the opposite of open

i am fascinated by gallows humor, that dark derogatory humor that many a resident has taken up as a shield in the face of overwhelming stress.  is it good?  is it bad?  i really don't know, but my thoughts are this - at the time, it helps.  why else would it exist?  i am thinking of internship and residency, typically the most intense years of any physician's young life.  the pressures are tremendous.  you spend your days in a state of mental and physical exhaustion, your responsibilities always falling just beyond where you think you can reach.  as soon as you become comfortable in one setting, you are advanced to something else.  there is no moment for complacency.  each month is like starting a new job over and over again, each ward with new people to integrate yourself with, new knowledge and skills to master.  and all the while you are caring for some of the sickest people in the world.

so under that tremendous pressure, you bond with your fellow residents by making terrible, inappropriate, dehumanizing jokes.  typically at the expense of your patients, but also your superiors and even each other.  you are too vulnerable and fragile to make fun of yourself.   the more stressed you are the more cynical and dark your humor.  but when i think about that humor now, the least biting of it still makes me laugh. a mild example is the diagnosis we gave to patients who refused to leave the hospital - adherent mattressitis.  saying it still makes me smile.  but shall i admit now that we referred to an older man in our medical ICU as the roach?  he resided there for months, one complication after another, yet still he lived, unkillable.  i hope you are aghast.  even i cringe as i see those words written on the page.  it seems unthinkable.  if a patient were to be a fly on the wall of the resident's lounge, the only feeling we could have would be shame.  but that is not the case.  the patient is not in that room. (in the presence of our patients we were different, we were professional and careful and caring, and all the things we knew were right.)    at the time, that dark humor lightened our mental loads.  it was the levity that served as a much needed counterbalance to the gravity of what we were doing.  for the worst of it, we can only forgive ourselves.

now i look back and see that dark humor as coming from a closed posture, a posture that removes you and limits you in some way, the opposite of open.  thankfully i no longer have much of a need for that type of humor in my life.  i would much rather seek out the humor that draws people in, that humanizes and opens us to each other.  it is one of the reasons i started this blog, to explore the possibilities of my own evolving sense of humor and its place in medicine and in my life. i am still exploring and i thank each of you for reading or commenting.

self revelation, don't leave home without it

whiney people are everywhere.  they are in line with me at the old navy check out counter.  they are in my home.  they are in my exam rooms.  there is even one sitting at my desk right now, in my chair.  look!  she is typing on my computer!  hey, wait a minute...

post-op instructions: there for a reason, or, how to get an incisional hernia

you had abdominal surgery three weeks ago.  now if you could just show me where your post-op instructions said 'after three weeks, feel free to have a go at chopping and stacking firewood.'

therapeutic intervention

my 89 year old habitually grumpy patient told me he didn't want to turn 90.  so i told him we could just go out back and i'd shoot him. that at least got a smile out of him.

how not to give bad news

part of my job is giving bad news.  it goes with the territory of doctoring.  and of all the bad news i give (i consider diabetes bad news) nothing is tougher than telling someone they have cancer. i really can't think of any other single word that can turn someone's life upside down so entirely and so succinctly.  i don't even like saying the word.  the "cer" part makes me think of slicing knives.  sometimes i catch myself going to great lengths just to avoid saying it, using stand-ins like growth, mass, tumor.  these are marginally better.  and i know once i say that c word, my patients will hear little else. but i try very hard to do this part of my job right, face to face, with plenty of time, because i feel that if it isn't done right, then the trauma of the diagnosis is heightened.   before we end our conversation, i try to give my patient the sense that we have a plan, or if not an entire plan, then at least a next step.

but as difficult a conversation as it may be, if someone has to tell one of my patients they have cancer, i want it to be me.  not the surgeon, for instance, that left the message, 'it's cancer, call me back.' on my patient's answering machine this week.  and anyway, how could i possibly complain about having to give someone bad news?  after all, it is not me that is being diagnosed with cancer.

top ten reasons primary care doctors need a good sense of humor (or at least a generally cheerful disposition)

reason #1:  you will get paged during how shall i put it an intimate moment.  you will then listen sympathetically as your patient describes their diarrhea to you in great detail.  your dear spouse will have to listen to you saying things back like, 'is there any blood or mucus in your stool?'

well after that reason do i need to give you more?

change

i drive by this house on my way to my daughter's school.  i know it's vandalism, but something about this particular graffiti grabs me.  when i see this, my heart beats faster.  my soul jumps up and shouts, 'yes.  yes!  we must change!'  okay, soul, what must we change?  i have no idea.  but i still like the message.

maybe it's because i was raised by two parents that have both shown me in their own unique way that change is good, that change brings growth, whether personal,  professional, or spiritual.  to me, that type of good, forward-moving change is the opposite of fear, it is fearlessness.  to change in a way that contributes to our growth as individuals is to say to fear, i see you and i recognize you but i will not be stopped by you.  (i know i am not saying this very well...)

so if there is something you have been thinking of changing - go for it.  be fearless. change.

can you get a refund?

me, pointing to the exam table and speaking loudly to my patient, 'CAN YOU SIT UP HERE?'

my patient, with her apparently expensive hearing aids, answering me, 'i better be able to hear, with what i paid for these.'

phlegm: the reason i'm not a pulmonologist

it's okay that you just coughed something up in my exam room, but please suppress the urge to show it to me.  if it's okay with you, i'll just use my imagination based on the sound of it making its exodus from your chest to surmise what it might look like.

apparently, your guess is as good as mine

my 92 year old patient was found dead on her kitchen floor this morning.  maybe not a bad way to go compared to some other options, but she leaves me with a dilemma.  in the state where i practice, you cannot list 'unknown' as the cause of death.  you must write something, anything, to satisfy the powers that be.  so we called the medical examiner's office and were essentially told to just put any probable cause. heaven forbid we reveal that we don't know everything...

and to my lovely now-departed patient - you were as mischievous in death as you were in life.  i will miss you!

it's a terrible condition

last summer my lovely niece spent two weeks chained to a desk helping me enter past medical histories into our electronic health record.  this involved the challenging task of interpreting my handwriting (i like to think of it as 'minimalist').  so i had a good laugh when i opened a record the other day to see that my patient suffered from chronic enema.  i think that was supposed to be 'eczema'.