On Truth, and Trust

I have an idealized version of myself. This version of me wakes up early and packs greek yogurt and (homemade) granola into mason jars. I pack gym clothes into my bag. I make coffee with time to spare. I stride out of my apartment at exactly the time that will allow me to be a few minutes early for work.

Then there’s the actual version. Some mornings I would barely pass as a functional traffic cone. Like Neo in the Matrix with, the way you perceive yourself can often be rosier than the truth. In the matrix, Neo’s hair is cut. His clothes fit a bit better.  He’s also not being hunted by sentient robot monsters. Perhaps it’s easier on the ego, or perhaps humans are just natural optimists, but it usually helps us to picture things in the best possible light.

Everybody lies. I lie. I’ve lied to doctors flat out. They say that physicians make the worst patients. It’s all true. The ones who know the repercussions of not following medical advice are often the most loathe to adhere to it. 7 day course of antibiotics for my bronchitis? That’s cute. How about 1?

The reason I bring all of this up is that medicine presents you with some very interesting ethical situations, specifically regarding lying and truth telling. In certain instances, you actually get to hold a pure lie detector test in your hand. I recently had one of these experiences with a patient who came to be one of my absolute favorites. I’ll call him Mr. Johnson.

Now, as most people in the medical field can attest, patient histories must be taken with a grain of salt. No matter what the guy slurring his speech, stumbling around your ER with breath that smells like the basement of a prohibition-era speakeasy tells you, it’s a safe bet that he’s been drinking. Taking a history is the start of a conversation. It’s one data point among many.

I was sitting down to take Mr. Johnson’s history. He had just had a heart attack, and I was trying to figure out why. I didn’t have to look very far – he had a history of severe coronary artery disease, he’d received coronary artery stents in the past for prior heart attacks, and had had multiple risk factors – older male, diabetic, history of cigarette smoking. But something else caught my eye looking over his chart: “history of extensive drug use.”

When patients are admitted to the hospital, they are triaged at several levels. The first stage is a triage nurse outside the ER, and the next is an ER physician. Much of the diagnostic workup is ordered in the ER, including quick resulting tests like EKGs and cardiac enzymes. Others take a bit longer to return, like urine drug screens.

When I went to speak to Mr. Johnson, I had the results of his urine drug screen back. Positive for cocaine.

I asked Mr. Johnson what he’d been doing when his chest pain came on. Nothing, he said. Had he been exercising? Nope. What had he been up to right before it came on? Just sitting at home, he said. I continued with the usual questions – where was the pain? Did it radiate? What did it feel like? Had he felt it before? Does he usually get chest pain when he exerts himself?

Now came the moment of truth. “Sir, have you used any drugs recently?”

Of course, I knew the answer already. But there was something more important at stake here. Did he trust me enough to share this info with me? Or had I come across as callow, uncaring; someone who would potentially judge him for this transgression. I had scanned his chart beforehand – no mention of drug use in the ER doc’s history. He hadn’t told anyone yet.

It’s easy to cling to our idealized selves. I was at my own checkup recently, and the doctor asked me how many times per week I exercise. “4-5 times per week.” Lie! He asked me how I’d been eating. “Mostly vegetables, and I’ve been really trying to avoid unnecessary carbs these past few months.” Lie lie lie! What did I have to gain by this? He knows my weight. He knows my cholesterol, my triglycerides. Is it out of self preservation? A refusal to look myself squarely in the mirror?

Mr. Johnson took a long pause before he answered.

I crave patient trust. As an internal medicine resident, I help my patients by altering long term disease progressions. Things like medication adherence, followup appointments, and lifestyle changes are paramount. Not the sexiest stuff, but immensely important. And it requires trust both ways. We trust patients to tell us their story accurately so we can make the right diagnosis and provide the right treatment. And they trust us to have their best interests at heart, to make sure what we tell them to do is worth it, and will actually help them. It’s pretty simple: If I have mutual trust with a patient, I can help them. If not, I probably can’t.

Before Mr. Johnson answered, I spoke up again. I told him, “Look, I’m not here to judge. I just want to know what happened so we can make the best medical decisions. Telling the truth is hard. But what you tell me doesn’t leave the room.”

“Doc, I’ve been clean for 6 years. I used to do everything. Heroin, cocaine, you name it. In and out of rehab. I’m 6 – er, was – 6 years clean, though. I swear. I absolutely swear. ”

“I believe you. What happened yesterday?”

“I messed up. I slipped. Coke. Not mine, though. A friend’s. I went to a party last night. My buddies are in town. From Cleveland…”

I had to know. “Are you…are you a Cavs fan?”

Mr. Johnson cracked a huge grin. He immediately hung his head, trying to look a bit more somber, but he noticed I was smiling too. His grin returned.

“Hail to the King,” he said.

“Amazing series,” I said.

And just like that, we had trust. The time for reminding him that drug use was bad for his heart would come, but not now. We spoke for almost an hour about the NBA finals, his childhood in Cleveland, his medical history. We spoke about his seven brothers and sisters, all of whom are now deceased. We connected. On my last day in the CCU, he asked for me to be his personal doctor.

He eventually had stents placed in his coronary arteries. I told him he’d have to take his blood thinners with Lebron-esque consistency. “I can do that,” he said.

I’m trying to learn from Mr. Johnson. It takes guts to tell someone you were wrong. You, alone, and not someone else. It’s hard to take responsibility for our shortcomings. But perhaps that’s what allows us to change.

BCM Live!

Check out my performance from the first annual BCM Live! These are two pieces I wrote about life as an intern. Huge thanks to Joseph Zhang for his remarkable video editing skills, and to everyone who came out and made it such a fantastic event.

Song 1: Day Callin’

Song 2: First Year BCM Love Song

The Final Whistle

Medicine has a way of numbing you to death. Since the only patients you can actually see and help are the living ones, death becomes an impossible-to-conceive-of finish line. Death is, in medicine, mostly a motivating factor. If you don’t give this drug, they might die. If you do this surgery, they may not die. But we skip over thinking about death itself, and just do our best to help patients avoid it. Although this is probably useful for the self-preservation of doctors, there is a vague incompleteness to not really thinking about it.

Imagine watching a football game with incredible intensity. You study the plays in depth, analyze the different offensive and defensive patterns, learn all about the individual players… but you never actually watch the end of the game. Inexplicably, with 1 second left, you switch off the TV and turn to the next game. You do this over and over, game to game. Each game is unique, but the rules are rigid, which makes understanding the game algorithmic. You learn to start seeing patterns.

Wouldn’t you be curious about what happens after the game? How the players react? What they look like when they are off the field? You’ve become a master at decoding the various plays, but what is the meaning of this game? You’ve never seen any post-game interviews, any parades through the city. You don’t know the standings, and you don’t know who will play next. You just know how the games go.

Stranger still, what are the players even doing on the field? How did they organize themselves this way? Who put the refs in charge? Since you can’t see any pre-game either, it is just as mysterious how the players got here, and why they seem really stoked about getting first downs.

The absurdity of our situation has not escaped modern thinkers. Atheist philosopher/neuroscientist Sam Harris has an incredible and uplifting talk on this topic, called Death and the Present Moment. I have returned to this talk many times during residency to ground me against the arbitrary nature of death that is part of daily hospital life.

As I sit here in the ICU, I’m surrounded by patients hooked up to machines and medicines to prolong their lives, to extend their games for as long as possible before the inevitable final whistle. I wonder about their lives, about the infinite tapestry of human existence, each of us a single thread. I wonder what these people valued, what they spent their time on, what memories they hold closest. Were they satisfied with how their life turned out?

We are all going to die; all of our games will one day come to an end. In light of our precarious situation here on earth, making sense of my existence has been difficult. In a span of about 3 years, I’ve been everything from righteous mystic to bemused Jew to intrigued atheist. Answers are elusive, and the hard facts seem downright cold. But I’ve learned one thing for sure –  it’s a gift to even be playing the game at all.

Courageous Hospital Administrator Saves Life

 

HOUSTON, TX – In a heroic and improbable fight against death and human mortality, hospital administrator Steve Phillips correctly identified that patient Dorothy Johnson should have been admitted under ‘observation’ status instead of ‘inpatient,’ saving her life.

“Each human life is a gift,” Phillips said at a press conference this afternoon. “We were able to identify Ms. Johnson as someone who could benefit from immediate bureaucratic intervention. By the grace of God, we did it just in time.” The conference was interrupted multiple times by flowers being heaped upon the podium.

Ms. Johnson had reportedly been admitted to the hospital for an exacerbation of her Chronic Obstructive Pulmonary Disease. However, she began recovering at a much faster rate than was initially expected. That’s when Mr. Phillips saw his opportunity, and struck. “Medicine is like improvisational jazz,” Mr. Phillips said. “You listen, you watch, you feel. But when it’s time for the solo, you’ve gotta be ready to go.”

Mr. Phillips called the inpatient medicine team immediately. Although his actions only appeared to change a technicality on her chart that won’t alter any medical or financial aspect of her care, Mr. Phillips warned not to be fooled by first impressions. “Don’t judge a book by it’s cover,” Mr. Phillips implored. “Sometimes, the book will have the wrong cover, or no illustrations.”

When asked how he deals with the high-stress environment of his job, Mr. Phillips was characteristically stoic and implacable. “I may have to call a team 10, 20 times during the day and interrupt them from whatever they might be doing to get them to change a meaningless, trivial designation that literally does nothing for patient outcomes. But if that’s what it takes to save a life, then that’s what it takes.” He added: “Medicine is like when you order a burrito at Chipotle with way too much meat. You have to do whatever it takes to get the job done. You have to stuff it all in there, even if it seems like there’s no way the tortilla will hold. You may even need a second tortilla. For my patients, I’ll use a hundred tortillas if it means better outcomes.”

Dr. Kenneth Brulo, head of medicine, became teary eyed as he recalled the events of the day. “When medicine works – and it’s rare – but when it works, it is so god damn beautiful. I just wish all of our faculty, staff, trainees, and students could emulate Mr. Phillips on a day to day basis, and strive to obsess over defunct, arcane, and ultimately worthless patient designations as though their lives depended on it.”

Mr. Phillips will receive his ‘keys to the city’ from Houston Mayor Sylvester Turner this evening. When asked if he was excited for the ceremony, he demured: “I’m humbled and honored to be invited. And don’t worry, I won’t poke around the governor’s mansion too much. I’ll just observe, and will likely leave 24-48 hours after my arrival.” As the old adage goes: you can take the administrator out of the hospital, but you can never take the hospital out of the administrator. Heroes are heroes, plain and simple.

Famous One-Liners of Fiction: A Medical Quiz!

The one-liner is the distilled essence of a medical case. It packs relevant history, lab values, and individual assessment into a single, concise sentence. My question: why limit it to medicine? Can you figure out which fictional characters the following one liners describe? (answers below)

1) 13 y/o male with a history of forehead dermatitis who presents to a British castle with myopia.

2) 40 y/o male with history of heavy alcohol use (1 L of rum per day) and being cursed with the inability to die who presents to Tortuga looking for pirates and more alcohol.

3) 58 y/o male with history of murdering people for political gain, high risk sexual practices, and giving creepy soliloquies who presents w/ recurrent nightmares and marital discord.

4) 30 y/o G1P0 from Naboo with history of elaborate dressing and being completely duped by a sith lord who presents at 39 weeks for induction of labor by a robot.

5) 2,019 y/o wizard with history of osteoarthritis and schizotypal personality traits who presents with an acute paranoia relating to jewelry.

6) 39 y/o male with history of childhood trauma, dissociative identity disorder, and affluenza who presents with mysterious bruises and scrapes he got “while working out” //// 39 y/o male with history of kicking everyone’s ass who presents with hoarseness and acute laryngeal edema.

7) 9 month old bilingual Pacific Regal Blue Tang with a history of irrepressible optimism who presents with recurrent bouts of amnestic fugue.

8) 54 year old evil medical professional with a history of alopecia areata and diabolical scheming who presents for psychodynamic group therapy after confessing homicidal thoughts towards his son, Scott.

9) 40 year old ogre with a history of acromegaly and depression who presents with severe jaundice.

10) 28 year old male with a history of watching the girl he loves be hit on by best friends/future arch-rivals who presents with total body hirsutism and leaky wrist discharge.

11) 47 year old imperial officer with a history of thinking that Vader’s commitment to the force is a “sad devotion to [that] ancient religion” who presents with acute respiratory failure from asphyxiation.

12) 43 year old archaeologist with a history of confirming Judeo-christian theology and killing nazis who presents with an erythematous forearm rash after an aberrant whip recoil.

13) 21 year old snow queen with history of heat intolerance and Raynaud’s syndrome who presents with cough, nasal congestion, and chills after blanketing her surroundings in a permanent winter.

14) 27 year old female with family history of incest and preternatural leadership abilities who presents to clinic inquiring about vaccinations for her three pet reptiles.

15) 36 year old eccentric male billionaire with history of heart transplant and hemochromatosis who presents for biannual pacemaker interrogation.

 

Answers:

  1. Harry Potter
  2. Jack Sparrow
  3. Frank Underwood
  4. Queen Amidala
  5. Gandalf
  6. Bruce Wayne /// Batman
  7. Dory
  8. Dr. Evil
  9. Shrek
  10. Peter Parker
  11. That guy from Star Wars Episode IV who thinks it’s a good idea to question Vader’s methods about returning the stolen data tapes
  12. Indiana Jones
  13. Elsa of Arrendale
  14. Daenerys Targaryen
  15. Tony Stark

Battling the Self

I don’t know about you, but I am prone to very bad anxiety. The topic of my discontent almost doesn’t seem to matter, from ruminating about my future to pondering my less-than-stellar performances in Settlers of Catan. My brain can dredge up levels of angst like waves, crashing my cortex and drowning my inner reason.

If it weren’t so awful, there would be a beauty to it. How you completely lose yourself to your worries. How the anxiety seems to wrap its way into your deepest thoughts and feelings and color them, like a teabag releasing its contents into hot water. Everything is ruined. I’m a failure. I’m not smart enough. I’ll never be good enough. It’s almost impressive how quickly and completely we can convince ourselves that the sky is falling.

Our brains are deft. Mine is excellent at detecting a topic that will cause anxiety. Like that weird Harry Potter creature Lupin shows to his Defense Against the Dark Arts class, our thoughts effortlessly morph to prey on deep-seated fears. What my brain isn’t particularly good at, though, is maintaining a sense of proportion. This was made abundantly clear to me this week by my patient Ms. Gonzalez.

The first thing I noticed about Ms. Gonzalez was her smile. Despite her very low blood pressure, despite the central line inserted into her jugular vein, despite the fact that she had been in the ER for almost a day, she was smiling. Her lips were taught and tight, bunched in against the puffy skin of her cheeks. This was not how Ms. Gonzalez was born. Her face had taken on a new, rounded countour from years of steroids used to control her underlying disease: Systemic Lupus Erythematosus.

Ms. Gonzalez is twenty five years old. She was born with Lupus, a debilitating autoimmune disease made famous on the show ‘House’ for its myriad presentations and problems. The body makes antibodies against itself, attacking normal tissue as if it were a pathogen. From the day she was diagnosed, Ms. Gonzalez has been taking multiple immunosuppressive agents daily to protect her from herself.

Something about Ms. Gonzalez’s smile shocked me. I felt embarrassed, almost. What have I been anxious about? Seriously, what even could I be anxious about, compared to what this person has gone through? She is afflicted by rashes and scars, by painful ulcers, by inflammation of the lining of her heart and lungs. Her kidneys may eventually shut down, tethering her to a dialysis machine for life. She’ll have early arthritis. Neurologic damage.

The worst part is, she did nothing to deserve this. She didn’t drink too much. She doesn’t use IV drugs. There is no sense of justice to be found here. This is in her DNA. Her illness is something she has been forced to confront on a daily basis. There is no running away from the thousands of doctors appointments and hospital admissions. No running from her warped skin, bloated where it was once smooth.

When I told her that the infection in her bloodstream had cleared and that she would be going home, she giggled with delight. She thanked me and said how happy she was to be going home soon. In her sparsely decorated hospital room, with old, frayed curtains separating her from three other moaning patients, she was radiant.

How does Ms. Gonzalez keep smiling? I don’t know. But I can’t stop thinking about her. She knows something about anxiety and suffering, deeply, that I haven’t figured out yet. In the face of fire, she was peaceful, happy, gracious. Unencumbered. Surely, if someone is allowed to be anxious or depressed, it’s a young Lupus patient with sepsis. But she wasn’t.

A Day in the Life

5:20 AM: Alarm goes off. Why did I choose medicine?

5:30: Alarm goes off again.

5:32: Alarm goes off again.

5:36: You win, iPhone.

5:44: Coffee brews. I get a tingle of excitement as I smell the grounds. I consider the line between appreciation and addiction. It’s blurry.

5:54: Pick out whatever shirt is least wrinkled in my closet. Apply to body.

6:05: Breakfast, like consistent flossing, is neglected.

6:35: Arrive at hospital parking structure. Contemplate the relative difficulty of diagnosing moyamoya and finding a parking spot. Oddly similar.

6:45: On my way to get check-out. How are my people doing?

6:47: Jesus Christ.

6:48: Jones’s BP tanked and is now in the ICU. Johnson is having a hard time breathing, and is on BIPAP now. Smith is having really bad diarrhea.

7:05: Checking labs. A little yellow flag pops up when a value is abnormal. There are flags everywhere. I am the leader of the flags. The flag charmer. I can almost hear them flapping their grim tidings at me. What an odd way to signal danger. Why isn’t it a skull? Or an unhappy face? What did flags ever do to deserve this?

7:45: Pre-rounding. Turns out Smith is having really bad diarrhea. He showed me. Yup, it’s diarrhea. Confirmed.

8:30: Morning Report. Med students for miles, all lined up in front of the coffee machine. There’s only so much coffee to go around. I’ve literally never seen so many med students in one place before. They’re phoning in med students from all over the country to get to this coffee.

8:32: Phew. The last med student got coffee. None left for anyone else. That was a close one, for a second there I thought that a med student might not get coffee.

9:30: Rounds begin.

9:50: Smith really does have bad diarrhea. By now almost every hospital employee knows about it, due to 1) the smell, and 2) Mr. Smith’s incredible storytelling abilities. The man may have been an editor in a former life. I feel like I know his diarrhea personally by this point. I agree to have dinner with his diarrhea next Wednesday.

12:15 PM: Noon conference. A much needed respite. I imagine what it must have felt like to wander the desert and see an oasis in the distance. Must have felt really, really good. I bask in the –

12:16: Beeper goes off.

12:18: It’s a new admission. I call back. No answer. I page back.

12:20: I get a page back. Call again.

12:21: Nothing.

12:22: Sisyphus didn’t have it so bad, right? At least he got consistent exercise.

12:23: Why do we still use beepers?

1:00-5:00: Call consults, place orders, round some more. During a lull in the afternoon, I talk with Smith’s diarrhea at length. We discuss his rough childhood, his difficult relationship with his mother, and his ultimate life goal of owning a vineyard in California.

6:00: Sign out to the night float, short and sweet.

6:16: Did I park on level 3 or 4?

6:17: Let’s try 3.

6:19: I hit ‘unlock’ on my car keys, and strain to hear the horn. Nothing.

6:18: Walk 10 paces north. Repeat. Silence.

6:20: Let’s try 4.

6:21: Hark! The clarion call. Faint, but perceptible.

6:22: I’m like an ultrasound, using the triangulating power of sound to find my position. Back and forth, back and forth. Seeing three dimensions in two. I’m closing in.

6:29: WHERE THE HELL IS IT?!?!

6:31: It’s not on 4. I feel my sanity slipping.

6:35: It was on 5.

7:02: Home at last.

9:25: I call Smith’s diarrhea to wish it a good night.

10:00: Bedtime. Relief. Release.

What’s in a Name?

Drugs have ridiculous names. To walk down the pharmacy aisle at CVS is to be awash in names that have been scientifically crafted to evoke certain feelings. They are usually some combination of uplifting and self-affirming, with a distinct yogic/new age quality.

Most drugs have 3 names — their chemical compound name, their generic name, and their trade name. For example, take naproxen, the quotidien workhorse of arthritis pain. Naproxen is the generic name of the chemical compound (+)-(S)-2-(6-methoxynaphthalen-2-yl) propanoic acid. And, fine. I get it. Don’t call it that frankensteinish combination of words, numbers, and arithmetic signs. But drug companies have decided that generic names like naproxen are not sexy enough. So in come the trade names.

Naproxen has a lot of trade names: Aleve, Accord, Anaprox, Antalgin, Apranax, Feminax Ultra, Flanax, Inza, Midol Extended Relief, Nalgesin, Naposin, Naprelan, Naprogesic, Naprosyn, Narocin, Pronaxen, Proxen, Soproxen, Synflex, MotriMax, and Xenobid. To reiterate – these are all the same drug. Same ole (+)-(S)-2-(6-methoxynaphthalen-2-yl) propanoic acid. Just say some of these names out loud, and let the positive associations pour in.

Aleve. Aleeeeeeeeeve. Let me aleeeeeve all of your pain. Come away with me, lets aleeeve this place.

Synnnflex. The syngery of flexion. The symphony of flexibility. The synchrony of flexing. Ooooooh yeahhhhh. Synflex!

Naprogesic comes very close to “aphrodisiac.” Feminax Ultra sort of sounds like the love child of Rachel Maddow and Megatron (two awesome people, it must be said). Accord just means “agree.” Antalgin literally breaks apart into “anti-algesia,” or “against-pain.” Why don’t we just start calling our drugs “good-thing” or “eat-me?”

I’ve decided I’ve had enough with these names. They’re too uplifting. Too focus-grouped. I want a new set of drug names. I want real life. I want raw emotion. Here are my suggestions for gritty, unique drug names that speak to a deeper pallet of human experience.

  • Decai – Live. Love. Decai. 
  • Voldemorimab – Making your blood pure again.
  • Oblivia – The night is always darkest just before Oblivia.
  • Agonee – If you want ecstasy, you’ll need Agonee.
  • Gread – Be a sweetie, get Gread-y!
  • Gread Extra Strength – For those who need a little more Gread in their life.
  • Gread Cold n’ Flu – No matter how you feel, you should always have Gread.
  • Despare – You don’t have a moment to spare! Despare today.
  • Expensiva – You can’t afford not to. 
  • Angwish  – When you angwish upon a star, your dreams come true.
  • Torchure Extended Release – There is no pleasure without pain.
  • Beuhring – Life should always be Beuhring.
  • Afrade – When you’re frayed, trust Afrade.

Haiku about Tug, the Drug Delivery Robot

The following are a series of haiku composed during short call about Tug, the drug delivery robot.

 

Lonesome, courageous.
Steadfastly he delivers
drugs and happiness

 

Patrolling hallways
Searching, seeking, yearning, he
gives, but never takes

 

Motorized gears turn,
But how does that explain the
size of his droid heart?

 

When the darkness falls,
and doctors fall prey to sleep
he looks over us

 

Silent as a mouse
loyal as a bassett hound
true’s the northern star

How to Dodge a Consult

As an internal medicine resident, a large chunk of my time is spent consulting other services to obtain their expert opinions. Sometimes, these consult requests are honored. Sometimes not. Equal parts frustrating and awe-inspiring, denying a consult is something of an art.

Here is a beginners guide to dodging consults: how to avoid doing your actual job, and letting someone else handle it. A guide to shirking your responsibilities, responsibly:

1. Master the technicalities of the order placement.

Internal Medicine: Hey, consulting you guys for suspicion of schizoaffective disorder. History of bipolar, but they’ve been off their meds for a while and they’ve had episodes of psychosis.

Psychiatrist: Wait, so is this a consult for schizoaffective or for bipolar?

Internal Medicine: Well, that’s why we’re consulting you. We’re not exactly sure.

Psychiatrist: You said schizoaffective, but the consult order said bipolar!!!

[whooping and high fives heard over the phone]

Internal Medicine: ….yeah, but…

Psychiatrist: If you want to consult us about shizoaffective, you’ll have to cancel that order and put in a new one, but we don’t take consults after 2 PM!

[The distinctive pop of a champagne cork is heard over the phone]

 

2.  Question. Everything.

Internal Medicine: Hey, we’ve got a woman in her late 40s with 1 day of RUQ pain, febrile, white count, D bili of 5, and alk phos 900. History of gallstones. You guys mind taking a look at her? Ultrasound shows pericholecystic fluid.  I’m pretty confident this is cholecystitis.

Surgery: Is that so?

Internal Medicine: …I think so.

Surgery: What’s her baseline alk phos? What type of pain is is it? When was her last CT? Who diagnosed these gallstones? Is she really a woman? How febrile is she? How long has she had this pain for? Who did the ultrasound? Who won the democratic presidential nomination in 1924? When –

Internal Medicine: Wait, so are you going to see her?

Surgery: Call us back when you have more of the history.

 

3. The Tautological Defense.

Internal Medicine: Good afternoon, esteemed colleague!

Dermatology: What’s up?

Internal Medicine: It’s a guy with really bad stevens johnsons. I’m not too comfortable managing it, wondering if you could help with some recs.

Dermatology: So if it’s an emergency, the on-call resident usually just sees them in the ER.

Internal Medicine: OK, but the ER admitted them.

Dermatology:  Right, but we actually don’t see floor patients, just ER emergencies. If it’s a floor patient, we just schedule them in clinic as outpatient.

Internal Medicine: It’s really bad, dude.

Dermatology: But the ER didn’t call.

Internal Medicine: I know!

Dermatology: Exactly.

Internal Medicine: What?

Dermatology: We’ll see them in clinic on Tuesday.

 

4. Subtly undermine their credentials.

Internal Medicine: Hey, sorry to bother you guys, but we’ve got a COPDer who’s not responding to his nebs and is on a venturi now. We’d like you guys to take a look.

Pulmonology: Who is this?

Internal Medicine: Gen Med. I’m the intern.

Pulmonology: Where’s your upper level?

Internal Medicine: She’s in clinic all day today.

Pulmonology: Yeah, usually the upper level will just consult us directly.

Internal Medicine: But I went over the case with her, she asked me to consult you guys.

Pulmonology: Nice try, bud. I’ll be looking out for her call. Tomorrow.

 

5. The “I’m on your side.”

Internal Medicine: Hey, can y’all see this one today? It’s Jones, the 70 year old with prostate cancer and urethral strictures. Rising Creatinine. You saw him in clinic.

Urology: Hey, thanks for checking in.

Internal Medicine: Yeah. You guys gonna take him back to the OR?

Urology: Good question. I don’t know, man. My attending can be really weird with some of these soft consults.

Internal Medicine: What do you mean?

Urology: Trust me, I want to see them. Like I’ll even see them just by myself. But my attending has been super busy this week, and it seems like we just saw them in clinic, so you may have to hold off on the official consult until Monday. I know, man, it sucks, I know.

Internal Medicine: I see.

Urology: In my soul – deep down – I know that seeing them is the right thing to do. The moral clarity of your request shines brightly, as if a great, blazing  torch lit atop an echoing mountain of freedom. I stand with you. But I stand in silence.

Internist: …

Urology: Just consult on Monday.

 

6. And, if all else fails, use one of these lines:

  • “He doesn’t sound that sick.”
  • “We don’t generally get consulted for that.”
  • “Did you consult IR?”
  • “Something something evidence based.”
  • “Let me call you back after this case – it may take a few hours.”
  • “I’m just stepping out for a conference.”
  • “I’m rotating off service tomorrow – it may make sense to just hold off on that consult for a few days. Thanks!”