Some sources of supplementation were ingenious. We who'd impregnated our wives were showered with baby supplies from drug companies seeking future consideration. These were immediately sold to the nurses at ten cents on the dollar. In a more visceral approach, most of us visited the blood bank every eight weeks to exchange a pint of red stuff for twenty-five dollars cash. Over my four years of specialty training, I'd sampled all these avenues of income, moving up in the hierarchy of choice each year.
As my senior residency began, I was introduced to the number-one money-maker of clandestine cash cows by the graduating Bill Johnson, M.D. The work was simple enough — twice weekly, the occupants of a nursing home on Eight Mile Road needed cursory checks to fulfill a state requirement. At fifty bucks a month, a quarter of my salary, this was a real plum.
Rounds were between six and seven in the morning, when 20 patients were examined, vital signs taken, and medica- tions reviewed. This time was chosen because each morning at eight, the Operating Room schedule began. Being late for a surgical assignment was a mortal sin.
The incident occurred during my orientation visit to the nursing home. Bill was flitting around, saying goodbye to the staff. I was somewhat surprised to find the entire ambulatory population awake, quietly sitting in the reception hall, awaiting their exams. I guessed the adage of “rising early” as one ages was correct.
With farewells completed, the aged patients stared intently at “The New Doc,” as we methodically did our exams. Bill was showing me the basic chart procedures when I happened to glance at a white-haired codger sitting in a corner. He looked 1 incredibly old and incredibly awful, with a florid, almost cyanotic face, glazed eyes, and breaths coming in shallow gasps. I tapped Bill on the shoulder, pointed to the old man and said, in a voice louder than intended, “That guy's going to die.” In retrospect, this was one of the dumber things I've done in my life. My statement was meant only as a generic opinion, but as God is my witness — at that precise moment, the fellow exhaled a death rattle and slumped down in his wheelchair, motionless!
Bill rushed to his side, checking for a carotid pulse. Finding none, he checked for other vital signs. Next, he beckoned to the head nurse and whispered something to her. In a few moments, an orderly arrived, who covered, then whisked the corpse from the reception hall. And during those few minutes, I saw every eye in the room upon me, and could hear a soft muttering among the clientele. Bill and I quickly finished our rounds and departed, hardly commenting on what had occurred.
Three days later, I arrived at exactly 6 a.m. for my first solo appearance. I walked in to find an empty reception hall. Nope, nary a patient to be seen. Not that there was silence, for from each of the two corridors, I could hear shouting and even a few high-pitched screams. The head nurse approached me to explain. It seems a daybreak announcement had reminded the population that “The New Doc” was coming today, and henceforth would be seeing them. The word spread like a contagion and a world-class octogenarian mutiny ensued. My imminent arrival had fueled it to a fever pitch. Apparently, no one wanted to be in the same room with the Evil Doctor who had the power to snuff out a life by merely pointing a bony finger at his selected victim and announcing his fate.
The staff's attempts at reasoning, cajoling, bribing, and even threatening their wards had failed. Walking down the corridors, my steps seemed to resonate from the tiled floors like Teutonic jackboots. My face at a patient's door evoked moaning from males and sobbing from females, both pulling bedclothes over their heads. I had run the gamut from room A-1 to B-15, confounded by this, when I glanced at my watch. My God, it was 9:15! I was a dead man because I had missed my surgical assignment.
All those hours of faithful service in the O.R., flashing my surgical skill to the pleasure of my mentors, my incredible diagnostic acumen at Grand Rounds, the covert hints at partnership from some of the Hospital Staff, all shot to hell. Who could respect someone who couldn't show up on time for scheduled surgery? A bald-faced lie about my wife's water breaking stuck in my throat, but finally slipped out.
You see, Your Honor, I had no choice but to offer this shameful prevarication, both to cover my own keister and to preserve the job for those who would follow.
Why the Chief of Service bought it, I'll never know, perhaps I was given a reprieve in light of my stellar past performance. That night, my first mirrored look at a certified liar repulsed me.
God's punishment was swift; my course was clear. The irreversible perception of me as a malevolent Motor City Mengèle made the nursing home job untenable. Hence, my negotiation with a first-year resident; I expounded on the wisdom of accepting the nursing home gig in exchange for his job. He agreed, and I was soon driving into the nether parts of Crime City, U.S.A., to do those crappy insurance exams again.
I offhandedly suggested to my subordinate that, unless otherwise occupied, it would be prudent to keep his hands in his pockets.
I was a resident in a Family Practice program in the early ‘80s. One of my assigned patients, whom we shall call Ann, was the type that would make me want to weep whenever I saw her name upon my schedule. Mercifully, her visits weren't frequent enough for me to require prescription antidepressants, so I just bit the bullet and got through each episode as best I could.
Ann never really had much of anything demonstrably wrong, but that never stopped diligent physicians from searching for the cause of her complaints. She had had multiple abdominal surgical procedures yet the surgical records either mysteriously vanished from her medical record or, when they hadn't disappeared, they reflected nebulous indications for the given procedure and questionable pathological findings from the procedure. Ann had convinced a neurologist that she had seizures and migraine headaches. Although narcotic requests were not part of her repertoire, Midrin (et al.) never seemed to quite do the job. And despite the fact that her seizure diagnosis was made totally by history, nobody had ever witnessed her having one. Her antiepileptic medication level never stayed in the therapeutic range unless she was an inpatient.
She got the E.R. physicians to admit her once for “seizures;” her low blood level of anticonvul-sant medication seemed to bolster the need for this admission. By the time I saw her on the ward, she had convinced all of the staff that she needed extra padding on all the bed rails, headboards, etc. It was a sight to see, especially in view of the fact that she was always asleep when I came by … or should I say she appeared to be asleep. She would certainly be somnolent if there was any hint that a discussion about discharge from the hospital was about to take place.
Ironically, Ann became a volunteer in the hospital. This seemed commendable and innocent enough at first. However, she would go from doctor to doctor telling each one that one of the others had prescribed a diuretic for her and she needed a refill and would they be “so kind to write her one?” She was let go after two days on the job. There was no medical reason for her to need a diuretic; what made her seek them remains a mystery. I remain thankful that it wasn't a controlled drug she was seeking.
Complicating Ann's predicaments was the fact that her husband was the head comptroller of the hospital. He seemed painlessly oblivious to the problems his wife caused to all the staff with whom she interacted. I even made an appointment with him, to meet him at his office to tell him that I just couldn't find any truth in anything his wife told me; I had secretly hoped this would annoy them enough that they would seek a different doctor, but it didn't work.
One late November day Ann presented to my office reporting that she had been vomiting everything she had eaten for the previous two weeks. Never mind that her physical exam showed nothing to support this. Never mind that her weight was unchanged. Never mind that some basic labs failed to support her contention. Then it struck me. “Ann, I saw you and your husband in the cafeteria on Thanksgiving Day and you appeared to be eating just fine.” She proceeded to tell me that that was the only meal in the last two weeks she hadn't vomited. Imagine that!
In an effort to look l
ike I was doing something to investigate this vomiting, I told her I would get a test that would assess the anatomy and functionality of the stomach and upper intestinal tract. What I had in mind was a test we called a “Hamburger Upper G.I.” (Does anybody still do this test?) Call it Freudian if you wish, but after I had completed the request form, I discovered I had written an order for a “Hamburger Barium Enema”! I was half tempted to leave the order as (mis)written, just for punitive purposes!
Ann actually went through with the Hamburger Upper G.I. When she returned to my office to discuss the results, she went to great pains to describe to me how horrible the ordeal was and how she would have never made it through the test if one of my co-residents hadn't been there to hold her hand and encourage her the whole time. Of course, when I asked “Bill” for his version of what went on, it was nothing like her description; Bill essentially was passing through radiology and greeted Ann then went on his way. The result of the test? Normal, naturally.
After I left the residency, I had my first non-residency job as a Family Physician in a clinic about a mile from the hospital where I'd trained. Gadzooks! Ann showed up not long after that, much like the proverbial bad penny. Fortunately for me, she was not eligible for care at the clinic for administrative reasons. That didn't stop her from asking for a “curbside consult,” but I felt comfortable deflecting it by requesting that she see her own doctor for such requests.
I only saw Ann once after that. She was working in a local department store; I only saw her there once and I took the coward's way out: I was able to pretend that I hadn't seen her lest she try to converse with me.
We've all had our dishonest and unreliable patients but for me, this one “takes the cake” … or should I say hamburger.
A LITTLE PREMATURE
I was a first-year resident doing free school physicals for poor farm kids in rural eastern Colorado. My fellow residents and I were taught to ask all the usual adolescent questions (drug use, alcohol use, sexual activity, etc.) when a large, healthy 17-year-old senior football player entered the room. I started my line of questioning for the 20th time that day when I got to my pat question, “Are you sexually active?” He replied with a hearty, “Yea, of course I'm sexually active!” My pat follow-up was, “Are you using some form of protection … like condoms?”
He replied, now rather sheepishly, “Well, I'm sexually active, but I haven't got that far yet.”
I was pretty goofy at the end of a 24-hour shift in the medical ER as an intern at a city hospital in 1966. The triage nurse informed me Mr. Block, a 47-year-old unmarried man, was in Room 12-B with the presenting complaint:
“Every time I smoke a cigarette, my penis shrinks a little bit!”
I was tired and told the nurse to tell him to blow the smoke out his ass, and then his penis would get bigger every time instead of smaller. The old biddy did NOT think this was funny, and insisted he had to be seen before I left.
Mr. Block had his “poor shrunken” penis on display when I entered the room, made it clear he would not object to very thorough examination, and said he hoped I would be – finally – the doctor who could bring him a prospect of recovery!
THEN A CREATIVE THOUGHT STRUCK ME!
I explained to the patient baseline and post-cigarette consumption measurements would be essential before examination and said I would be back after these tests were completed.
Two cute little pure and innocent 18-year-old student nurses were always hovering by the nursing station ready to follow doctor's orders literally (Those were the good old days!), so in my most officious “high and mighty” doctor lingo I handed them Mr. Block's chart and said, “We have a possible case of Oro-Peno-Recto-Nicotine Stenosis in 12-B. This is quite rare! Baseline measurements must include circumference and length of his penis (while pulled out as far as possible), then after you give him an enema take his rectal temperature leaving the thermometer in a full 5 minutes. Then allow him to smoke a cigarette of his choice, and 5 minutes after he is done measure circumference and length of his penis again, and then check rectal temperature again. [In that era, temperature was always taken rectally, for you young docs!] Bring me the measurements when you are done and we will decide what to do.”
With ashen, horror-stricken faces, off the student nurses went to do their duty, and of course I retreated into the interns’ and residents’ lounge to entertain my (equally goofy) colleagues with this great story. I was also putting through a call to the local psychiatric hospital to send over some techs to haul the guy off into the nuthouse. (We could actually do that way back then!)
THEN THE BAD NEWS STRUCK!
The psych hospital intake nurse said: “Oh, no, not Mr. Block again, no way! He does this act all over the state! He isn't ever coming back here again!” I was starting to realize my “joke” was not so smart when the shrieking bellow of the ER Head Nurse could be heard halfway to Canada!
“Dr. Baarrr!”
Oh, she was hopping mad! The student nurses had been caught in the act of carrying out my orders when Mr. Block started screaming bloody murder. He didn't want any girls in his room pulling on his penis and giving him an enema! The Head Nurse found him curled up in a corner with a blanket pulled up to protect him against the students. She told me (and the other now very quiet interns and residents in the lounge) this was the same man who showed up in ERs all over the western part of the state every summer for the past 20 years with the same complaint. He knew there would always be a new shift of young doctors to try to entice into examining him, but she had never seen or heard of any intern or resident stupid or crazy enough to give whacko orders like I did!
The Chief of Medicine kind of hammered home that point the next day in his office, but then he paused for a moment and said, “You know, this man has now been physically examined by hundreds of young male doctors over some 20 years, and there might be a lesson here for him. You ordered something he was totally unprepared for and did not expect. This might completely disrupt his long-standing pattern of malingering! I see here, in your record, you are applying to Yale, Harvard, University of Colorado, and Stanford for a psychiatric residency. Did you use a psychiatric perspective in ordering these crazy tests to disrupt his malingering pattern?”
I gave great thought to my answer, but then answered honestly: “No, sir. I was goofy I was tired, there was a Code Blue in the ER that shift we pulled through and one I helped with upstairs in ICU we lost, and we had a 7-year-old brought into Peds ER in full arrest, everybody tried to help. The kid died an hour before this whacko showed up, and I got to be the one to tell his mother there was nothing more we could do, because I was the only intern applying for a psych residency I had no patience left for a nut case like this. All I had left was a really wicked sense of humor.”
The chief thought this answer over, and said: “Two senior residents there were evidently laughing right along with you, so I gather you had full collegial support. It was not a wise or conventional idea, but I can't and won't blame you for using it. Good day.”
So I posted a note in the ER doctors’ lounge:
“By order of the Chief of Medicine,
henceforth, all prospective cases of
Oro-Peno-Recto-Nicotine Stenosis must first
be evaluated at St. Mary's Catholic Hospital ER”
(knowing all exams there would be done by nuns).
THOSE WERE THE “GOOD OLD DAYS!”
UPDATE: When I was just a tired kid intern, I had no idea of the horror of the Pandora's Box I was opening when I played that little “innocent” joke. By the end of that academic year, all manner of shout had hit the fan. In fact, in my interviews for residency positions at Stanford, Yale, U. Colorado, Harvard, Cincinnati, and U. North Carolina, there were nasty questions about this incident - and my judgment, and my “problematic” impulsivity Tragically, a far more complete picture emerged over the next few months, and the case was presented and discussed at length at a combined Medicine/Psychiatry Grand Rounds in th
e fall of that year. It turned out the man was once a first-class ER nurse trained at a major university who lost his license four years prior, and had been hospitalized at as many as eight to ten psychiatric hospitals all over the NE for similar complaints. He had evidently been seen for an assortment of pelvic complaints at many dozens of medical ERs all over, with visits mostly in the months of July, August, and September.
He used all manner of chief complaints, some very conventional such as suggesting inguinal hernia symptoms or VD; he apparently inflicted bruises and lacerations on his penis and testicles to require minor surgical attention; and then there were the more bizarre complaints such as he manifested when I saw him. I remember one reportedly was,
“I accidently slipped a glass drink stirring straw down my penis, and now I can't get it out!”
Further data emerged that he was amazingly careful and purposeful, to the point that he collected the names and pictures of all new medicine and surgery interns and residents, and found ways to (“innocently”) connect with house staff scheduling personnel at dozens of hospitals in the area. Among the perhaps 250 house staff at the Grand Rounds, dozens of us were interns and residents who had seen him, and we were invited to stand. It was instantly chilling! The professor pointed out how we were all very “boyish,” athletically built, seemingly “handsome” young men. We had been purposely preselected. He also wanted very naive and inexperienced interns and residents examining him, presuming this would lead to more thorough evaluations, and this was evidently why he usually went to ERs immediately after a new batch of interns and residents started training every summer.
The Placebo Chronicles: Strange but True Tales From the Doctors' Lounge Page 10
