medicine


I’m looking for opinions/advice on how to deal with people doing impressions of others. A lot of the guys here like to do “impressions” of various attendings. To me it feels like mocking them for being older than us, or for having a pet phrase or two, or for always approaching a problem in the same way. I’m not sure whether it’s mocking, though. They don’t do it as much about the attendings we don’t like as about the nice attendings. But of course they wouldn’t do it if the attending was around, and I’m pretty sure the attendings wouldn’t like it if they heard it. I wish I could stop these conversations, but I don’t know what to say.

Ok, that’s the Dear Abby section for today. Now, some stereotypes from another angle:

Another group that my colleagues like to do imitations of are medicine residents in general (not one in particular). At one point today I had decided that was really enough, and we were setting a bad example for the medical students, and I needed to do something to slow it down, or at least demonstrate that we do respect our colleagues. And then we got a consult from the medical ICU, and the medicine resident said, at various points in the conversation, “I know there’s nothing you can do for this guy, but my attending said, ‘He’s crashing, and I’m not sure what to do about it; consult surgery.’ . . . Yes, I’ve been here all morning; it took me four hours to put in a central line, that’s why I didn’t call you earlier. . . Sure, take the chart, I’m going to be writing a note here for quite a while longer [1hr, by my count]. . . We were going to get an ultrasound to evaluate the ascites. You guys don’t do that kind of thing, do you? You just touch it.”

That, my friends, is an admission I could not make up. Every single medicine stereotype that the other surgery residents had been quoting to the med students, in living color – from one of the smartest, most competent (except for lines) medicine residents. He knew the consult was ridiculous. At least he called us about it, and we had an intelligent conversation about the patient. (And as for the ascites, yes: we had a CT, and an abdominal exam. No need to be repetitious with the ultrasounds, except if you intend to tap it. At the beginning of this year, I was puzzled when called upon to say whether someone’s abdomen was distended or not. I couldn’t tell the difference between distention (which is usually pathological) and obesity (which is physiological – not an immediate surgical pathology). I’ve learned the difference now, though. Distention, even an obese person, gives a different texture, a different quality under the skin. It’s fluid, or air, that shouldn’t be there; and you can sense how the skin is stretched in an unusual way to accomodate it.)

And then finally, another group whom I have decided to abandon all scruples concerning, and make bitter and sarcastic remarks about without reserve: the ER, and especially the ER residents. I think, honestly, ER doctors with specialty residents in-house are obliged to do better than this, because they think a bit longer before calling an attending in from home, than before calling a resident down the stairs.

Today, ten minutes before sign-out, we got a page from the ER, for a young man who had arrived only 15 minutes before. (I know, because we were down there evaluating a genuine surgical issue when the fellow was brought back.) The consult was for appendicitis in a patient with no other medical problems. No labs had been done, and certainly no imaging. We went to see the patient, and a few moments later informed the ER resident that in our opinion, a young man with groin/testicular pain as well as right lower quadrant pain, who had a history of both kidney stones and Crohn’s disease, deserved a little investigation into other possible causes of pain (testicular torsion, kidney stones, Crohn’s disease) before being summarily dumped on the general surgery service as an appendicitis. (If it were one of those other causes, he should have been sent to urology, or colorectal surgery, or even plain medicine.) So I apologize to the excellent ER doctors in the blogosphere, but I’m giving up being polite about the ER for right now. From here on, I’m going to fight every call from them until it’s been properly – even exhaustively – worked up. And all stereotypical jokes are fair game. As my chief remarks, we’re not asking them to think like surgeons, just like doctors. Examine the patient and think for two minutes!

(My patient is dying of cancer, and I can’t fix him, I can’t help him, I can’t even make him comfortable. Every time I go to see him, he holds my hand and cries. I hate cancer. My patients are all sick, and I can’t fix them. I’m tired of sick people. Did you know everyone in the hospital is sick? I forget what healthy people look like. All my patients end up in the ICU. The world is broken and I can’t mend it. . . The creation also shall be delivered from the bondage of corruption into the glorious liberty of the children of God. The whole creation groans and travails in pain together until now; and not only they, but we also, who have the first fruits of the Spirit, groan within ourselves, waiting for the adoption, to wit, the redemption of our bodies. And we are saved by hope, but hope that is seen is not hope, for what a man sees, why does he yet hope for? Likewise the Spirit also helps our infirmities. . .)

Ok, that was slightly better. No nasty jobs from the floor or the ER. Fewer undesirable consults from the ER. (I fail, I really fail to understand, why an ER attending and senior resident would call me, show me a CT scan and an EKG, and ask me what we ought to do about it. Dude, I don’t know! I can see that there are QRS complexes, and that we don’t need to initiate the ACLS protocol. Beyond that, why are you standing there looking at me like I ought to solve the problem? The patient is in your ER! Doesn’t matter that a surgical service discharged him a few days ago; he and his ekg are in your ER now.) (I mean, I appreciate the vote of confidence, but my head isn’t that big; I know this is out of my depth.)

I’m beginning to fantasize about adding a lecture to the series of “basic medical things you really ought to know, in case you weren’t paying attention to this part in medical school” that the hospital sets up for the interns during July. In addition to the [valuable] medical things like, when it’s time to intubate, how to think about renal failure (since thinking seems to be the only thing you can really do about it), management of acute coronary syndrome, and so on, I would like there to be a lecture on, “how to consult surgery appropriately.” It would include such basic concepts as

1) don’t call it a rigid abdomen unless it is
2) on the other hand, if you think it is a rigid abdomen, please call us now and not six to twelve hours later
3) please don’t consult us about the possibility of bariatric surgery for a morbidly obese patient during his hospital stay for another medical issue! this requires six months of outpatient preparation, and does not require an urgent in-house consult
4) please don’t mention the words “elevated lactic acid” if you want to be taken seriously; in fact, just don’t check it at all
(sorry, non medical readers; it is the fond belief of medical people that elevated lactic acid is a sign of infarcted bowel, which if true would require immediate laparotomy; however, it is the firm opinion of surgeons, at least at this hospital, that lactic acid can be elevated for many reasons, including renal insufficiency and general low-flow state, and is of no value compared to the clinical exam and, ok, the CT scan; nevertheless, people persist in checking it, and then stat-paging us because the patient, who is sitting up eating, needs to go to the OR now)
5) try to strike a happy medium between consulting us the second you get a positive c diff test, and waiting until the patient is septic on multiple pressors to ask us about a possible colectomy

As you can tell, the main problem with my scheme is that it would be next to impossible to give this lecture without being incredibly arrogant and snarky. So perhaps it’s just as well that no one tries.

I need to stop reading The ICU Book, or at least stop quoting it to my fellow residents. The author has now demonstrated to his satisfaction (though not entirely to mine; I’m still lagging a couple equations behind) that blood gas measurements are entirely useless, and in fact detrimental to patient care, and that most medications used for acute onset atrial fibrillation have no value whatsoever. I think his next chapter is about how giving people oxygen is in fact bad for them.

Everyone talks a lot about communication among members of the healthcare team, but usually they’re referring to communication between doctors and nurses. In my experience, most doctors do a decent – or at least a passable job – at this, since you usually have to tell the nurse what needs to be done in order for it to happen. Also, as in the old military paradigm, the troops do a better job if they know what the plan is, so they can make intelligent adjustments to unexpected circumstances.

I’m a little more puzzled by the communication between different groups of doctors – or lack of communication. It’s not at all uncommon for an ICU patient to have anywhere from three to six different specialists “following” him (I always cringe when I write that – it sounds like a stalker is loose in the hospital), and floor patients, if complicated, will have their own small entourage. These specialists rarely talk to each other, or even to the primary (ie, admitting) service. They all round at random hours of the day, and leave notes in the chart, and expect these notes to enlighten everyone else as to their thoughts.

Of course, since the notes are illegible, no one is very enlightened. I’ve decided that it saves time not to try to read the subjective part, or the physical exam, or the labs. If I can just sort out a few key phrases in the plan section of the note – continue, stop, start some medication or other – I’ve got enough to report on. Then, if I can figure out the signature, I can even tell whom I might page if I have urgent questions. It’s gotten so I recognize the handwriting of all the ID specialists (I think the whole group buys special pens), the critical care attendings we see most often, and the endocrinology and urology PAs. For the rest, if I recognize what their plan is, it might give me a clue as to which specialist would be interested in that subject, and then I see if the operator knows which resident is involved with that specialist.

The only times we actually talk to each other are as follows: 1) Two attendings meet each other at lunch; in this case they will discuss the patient in detail, and mysteriously produce a plan, and then blame their residents for not acting on it, already. 2) An attending decides to round so early that his path and mine actually cross, in which case I’ll ask a great many questions, for my education, and to figure out the plan. This is indeed very informative, but if I don’t time it just right, I won’t see him the next morning, and so will lose track of his plans. 3) There’s something so critical going on that I play tag via the operator, paging every resident and fellow who seems connected to the attending we originally consulted, until I track down someone who knows what the plan is. 4) The consulting service has such an important idea that they page me to tell me to act on it. This is fairly rare, and usually annoying when it happens: is it really that much simpler to page the intern to tell me to write orders, than to just write the orders yourself? But I’m glad to hear from them, so I don’t complain.

My approach is: 1) To write very neatly. I actually scare myself because mine are almost the only legible notes in the chart, so everyone always reads mine for information, and I can only hope that I’ve correctly interpreted and quoted everyone else’s chicken scratch. I would hate to be the only person the lawyers can pin down as saying xyz. But at least no one is in doubt as to what I thought; my attending may have thought something different, and his note below mine may be a beautiful arabesque of loops and squiggles; but my plan is what counts, since that’s what everyone reads. 2) To call other services quickly when I have questions, and especially when we have any plans for patients who are admitted to a medicine service. I can only imagine how frustrating it would be to come in and find that the surgeons have kidnapped your patient into the OR, so I try to let them know what our plans are. 3) To hang around the patients’ rooms whenever feasible, since this makes it more likely that I will actually catch the other services as they round.

I’m not sure what better approach there could be. Legibility is the holy grail of medical records – desirable, and unattainable. But at least one’s pager number should be written legibly, so it’s not such a daunting task to track the writer down and ask what he was thinking – or some other diplomatically worded question which doesn’t imply that the time spent writing in the chart was worthless. (Also, this is where talking to the nurses comes in handy. If everyone talks to the nurse, she (or he) then serves as a repository of easily accessible information – if you can find the nurse. Sometimes this is easier than finding the chart, other times vice versa.)

Oh yes. And everyone politely writes at the end of their note, “appreciate consult,” or “appreciate cardiology input,” or “will follow endocrine’s recommendations.” At least we’re courteous in our illegibility. (Sometimes this helps because you know what letters have to be involved there, so, like the old codes, you can extrapolate back to the main body of the note.)

What else is there to say about work? The amazing storm of OR cases continues. I feel bad because they’re two-person cases, which means the medical student is lucky to scrub, and certainly gets to do nothing whatsoever during the case. I remember how frustrating that was, especially going to the OR, haunting the holding area, waiting and hoping that the resident wouldn’t show up, and how crushing it was when they would blithely wander in and take over everything. That doesn’t prevent me from – wandering blithely in and taking everything, though.

I read Bongi’s post about assisting the surgeon yesterday, and consequently thought very carefully about my actions today. I think I did fairly well, not that it was a complex case. But even after just a week at this, I’m getting better at telling what the attending wants to do, and what direction the tension, or suction, or light, needs to go to help that happen. I read a fascinating article somewhere once about how the human brain can calculate what another person is going to do next. Apparently, when one watches another person’s motions, one’s own motor cortex lights up as if performing that action. So you can almost feel what’s going to happen next, because you can tell what your body would do next, if it were in that position. For example, someone holds a glass, and you can tell if they’re going to put it down, or drink from it, from just a split second of movement. You can watch someone walk down a hallway, and tell where they’re going to turn before they actually pivot. Similarly, with more experience, I can start to see where the surgeon’s hands are going next, or what part of the field they’re heading towards, before it actually happens. Fun.

I love AAPS. For one thing, Ron Paul is a member. For another thing, they send out delightfully informative, heretical, subversive pieces of news like this one: A major study shows that Zetia has no preventive effect on heart disease or heart attacks. This article also reviews the fact that most of the statistics showing benefit for statin drugs (and also for many other famous medications) are only impressive when given as relative risk reduction. The absolute risk reduction for many medications is not at all persuasive. This is the difference: if 100 people take a pill, and 100 take a placebo, and in the placebo group two people die, or have a heart attack, or develop angina, and the medication group only one person has that bad outcome, the relative risk reduction is 50%: half as many people died when they took the medication. The absolute risk reduction is 1%: 1 out of 100 was significantly affected by having taken the medication. Now if the effect you’re measuring is death, 1 in 100 may be a good cost/benefit ratio. But if the effect you’re measuring is just reduction in cholesterol, or slower development of coronary artery disease, and you can’t even show a survival benefit, it starts to look worse. Also bear in mind that the side effect rate is probably at least 2-3%, and probably higher, depending on what you count as significant side effects. This is why I can’t stand medicines.

(And yes, to be fair, I’ll apply this to surgery too: We say that you will get very sick if you have appendicitis, and don’t let us take it out. Similarly with gallbladder disease, and sigmoid diverticuli, and so on. But I suspect that the mortality/morbidity rate for these diseases untreated, or treated only with antibiotics and never with surgery, is not as high as we give patients the impression it would be. Or perhaps I’m underestimating the amount that surgical diseases contributed to the low life expectancy prior to this century. At any rate, it would now be impossible to do any kind of study of what happens to appendicitis if not surgically treated. And, the mortality can indeed get quite significant if you add in a few other medical problems. So I’ll keep doing these surgeries. But I’ll feel quite happy about not reording zocor and the rest for my patients who are hospitalized for a couple of days. If I get their blood pressure within reasonable limits, that’s enough.)

(On the other hand, I’m disgusted with myself for losing interest in general medical problems. I used to swear I would try to maintain some knowledge about overall medicine: thyroid disease, basic cardiac issues, diabetes – all that. For the first few months here, I did try to handle that stuff as much as my seniors would let me. Now, I’m beginning to care as little as the next surgeon. Diabetes? Sure, consult endocrine. Bad COPD? Sure, consult pulmonary. (Not that the consult does much good. Pulmonary always recommends nebulizers and pulmonary toilet, things we order reflexively in smokers and asthmatics. Endocrine puts the patient on insulin, and adjusts based on fingerstick results, which is really fairly basic math: addition and subtraction. And then they do their usual battery of tests (pulmonary function, or TSH/T4/ionized calcium/HgbA1c/microalbuminuria), which by this time I can predict, but admittedly have little interest in interpreting. I’ll quote you a cardiology consult I got the other day: “Recommend decreasing iv fluids when appropriate per surgery service.” Do tell. Usually when the patient has been resuscitated after surgery, we tend to turn the fluids down the next day or two, of our own accord. Thanks for that scintillating insight.) I’m studying for Step 3 right now, and am having great difficulty mustering any interest in the subject whatsoever. The review book has no chapter on general surgery. I looked three times. No wonder we get urgent consults for asymptomatic gallstones.)

(Ok, I’ll stop there, and get ready to duck the comments.)

Another good day. I was running nonstop (although I admit that my commitment to patient care has declined to the point that I did take ten minutes for lunch, and thus missed a few items of scut, which will keep for tomorrow), and didn’t get much done other than put out fires. Bless their hearts, the nurses had a whole list of jobs for me (reorder the pain medicine, reorder the iv fluids, change the blood pressure meds to po, and so on)  none of which I considered essential except the ones needed to keep the PCAs (patient controlled iv narcotics – very popular with patients and staff) running.

We had a sweet little old guy go into afib with rapid ventricular response. The junior and I pushed some iv meds on the unmonitored floor (to the glee of the patient’s nurse, a very sharp young man, who had initially noticed the tachycardia and brought it to our attention, and the consternation of the nurse manager, who nevertheless had to agree that it wasn’t contrary to protocol if we did it). Eventually the patient stabilized and was moved to a monitored floor. I sent him with very specific transfer orders, and instructions via the nurse giving report, and the nurse who transferred the patient. I thought I could take a few minutes to catch up, and then go over to see what happened.

Half an hour later I called over to check. “How’s my little old guy doing?” The nurse answered, “Oh, I just called the nurses up there to check. Are you going to consult cardiology?” Me (thinking, why would we, we had the rate under control, no symptoms, give us a chance to try chemical cardioversion): “Not right now, no; what’s the rate?” “Oh, 180s.” Me (flying nearly off the handle; or maybe entirely off): “Were you planning to call and tell me that?” Nurse: “It’s ok, it was 160s till just now.” (It had been 90s when I sent the patient over to the cardiac monitoring floor; I thought they cared about cardiac rhythms there!) Me, sarcastically: “Honey, for your information, that’s the kind of thing you’re supposed to tell me about!” I hung up and ran over, to find the nurse blithely filling out useless forms on some other patient. I’m afraid I spoke rather sharply, and told her the forms could wait, but right now we needed to get this patient’s heart rate under control, and go start putting a drip together. He was 85 years old, and had been complaining of chest pain, vaguely, on and off. (And yes, we had done all the tests and medications for acute coronary syndrome.)

Of course, half an hour later, it did turn into a cardiology consult. Turns out the patient was not having a heart attack and is still quite happy and doing much better. Like most of my patients with new onset afib postoperatively, he was more distressed by our concern and rapid activity than by any actual symptoms.

Come to find out that nurse was very senior, and a rather important person on the cardiac floor, and on a first name basis with my attending. Bother, wrong person to snap at. But I don’t care how senior she was, calling another nurse to ask if a cardiology consult is planned is nowhere on the list of things to do when your octagenarian patient’s heart rate shoots up to 180 – or even 160. I would try to talk to her to smooth things over, but I don’t know what to say. I apologize to a lot of people these days; but I’m not going to apologize for that one. I wouldn’t mind if she had called my junior or my chief – but to call the other nurse, and not even mention the heart rate?? [ok, stopping the rant now]

Anyway, in between being concerned for my patient, I was also thrilled. This is the kind of situation that would have completely bowled me over a few months ago, but now I knew exactly what to do, and the senior residents agreed with my plans. (Not calling cardiology at first was their decision, back when the heart rate wasn’t so rapid.) It was still good to have them there checking on me, but it begins to feel as though, in five months, I might be ok to do this more on my own. It was almost like a test situation, there were so many variables, so many medications that we used and tests that we ran, and so many decision points based on the response to medications or results on tests. Now that the patient is ok, I’m almost glad it happened.

For the rest of the day, various other patients went downhill in more surgical and less easily reversible ways. On second thought, maybe there is something to be said for medicine. I know I’m going to offend my medicine friends again, but somehow it’s a different kind of stress to consider what medication to give, rather than whether the patient is going to die without you cutting him open, and committing him to all the risks that that entails. Or maybe it’s just that we weren’t giving enough weight to our consideration of which medication to use. I’m sure if I’d stayed around to ask cardiology, they could have told me a dozen frightening consequences to any wrong choice, that I just wasn’t particularly aware of.

No doubt this is extremely lame, and I ought not to be confessing it in public. But as a result of studying for the inservice exam, I have finally grasped the significance of FeNa (the fractional excretion of sodium in the urine, calculated as (urine sodium/creatinine)/(plasma sodium/creatinine) ), and urine sodium, and urine electrolytes, relative to acute renal failure. This is one of those topics that people have been asking me about for the last three years, and I always gave them a blank stare and some kind of mumble. (The answer to the equation is either more or less than 1%, so you have a 50% chance of guessing the right one in a yes/no question.) Then they would give me some rapid and forceful explanation about its extreme and vital importance, which I of course didn’t understand. Back at the beginning I used to look it up in huge textbooks, and by the time I got to the end of the five-page section on the subject, I’d forgotten the beginning, and didn’t get anything out of it.

Now, having had more patients than I can remember suddenly develop oliguria (low urine output), and having stood there staring at their ins-and-outs sheet, and trying to correlate it with the latest electrolyte panel, and being still at a loss to figure out whether they were dehydrated, and needed a lot more fluid, or were well hydrated, and had acute tubular necrosis for some other, possibly reversible, reason, I am very interested to discover that the FeNa will help me figure this out. They told me this many times in the last six months, but now I get it; and you will find me checking urine electrolytes without having to be reminded, because I finally want to know what they show.

I know; I should have figured it out a long time ago. But the relationship between the esoteric calculation and the patient’s problem never clicked for me before. Better late than never, hmm?

The attendings I’m with this month do some amazing surgeries. Shocking, actually. The procedures are necessary and lifesaving – but also brutal and mutilatory in a way I’ve never seen before, somehow even worse than burn surgery. The med students are standing there looking horrified, and I try to act cool, as though I have any idea what’s going on; but I don’t even know what the next general step is, and I can’t quite believe it when I see it happening.

They gave me the weekend off, and I don’t know what to do with myself. It would really be less boring to be back in the hospital. I want to know whether Mr. A will be any less depressed this morning, how Mr. D’s PE is coming, whether Mrs. R’s mysterious fever continues, and where it’s coming from. I suppose I should clean the house, but that won’t take long. I suppose I should study. That ought to occupy the rest of my time. The surgery intraining exam is in three weeks, and since the senior residents are scared of it, I can only imagine how much trouble the interns are going to be in. At least I get to go to church tomorrow, maybe for the only time this month.

The other day, being at loose ends at lunch time, I fell in with some medicine interns, whom I’ve been friends with since we suffered through ACLS and orientation together, and we sat down to eat in the cafeteria. I was enjoying talking about nonsurgical subjects (such as medical ICU patients – one of the interns was excitedly relating how he had finally gotten to do a central line – and the other interns’ children, and the nonexistence of global warming) when my least favorite surgery chief resident came in, with some other surgery residents. He sat down a couple tables over, and started taunting me for being on the dark side and having forgotten who I was. I said I was being friendly. “Well, don’t be too friendly, or they’ll start calling you to help with central lines.” “They already did,” I said flatly, and he finally left me alone. (I didn’t think it was necessary to add that the last time medicine had asked me for a friendly central line, I failed miserably, and had to be fished out by my senior.)

Why does a drug go and be a controlled substance, when there are absolutely no narcotics in it? Just to trip up poor interns, and make them get paged by angry patients and pharmacists at night. It’s very difficult to either apologize or be authoritative about one’s lack of a DEA number when your cell phone connection is breaking up. . .

Chief’s advice: don’t write scripts. Let the interns do that. Ha.

My hospital has, among other distinctions, a pediatric psych unit. You may well ask, what on earth is a pediatric psych unit? Now that it’s fashionable to diagnose not only 15-year-olds, not only 10-year-olds, but even 7 and 5-year-olds with psychiatric diseases, sooner or later children will turn up who are “not doing well on medications,” and by somebody’s standard need to be admitted to the hospital.

It makes me sick to see these poor children in the ER with this diagnosis on their charts. To my mind, drugging your 7-year-old with high-powered anti-schizophrenic medications like abilify and zyprexa (remember the horrible side effect profile of most of these drugs: zyprexa is well-proven to cause diabetes, for instance) is downright child abuse; not to mention then allowing strangers to incarcerate them in a “hospital” because they’re not behaving the way you want them to.

The usual story is that they’re being violent at school: kicking, hitting, maybe even biting the staff. Folks, since when is a 50-pound child a threat to anyone? Are you really telling me you can’t control a normal-sized first grader? You have to admit him to the hospital for this? The problem with these children is that their parents are too lazy to discipline them properly. I support corporal punishment; which these children clearly haven’t had enough of. Now, once they’re this violent, I could see an argument that more violence of any kind in response won’t help. Ok, fine. But I guarantee you that anyone, if put in an empty room and left strictly alone, will quiet down sooner or later. Maybe two hours later. But far better that their parents or teachers should spend that time watching out of the corner of their eye (rather than giving the child a wrestling match and a shouting match, the way he wants), than that these little children should be institutionalized at this age.

Can you think of a worse thing to do to a child who’s already having trouble adjusting to the world, whose family situation is no doubt very fluid and unreliable, than to take him away from everything he knows and put him in the four walls of a hospital?

The crowning irony is that these children, here in the ER, seem well-behaved. They’re not bouncing off the walls, or yelling, or demanding anything. They sit quietly, smile at us, cooperate with everything. If there’s any point where they can be got to do this, then with proper encouragement, they can do it all the time. Most often, their family will say in bewilderment that the child is fairly cooperative at home; maybe annoying, but not completely out of hand. It’s only at school that they go completely wild. Maybe because they’re locked up all day with peers who are having just as much trouble as them?

These children are being abused. I hate to think of what their lives will be like in ten or fifteen years, when they become young adults who’ve never been given the chance to cope with the world except through the film of psychiatric drugs.

Further installments of the medicine/surgery disconnect: 

After a lengthy discussion in the OR about one of our patients who seems to be drifting along, securely not dead, but not making any noticeable progress towards getting out of the ICU, a few of the interns decided to talk to the medicine attending (who is very approachable; it’s not just any attending that interns could consider offering suggestions to). He listened very politely to our (perhaps wild) ideas about changing some of the medications around, and then answered (and I quote): “What he’s on certainly isn’t doing a whole lot of good. But it’s what’s classically indicated for his diagnosis, and I’m not excited about trying anything else. We’ll just leave things as they are.” Which was a very definite close to the conversation.

And we were left to meditate on the fact that almost any surgery attending, faced with three weeks of unsuccessful therapy, would be quite happy to start ignoring the book and branching out, on the grounds that since what we were doing wasn’t helping, some alternatives certainly couldn’t do much worse. Whatever the options might be, sitting still is not a popular one with surgeons.

 Who knows. Perhaps we’re just directing our frustration with the patient’s non-improvement towards the medicine attending. Perhaps we had no idea what we were talking about (where’s The ICU Book gotten to?). Or perhaps it’s another true indication of completely different ways of thinking about problems. I wonder whether men and women think more or less differently than surgeons and internists (which is stronger, learned or instinctive behavior – or are both of these differences inborn?). Opinions, anyone?

(But nothing could really spoil the delightful prospect of a whole weekend off – two days in which not to wake up to an alarm clock or get called in the middle of the night.)

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