Inservice

Yesterday was my inservice exam, an annual test required of internal medicine residents. I'm a fast reader and was completely clueless about far more questions than is strictly optimal (second line therapy for psoriatic arthritis, anyone?) which meant I finished the morning session with more than an hour to spare. To kill time, I wandered over to Nordstrom in search of new shoes, something I very much need. But I'm pathetically out of practice when it comes to shopping. I wander aimlessly, I can't settle on any particular object, I get overwhelmed before I try anything on. So after a quick look through shoes and around sweaters, I spent the hour eating nicoise salad at the Nordstom cafe, bent over the new Jonathan Franzen novel. I'll curse myself Monday morning when I still have no suitable shoes to wear to work.

Work this month is the "same day" clinic at the veteran's hospital. It's like urgent care and so far, I like working there, for the simple reason that I never get in before 8 AM and I never leave after 4 PM. (If I had known, eight years ago, that my criteria for professional satisfaction were so simple, I could have saved myself a lot of trouble.) But I do find myself amazed on a near daily basis by the complaints that bring patients to the doctor. Two days of mild cough. Intermittant toe pain (that's not even happening right now). One guy came in Friday because he'd changed his mind about that prostate biopsy the urologist offered him nine months ago. I met a woman last week who was having a mild sore throat and "when I stand up, I get nauseated". I'll admit I have limited tolerance for this sort of thing. Brian likes to joke that my favorite clinic patient is actually dead, holding a slip of paper with the diagnosis. What a trouper!, he says, mimicking me. I don't think that's entirely fair, but I do get annoyed with complaints that any reasonable person would treat with common sense and patience. Sometimes, I want to tell my patients, people cough and then a few days later they stop. Once in awhile, we all get a headache. And I bet if I got a new fitness machine, my knee might hurt a little the next day too.

On the other hand, some patients are too stoic or too scared for their own good. Last week I saw an elderly man with shingles in his eye; he'd waited six or seven days before coming in. I suppose he was thinking, whatever it is, maybe it'll go away. And it probably will, but it may take the eye with it. Or the 85 year old woman, coughing for the past three months and losing weight despite forcing herself to eat, who just casually mentioned that her mother died of tuberculosis. Or the obese smoker with a family history of early heart disease whose worried wife hauled his butt in after three days of left-sided chest pain that started when he was cleaning a pool. Our exchange was mind-boggling. "I don't understand why this is happening to me," he kept saying.

"Well," I said, "for one, you're fat. For two, you smoke. Your mother had her first heart attack in her 40s. Your blood pressure is 175/95 and God only knows about your cholesterol."

"OK," he said, "but why is this happening to me?"

We went around like that for several minutes, until finally, I said, "I don't know why this is happening to you. Sometimes people get chest pain. And sometimes it's nothing, but sometimes it's a heart attack. Please let me take care of you."

And you know, it's taken a long time to get to say that. Four years of undergraduate education, five years of medical school, a grueling internship. But finally now, ten years in, I can look my sick patient right in the eye, and offer to take care of him, and actually mean it. And that exchange -- of help offered and help accepted -- is exactly as satisfying as I thought it would be. So maybe same day clinic isn't so bad.

Unrelated: we went fake-real camping two weekends ago (where you sleep in a tent 10 feet from the car and eat steak and drink beer and drive into town in the morning for a decent cup of coffee, not to be confused with fake-fake camping, where you stay in a hotel and tell Sam, "We're camping!"). Brian is begging me not to share these pictures with you until he has a chance to process them, but too bad for him.