Tardy has a new definition here. In college, of course, there’s the five-minute rule: you wait five minutes for an MA, ten minutes for an assistant professor, and 15 minutes for a full professor. Then you can bolt from class and go do something else. Here, the rule is: you better be there 5 minutes early for anything with an MD; and if they’re late, you just stay put – for an hour, if necessary. Thus, with the attendings, rounds are scheduled at a certain time, but if they come five minutes early, they expect to start right away. Same thing with lecture.
The way our Tuesdays work, we’re in the hospital in the morning, then at 11 we have lecture in a different building, and stay there for “didactic” the rest of the afternoon. A few weeks ago one of the guys was very late to didactic, and I foolishly tried to excuse him to the secretary who was taking attendance. Thus I got myself a lecture on the importance of showing respect to the lecturer (usually a resident) by coming on time, and the guy got his own lecture when he showed up an hour later. So today, I figured I was setting myself up when I decided to stay late at the hospital and finish writing an H&P (history and physical; for some reason these have to be handwritten, not typed). The intern I was working with had his own didactic to get to at 12, and he had two other patients to see; he had also missed the first part of the interview, where I got the patient to explain why he was there (sort of the key piece of information). So I stayed, and wrote down all the details the intern would need to dictate his admission note when he got back from the other two patients. (The interns and residents are in a double bind: they have to get to didactic on time, too, but if they don’t get these dictations turned in by noon, a lady from medical records comes by and lectures them sternly on deadlines.)
Well, I got lucky; the lecturer this morning was one of my preceptors, so he didn’t mind me being late, and the secretary wasn’t there to notice. Then, after our quiz and case discussion in the afternoon (wherein we discovered that a coin toss was a more reliable method of figuring out some questions than our own cogitations), we had a lecture at 4 pm – by the chair of the department. So when she didn’t show up, we waited for 30 minutes. At that point someone got restless, went and inquired, and found she had been on the phone for the last half hour with a patient crisis. So we left. The trick is that the week before, the lecturer had not showed up for the whole hour, and we never heard from him till he turned up today, a week late. So as we marched out through Katrina’s rain, we plotted rebellion and mutiny for next week: if we all leave at the same time, say after half an hour, they can’t do anything to us, can they? I mean, obviously you have to take care of your patients, but one could at least let us leave.
The patient this morning: a middle-aged black man, walking down the street with a shard of sharp glass, told a policeman he was feeling suicidal, and the policeman brought him to the hospital. (Echoes of the guy a few weeks ago, walking down the street with a rope – is this unique to our city?) He then tells me that he was feeling suicidal because he’s been hearing voices in his head for the last 15 years, and today they up and told him to kill himself. (Yes, that’s skepticism you hear; usually if you’ve been hearing voices for 15 years, you’ve turned up in the hospital several times, but we don’t have many records on him.) Then, me being thorough, I asked if he ever saw things other people didn’t see. He sort of closed his eyes to think, then said, “well, you know, maybe I do; I think I might see some people, they might not really be there; they bother me a lot.” My fabrication-detector started blaring. Then I went on to psych review of systems: he endorsed various bits of depression, so that sounded realistic. Then when I started asking symptoms of mania or psychosis, he randomly endorsed every one that sounded interesting: paranoia, manic sleeplessness (only needing less than two hours of sleep a night), TV talking to him personally, and so on. As though he had figured out what symptoms would make us most interested in keeping him there for a long time. On the other hand, one of his children died of cancer recently, and he’s had a couple of accidents, which make his complaint of severe back pain sound plausible (and it takes a lot to make hospital personnel believe back pain stories). So he could really be depressed and suicidal. And he’s not asking for vicodin much. So why is he making things up? Or is it just my fabrication-detector that’s not calibrated yet? I’m just waiting for him to suddenly develop homicidal commands from his voices, and maybe recognize one of them as David Letterman’s, and that should clinch it. Check back for an update tomorrow.