they don't."

Me: "I'm going to ask my blog readers about that."

Dr. Orthochick: Disability

Me: Do you work?

Patient: I'm on disability

Me: For what?

Patient: Social anxiety. But I don't need to take medications for it.

Me: Uh, OK

Patient: If I'm going someplace where I don't know anyone, I get really nervous.

Me: I see.

Patient: But I also think I have a touch of bipolar. Sometimes I can be really happy and really sad in the same day

...and if you would excuse me, I'm off to file my disability application, which is approximately 20 years overdue.

(I told that one to another resident, and he told me he had a patient the other week on disability for chronic back pain who was up on her roof shingling when she fell off and broke her femur. He heard her talking to her sister and she said "my disability coordinator is not going to like this one.")

Final story: one of my buddies who's a primary care physician in Texas told me this one:

Patient: I'm just here for my yearly physical so I can keep on getting disability

PCP: You're 22 and you don't take medications. Why are you on disability?

Patient: I'm gay

PCP: So?

Patient: Well, when I tell people I'm gay, I get made fun of. So I can't work.

Med Students = Time Suck

When I was a med student, I never got it when attendings said that med students ate up more time than they save. I mean, at best, I was like a little slave, fetching information, vital signs, and sometimes beverages. At worse, I was a silent shadow.

But now, as an attending, I totally get it.

When you have a student, unless you're a total ass, you have to teach them. And that takes up time.

Plus, let's face it, you can't cut corners as much when someone is observing you.

And finally, they're rarely helpful. Even when they think they're being helpful, like when they just spent over 2 hours writing up an H&P. Because I could have done the same damn thing in like 10 minutes.

Good news and bad news

From a physician's neurology consult note:

"The good news is that the patient has a normal neurological exam. The bad news is that the patient has a normal neurological exam, so there is no explanation for his symptoms."

I think this doctor was having just a little too much fun writing his note....

(Also, the exam was NOT normal, but that's another issue.)

Weekly Whine: Bugs

We live a stone's throw away from the woods and we're overrun with like a dozen varieties of bugs that crawl under our front door. Here are some photos I took from within my apartment:











Yesterday I saw an ant carrying another dead ant. There's so many bugs, apparently they feel obligated to dispose of their dead.

And the best part is that both my kids are braver about killing them than I am.

Needle Fail

I grabbed a needle to do an injection yesterday and this is what it looked like:



In all my many years of needle usage, I don't think I've ever seen that before....

How a doctor finds a PCP

I have been with my PCP for a few years. This is how I found her:

1) Located a reputable practice nearby

2) Located at list of practice's physicians and their photos

3) Picked out female doctor who "seemed nice"

4) Googled her to make sure nothing horrible was written

And that's it.

How did you choose your PCP?

Chance of change

When I used to stress about exams in college, I used to try to calm myself down by thinking about it analytically, about how, say, five points on a test could influence my entire life.

Making a lowball extimate, there's a 0.1% chance that five points on any given test will influence my final grade.

And there's maybe a 0.01% chance that any one particular grade will influence what graduate school I get into.

So that's a 0.00001% chance of five points on any one test influencing my life in a major way.

Unfortunately, this didn't calm me down much, because while that number seems pretty low, it's actually very high, considering how many exams I used to take over the course of college.

I guess the moral is that one little thing can change your life in a big way, but it probably won't.

Dr. Orthochick: Suturing

During my intern year, I got a consult on a woman who had flipped over the handlebars on her bike without wearing a helmet. Considering what could have happened, she actually looked pretty good. The patient had a laceration right near her eye. It was bleeding a not insignificant amount, so my attending Dr. Goy told me to suture it up but if I couldn't do it, to call ophtho.

I'm not a particularly confident suture-er in the best of times. By "best of times" I mean, clean incision on the leg of about an inch in a guy who's covered in prison tattoos and doesn't really care what his skin looks like. Not "5mm bleeding laceration right near the lower eyelid of a young woman." Plus eyes make me squeamish. Just the though of ocular trauma makes me squirm. Like that time back when I was volunteering in the ER and there was that patient who had a screwdriver stuck in his eye. If nothing else, he did remember that when you get something stuck in your body, you're not supposed to try and pull it out on your own.

I got everything set up and numbed up the woman's eye, which involved sticking a needle right near her eyeball. i would say this was probably as terrifying for me as it was for her, since I was one muscle twitch away from stabbing her right in the cornea. And when you haven't eaten or drank anything all day and you've never actually sutured anything near an eye before, you tend to get a tad shaky. So I stuck the needle in as best as I could, she attempted to turn her head because I'm pretty sure that's the natural response to pointy objects coming at your eye, and I wound up injecting her about a centimeter distal from where I wanted to. Which meant I had to try again. And again.

Me: OK, so let's talk about something else so you don't think about this needle. Do you like clouds? Or ducklings? How about baby seals? Or wait--baby penguins!

Woman: I--

Me: Did you see "March of the Penguins?"

Woman: No, I didn't--

And at that point I stabbed her in the right place. Because baby penguins are so adorable that just thinking about them can make you forget that you've got a needle headed straight for your eyeball.

Once I thought I had gotten enough of her face numbed, I attempted to suture her. But I really didn't want to suture her eye closed, and the laceration was pretty close to the lower eyelid. As in, close to the point where I think my first pass through the skin would have sutured her lids closed if I hadn't pulled it out. But the stupid cut kept on bleeding, so I didn't have a great view, plus she had blood on her eyelashes so every time she blinked, blood got into different parts of her lower eye. Also, when she had her eye shut I really couldn't see anything, but with her eye open, any time I lunged at her with the suture needle, she closed her eye. As one does when one is being approached by a needle wielded by a shaky intern.

I made another stitch and tied it before I realized I had only gone through the skin on one side. So I cut it out.

And around that time, I decided it would be a good idea to call an ophthalmologist.

(The ophthalmologist on call was really nice. He came to the ER to see her, decided that we shouldn't suture her because there would be too much tension in the area, and did a full eye exam on her to make sure her eye was OK. Then he called me to tell me the results. Then he called me about 30 minutes later to say he had forgotten to write for her to get erythromycin ointment to the eye and could i please do it? Seeing as how I had dragged him out there on a crap consult, I graciously agreed. Also, he said "bye bye" both times when he was getting off the phone with me, which was kind of cute.)

I don't think Dr. Goy was all that surprised when I told him that I had called the friendly local eye doctor to come in to examine the patient.

Food Fail

I don't get it. No matter what food I bring to book club, nobody eats it. Not even a single bite or taste.

I have brought:

--variety of fresh baked goods from supermarket

--Freshly made guacamole and chips

--Double chocolate chip cookies taken out of oven 10 minutes ago

WTF???

Addiction

Patient: "Can you give me some Percocet to tide me over?"

Dr. Kenalog: "Every time you come here, we give you Percocet. I can't keep giving it to you. I don't want you to get addicted."

Patient: "I don't have an addiction personality for everything. Only for cocaine and marijuana."

(I swear to god she said that.)

Weekly Whine: Talking with Stethoscopes

It bugs me to no end when patients try to talk to me when I'm listening to their chest:

1) I cannot hear them at all

2) It makes it harder to hear their heart/lungs

3) When I tell them to stop, they rarely do

Public Service Announcement: Do NOT talk to your doctor when she's listening to your chest!

30 hours

I haven't been in the hospital for thirty hours straight in a LONG time. It's horrible, but there's also something kind of great about it. It's sort of like that joke:

Q: "Why are you hitting yourself with a hammer?"

A: "Because it feels so good when I stop."

(I actually looked up this quote so that I could get it right and I found it as a quote from Grey's Anatomy. So clearly I'm not the only one who likens being a doctor to being pummeled with a hammer.)

Anyway, things that are great about spending 30 hours in a row in the hospital:

1) Getting home

2) Turning your pager off

3) Taking that first post-call shower

4) Eating a meal that isn't from the hospital cafeteria

5) Brushing your teeth. With an actual toothbrush and not with your finger.

6) The post-call sleep

Ahh...

Blogging Smart

A little while ago, I made a post talking about nannies and how challenging it is for working women to pay nanny taxes for a number of reasons. Let's not rehash that discussion.

Anyway, a couple of commenters said that I was "dumb" or "naive" for blogging about this because I could get caught for not paying my nanny taxes. Because obviously if you're writing a post about something, it must be something that affects you directly. If you're writing against the death penalty, you're probably on death row for murder.

But in any case, let's examine this assertion:

I have mentioned several times on this blog that I use full time daycare that costs me about 40K per year. If I were paying a nanny on top of that, I think I'd have to vomit in disgust. But say there's somehow some IRS agent reading my blog who thinks to himself, "Well, this person says she uses a daycare. But she wrote about nanny taxes, so I think she's lying and really using a nanny and skimping on taxes. I'm going to investigate this further."

However, I blog anonymously, so this IRS agent has to use their IRS powers in order to find out my identity. Then maybe they make further investigations and discover that I have been telling the truth about using full time daycare for many years. But, unsatisfied, this agent keeps digging, through the many states I've lived in through my kids' lives, certain that at some point, maybe for just a few months, I employed a nanny that I didn't pay taxes on. And, damn it, they will get me.

If there is any IRS agent out there who would do all this, they probably deserve to be fired for wasting taxpayer money.

So no, I had no concerns about blogging about nanny taxes. Honestly, if I really did have a nanny I wasn't paying taxes on, I'd be more nervous about it. But I don't.

I am, in fact, super careful about what I blog about. In that vein, there are three things you will never see me blog about:

1) Any patient I've seen in the last three years. That's an extra layer of precaution that I take because I can. I privately journaled all through training so I have no shortage of stories about patients I saw long ago. Even if I said it just happened yesterday, I'm making that up. And on top of that, I change all the remotely identifying info. The chance of a patient recognizing himself is essentially zero.

2) Anything negative about a coworker. Really, anything about a coworker, but especially anything negative. That's a really dumb thing to do, and the way a lot of people have been "caught."

3) Anything negative about my daycare. Is my daycare perfect? No, of course not. But you won't hear a peep about it on this blog. Because the thought of a worker discovering the blog and treating my kids badly because of something I said doesn't seem out of the realm of possibility. There are people out there who have less anonymous blogs than mine and still complain about their childcare providers. Big mistake, in my opinion.

Even though I blog anonymously, I try to plan all my entries so that if everyone I know in the whole world saw it, I wouldn't feel ashamed or scared. To me, that's blogging smart.

Dr. Orthochick: Boobs

So last week at work some attending in the internal med part of the office complained to the office manager that my shirt was too low-cut. I have no idea which doctor because none of them have ever spoken to me.

Anyway, the office manager decided to talk to me about this at a time when I wasn't wearing said shirt, so I don't even know which shirt it was. So she told me not to wear it, I said that was fine, and the world kept on turning.

Since that time, the office manager has had a freaking vendetta against me. I was getting coffee the other day and I noticed her eyes were glued to my chest.

Me: Can I help you?

Office Manager: That shirt is not appropriate for a professional workplace.

It should be noted, I was wearing a cardigan. And I had a shirt on under the cardigan.

Me: Really?

Office Manager: It's a little tight, don't you think? I'm sure your patients are getting uncomfortable. I'm uncomfortable staring at your chest.

So wait. She's staring at my chest and she's uncomfortable?

Me: OK. I won't wear it again.

Office Manager: Please don't. I don't understand why you young girls get them so big.

Me: Wait, what?

Office Manager: I don't get why you feel the need to have surgery. Can't you just be happy with what you have instead of getting them so big?

Me: Oh my G-d. You think I had a boob job.

Office Manager: Well, didn't you?

Me: No! These are all natural.

At that point I was pissed as hell so I started getting a little obnoxious. I asked her if she wanted to touch them or see them. She said that wasn't necessary.

Seriously though, she stares at my boobs, accuses me of having a boob job, and then complains that I'm the unprofessional one?

Why My Intern Is Crying

(Feel free to add your own...)

Weekly Whine: Fight Scenes

I feel like lately I've been noticing the fight scenes in movies go on for way, way too long.

I mean, I get that you want to build suspense about who's going to win, but seriously, how long can you watch two people punching each other? I may as well go to a boxing match.

If a fight scene involves multiple surfaces, meaning first they're fighting on land, then on a train, then on a boat, that's just too much. A fight should involve a MAXIMUM of two surfaces.

If a movie is over two hours long and the fight scene goes on for like 30 straight minutes, please, for the love of God, cut out the fight on the motorboat.

I want a house!

As a long time leaser of apartments, I am beginning to get some major jealousy about the fact that practically everyone I know has a house. Why I want a house:

1) More space

2) Backyard

3) Fixed payments

4) Probably some other financial benefits

5) Everyone else has one

Here's why I don't want a house:

1) Harder to just up and go

2) Fear of commitment

3) No built-in maintenance or snow removal

4) Fear of stairs

5) Fear of houses (I've never lived in one)

I wonder if a house is in my future. It seems like a natural part of growing up...

More supermarket bitches

I could probably write a weekly post about annoyances at the supermarket. I won't, but I could. But one more:

I went to the supermarket at about 10AM on a weekday, not a very crowded time. All the lines had a few people on them, but the 12 items or less line was desolate. I had about 20 items. So I went to the "12 items or less" cashier and before unloading, said, "Hey, I have a little more than 12 items but since you're empty, could I pay here?"

She said yes.

So I unloaded and the transaction went smoothly. But about halfway through scanning items, this elderly guy with one item comes over and give me a stunned look. He decides to wait the (literally) 60 seconds for me to be done, but is clearly not happy. (As usual, the self-checkout was totally empty.)

Then as he gets to the cashier, she says to him, "I know."

WTF????

I *asked* her if it was okay to use the line and she said yes!

Was I in the wrong here?

People are so nuts at the supermarket. I remember there was a time when a regular line turned into express, and one of the women already waiting made the cashier take the sign down because she was scared people would yell at her.

Dr. Orthochick: The Real Doctor

Dr. Attending: This is Dr. Orthochick. She's going to see you first and then I'll see you.

Patient: OK.

Dr. Attending departs

Me: Hi, I'm Dr. Orthochick. So what's been going on since the last time you were here?

Patient: I'll tell you when the doctor gets here.

Me: He'll be in after you and I finish talking.

Patient: No, I'll wait for the doctor.

Me: I am a doctor.

Patient: I'll wait for the real doctor.

At that point, she started reading the copy of People magazine in the examining room.

And that was the end of that patient interview for me.

Time per patient

This was a comment I received last week on one of my posts:

I am an Internal Medicine resident in the US, and considering a career in Primary Care. I have a question for those of you who are already practicing. I would like to limit the number of patients I see per day by having 30 minute encounters for follow ups, 15 minute for acute visits, and 1 hour for annual physical or new patient visits. I plan to request these time slots at interviews. How plausible would that request be?

I don't know if I have ever had a physician spend anywhere close to an hour with me, so I'm guessing not very. Any other wisdom?

Weekly Whine: Dentists, Part 2

I've been lucky enough never to have needed to have a cavity filled, but unfortunately, my daughter has not been so lucky. She's had three cavities thanks to her back molars not forming properly and 3/4 of them developing cavities. And then one of those cavities had to be refilled last year.

For reasons I don't understand, the insurance would not cover the filling (which was over $100) because they used the tooth-colored filling instead of the metal filling.

I called the dentist and asked if we could use the metal filling instead. It's a baby tooth after all. They said that most practices only carry the tooth-colored filling these days. I asked if they could order the metal one and they said they couldn't.

I called the insurance company and explained this to them. They said that it was up to me to find a practice that used a filling that they would cover. I called a bunch of practices in the area just out of curiosity and they all just used the tooth-colored filling.

Delta Dental, you suck.

From Fizzy Jr

I know that there haven't been many cartoons lately, so my daughter decided to pitch in and make one:

I love that I can now not only tell what her drawings are but also who they are. Pretty good for a recent kindergarten grad, right?

Supermarket bitch

Mr. McFizz told me this story today, asking me if I thought he was in the wrong. I told him I'd post it here:

He was at the supermarket this morning buying a basket of food. About ten items. It was not very crowded but not totally empty, so he got on line behind another guy who was having his food scanned.

A middle-aged women then came up behind him with one item and said, "Can I go in front of you? I just have the one item."

Mr. McFizz said, "I don't have much. I won't be long." And wouldn't allow her in front of him.

The woman apparently got all snippy and said, "Well, gee, thanks for nothing."

My first response was: Why didn't she just use the self checkout line, which is almost always empty?

My second response: He probably should have let her go ahead of him, but her being a bitch about it is worse than his refusal. My opinion is that the person complaining about someone being discourteous is often more discourteous than the original offender.

Dr. Orthochick: Thanks for the consult!

The trend in medicine is, at the end of your consult note you say something along the lines of "thank you very much for allowing me to participate in this extremely pleasant patient's care." The first time I read a consult note it was for a patient who was intubated, ventilated, and sedated, and I thought it was really nice of the consultant doc to realize that when the patient woke up, he was actually a nice guy. I didn't realize that it was just a formality.

There are some variations on the subject, my cardiac electrophysiology attending used to end with "thank you very much for allowing me to participate in the care of this very pleasant but very unfortunate patient," because all his patients had problems that were pretty much not compatible with any sort of quality of life. Some people write "Thank you for allowing us to participate in this patient's care," I guess that's what you do if the patient sucks.

Anyway, I usually do the extremely pleasant patient thing, regardless of whether or not the patient is a raging bitchaholic and regardless of how stupid the consult actually is. It's kind of a reflex. I do it right before I say "ok, thanks, once again this is Dr. Orthochick dictating a note on patient ____ for Dr. Attending."

I was with Dr. Angry last week and he told me to dictate a note on a new patient to the patient's primary doc. So I did the whole thing while he sat there and stared at me and then at the end I started with "thank you very much for--" and he totally grabbed the recorder away from me.

Dr. Angry: Don't say that! You don't have to thank the doctor for referring a patient to us. We want him to continue to make referrals but you don't have to say "thank you very much!" We're the ones who did him a favor! So why are you thanking him very much?

So he recorded the end as "thank you for your referral. Please contact me if I can be of any further assistance."

I gotta say, I'm not really seeing the big deal. I'm pretty sure the primary doc has figured out by now that I'm not thanking him because I actually care that he sent me a patient and the difference between "thank you" and "thank you very much" is pretty minimal. I mean, I think the primary doc knows that I'm just saying it as a formality. And Dr. Angry says his part as a formality, not because he actually wants the primary doc to contact him with questions.

In conclusion, if someone in medicine thanks you for your referral, it does not mean they're actually thanking you. And if they say the patient is "extremely pleasant" it can mean the patient is anything on a scale of angelic to dead to raging superdick. So really, don't read too much into the last line of a consult.

I was starting to get annoyed at Dr. Angry yesterday so I decided to get back at him by doing one of the things he really hates: I thanked the referring physician in my dictation.

I was dictating my note and at the end I turned off the recorder (Dr. Angry didn't notice) and said:

"Once again, thank you so very much for your kind referral of Ms. Smith. We really appreciate your sending her to us and we hope that we can continue to work with you to manage her care. We had such a lovely time meeting her and we want to thank you again for giving us that opportunity. Have a great day. We did, because we had the pleasure of--"

At that point, Dr. Angry grabbed the recorder out of my hands and started rewinding it.

Me: I didn't actually record that. I was just doing it to piss you off.

Dr. Angry: Well, it worked.

Number of Patients

I have a salaried physician friend who was recently told by her employer that she needs to up numbers, i.e. start seeing more patients. Because she wasn't seeing enough patients to earn her salary.

Truthfully, in the real world you have to see a lot of patients. In residency, I saw anywhere from 4-5 to 15-16 per day, depending on the rotation. As an attending, I average 20.

How many patients do you see each day?