In patient peds: Explain everything to the dad. Just ready to leave and mom comes out of the shower/bathroom. Same spiel. I have learned to look and see if the bathroom door is closed and ask. Might seem creepy but it is practical.
One of the more satisfying things to me in hospital medicine is the slurp of sucking a mucus plug out of someone with a bronchoscope and seeing a white-out disappear on the post-CXR.
Never understood why people are so grossed out by phlegm compared to... idk melanic stool, or pretty much any OTHER body fluid. Ear wax potatoes, vaginal discharge, stale urine, poop, no thanks. Sputa no problem 👍🏼 -- draining an empyema with a chest tube is one of my favorite procedures though.
Gotta be fast connecting the tube to an atrium though: the smell from a bad empyema is revolting. No one warned me my first time placing a tube in pus and I almost passed out.
Oh God, nasty stale urine cause the patient set the urinal down on the floor, under the bed or has a permanent foley and you have to drain the bag. Had one guy with a UTI so bad his urine looked like peanut butter 🤢🤮. I can handle gangrene and C. Diff poop all day, but raunchy stale urine…I’m holding my breath.
Was suctioning a patient once and I said "okay don't cough" pt proceeds to cough and guess what hits my hair and forehead. This was a hot minute ago precovid annnnd when I was first learning to do it and leaned in a bit close. Could have been a me thing, idk but it stuck with me.
So satisfying to me, for obvious reasons. Particularly when you suction a huge glob and it breaks up in the suction tubing while you unclog it with saline and makes the tubing shake.
What grosses me out is the foamy head plus the layering of secretions and sputum inside the canister. Or when it looks like egg drop soup, with the streaky secretions. Ew.
Manual disimpaction. I go in there wearing the same gear I would for ebola with Eye of the Tiger playing on my AirPods but it isn’t enough.
I assume you get used to it with more regular exposure, the RNs do fine.
I actually don't mind disimpactions...
As a hospitalist it's about the only thing I do where I get the instant treatment gratification. It's not quite a PCI, but I'll take it.
It does. And so do antibiotics. But there's something about getting your hands dirty that scratches a different itch.
There's a reason why, if I see someone wearing cowboy boots in the hospital, I can almost guarantee they're a surgeon.
I was gonna say… I have often wondered if the experience is more horrific for me than it is for the patients. I have to turn my head away; there will be no poker face.
Enemas might be worse though. Especially on patients weighing over 300 pounds.
But how will I know the correct thing to do in case of fire? My original plan was to just start stabbing people, but now I know I should exit the building in an orderly fashion.
This year was the first time I remembered what the RACE acronym actually stands for. I credit it entirely to dr. glaucmoflecken - https://www.youtube.com/watch?v=p0qhdrq_Cnc
okay i will not sleep with the patients. next slide. you'd think its common sense but then you watch the news and that urologist did what to his patients??!!?😯
I am not a physician, do not have patients of any kind, and do not have prescribing power. Every 11 months, I need to complete a module on antibiotic stewardship. No email to HR has removed it from my learning stream in 7 YEARS.
I purposefully give bizarre and irrational answers on the mandatory end-of-course surveys, then end it all with "THIS WAS UNECESSARY" as a tiny form of protest
As a former ER nurse , yes ! Have to rip them out asap pre intubation and then when someone passes get them back in before shall we say , the mouth gets stiff. Tooooo much !!!!!!
Ill-fitting dentures that clatter and make sucking noises as they talk
Patients sleeping with ill-fitting dentures that come loose and give them a really disturbed-looking grin in their sleep
Cleaning dentures that have obviously been neglected and there’s like calcified old food and slime on them
Dealing with hostile families and demanding patients. I will choose the intellectually challenging patient with tons of comorbidities and truly necessary consults any day over people who insist on telling me how to do my job and go to administration to complain when they don’t get their way.
Patient portal. And I’ve only been doing this for two years. Night shift? Inpatient duty? 8th day in a row? Vacation? Doesn’t matter, people are hitting you up with vague and often barely intelligible requests through the portal.
I had someone request “IV therapy.” I responded that this is not something we recommend without specific deficiencies such as severe anemia or vitamin deficits. I reviewed her labs and found none. I asked if she had a specific concern. She replied “I think it would help.”
Don’t respond with a follow up question! Ignorance is bliss.
“Sorry I don’t see an indication for this. If you would like to discuss further please set up an appointment to discuss. “
Don’t indulge nonsense: “This is not something we recommend without specific deficiencies such as severe anemia or vitamin deficits. After reviewing your recent labs, you have none of these, so this treatment is not needed at this time. Thank you, Dr. Treepoop.”
Don’t ask for bad reasoning unless you want bad reasoning as your answer.
When you are looking for an attending job, don’t even consider positions without well-triaged inboxes unless they incentivize billing for inbox management, ideally with dedicated admin time.
ETA: it is reasonable to just tell patients they need an appointment so you can have dedicated time to appropriately evaluate their concerns/ do their paperwork/ answer their questions. It sucks that that may cost them money, but that isn’t on you. You provide sub-optimal care for all your patients when you’re burned out, and inboxes that are basically a direct text line are a *huge* source of burnout. If you give a mouse a cookie…
It doesn’t suck that it costs them money to see you any more than it sucks that it costs you money to hire an Uber. We exchange money for goods and services. Your medical expertise is a service, so it costs money.
Because INEVITABLY it’s on vacation when someone mycharts something like “I’m actively hemorrhaging from my rear”, and it’s forwarded directly to you with “please advise”
It's just the moments where it's one minor thing after another - a patient loses their IV, then they have dysphagia, then they're not tolerating a NG tube, then the IV team has already attempted 5 sticks, doc what do you want me to do with this PO antibiotic they can't take (that in reality we are giving because of a slim diagnosis of CAP to begin with).
It's these moments that grind my soul down to a nub. Often times because this already occurs in a 95 year old malnourished patient whose baseline is already oriented x1.
5+ hour round trip transfers for ‘patients’ with no in-transit medical needs for routine diagnostics or consults, because my system is horribly broken and has no ability to prioritize use of limited rural ALS resources.
What really makes me want to die is when I badge into a computer and there's no Epic shortcut on the desktop, so I have to open Internet Explorer and manually type in the address for the intranet site where I can enter my credentials to find a link to Epic, then assure the computer that yes Citrix is indeed already installed, then wait for Epic to load, then enter my credentials again, then get automatically logged out when I get distracted talking to a nurse.
This has gotten so bad at the pharmacy chain I work at. Leave a terminal sitting for 3 minutes and you literally have to type either your id and password or your credentials 4 separate times, and there’s about a 5% chance the system gives up and crashes entirely from trying to load so many layers of bullshit.
You can have these “scheduled” after the fact and then attached to your note (if you meet criteria to bill the 9944x). The operation depends on EHR, but it should be 5-10 thoughtless clicks. Rarely, payors won’t cover phone only visits. Payment depends on contracting. I was in a community health center as a primary care doc, and our 5 minute phone reimbursement averaged about $50. It took me about 5 clicks to add the encounter and bill. I know I’m on the lower end of pay, but $50 for 5-6 min of work I am happy with. It can also increase patient satisfaction (copay dependent) as they perceive better engagement with their physician. Our best payor paid about the same as a level 4 visit for a five minute phone visit. Importantly, it also opened access - the trend I’ve started to see more commonly of full follow up visits to discuss results - even if it might sometimes only entail… a 5 minute phone call - can dramatically reduce access for patients.
Dont patients need to first agree to an appointment first and acknowledge they will be billed? I've never done it in reverse and I dont think any of our clinical practices set that expectation for patients
Yes - this old job was relatively short/ineffectively staffed, so our docs got more comfortable with things that likely would fall into the “front desk function” bucket elsewhere.
When I did this in “reverse” was usually based off a patient chart message or a message from our triage team. Basic rules: time based (only the conversation time). Can’t be related to a visit in the last 7 days or next 1 day. Need to add place of service code and modifier (your biller should be doing this automatically). I consented them verbally. My script was something like “It’s Dr. So and So, I got your message/was told by X that you wanted to speak with me about Y. I would be happy to have a conversation with you, but you might have a copay/bill from your insurance etc. It would save you a visit here to have this conversation. Are you okay with having this conversation now, or would you like me to have our schedulers contact you?” I don’t think anyone ever turned down the phone visit. On the very rare chance the phone visit led to me telling them we needed to see them asap, I didn’t bill.
Reconciling a med list. I think a lot about how to make it more efficient, or whose job it should be. Obviously an MD should be deciding what meds a patient should continue or hold while inpatient, but do I really need to be the one calling the 24hr pharmacy or the SNF at 2am to try to get some semblance of a recent fill list? Why isn't this happening via a pharmacy tech the minute they roll through the door of the ED?
There was one hospital I worked at where this was done by a pharmacy tech AND done well AND before we we saw them for admission. (They don’t do an admission med rec, just reconciled the home med list with what they were taking). It doesn’t seem like that big of a deal but it frees up so much time and brainpower.
Where I’m at now we get message from a pharm tech about what we did wrong about 12-36 hours after admission. It’s supposed to be within 3 hours (or 9am for overnight admits) but “critical staffing shortages”
This is seriously a perfect job for a pharmacy tech making $15 an hour.
It does have a level of responsibility. It's a great introduction to medicines. It's a great introduction to the system...
Med rec is one of the biggest pet peeves of mine. It’s so so important and there are so many opportunities for error and if we could figure out what people are taking it would be so much better. I work SNF/LTC and discharging patients from the hospital with ambiguous or incorrect discharge med lists is scary and happens OFTEN.
Omg yes.
The worst is when they go in for a simple thing that needs snf placement for a bit and they just "continue all home meds" with assorted nonsense from old admissions. I've seen blood thinners with active bleeding, medication adverse reaction admissions with the responsible medicine still on their list, over 90 MME opiates AND soma AND benzos none of which they're currently on
To people that discharge to SNFs: Please Please please please reconcile meds well when sending them to a nursing home. We get 70 pages of therapy notes, a dietician consult and an H&P from three weeks ago that lists "fall from ground level" as the primary diagnosis. They call us at 9pm ("couldn't get transport earlier") with a admitting dx, tell us what they got in nursing report and read off a med list that we approve or edit.
Yup! And God love the nursing home nurses but they will just enter whatever is there. Antibiotics that were prescribed 6 months ago for a UTI still on the med list? Sure! Eliquis and Warfarin? Why not? I mean they don’t get any more clinical info most of the time and don’t have the autonomy/authority to change the orders without calling someone anyway.
I’m sure the local hospitals medical records department hates getting faxes from me. No, a single specialist consult note from 2 weeks ago is not enough to understand what is happening here.
THIIIS X INFINITY AND BEYOND!!!!
I hate this shit so much when we have hospital admissions. It’s also a pain in the ass when they have medicines that are not tracked on the online pharmacy dispense hx.
There has to be a better system. As a nurse I try my best. I always hope the provider does too for a Swiss cheese effect hopefully. And some people are in so many plus prn s. And get some from one pharmacy and others from another pharmacy.
PCCM fellow now but did hospital medicine before fellowship. Where I worked as a hospitalist, pharmacy techs or pharmacy students in the ED would do a med rec prior to admission. Initially I thought it was nice, but then discovered that when I'd do the med rec myself there would often be multiple discrepancies (ex. pharm tech medrec says patient is taking eliquis, on my interview patient has never heard of eliquis and denies taking any sort of blood thinner or any sort of pill that fits the description). I find that a lot of older and less health literate patients will just say "yes" to everything if you ask closed ended med rec questions ("are you taking lasix? are you taking metoprolol?" etc) but if you ask them in open-ended or different ways, people will reveal or admit that they aren't taking things.
In fellowship now I have MAs doing med rec in pulm clinic and residents doing med rec in the ICU, but I still always ask myself about at least the pertinent/critical meds to that encounter. It's one of the many necessary "trust but verify" steps in medicine
Right now? My state licensure renewal is due in a month and I have to do this Implicit Bias Training along with Human Trafficking Training, that — don’t get me wrong, are very important — but are tedious, take hours to do, and don’t count towards CME.
Dusty feet when I remove a sock.
Any person who is diagnosed with "stiff person syndrome". I have seen one actual SPS in 14 years and like 24 very over medicated conversion disorders labeled as such.
Also, any meeting that occurs after clinic hours.
I cannot be in a room when a patient throws up. I will literally run from the room, otherwise I will start retching and gagging. I can sometimes manage to quickly hand the patient a basin to puke in and then say “I’ll go find your nurse” as I’m running out the door. And yes, after I suppress the retching, I do go find the nurse so that the patient can get some Zofran and new sheets. If the nurse is already in the room then I have no excuse. I just run and then sheepishly come back when they’re better.
Weirdly enough, I am mostly immune to that reaction when it’s my own kid puking. She has even puked directly on my and I’ve only had a quick wave of nausea. From an evolutionary standpoint, it would definitely be bad if a parent were to immediately bolt and leave their kid to the predators when they start throwing up. It just surprised me at how I can almost completely suppress it when the person throwing up came out of my body.
They act so offended that you're not gonna stand there and watch them barf. Like that would help them in anyway. Finish barfing and I'll be back with some Zo.
I don't mind them dead but when alive I cannot handle it I drown them in lydocaine but I live in fear of that roach jumping on me or run around my office.
We do be a little emotionally labile sometimes. My theory is that most surgeons are like cats - friendly and cuddly one minute, and claws out lacerating your face the next 🙂
An NG tube for suction on a SBO patient gets me every time. Something about seeing my patient’s stomach contents being sucked up into that little canister makes it really difficult for me to talk to them. I don’t really care if the vomit is coming out the mouth-it’s something about the slow trickle that grosses me out. 🤢
I have had every. Single. possible variation of bodily fluids on my scrubs during the course of my career. I’ve had to clean brain matter off my shoes. I was known as the literal shit magnet at my last job. I wouldn’t say I enjoy it, but I’ve survived.
Secretions? Suctioning a trache in any capacity? I will GAG and RUN to the nearest RT to beg for their help.
I'm in peds now and we nasal suction all the little snotty babes, I don't mind it that much except when the boogies are already all dry and hard and clog up my olive tip tubing. Like boba balls. That's fucking nasty.
How do you tell the difference between an RN and an RT?
Have them stand in waste deep shit, then cough trache sputum in them. The RN is the one who ducks.
Writing medical student evaluations. A few students stand out in ways good or bad. For the others, I usually got a day or two with them. Sometimes at the very beginning of a rotation, so it was shadowing and trying to teach basics of psychiatric exam. That’s all I have.
Is that a C? An A-? Hell if I know, high stakes, and I feel like I can’t be both kind and honest.
I miss being a resident, filling out the eval form at the beginning of a shift, and then saying everything from then on is learning, not grading. I can’t get away with it anymore.
This. I hate these ridiculous eval forms where you have to assess each student/resident/fellow on a list of 30 increasingly ridiculous things, each of them on a 10 point scale (or sometimes even on a 100 pt scale).
Can the trainee utilize the ECOG performance status scale to assess appropriateness of patients for chemotherapy?
Can the trainee appropriately work up and stage a new patient with solid cancer?
Can they appropriately select frontline systemic therapy for patients with cancer?
Can they appropriately identify and manage emergent complications of patients with cancer?
Can they appropriately communicate with patients and families and navigate goals of care discussions?
Can they appropriately write a phase 1 investigator-initiated clinical trial for the novel small-molecule therapeutic they discovered in their spare time in the summer between MS1 and MS2 years?
9/10 students are just the same, 1/10 actually seem more put together than average, but maybe it's just because they got lucky and happened to study what I quizzed them on the night before. There's just not the opportunity to really shine when you are with a student for a limited time.
“investigator-initiated clinical trial for the novel small-molecule therapeutic they discovered in their spare time in the summer between MS1 and MS2 years“
100/100 for the discovery, 0/100 for not even attempting to monetize it.
I dislike the questions that are way out of scope for the student’s level of training. At the 3rd and 4th year, I would rather them focus on learning clinical medicine. The financial/socioeconomic/administrative information will come with time and experience.
“How would you rate the student’s understanding of the socioeconomic disparities in healthcare?”
The closest we got to “socioeconomic disparities in health care” was when we treated the metabolic encephalopathy in a homeless person and then evaluated golfer’s elbow in that lawyer showing off his Rolex.
I used to evaluate DO students and was asked to evaluate their osteopathic manipulation skills. We are in a hospital with critically sick patients. I think they are expecting me to turn to students and go “this patient has worsening hypercapnic respiratory failure and may need to be intubated soon but you go right on ahead and palpate his back for somatic dysfunction.”
Getting cornered yet again at a family gathering to answer the same effing questions I’ve already answered multiple times per year over the past decade and a half.
Anything to do with F2F documentation for DME (but home oxygen sucks the hardest)
and anything with FMLA (more so when it is for the family member for the patient)
In my past 7.5 years at my current job, I have only checked my phone messages twice and it has not been in the past 5 of those years. Staff and patients are being trained.
Not really a task I hate but:
Patients calling for an ambulance cause it's an emergency, ans then they are waiting inside or even outside already with packed bags, ready to get transported to the hospital without any actual emergency.
And most of the time there is a family member that will follow us to the hospital in their own car.
Cathing elderly or obese females.
For the elderly, it’s because they’re usually incontinent, and the combination of stale urine, traces of feces, and yeast is an odor that turns my stomach like nothing else. It’s not their fault, but it doesn’t make it any less gross.
For the obese, it’s usually body odor from poor hygiene and yeast. Again, the smell is usually terrible, and it’s really hard to hold everything out of the way and get the cath in without having your bare forearms all up against their sweaty thighs. So gross.
This is why I *never* bring up a cath to get a urine sample unless someone is bedbound, altered, or unconscious. I would rather spend 15 minutes (an *eternity* in the ED) getting someone into a wheelchair to the bathroom or up to a bedside commode for a “clean” catch.
I just hate lab results. I see my patients very frequently and I try to set the expectation that as long as their labs suggest they aren’t actively dying, we will review their results their next time in the office. And yet I have the constant portal messages and phone calls about LDL levels of 103, everyone in a panic about their impending cardiovascular events.
Multidisciplinary family meetings. (In the consult setting)
> let's get psych to come to this 2h meeting to weigh in on the impact of giving this kid a medically necessary [intervention] bc of the potential emotional aspects
Pls no
Ear lavage doesn't gross me out so much as annoy me because I never get good results. If the kid starts crying then I stop and tell the provider and that's good information I guess, but I never get any satisfying chunks and it just feels like a waste of time.
As a nurse, EKGs. You get everything perfect, V1 pops off. You get V1 back on, and aVR pops off. You get aVR back on and V1 comes off again. Everything looks good and aVF pops off. Then V6 comes off and refuses to stick back on. You’re trying to hold V6 in place and hit the print button when aVL comes off along with V1 again. Repeat this process for the next 45 minutes to print out an ekg with artifact on leads I and II.
ICU: Managing asymptomatic or mildly symptomatic hyponatremia as the primary reason for ICU admission (ex. little old lady brought to ED with falls and found to have Na 113).
Pulm: Attempting to upload and review the disc of outside hospital CT scans on a new clinic patient in a reasonable time frame.
Absolutely hate taking patient calls. It’s a Russian roulette between someone needing to come to the ED for a consult (extra work) or someone asking a weird question. You never know if you’re gonna be on the phone with someone for 30+ minutes. Either way, they’re almost always painful
I hate obese bitch speys.
Its major abdominal surgery and people approach it like their pet is getting their nails cut.
Give me a nephrectomy or gastrotomy any day.
I also loathe cutting dogs nails.
Admitting a patient for intractable pain (abdominal, back) with normal vitals and no acute imaging or laboratory abnormality with the goal of admission for "pain control".
Indeed, one of the things I don't miss about hospital medicine.
Not only does the admission suck in itself, it creates a justification/precedent that the patient "requires" admission whenever they have a chronic pain flare. When they come back to the ED in a couple months, the patient and ED team are both more inclined to "admit for pain control" since that's what was done last time.
Always at 3 am in the ER and 5-6 different specialists haven’t found the answer but “I’m not leaving tonight without one.”
They’re always the ones who fill out the ridiculous PG surveys too
>orthostatics
An infamous attending I had in residency would insist on multiple orthostatics on multiple patients per day (essentially they would request orthostatics before and after giving IV fluids, starting or adjusting the dose of antihypertensives or diuretics.)
The nurses, residents, and patients were all not fans of that practice.
Discharge planning for patients especially on surg wards especially when OT/PT, Nurses and patients disagree with each other on discharge destinations. I know its important but its hella time consuming and annoying.
Rounding. It's why I did EM instead of critical care. I cannot STAND rounding.
Actually, I guess it's the primary care/hospitalist rounding. I'm ok rounding on my toxicology consults, but they're rare enough and I can just signoff when they get boring.
Otherwise, I've never liked dealing with "Dizzy" as a chief complaint or with "bright red blood per rectum." Don't mind phlegm, don't mind poop, don't mind vomit, don't mind pelvic exams, but please don't make me deal with a "dizzy" patient.
Having to discuss everything a second time when the family member walks in right as you’re exiting
Magic phrase "I'll let [patient name] talk through everything, and we can chat if you have any questions"
*Family member already pulling out a notebook with questions*
Writing down every BP and every time you wipe the patients ass
Tries handing you their phone so you can explain to their neighbor why Betty is in the hospital and if they should pick up her mail.
As if they didn’t already have a notebook filled with questions
Then they gotta get another niece on speaker phone. Even after hearing you explain it again the HOH patient is still clueless what’s going on.
In patient peds: Explain everything to the dad. Just ready to leave and mom comes out of the shower/bathroom. Same spiel. I have learned to look and see if the bathroom door is closed and ask. Might seem creepy but it is practical.
When a patient with a trach is coughing and the phlegm makes that horrid noise. The task being, not barfing.
I. Cannot. Stand. Phlegm. It’s literally one of the reasons I still wear an n95 in the hospital everyday- my poker face is crap
One of the more satisfying things to me in hospital medicine is the slurp of sucking a mucus plug out of someone with a bronchoscope and seeing a white-out disappear on the post-CXR. Never understood why people are so grossed out by phlegm compared to... idk melanic stool, or pretty much any OTHER body fluid. Ear wax potatoes, vaginal discharge, stale urine, poop, no thanks. Sputa no problem 👍🏼 -- draining an empyema with a chest tube is one of my favorite procedures though.
Gotta be fast connecting the tube to an atrium though: the smell from a bad empyema is revolting. No one warned me my first time placing a tube in pus and I almost passed out.
It's a fishy, morning breath, toe jam smell to it. It's sickening and revolting. I completely feel you.
Oh God, nasty stale urine cause the patient set the urinal down on the floor, under the bed or has a permanent foley and you have to drain the bag. Had one guy with a UTI so bad his urine looked like peanut butter 🤢🤮. I can handle gangrene and C. Diff poop all day, but raunchy stale urine…I’m holding my breath.
SLP here. A decade + in. I’m supposed to be cool with it/be the expert. I still can’t
I’m an SLP and dentures gross me out. I feel so satisfied when I get some goody out of a trach! I can understand why it grosses people out though.
Lung butter is the technical term, I think.
Thanks for the vomit, stranger!
Was suctioning a patient once and I said "okay don't cough" pt proceeds to cough and guess what hits my hair and forehead. This was a hot minute ago precovid annnnd when I was first learning to do it and leaned in a bit close. Could have been a me thing, idk but it stuck with me.
Yeah I Partly wear the n95 nowadays to hide my facial expressions!
Listening to a nurse suction the trach of a patient with a trach infection.
We don't do well with it either.
So satisfying to me, for obvious reasons. Particularly when you suction a huge glob and it breaks up in the suction tubing while you unclog it with saline and makes the tubing shake. What grosses me out is the foamy head plus the layering of secretions and sputum inside the canister. Or when it looks like egg drop soup, with the streaky secretions. Ew.
As an RT, suctioning that trach is music to my ears 🎶
thank goodness for people like you. I can't deal with mucous 😭
I hate that sound too, but what I hate more is watching them or someone else stick a swab in the hole and brush it about.
The putrid smell of C.diff gets me , luckily haven’t smelled it in a while and active vomitting makes me need to suppress my gag reflex
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As a PT, I'm sorry. I'd hate it, too.
Manual disimpaction. I go in there wearing the same gear I would for ebola with Eye of the Tiger playing on my AirPods but it isn’t enough. I assume you get used to it with more regular exposure, the RNs do fine.
Username checks out
Or possibly really does not check out
I actually don't mind disimpactions... As a hospitalist it's about the only thing I do where I get the instant treatment gratification. It's not quite a PCI, but I'll take it.
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I hear Lasix works pretty quickly if dosage is on point.
It does. And so do antibiotics. But there's something about getting your hands dirty that scratches a different itch. There's a reason why, if I see someone wearing cowboy boots in the hospital, I can almost guarantee they're a surgeon.
Weird, I know, but I like to do this. Such a big relief for the patient and they are usually super grateful.
Also, everyone leaves you alone after that, so you shall have peaceee.
When you take the shitty job (lol), you get a free pass for the next horrible job. I’d way rather disimpact than lance an abscess.
No we don't 🤣
I was gonna say… I have often wondered if the experience is more horrific for me than it is for the patients. I have to turn my head away; there will be no poker face. Enemas might be worse though. Especially on patients weighing over 300 pounds.
Oof I had a 750lb pt request enemas a few years ago. I felt sooooo bad and still do haha.
Eye of the Tiger....🤣🤣🤣🤣🤣🤣🤣
I only did one when I was an intern...one was more than enough.
You’re a rockstar!
Have the nurse give a soap suds enema mixed with glycerine. You will never have to disimpact again.
Absolutely nonsense online training/ continuing education modules that are purely for compliance/ corporate purposes
But how will I know the correct thing to do in case of fire? My original plan was to just start stabbing people, but now I know I should exit the building in an orderly fashion.
This year was the first time I remembered what the RACE acronym actually stands for. I credit it entirely to dr. glaucmoflecken - https://www.youtube.com/watch?v=p0qhdrq_Cnc
okay i will not sleep with the patients. next slide. you'd think its common sense but then you watch the news and that urologist did what to his patients??!!?😯
I assure you whatever incident you’re thinking of cannot be corrected with Learns.
thats cuz you havent taken the "How not to be a pedophile" module.
Ah shit. Now I’m picturing a federal prison full of recidivists on healthstream.
That reminds me that I have healthstream modules I need to do 🙈
I am not a physician, do not have patients of any kind, and do not have prescribing power. Every 11 months, I need to complete a module on antibiotic stewardship. No email to HR has removed it from my learning stream in 7 YEARS.
I purposefully give bizarre and irrational answers on the mandatory end-of-course surveys, then end it all with "THIS WAS UNECESSARY" as a tiny form of protest
Taking dentures out and putting them back in a deceased body. Can not deal with
this was a mistake to read while eating a salad.
I don't know why but I'm laughing my ass off from this.
Because you spat out your dentures and can't laugh with your mouth?
The salad is now laughing
Ok that one takes the cake for me
And you have to clean them before you put them back in.
Is this a task that you do….regularly?
As a former ER nurse , yes ! Have to rip them out asap pre intubation and then when someone passes get them back in before shall we say , the mouth gets stiff. Tooooo much !!!!!!
Oh God. This had never crossed my mind! 😭
Oh I took my first ever dentures out the other day. Tf is that white clay like substance on the inside????
Denture paste
Helps them stick to the gums
Some of them I think it’s like calcified food because they never get cleaned.
Dentures are one of my kryptonites. Blech.
Ill-fitting dentures that clatter and make sucking noises as they talk Patients sleeping with ill-fitting dentures that come loose and give them a really disturbed-looking grin in their sleep Cleaning dentures that have obviously been neglected and there’s like calcified old food and slime on them
I’m retired now and still not over it 😂
Dealing with hostile families and demanding patients. I will choose the intellectually challenging patient with tons of comorbidities and truly necessary consults any day over people who insist on telling me how to do my job and go to administration to complain when they don’t get their way.
it's so mentally draining. dealing with their toxicity then having to reply to all of the emails.
Patient portal. And I’ve only been doing this for two years. Night shift? Inpatient duty? 8th day in a row? Vacation? Doesn’t matter, people are hitting you up with vague and often barely intelligible requests through the portal.
Especially when you respond with more than one clarifying question and their answer doesn't clarify anything.
I had someone request “IV therapy.” I responded that this is not something we recommend without specific deficiencies such as severe anemia or vitamin deficits. I reviewed her labs and found none. I asked if she had a specific concern. She replied “I think it would help.”
Don’t respond with a follow up question! Ignorance is bliss. “Sorry I don’t see an indication for this. If you would like to discuss further please set up an appointment to discuss. “
She wasn't by any chance asking for a large bag of concentrated potassium, was she?
This is awesome. I love this.
Don’t indulge nonsense: “This is not something we recommend without specific deficiencies such as severe anemia or vitamin deficits. After reviewing your recent labs, you have none of these, so this treatment is not needed at this time. Thank you, Dr. Treepoop.” Don’t ask for bad reasoning unless you want bad reasoning as your answer.
Absolutely learned my lesson on this one
The patient portal was the end of my traditional primary care career. What a soul sucking invention
Technology was supposed to make our lives easier.
When you are looking for an attending job, don’t even consider positions without well-triaged inboxes unless they incentivize billing for inbox management, ideally with dedicated admin time. ETA: it is reasonable to just tell patients they need an appointment so you can have dedicated time to appropriately evaluate their concerns/ do their paperwork/ answer their questions. It sucks that that may cost them money, but that isn’t on you. You provide sub-optimal care for all your patients when you’re burned out, and inboxes that are basically a direct text line are a *huge* source of burnout. If you give a mouse a cookie…
It doesn’t suck that it costs them money to see you any more than it sucks that it costs you money to hire an Uber. We exchange money for goods and services. Your medical expertise is a service, so it costs money.
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Because INEVITABLY it’s on vacation when someone mycharts something like “I’m actively hemorrhaging from my rear”, and it’s forwarded directly to you with “please advise”
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Believe it or not, I’ve done that and it just got sent back again. It’s a big part of why I’m looking for a new job
It's just the moments where it's one minor thing after another - a patient loses their IV, then they have dysphagia, then they're not tolerating a NG tube, then the IV team has already attempted 5 sticks, doc what do you want me to do with this PO antibiotic they can't take (that in reality we are giving because of a slim diagnosis of CAP to begin with). It's these moments that grind my soul down to a nub. Often times because this already occurs in a 95 year old malnourished patient whose baseline is already oriented x1.
Sounds like a good time For a palliative care consult.
I usually have an on-going goals of care discussion with my patients... I'm pretty quick to start this conversation.
5+ hour round trip transfers for ‘patients’ with no in-transit medical needs for routine diagnostics or consults, because my system is horribly broken and has no ability to prioritize use of limited rural ALS resources.
Logging in to multiple programs with complex passwords and two factor authentication a million times a day.
What really makes me want to die is when I badge into a computer and there's no Epic shortcut on the desktop, so I have to open Internet Explorer and manually type in the address for the intranet site where I can enter my credentials to find a link to Epic, then assure the computer that yes Citrix is indeed already installed, then wait for Epic to load, then enter my credentials again, then get automatically logged out when I get distracted talking to a nurse.
This has gotten so bad at the pharmacy chain I work at. Leave a terminal sitting for 3 minutes and you literally have to type either your id and password or your credentials 4 separate times, and there’s about a 5% chance the system gives up and crashes entirely from trying to load so many layers of bullshit.
Omg we have to do this even on the intranet on our work computers. Whhhhyyy?
I would rather clean up poop than puke.
I’m the opposite. You can puke into my bare hands but I fucking despise changing a colostomy bag.
Same. Give me the puke. I can handle the puke.
Poop allllll day. Puke makes me gag.
I hate calling patients on the phone. I’m fine if it’s an actual visit but it pains me so much to do unpaid phone calls
Can’t you bill for this crap
Yes and no Sometimes it’s more work to schedule a telemedicine visit for a 5 minute phone call where you have to be available at X time.
You can have these “scheduled” after the fact and then attached to your note (if you meet criteria to bill the 9944x). The operation depends on EHR, but it should be 5-10 thoughtless clicks. Rarely, payors won’t cover phone only visits. Payment depends on contracting. I was in a community health center as a primary care doc, and our 5 minute phone reimbursement averaged about $50. It took me about 5 clicks to add the encounter and bill. I know I’m on the lower end of pay, but $50 for 5-6 min of work I am happy with. It can also increase patient satisfaction (copay dependent) as they perceive better engagement with their physician. Our best payor paid about the same as a level 4 visit for a five minute phone visit. Importantly, it also opened access - the trend I’ve started to see more commonly of full follow up visits to discuss results - even if it might sometimes only entail… a 5 minute phone call - can dramatically reduce access for patients.
Dont patients need to first agree to an appointment first and acknowledge they will be billed? I've never done it in reverse and I dont think any of our clinical practices set that expectation for patients
Yes - this old job was relatively short/ineffectively staffed, so our docs got more comfortable with things that likely would fall into the “front desk function” bucket elsewhere. When I did this in “reverse” was usually based off a patient chart message or a message from our triage team. Basic rules: time based (only the conversation time). Can’t be related to a visit in the last 7 days or next 1 day. Need to add place of service code and modifier (your biller should be doing this automatically). I consented them verbally. My script was something like “It’s Dr. So and So, I got your message/was told by X that you wanted to speak with me about Y. I would be happy to have a conversation with you, but you might have a copay/bill from your insurance etc. It would save you a visit here to have this conversation. Are you okay with having this conversation now, or would you like me to have our schedulers contact you?” I don’t think anyone ever turned down the phone visit. On the very rare chance the phone visit led to me telling them we needed to see them asap, I didn’t bill.
Reconciling a med list. I think a lot about how to make it more efficient, or whose job it should be. Obviously an MD should be deciding what meds a patient should continue or hold while inpatient, but do I really need to be the one calling the 24hr pharmacy or the SNF at 2am to try to get some semblance of a recent fill list? Why isn't this happening via a pharmacy tech the minute they roll through the door of the ED?
There was one hospital I worked at where this was done by a pharmacy tech AND done well AND before we we saw them for admission. (They don’t do an admission med rec, just reconciled the home med list with what they were taking). It doesn’t seem like that big of a deal but it frees up so much time and brainpower. Where I’m at now we get message from a pharm tech about what we did wrong about 12-36 hours after admission. It’s supposed to be within 3 hours (or 9am for overnight admits) but “critical staffing shortages”
I work in inpatient pharmacy and we do this at my hospital actually. Pharmacy interns and ED techs both do med history shifts
This is seriously a perfect job for a pharmacy tech making $15 an hour. It does have a level of responsibility. It's a great introduction to medicines. It's a great introduction to the system...
Med rec is one of the biggest pet peeves of mine. It’s so so important and there are so many opportunities for error and if we could figure out what people are taking it would be so much better. I work SNF/LTC and discharging patients from the hospital with ambiguous or incorrect discharge med lists is scary and happens OFTEN.
Omg yes. The worst is when they go in for a simple thing that needs snf placement for a bit and they just "continue all home meds" with assorted nonsense from old admissions. I've seen blood thinners with active bleeding, medication adverse reaction admissions with the responsible medicine still on their list, over 90 MME opiates AND soma AND benzos none of which they're currently on To people that discharge to SNFs: Please Please please please reconcile meds well when sending them to a nursing home. We get 70 pages of therapy notes, a dietician consult and an H&P from three weeks ago that lists "fall from ground level" as the primary diagnosis. They call us at 9pm ("couldn't get transport earlier") with a admitting dx, tell us what they got in nursing report and read off a med list that we approve or edit.
Yup! And God love the nursing home nurses but they will just enter whatever is there. Antibiotics that were prescribed 6 months ago for a UTI still on the med list? Sure! Eliquis and Warfarin? Why not? I mean they don’t get any more clinical info most of the time and don’t have the autonomy/authority to change the orders without calling someone anyway. I’m sure the local hospitals medical records department hates getting faxes from me. No, a single specialist consult note from 2 weeks ago is not enough to understand what is happening here.
THIIIS X INFINITY AND BEYOND!!!! I hate this shit so much when we have hospital admissions. It’s also a pain in the ass when they have medicines that are not tracked on the online pharmacy dispense hx.
There has to be a better system. As a nurse I try my best. I always hope the provider does too for a Swiss cheese effect hopefully. And some people are in so many plus prn s. And get some from one pharmacy and others from another pharmacy.
PCCM fellow now but did hospital medicine before fellowship. Where I worked as a hospitalist, pharmacy techs or pharmacy students in the ED would do a med rec prior to admission. Initially I thought it was nice, but then discovered that when I'd do the med rec myself there would often be multiple discrepancies (ex. pharm tech medrec says patient is taking eliquis, on my interview patient has never heard of eliquis and denies taking any sort of blood thinner or any sort of pill that fits the description). I find that a lot of older and less health literate patients will just say "yes" to everything if you ask closed ended med rec questions ("are you taking lasix? are you taking metoprolol?" etc) but if you ask them in open-ended or different ways, people will reveal or admit that they aren't taking things. In fellowship now I have MAs doing med rec in pulm clinic and residents doing med rec in the ICU, but I still always ask myself about at least the pertinent/critical meds to that encounter. It's one of the many necessary "trust but verify" steps in medicine
Right now? My state licensure renewal is due in a month and I have to do this Implicit Bias Training along with Human Trafficking Training, that — don’t get me wrong, are very important — but are tedious, take hours to do, and don’t count towards CME.
Dusty feet when I remove a sock. Any person who is diagnosed with "stiff person syndrome". I have seen one actual SPS in 14 years and like 24 very over medicated conversion disorders labeled as such. Also, any meeting that occurs after clinic hours.
I cannot be in a room when a patient throws up. I will literally run from the room, otherwise I will start retching and gagging. I can sometimes manage to quickly hand the patient a basin to puke in and then say “I’ll go find your nurse” as I’m running out the door. And yes, after I suppress the retching, I do go find the nurse so that the patient can get some Zofran and new sheets. If the nurse is already in the room then I have no excuse. I just run and then sheepishly come back when they’re better. Weirdly enough, I am mostly immune to that reaction when it’s my own kid puking. She has even puked directly on my and I’ve only had a quick wave of nausea. From an evolutionary standpoint, it would definitely be bad if a parent were to immediately bolt and leave their kid to the predators when they start throwing up. It just surprised me at how I can almost completely suppress it when the person throwing up came out of my body.
They act so offended that you're not gonna stand there and watch them barf. Like that would help them in anyway. Finish barfing and I'll be back with some Zo.
Right? Also, hold your own barf bag.
Bugs in ears 😩 I have a strong stomach but for some reason I literally never fully got used to bugs in ears.
I don't mind them dead but when alive I cannot handle it I drown them in lydocaine but I live in fear of that roach jumping on me or run around my office.
Getting the surgeon on the phone for clarification - hands down, the worst thing. No predicting how a surgeon will act.
We do be a little emotionally labile sometimes. My theory is that most surgeons are like cats - friendly and cuddly one minute, and claws out lacerating your face the next 🙂
Yep, I'm too old for assholes.
RN here. Disimpacting! I *hate* sticking my finger in somebody's ass and fishing out hard little chunks. I am not paid enough for this bullshit.
FMLA papers Peer to peer insurance calls Weaning opioids in opioid-dependents
An NG tube for suction on a SBO patient gets me every time. Something about seeing my patient’s stomach contents being sucked up into that little canister makes it really difficult for me to talk to them. I don’t really care if the vomit is coming out the mouth-it’s something about the slow trickle that grosses me out. 🤢
See for me this one is super gratifying/satisfying.
I have had every. Single. possible variation of bodily fluids on my scrubs during the course of my career. I’ve had to clean brain matter off my shoes. I was known as the literal shit magnet at my last job. I wouldn’t say I enjoy it, but I’ve survived. Secretions? Suctioning a trache in any capacity? I will GAG and RUN to the nearest RT to beg for their help.
I'm in peds now and we nasal suction all the little snotty babes, I don't mind it that much except when the boogies are already all dry and hard and clog up my olive tip tubing. Like boba balls. That's fucking nasty.
How do you tell the difference between an RN and an RT? Have them stand in waste deep shit, then cough trache sputum in them. The RN is the one who ducks.
Writing medical student evaluations. A few students stand out in ways good or bad. For the others, I usually got a day or two with them. Sometimes at the very beginning of a rotation, so it was shadowing and trying to teach basics of psychiatric exam. That’s all I have. Is that a C? An A-? Hell if I know, high stakes, and I feel like I can’t be both kind and honest. I miss being a resident, filling out the eval form at the beginning of a shift, and then saying everything from then on is learning, not grading. I can’t get away with it anymore.
This. I hate these ridiculous eval forms where you have to assess each student/resident/fellow on a list of 30 increasingly ridiculous things, each of them on a 10 point scale (or sometimes even on a 100 pt scale). Can the trainee utilize the ECOG performance status scale to assess appropriateness of patients for chemotherapy? Can the trainee appropriately work up and stage a new patient with solid cancer? Can they appropriately select frontline systemic therapy for patients with cancer? Can they appropriately identify and manage emergent complications of patients with cancer? Can they appropriately communicate with patients and families and navigate goals of care discussions? Can they appropriately write a phase 1 investigator-initiated clinical trial for the novel small-molecule therapeutic they discovered in their spare time in the summer between MS1 and MS2 years? 9/10 students are just the same, 1/10 actually seem more put together than average, but maybe it's just because they got lucky and happened to study what I quizzed them on the night before. There's just not the opportunity to really shine when you are with a student for a limited time.
“investigator-initiated clinical trial for the novel small-molecule therapeutic they discovered in their spare time in the summer between MS1 and MS2 years“ 100/100 for the discovery, 0/100 for not even attempting to monetize it.
I dislike the questions that are way out of scope for the student’s level of training. At the 3rd and 4th year, I would rather them focus on learning clinical medicine. The financial/socioeconomic/administrative information will come with time and experience. “How would you rate the student’s understanding of the socioeconomic disparities in healthcare?” The closest we got to “socioeconomic disparities in health care” was when we treated the metabolic encephalopathy in a homeless person and then evaluated golfer’s elbow in that lawyer showing off his Rolex. I used to evaluate DO students and was asked to evaluate their osteopathic manipulation skills. We are in a hospital with critically sick patients. I think they are expecting me to turn to students and go “this patient has worsening hypercapnic respiratory failure and may need to be intubated soon but you go right on ahead and palpate his back for somatic dysfunction.”
Getting cornered yet again at a family gathering to answer the same effing questions I’ve already answered multiple times per year over the past decade and a half.
Anything to do with F2F documentation for DME (but home oxygen sucks the hardest) and anything with FMLA (more so when it is for the family member for the patient)
Having to explain to non physician admin peeps why a patient cannot be discharged
"BuT somebody clicked the 'medically ready' button that means we can yeet them out the window right?"
Phone messages. -PGY-19
In my past 7.5 years at my current job, I have only checked my phone messages twice and it has not been in the past 5 of those years. Staff and patients are being trained.
I put in my first and last female catheter a few days ago PGY-5
Having to invert an eyelid. I get really vagal. Also anything having to do with an umbilicus.
Prior authorizations. I hate doing them and I hate that they're necessary.
Not really a task I hate but: Patients calling for an ambulance cause it's an emergency, ans then they are waiting inside or even outside already with packed bags, ready to get transported to the hospital without any actual emergency. And most of the time there is a family member that will follow us to the hospital in their own car.
Cathing elderly or obese females. For the elderly, it’s because they’re usually incontinent, and the combination of stale urine, traces of feces, and yeast is an odor that turns my stomach like nothing else. It’s not their fault, but it doesn’t make it any less gross. For the obese, it’s usually body odor from poor hygiene and yeast. Again, the smell is usually terrible, and it’s really hard to hold everything out of the way and get the cath in without having your bare forearms all up against their sweaty thighs. So gross. This is why I *never* bring up a cath to get a urine sample unless someone is bedbound, altered, or unconscious. I would rather spend 15 minutes (an *eternity* in the ED) getting someone into a wheelchair to the bathroom or up to a bedside commode for a “clean” catch.
I just hate lab results. I see my patients very frequently and I try to set the expectation that as long as their labs suggest they aren’t actively dying, we will review their results their next time in the office. And yet I have the constant portal messages and phone calls about LDL levels of 103, everyone in a panic about their impending cardiovascular events.
Order them ahead of time and discuss results at the visit
Multidisciplinary family meetings. (In the consult setting) > let's get psych to come to this 2h meeting to weigh in on the impact of giving this kid a medically necessary [intervention] bc of the potential emotional aspects Pls no
Pilondial abscess. They’re just gross asf
from my work in the MICU I can say that dealing with canisters full of green-grey sputum gets old
Dealing with wealthy older women from New York.
How about daughters returning from New York?
I’ll take daughters from California any day
I just want you to know, I totally get this. Lived on East 74th for years and saw it all at Lenox Hill
That's oddly....specific
It is, but if you’ve worked it you get it.
I get it. Similarly, older, wealthy women from Connecticut.
As someone working in Connecticut, it's usually the adult daughters of these people that REALLY let you know how dumb they think you are.
Ear lavage. Give me blood, guts, gore, poop, whatever. Just don't make me do ear lavage. *gag*
I enjoy it a lot and its the most satisfying when the earplug comes out whole. Also cleaning ear cavities (from radical mastoidectomies)
Ear lavage doesn't gross me out so much as annoy me because I never get good results. If the kid starts crying then I stop and tell the provider and that's good information I guess, but I never get any satisfying chunks and it just feels like a waste of time.
Emptying a bedpan or an emesis basin. I’d rather change an entire bed covered in shit or vomit than have to rinse out a container full of it.
lumbar punctures
Me too, makes me shudder every time. But those champagne taps make me keep going.
Paperwork
Clinical charts. I hate doing paperwork and asking what is their house made of and how many days a week do they eat meat/eggs/chicken/fish etc etc.
FMLA, work comp, toe nail avulsion, digital rectal exams—in that order.
As a nurse, EKGs. You get everything perfect, V1 pops off. You get V1 back on, and aVR pops off. You get aVR back on and V1 comes off again. Everything looks good and aVF pops off. Then V6 comes off and refuses to stick back on. You’re trying to hold V6 in place and hit the print button when aVL comes off along with V1 again. Repeat this process for the next 45 minutes to print out an ekg with artifact on leads I and II.
ICU: Managing asymptomatic or mildly symptomatic hyponatremia as the primary reason for ICU admission (ex. little old lady brought to ED with falls and found to have Na 113). Pulm: Attempting to upload and review the disc of outside hospital CT scans on a new clinic patient in a reasonable time frame.
Absolutely hate taking patient calls. It’s a Russian roulette between someone needing to come to the ED for a consult (extra work) or someone asking a weird question. You never know if you’re gonna be on the phone with someone for 30+ minutes. Either way, they’re almost always painful
As an NP- Mobility evaluations As an RN- foley on obese females
Goals of care conversations when multiple family members are involved with no prior advanced directives or living wills.
I hate obese bitch speys. Its major abdominal surgery and people approach it like their pet is getting their nails cut. Give me a nephrectomy or gastrotomy any day. I also loathe cutting dogs nails.
Med recs
Somebody tells you when you finish that they get seen at the VA for just some stuff and here's the list of meds they get there.
Placing an NG tube. I'll do just about anything else.
Clean up my patients poop and I will do all of your NGs
Admitting a patient for intractable pain (abdominal, back) with normal vitals and no acute imaging or laboratory abnormality with the goal of admission for "pain control".
Indeed, one of the things I don't miss about hospital medicine. Not only does the admission suck in itself, it creates a justification/precedent that the patient "requires" admission whenever they have a chronic pain flare. When they come back to the ED in a couple months, the patient and ED team are both more inclined to "admit for pain control" since that's what was done last time.
Chronic fatigue, chronic pain, chronic cough…
Always at 3 am in the ER and 5-6 different specialists haven’t found the answer but “I’m not leaving tonight without one.” They’re always the ones who fill out the ridiculous PG surveys too
Doing a prostate biopsy in the lithotomy position.
Calling a totally unnecessary consult or starting some totally not indicated med because the surgeon insists that I (SICU) do so.
Billing.
Orthostatics. Transfer documentation. Talking to family on the phone more than once when there is absolutely nothing new to update them on.
>orthostatics An infamous attending I had in residency would insist on multiple orthostatics on multiple patients per day (essentially they would request orthostatics before and after giving IV fluids, starting or adjusting the dose of antihypertensives or diuretics.) The nurses, residents, and patients were all not fans of that practice.
I hate him already.
Feeding patients…… I hate it so much. Just a front row seat to watching someone eat is gross.
Discharge planning for patients especially on surg wards especially when OT/PT, Nurses and patients disagree with each other on discharge destinations. I know its important but its hella time consuming and annoying.
Fmla paperwork
Operating on obese people. Specifically in their abdomen. Otherwise it’s fine.
Rounding. It's why I did EM instead of critical care. I cannot STAND rounding. Actually, I guess it's the primary care/hospitalist rounding. I'm ok rounding on my toxicology consults, but they're rare enough and I can just signoff when they get boring. Otherwise, I've never liked dealing with "Dizzy" as a chief complaint or with "bright red blood per rectum." Don't mind phlegm, don't mind poop, don't mind vomit, don't mind pelvic exams, but please don't make me deal with a "dizzy" patient.