How much do you think the property tax is for one McCain property?

I officially started my time in the hospital proper.  Until now, I've been at the medical center, but technically I was assigned to the outpatient clinic of Internal Medicine.  Now, I'm on inpatient medicine of Internal Medicine.  These are the patients who are the sickest - CCU, MICU, ICU, etc., as well as the well-loved "wards" are all part of Internal Medicine.  Outpatients aren't as sick, because they can walk in and walk out again.  Inpatients are kept overnight, often for several nights.

I'm starting out responsible for one patient.  He is a man who's fallen on tough times.  He's a skilled worker in the civil engineering industry, but since land development has come to a screeching halt (though not evidenced by all the building going on across my street, darnit), he's been laid off.  Money woes caused problems with his family, and that made him more stressed out.  That led to an exacerbation of his illness, but he can't buy medicine because he doesn't have money anymore.  So he doesn't get better, so he can't get a job, so the financial picture doesn't improve his family relations... and it goes on and on.  In his hospital admissions interview, he cited finances were the thing that worried him most about being in the hospital.  Why can't people's biggest worries be about their illness?  And he has some serious stuff going on.  Why is it that in the USA, in the 21st century, a skilled worker cannot pay for the medications he needs?  Why is this so often the boring, dry topic of my blogs?  I wish I had sunnier things to post!  Or I could just content myself with telling funny stories.  But when you see patient after patient, concerned with or worse, suffering as a result of, the inability to pay for their health care, what do you do?  How can I meet patients like this day after day and not spout off every so often?  

Seems like it used to be that doctors had to bear the looks in the eyes of their dying patients and live with the guilt of not being able to save them.  Now, doctors scramble to do whatever they can to get patients medications and treatments so they will not have to look into their eyes, knowing they *are* able to save them, but having to weigh the cost.  What is the value of a human life?  According to one of my professors, the average cost the U.S. as a society has deemed acceptable to save a life is about $50,000.

I wonder if my patient is going to vote for John McCain.

The Lying Patient

A sample bedside conversation alone with a patient:

Me:  "Hi, how are you feeling today?"

Patient:  "Oh, just great.  Thanks for asking!"

Me:  "So you don't have any pain today?"

Patient:  "What pain?"

Me:  "The pain that brought you to the hospital."

Patient:  "Oh, that went away a long time ago, I took some medicine and it went right away."

Me:  "So you're not having any pain? At all? Are you sure?"

Patient:  "No, no.  No pain."

Half an hour later with the attending and the whole team watching:

Attending:  "So I hear your pain went away?"

Patient:  "Went away?!?!  My God, it's never been worse!  In fact, I think I'm having a heart attack right now!"

Patients are *notorious* for changing their stories, invariably making you look stupid.  As if 3rd years need help with that.

Hospice Reflection

Part of being a med student is visiting hospice patients. The really odious part is having to write our thoughts on it. An excerpt of my "reflections" at 1am:

"The most important thing I can glean from my hospice experience, if I can remind myself to do it often, is to enjoy life and appreciate the minor things I take for granted. If I were told tomorrow I couldn’t drive anymore, I would probably actually relish my commute. If I were to learn that I was going to be in an accident and I couldn’t walk anymore, I’d probably go for a good, exhausting run.  Stripped of a long life expectancy, a hospice patient may actually have an advantage most of us don't have – the hightened awareness to consciously appreciate and experience what is left of their lives."

Given that I whipped up over a page of these sorts of paragraphs in the last hour, as I sit blurry-eyed in front of my computer, I wonder, was my parents' hard-earned money for a liberal arts degree worth it?  (Let us also recall that my essay-writing skills have already earned me $271 in exonerated fines for a carpool land violation, plus hundreds more in savings from my insurance rates NOT going up as a result of that ticket.)

Empathy

First of all, I must say y'all are commenting like champs! I love watching That McNabster Guy vs. TGTAdventurenz - it's almost like watching the Olympic women's pole vaulting!

And on to today's depressing business. We were on task to find cool physical findings on patients today, so we were running around the hospital with our resident, dropping in on patients for a quick visit. Next up was a ptosis patient. (No, it's not an ailment unique to African click language speakers, it means "droopy eye" - why they can't just say "droopy eye" I don't know, but I think it has to do with keeping up with the lawyers and their secret language.) We'd already seen a girl with scleroderma, where the skin begins to tighten and calcify, and eventually you can't bend your fingers or open your mouth anymore - very sad; a patient who had an ablation to correct her irregular heart beat, but who ended up with a punctured lung- very unlucky; a patient with an old heart valve replacement that apparently clicks so loudly at night it keeps his wife awake - how exhausting; and other fun things. They were all supposed to be quick, in and out visits, but our ptosis patient trapped us!

He had just been diagnosed with leukemia and started on chemo. He was very angry. He let us know it. He was so angry at his primary care doctor for not catching it, he was gonna sue him as soon as he got out of the hospital. Can you say Stage One of the classical stages of loss? He went on and on and on, and in the end he was very appreciative of everyone at UCI because we had turned his life around (obviously it was our great work, since the four of us had never seen him before), but he sure let us have it. We were all very sympathetic and very professional and listened to him rant and rave for a half hour before we cut him off, but it just reminded me why I want to go into emergency medicine - so I don't have to deal with the same irate patients over and over.

The most depressing part was that I didn't really want to listen to him anymore, because I didn't care that much.

Times Are A Changin'

I scrambled onto the employee shuttle bus, the last passenger before the door closed, and made my way to the one open seat. As I settled in for the ten minute ride from the parking lot to the hospital, I noticed: every single person on the bus was a woman. From the med students and lab techs with the white coats and the nurses with their conspicuously colorful scrubs to the more loosely business-attired clerks and the bus driver in her uniform, some were carrying lunch bags, some carrying Coach purses; stilettos, tennis shoes, clogs; long hair, grey hair, messy hair, perfectly coiffed hair; lots of mascara, lipstick and rouge, but also some without... it was a feminist's dream.  

I wanted to snap a black-and-white with the morning sun streaming through the windshield and the faces at the rear of the bus in shadows, and title it something ordinary like "Off to Work," but display it alongside old 50's typical male work scene photos, you know, the kind where all the men have the thick-rimmed glasses and crew cuts and suits.  The best part? An entire shuttle bus of workers on their way to run a major medical center in a densely populated metropolitan area happened to be female, and no one but me seemed to notice.

Medical Ethics

If a patient came to you and told you his complaint, but then asked you not to document it because he was afraid of complications with his new life insurance policy, what would you do?

If a pharmaceutical company rep offered to bring you and your staff lunch so he or she could spend lunchtime telling you about a brand-new drug, would you accept?  A free nice dinner with just you and the rep?  Would you accept a trip for your family to go to Italy?  How about a Starbucks latte?  A pen with the name of the drug on it?  

If a doctor yelled at the nurses and a med student for not completing the overnight lab work as ordered because he felt the delay would adversely impact his cancer patient's surgery scheduled for that day, should he be punished for unprofessional behavior and creating a hostile work environment?  Or should he be lauded for advocating on behalf of the patient?

If you needed to learn how to perform a pelvic exam, and the young female patient was visibly uncomfortable but didn't specifically request that medical students not be present, would you stay or leave the room?  What if you had to perform that exam that week and have it signed off in order to complete your required procedure practice and pass the rotation? What if you later found out she had been raped in the past?  If the different scenarios changed your answers, how could you justify them?

If you were a nonreligious surgeon but a seriously ill patient wanted you to pray with herbefore the surgery, would you?  What about if the patient asked you to carry a "lucky charm" in your pocket as you performed the surgery?  What if you were atheist and actively did not believe in a god?

What would you do with a patient who is elderly, just feels "done" with life, and can't wait to die?

How would you react if you found out your patient was doing or has done illegal drugs?