Dear Mrs. Canseco,
You and your husband have had a long, fulfilling life together. Ever since your marriage over 50 years ago, you have stood by his side through good and bad times. And when he was diagnosed with end-stage lung cancer this year, you were there ready to support him to his last breath. However, there comes a point when devotion gives way to fanaticism—and you cross that line a few weeks ago.
When your 75-year-old husband was admitted to the hospital two months ago in respiratory failure, the admitting physician was not being cruel when he inquired about Do Not Resuscitate status. He had nothing personally against you or your husband when he brought up the idea of seeking Hospice care.
You wouldn’t hear any of it. You demanded that your husband be placed in the intensive care unit and be given round-the-clock supervision by nurses and physicians. When I spend five minutes with your husband every morning pre-rounding, followed by another 30 minutes telling you that nothing has changed in the past 24 hours, stop accusing everyone on the staff of “not explaining what’s happening.” Your weekly family conferences where my attending and I sit down with you, your three children, your brother, and two of his kids are really getting to be a drain on our time. I just don’t know how many other ways I can tell you that after being in a coma and on a ventilator for the past two months, your husband really doesn’t have a shot in hell of living through this. You have refused pain medications, saying that we are, “Killing your husband.” You have declined a Hospice evaluation, stating that, “We are turning our backs on your husband.” When we brought in a pulmonologist to reevaluate the situation, only to have her agree with us, you accused her of, “Not knowing your husband.”
But expertise be damned. Your daughter, the massage therapist who has had extensive training in medicine, told you that she believes your husband will make it off the ventilator without any problems if we just wait a little longer.
You’ve treated our hospital like it’s a hotel, having moved in and spent 61 consecutive nights sleeping in your husband’s room. You have refused to leave the room under any circumstances, claiming that bad things would happen to your husband if you walked away. You have demanded that the hospital provide you with meals from the cafeteria three times a day. You have demanded that nurses be forever present in your husband’s room so that they can respond to your every beck and call. You have neglected that these hard-working nurses have four—sometimes five—extra patients who are also very sick and must be seen. I wish I could just put a white coat on a mannequin and place it in your room to try to give you some kind of solace. He could have an outstretched arm to hold your hand with an audio tape on continuous replay saying, “I am here for you.” Because in the end, that’s all that I can offer you at this point.
And then there’s the issue of the money. Don’t act like it doesn’t exist. The combined hospital bill from your stay so far is going to run well over $200,000. But you have never cared how these services are going to be paid. You proudly flaunt that you have no insurance and since you’re not an American citizen, you are ineligible from Medicare. Neither you nor your husband own any property. When it comes right down to it, we’re all really working for you for free.
You have shown us that you know more about the pathophysiology of a coma than any physician ever could. You have taught us that living on a ventilator is better than dying with dignity. You have pointed out that our nurses are incredibly mean and lazy for not dropping everything they’re doing in another patient’s room to come see your husband, whose condition has not changed in two months. Thank you for giving me the opportunity to learn by having your husband as a patient. Thank you for teaching me that everything my attendings tell me is wrong, that medical care is free, and that nurses don’t care about people in a hospital.
Sometimes I encounter patients who are so inept that I wonder how they can remember to breathe and feed themselves. I occasionally have people show up to the emergency department who give a history that closely resembles Abbott and Costello. The following is a real honest-to-God encounter I had recently.
Me: what brings you to the hospital today?
Her: I fell and hurt my arm.
Me: how did you fall?
Her: I slipped in a chair.
Me: did you fall on the floor?
Her: no, I was in the chair.
Me: did you fall into the chair?
Her: no, I was already sitting there.
Me: so let me get this straight: you were sitting in a chair and then fell into that same chair.
Me: and you hurt your arm?
Me: where on your arm does it hurt?
Her: right here on the inside.
Me: how did you hurt the inside of your arm?
Her: I fell in the chair.
Me: did you hit something?
Her: I hit the chair.
Me: on a scale from 1 to 10, how bad is the pain right now?
Her: it’s a four.
Me: I see here that you have a previous history of arthritis. What is your pain level usually?
Her: it’s a four
Me: so let me get this straight, you’re in the same amount of pain right now that you are always in?
Me: what’s different about today than any other day?
Her: I hurt.
Me: is this a new kind of hurt?
Me: what’s different?
Her: I fell.
Me: I see. How about I just send you out on some ibuprofen?
I tried to log into my website this week from a nursing floor only to discover that my hospital has blocked access to halfmd.com, saying that it is “inappropriate for the workplace.” I wonder how they came to that conclusion.
Over the past few weeks, several medical students in the first through third-year classes have been asking me what the final year of medical school is like. I’ll be the first to confirm that the fourth year is indeed the promised land of your medical education. After working nearly 80 hours a week as a third-year medical student, you can look forward to the warm light at the end of the tunnel that is your fourth year.
Whenever I encounter residents or attendings and tell them that I’m a fourth year student, they tilt their heads to the side, stare off into space for a few seconds, and release a nostalgic sigh as they remember the joys of their own fourth year. A typical conversation might go something like this:
Senior resident: You’re late. Where have you been?
Me: I’m a fourth-year medical student.
Senior resident: Oh, in that case you don’t even have to be here. Would you like to go home?
The final year for medical school can roughly be divided into two domains: getting into residency and vacation. You’ll certainly have to do some work this year as you will travel the country on externships in an attempt to impress various programs where you might want to enter residency later. During these externships you’ll serve as a star student reliving the 80-hour work weeks that you grew to hate so much during third year. You will study hard, work hard, arrived early, leave late, and introduce yourself to every faculty member in the department in the hopes that you can get a favorable review when the time comes to apply for residency.
Fourth-year is also filled with lots of administrative headaches such as tracking down grades, securing rec letters, meeting with deans, applying through ERAS, setting up interviews, booking flights, and voting in the presidential election. But after your you have finished all of those tasks, you are ready to enjoy the next six months.
Whereas the third years are required to take courses in surgery and obstetrics where they invariably get yelled at for not knowing everything on the first day, fourth years get away with courses such as nuclear medicine and geriatrics. Typically, the day starts at 9:00 a.m. when I come in and meet my resident to obtain his signature on my attendance form. I then go home at 9:05. Thanks to the accreditation board which requires that we attempt to learn something during this glorious year, clerkships hold afternoon lectures which usually revolve around having an attending show up late, tell us how wonderful fourth-year is, give out the answers to the final exam, and then end class early.
That’s not to say that all medical students take fourth-year so lightheartedly. There are a few scabs at could never let go of being a gunner for the previous three years and for some reason, feel the need to study and work away their last year of freedom. These students will take clerkships in the intensive care unit and hematology/oncology service where they will work to the point of exhaustion while the rest of us play drinking games during the presidential debates. As for me, I started brewing my own beer and I’ve been working my way through all of John Grisham’s novels. As far as I’m concerned, those are the only sorts of activities that fourth-year medical students should be involved in.