What NOT To Say In Residency – May ’07

What NOT to Say In Residency

Slowly, with some pain, I’m learning that there are things you don’t say in residency…you just don’t.

During surgery, for example, you don’t say oops. EVER. Even if blood is squirting at you.

You don’t just sorta GUESS when you’re talking to a patient about a strange growth, “Welll, I ‘spose it could be cancer.”

And with teenagers, things like “Remember kids, safety third!” or “Try sex with your friends, you’ll like it!” is pretty much, I’ve found, not really protected by the First Amendment.

My clinic notes, for example, have occasionally gotten me into trouble. My problem is, clinic notes are boring. After my 20th note, I have to resist the urge to write into a patient’s chart something totally outlandish in the midst of dry, clinical language:

“88-yr male arrived today describing longstanding anxiety and depression. I urged patient to double his cigarette smoking and to consider more fast food. Also encouraged resuming the practice of shooting at rabbits with .22 caliber rifle as they run across his neighbor’s porch. Pt. and I both agreed that these activities would likely cheer anyone up. Expect full recovery from above symptoms after 1 or 2 weeks of therapy. Follow-up when eyesight fails.”

Truth is, nobody reads clinic notes but lawyers anyway. Why not make ‘em fun? Actual docs might start reading them again.

I’ve been reprimanded for clinic notes that WEREN’T jokes, too. I once stated that I agreed with my patient that the 14-question worksheet we use to define someone as depressed was pretty esoteric and only vaguely related to reality. Really, can you actually define someone as depressed with a 14-question worksheet? But – I will admit in sheepish retrospection – actually writing that in the chart wasn’t exactly my shining moment in clinic charting. The few weeks following that mismanagement of clinical honesty were long ones, let me say.

The closest I’ve come to REALLY getting strung up, however, involved a bad case of anal warts. The patient was a cool guy, about my age, and we got along well. Since I knew he’d never seen is own rear-end (like most of us), I brought in our 1200 page dermatology book to show him what his warts looked like.

“But bro, yours are worse than the book.”

“REALLY?” He said, incredulous, “Worse than the textbook?”

“Yeah. Like, twice as bad.” I paused. “I believe congratulations are in order.” I said, straight-faced.

“That’s AWESOME!!”

We both laughed.

“I have a camera on my cell phone.” I told him. “I could get pics. We could send it in to the derm text book and your warty tush would be famous probably forever. You could show your grandkids!” I said.

“Yeah, dude. Get a shot, man!” The patient rolled over and got in position, exposing me to the full viral glory of his condition. I took a couple of pictures. When I showed him, he was actually grateful to see what had been plaguing him for so many years. But the pictures were also of poor quality and we both knew they weren’t going any further than my camera phone.

“I’ll erase them,” I said.

“Well, thanks for showing me,” he replied. “They’re pretty gross but I’m glad to know what I’m dealing with.”

Later, when I’m reporting the story to my preceptor, with numerous other docs in the room, I mention that I took some pictures of the warts.

A small gasp**, “You got permission, right?” I’m asked by a passing doctor in stark sincerity.

My though is, “who on this entire planet would even PONDER the idea of getting pictures like that without permission?” It was just flat-out goofy to me that someone would honestly ask that question. It was BEGGING for a response of flagrant hyperbole, such as “How’m I gonna post those things on MySpace if the patient KNOWS about it?”

Over the next 2 weeks, docs and nurses would approach me, looks of deep concern on their faces. Each pulled me aside to “just mention” they “overheard” me talking about taking pictures – of a patient’s anal warts, no less – without permission. This, I was reminded, violates HIPAA regulations, the Geneva Convention, the Oslo Accords, the 4 Spiritual Laws, probably my wedding vows, and various other creeds and accords.

I contemplated addressing each of my inquisitors as “Your Honor”, as in, “No, Your Honor, there is no truth to those accusations.” But, I’ve realized that this is a serious matter. Straight and direct answers to these kind of questions are vitally important in the medical profession. In this case, knowing I needed to put rumors to rest quickly before things got out of hand, I opted to reply earnestly and honestly, “Don’t worry about those pics, I’ve totally and completely deleted them. You have nothing to fear. The fact is, I didn’t have enough memory on my phone for those pics and the video of my patient with active syphilis getting a vasectomy. Yikes. That one is NASTY!”