5 Things Your Doctor Really Wants to Say to You (But Won't)

Here's one of my personal favorite stories from my time in the ER: A couple was seen by their family practice doctor earlier in the day for the wife's constipation. The doctor gave her two boxes containing enemas. For those fortunate enough to not have used these, each box contains enema fluid in a bottle with an uncomfortably long spout. This poor, hopefully illiterate woman took one look at that spout and knew exactly what it was for: drinking.

But that's not why she came to the ER. No, she only saw us because she hadn't wanted to drink the second bottle and wanted to see if she could get by with just the one.

I asked the husband: "Did these come in a box?"

"Yes."

"Are there any instructions, say, with pictures, on the side of the box?"

Long pause. Then:

"So is it a problem if she drank the enemas?"

Professionalism. I didn't crack. In fact, because I'm a good doctor, I called poison control, and because I'm a better human being, I immediately muted the phone to hide the peals of laughter ringing on the other end. But hey, laugh all you want -- the enema still worked. But the woman suffered horrible, horrible abdominal cramps. In this case (in this ONE case), anal insertion is preferable.

There is a specific code in our manual that means "Patient was injured while landing a spacecraft."

Why? Well, medicine is like everything else on the planet -- it all runs on computers. We have to carefully catalog every little thing that's wrong with a patient, and, since this is all getting entered into a database somewhere, it needs to be done in the form of a code, so the insurance company and the government know what we're asking them to pay for. Makes sense, right?

Well, give me a moment to explain the utter insanity of this system. First of all, there are a lot of fucking things that can happen to a person (see: Modified Dildo Accidents). Right now, we use a list of codes called ICD-9 (International Statistical Classification of Diseases, Volume 9). That little beauty contains roughly 15,000 codes. And if you think that surely covers every possible scenario a human body can encounter in the natural universe, well, the government disagrees. They're about to unleash ICD-10, and for my profession, it's Y2K (look it up, kids) and all the bad parts of the Rapture blended together and then spiked with a shot of Mayan Apocalypse. You see, ICD-10 has roughly 155,000 codes. There's a code for everything, and I mean everything. Examples:

T63622A -- Suicide by jellyfish
V9542XA -- Injury during forced landing of a spacecraft, initial encounter
V9107XA -- Burn from water skis catching on fire
V9840XB -- Genital injury sustained from Klingon Mating Ritual

I only made one of those up.

I'm not whining about having to do complicated paperwork -- I know nobody is going to feel sorry for anyone making a surgeon's salary. But if I code a Medicare patient incorrectly, it's fraud. Against the federal government. I could go to jail, and while I make good money, it's not enough to pay for one of those fancy prisons the guy got in Wolf of Wall Street. What if I code for a lesser amount of money, just to be safe? That's fraud, too! It has to be perfect, every time.

And soon everything will be based on this new system, and it will be virtually impossible to do it right. Insurance companies don't know what to do with it. No one knows how it will affect billing. We've actually been told to expect to not get paid for three to six months once it starts. And we're not alone. Hell, 65 percent of clinical documentation doesn't include enough data for doctors to even make a code under the new standards.

The conversion happens October 2015. So yeah, party your asses off this Halloween. Break out the vodka-soaked tampons and start all the fights you want. But next year, maybe just stay inside and avoid injury until we get this sorted out.

Some of these people are lying.

So, I'll look at one MRI and see what looks like a big herniated disc and have the patient skip right out of the room, insisting they feel fine. Then I'll get a young, otherwise healthy man with a normal scan who's limping in like he's fresh out of the opening scene of Saving Private Ryan. So, us doctors are forced to make huge decisions that impact these people's lives -- proof of disability for benefits, and prescriptions for addictive medication -- and in many cases it is impossible to know who's being honest.

I've had people whose immediate response to "You need surgery" was "Does this mean I can go on disability?" And they never ask that with the tone of dawning horror you'd expect from someone who just suffered a life-altering injury. No, they take the exact same tone as a 5-year-old asking if Santa's going to come tonight. But just because that person exists, it doesn't mean the next one isn't telling the truth.

And it's hard not to let your feelings toward one patient carry over to the next -- I'll see a little boy who has just come out of surgery to have a tumor carved out of his spine excitedly talking about how all he wants to do is be well enough to get back on the playground, then I'll see a 40-year-old man demand narcotics ("Other medications just don't work, Doc! I'm allergic to Motrin and Tylenol! I can only take Percocet!") and weave a sad story about how he really, really wants to work, but just can't. Think Cousin Eddy from the Vacation movies.

And this becomes part of the diagnosis. In elective back surgery, we all look for red flags like chronic unemployment, a long history of workman's comp claims and frivolous lawsuits, and a fine, connoisseur's appreciation for methamphetamine. It's actually scientifically reproducible that candidates with those factors in their background are less likely to recover. Because they don't want to.

But I have to be professional and empathetic, and hey, maybe this next guy's not lying about how much pain he's in. I can't start spewing sarcasm, Dr. House-style, or sign my name on the prescription pad as a little drawing of a hand giving the middle finger. But I still want to say ...

Telling parents that their healthy little boy is going to die in a year sucks. It's emotionally crippling, but I can't let that show on my face when I deliver the news because, well, I'm the professional (although if I'm too cold and clinical, I'm just an asshole). But no matter how that conversation starts, it nearly always ends with the same lines from the parents:

"We'll go to a better hospital."
"We'll find a better doctor."
"You're wrong."

And that's perfectly understandable. You're losing your kid; you can vent all you damn want, and I'll never think less of you or even make a comment in my defense. But then, after dealing with that, I have to go to my adult spine clinic and immediately deal with the guy with a nearly invisible disc herniation who's demanding narcotics and a disability statement. So you can see why a person would get cynical in a job like this. And even more so when we have to say things like ...

I vividly remember sitting a family down to give them "the talk" -- explaining that grandpa was going to die, and that medical science could do nothing to stop it. He'd had a head injury, and the pressure on his brain was way too high and we couldn't bring it down. Right as I was telling them that he'd never wake up, one of his daughters asked me: "Is he supposed to be getting out of bed?" And that's exactly what the old badass was doing, medical science be damned.

So why did we seem so quick to give up on him? Well, that's one of the horrible calls you're forced to make in this business.

Let's take something like a ruptured brain aneurysm -- around 15 percent die before ever reaching the hospital, and we know statistically that 50 percent will be dead or severely disabled (think: vegetable) within a month. Most of the other survivors will have a permanent disability. All told, only about 1 in 5 patients comes out of it as the same person.

So when we get one of these patients whose odds are even worse than that -- say, your 75-year-old grandma -- what do we do? Do we go for broke to try to save her life, knowing that we're almost certain to create a completely dependent nursing home patient who may spend the rest of her years in a vegetative state? Remember, it's not a "better safe than sorry" situation -- every operation I perform with no chance of a good outcome means less time I have to work on people I might actually help. Doctors aren't obligated to perform futile operations -- I have to make that call, and I have to do it knowing that sometimes we're wrong. See the old man above.

There are even times where we'll all agree -- doctors and family both -- that if the patient starts to "code" (have a life-threatening crash), we'll stop treatment. Then it actually happens and everyone panics -- including the doctors. So, we save their life and feel like heroes. The problem for these families comes three or six months later, as the grim reality sets in that we didn't actually save them.

And that's actually worse. If a person dies, the family grieves, works out their anger, and then gradually hits acceptance. You remember the person as they were. If we turn a perfectly good dead person into a chronically vegetative person, then we've just prolonged the grieving process for months or years, and the person they knew is gone either way.

Life is short, is what I'm saying. So, hell, if you want to cram something into your ass, go for it.

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