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I find it to be a hilarious perversity that I am now an Intern's Boss. Last weekend (I think it was the weekend, anyway..), My intern paged me at about midnight about a patient that was dying. Tachypneic, Tachycardic, Hypotensive. On Death's Door. Old, demented. Let me just say it, she was a total gomer. My intern is alone, scared. He's not sure what to do, medically, ethically, or morally. She's DNR/DNI, but nevertheless in our ICU, a place known to keep people alive forever, and being aggressively treated... Should he get a lactate? Or cardiac enzymes? What if they are high? And plus we can't start pressors. She's not a surgical candidate in the case that there is an abdominal crisis brewing. She won't go to cath if she's getting an MI...Should we maybe just broaden our antibiotics...? He's asking good questions, concrete but insightful, thinking about all the right stuff... I am apathetic and cannot rouse myself from the couch or fully out o...

In a recent desperate cry for help with my current existential career crisis, my sister pointed out an interesting and enlightening observation about my recent theme of processing with a statement to the nature of: I am boiling down all of my problems to a simple issue... the ethics of dying... when, in fact, most of my frustrations seem to reflect a much more complex systems flaw in a setting of deep personal discontent. She suggests that remaining in an extended, artificial, structured, and underpaid academic environment (i.e. Fellowship) may not lend the complete answer that I am searching for. When I think about it, she is probably correct. I suppose it is quite easy to boil down all your problems to something that you have an innate passionate feeling about. I see people doing this all the time. For an individual person, everything that is "wrong" or "right" in the world really comes down to a single thing that they feel very strongly about, for example, being ...

I recently read an article by Atul Gawande in The New Yorker entitled "Letting Go." Other than being a beautiful and heart-wrenching compilation of stories about one of modern medicine's true failures, it brought to mind a fascinating concept... "Is she dying?" The implications of that question in conjunction with an idea I recently read from a fellow resident suddenly make me realize that we are thrusting a decision on suffering and uninformed families that we are not prepared to deal with ourselves... Before this realization, I don't think I ever understood the complexity of what we are asking from the families of our terminal ICU patients... It seems like we get to a point - as health care providers - when suddenly we all agree that a patient is dying.. The tragedy of the timing is that, once we get to a point at which we agree that the person will die, it is beyond the point at which the patient has anything at all to do with it.. I often think...

Death of an Ordinary Family Doc I had an interesting and traumatizing experience last night that again shook my core and reaffirmed my belief that when the layers fall away, I am ultimately a scared and unprepared coward in the realm of primary care medicine... I've had that realization many times in the past... I think it is rooted in the fact that, as Family Physicians, we are in a unique position in which we are expected to know something about everything in medicine, to do everything possible for anyone, and to utilize resources in such a way as to do this in the most cost-effective manner to reduce healthcare costs while educating people with a pretense or hope that this will enable some sense of personal responsibility... And we should perform this task without personal consideration of constraints limited by our own effort, time, or level of frustration. A Daunting Task. However, I do not mean to suggest that it is impossible to accomplish this task well. In fact, I ...

For a variety of reasons, I am back inside my maximum overdrive of introspective over-thinking and mega-processing... It tends to happen to me when I am working a lot and under socialized. Minimal life distractions. Lots of thinking time. I have been in Salt Lake Regional almost every day for the past 2 months.. If that doesn't instigate some introspection about what you are ultimately doing with your life, nothing will. Also, I am living alone again. A few things happened to me over the past few weeks. First, I am pretty much absolutely positive that I want to do palliative care. Previously, I had decided that ultimately I should get a real job in the real world after residency before making any more rash decisions about my career direction. I felt like this was fairly important to me because I have noticed that I often sound like a naive and clueless child when I talk or write about "life" or my work. But this is what happened. Two months ago, my geriatri...

Lately, I find myself preoccupied and fascinated with the idea of change and discontent.. This preoccupation comes to me in the setting of my 4th move within 2 years since moving to Salt Lake City... I have to wonder, is discontent just moving along with me, or am I moving away from discontent, even if in a slow and wide spiral.. Since moving to Utah, I've been told by friends or mentors that they suspect I have some sort of internal or innate discontent seeded within me that is traveling with me, haunting me. These people often recommend things to me such as: psychotherapy, prescription antidepressants, etc. I have been continually surprised and sort of offended by this genre of accusation. Since moving here, I have attributed my discontent directly to my incompatibility with this particular job. And this job is certainly a very reasonable explanation for discontent. This is a miserable job located in a place with a culture almost incompatible with life. It makes s...

A few recent surprising self-realizations, Part Deux. Plus just some general clarifications about life the way I see it currently. continuation from 8/09.... 1. When a dying man who is NPO in the ICU begs you for water, you should give it to him. Regardless of whether he may aspirate or may go to surgery. It's bad enough that he is tied to a bed with tubes coming out of his neck, groin, wrist, and penis, tele leads all over his chest, and BP cuff and SCDs firing every few minutes... Give the old dying man water. Period. 2. I like some people a whole lot. But I don't like most people much at all. This sentiment is exacerbated by sitting across from 25 of them complaining in my face all day in a rapid-fire clinic session that has to be similar to speed dating in Manhattan. 3. The only thing worse than sitting in clinic all day is sitting down to chart afterwards.. For 5-8 hours. Recapping every painful conversation, discussing all the possible things their problems coul...