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The medicine wards team is the bread and butter of the teaching hospital. To understand the type of care you’re getting at a hospital, it’s important to know the roles of the various members whether you’re a patient or practitioner.

Medical Student

• Number per team: ~2
• Experience: 2-4 years of medical school, plus various incredibly fake Standardized Patient* experiences.
• Specialized role: dodging as much work as possible so that they can study for their shelf exams and actually learn something.
• Underrated abilities: taking incredible social histories, copy-pasting resident assessment and plans, asking how the page operating system works, asking attendings questions (to ‘show their interest’) that prolong rounds by ~20 minutes per question.
• Dies inside when: asked to obtain outside hospital records.
• Common line: agreeing with anyone on the team about anything.

*an actor is paid to memorize a spreadsheet of symptoms and repeat them when prompted. It’s not very realistic. I wish the simulated schistosomiasis was more Shakespearean. “Ahhh! Hark! Doctor! Woooee is me! Ere I sat, with naught but a care in the world, when perforce did a foul ache spring forth from my innards and rest in my side. Methinks mine humours have been wrent asunder!”

Intern

• Number per team: 1-2
• Experience: 1-12 months of actual responsibility.
• Specialized Role: discharging patients as soon as humanly possible.
• Underrated abilities: constipation management, Tylenol dosing, instinctively resisting nursing staff requests to give patients “something to sleep,” ability to cry very discretely when looking at social media and seeing people actually enjoying their lives.
• Dies inside when: a friend utters the phrase “what are you doing tomorrow?”
• Common line: introducing themselves to other residents as ‘doctor’ so-and-so, before realizing how douchy that sounds.

Resident

• Number per team: 1
• Experience: intern year, plus between 1-6 years of additional training.
• Specialized Role: actually knowing anything about how to help the patients.
• Underrated abilities: showing up to the hospital the latest and leaving the earliest, conjuring a morning report out of a straightforward admission, worrying at all times that your interns are killing your patients, retaining sanity during 28 hour calls.
• Dies inside when: discharges get delayed.
• Common Line: [to intern, morning of surgery, anesthesia calls and asks for the resident] “YOU MADE HIM NPO, RIGHT???”

Fellow

• Number per team: 0-1
• Experience: Brittany Spears said it best: I’m not a girl resident….. not yet a(n) woman attending / All I need is time / A moment that is mine / While I’m in between.
  
• Specialized Role: making you feel guilty for consulting their service.
• Underrated abilities: competently managing patients within their specialty, forgetting all medical knowledge not related to their field, being grossly underpaid.
• Dies inside when: consulted at 4:58 PM.
• Common Line: [to resident] Tell me about the one you just saw. In 4 seconds.

Attending

• Number per team: 1
• Experience: years and years. Team leader. Most senior member.
• Specialized Role: knowing how not to get sued.
• Underrated abilities: adjusting the entire team’s rounding schedule based on little Billy’s soccer practice, warping space-time to somehow know what to do with a patient before they are presented, boosting team morale with food (re: buying loyalty), elegantly dissing the other team’s management decisions.
• Dies inside when: they hear this before the one liner: “Ugh, this guy. Super complicated, he basically has everything. 6 admissions in the past 9 months….”
• Common Line: “Strong work, team.”

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.

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.

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