Thursday, September 22, 2011

Episode 23: Tell Me Sweet Little Lies

The silence in response to my last post was absolutely deafening. To date, I have received zero comments. How could this be? I’ve asked around, I’ve done the math, and I have a few explanations. 1. “This is what happens when you don’t post regularly.” True. Although I still have readers (unless all those hits are me, a possibility that I’m not totally ruling out), it does seem that I’ve lost a good percentage of my following by not posting regularly this summer. 2. The second, scarier, but probably more likely reason that the comments have fallen off so precipitously: “ wasn’t your best work.”

This second answer was not much better than the response I got after a night of disastrous Karaoke in 2007You can read all about it, but to sum up: After I performed what was the most unfortunate karaoke number in the history of really bad lesbian bars (and people, that is saying something), I confronted my "friends" for failing to support my (admittedly disastrous, train-wreck, but still my) karaoke effort in any way. I mean, shouldn’t your friends at least clap for you after you went through the trouble to sing in front of an audience of hostile strangers? After a minute or so of awkward silence, one of the group answered with, "Well, I don’t really consider you a friend.” Or something like that. What does this have in common with “Well, it wasn’t your best work?” Both are harsh. And both are probably true.

In my defense, the last episode was nobody’s best work. It rehashed a stale, overdone plotline without including much new material or any good one-liners. It was filler, and it was obvious it was filler, and maybe that led me to be OK with leaving the last entry of this blog as filler, and my readers (note: I am back to calling you readers instead of fans) could smell mediocrity from a mile away. For this, I am sorry. Or maybe I’m not sorry. Although I’m the one watching and writing about these crappy episodes, I’m glad that when the content of the blog is boring or worse, just bad, people don’t waste their time trying to think of something to say. Plus, I know that some of you are really my friends, so much so that you’re kind enough not to say anything when a post just isn’t good. I’ll admit I shouldn’t have put the 9/11 stuff in there. It was cheesy, and I knew it, and I still included it, like I was writing for the New Yorker or something. Maybe instead of bitching about the lack of comments, I should be thanking you for not saying anything mean.

Of course, there is another possibility, one that is some ways much worse: Perhaps I have neglected this blog so terribly and for so long that no one read that last post. It’s clear that we have reached the point of this show where the novelty of my blogging about it has worn off. It’s hard to make fun of the same, dead-end plotlines again and again. Nothing seems to have happened this entire season. Plus, I started this blog because of a breakup, and that breakup is long over. So maybe it’s time to call it a day on the blog. If it’s not making my readers happy, then what’s the point?

And yet…Am I over the breakup? I feel like I am, except in the sense that no one ever TOTALLY gets over a bad breakup-it’s a scar…or maybe more like a tattoo. It’s there. It doesn’t hurt so keenly, but I’m left, staring at the thing, and still wondering about the same thing I was wondering about in March: Am I at risk of just making the same relationship mistakes again and again? Because if so, I need some therapy, or maybe even a miracle cure.

Which brings us to today:

This episode, named after a Fleetwood Mac song, is really all about Cristina Yang, which makes it the best episode I've seen in a long time. As the title would indicate, the theme is:

“Our patients lie to us all the time. The rule is: every patient is a liar until proven honest.”

First, I don’t think this is true. I don’t think my patients are liars. I think patients, for the most part, tell the truth, and I think most doctors would agree with me. The only patients I don’t believe are the patients who have positive tox screens but SWEAR that they don’t do drugs. Liars. Every one. Other than that, do I have any reason to think that you’re lying about your history of hypertension and hypercholesterolemia? No.

“We lie to ourselves because…the truth? The truth freaking hurts.”

There’s a patient who is a guitar player who unfortunately gets his fingers cut off in some sort of stage accident. Even more unfortunate, the only hand surgeon on staff is…?McDreamy?  Even my humanities-oriented girlfriend picked up this. She watched him sewing the guy’s hand and asked, “Isn’t he a brain surgeon?” Why yes. Supposedly. 

Since when is McDreamy a hand surgeon, you ask? I don’t know, but I wouldn’t trust any neurosurgeon to reattach my severed fingers. (Well, I'm really hoping I'll never have to have anything reattached, but you know what i mean)
Alex is taking care of a competitive eater with an esophageal tear, and this inspires a pretty funny hot dog eating contest among Cristina, George, and Alex. Cristina uses the water on the buns trick and wins the contest:

But loses her cookies after the fact:
And this is why we love Sandra Oh! She's hot, and a touch butch, but not so hot that she'll refuse to do this scene or a scene where she stuffs her face with a hot dog.

In other Cristina news, Cristina lied to Burke, telling him she moved in with him when she actually kept her apartment.
Meredith: Truth. Did you move in with Burke or not?
Cristina (sighs): I told him I moved in with him. I’m keeping my old apartment. (Meredith gives her a look) What? I sleep with Burke every night. My clothes are there. So I still have my apartment, big deal.
Meredith: You have to tell him.
Cristina: Actually, I don't.
Meredith: So I’m supposed to go to dinner at your fake apartment with the guy you fake live with?
Cristina: Oh, I would never have you over to dinner with Burke. That’s weird.
Meredith: This is my point. Stop with the lying.
Cristina: And you’re being honest? That last time you called him Mc Dreamy you were all a-twitter with love.
Meredith: We're just friends.
Cristina: Uh huh.
Meredith: We are.

Really, Cristina is having quite an episode:
Cristina is so right: Why is this neurosurgeon always in elevators with interns? Creepy.
Derek: What is your problem? I’m your boss. What’s the matter-
Cristina: No you’re not my boss right now. We’re in an elevator. That’s your specialty, right? McDreamy moments in elevators?
Derek (warningly): Dr. Yang...
Cristina: You know what, for a moment, I’m not Dr. Yang, and you’re not Dr. Shepherd. You’re the guy who screwed up my friend. The guy who drove her to get a dog she can’t keep, a dog she only got because her boyfriend lied to her about his wife.
Derek: I never lied to her.
Cristina: You know what? I know a liar when I see one, ‘cause I’m a liar. Fine you want me to lie to the patient. I’ll lie.

Bailey is having Braxton hicks contractions, leading Addison to tell her to stop working so hard.

There’s a patient who refuses to leave after being discharged:

George: “If she refuses to leave, what am I supposed to do?”
Chief: “She’s 78 and non-ambulatory. You have the upper hand. Use it.”

But George fails to get her out, and when the chief catches him doing her errands,  
George asks: “Have you met Mrs. Larson?”
Chief: “Why do you think she’s been here so long? In a private room? We can’t keep her. Not on the surgical service.”

This inspires George to spend the rest of the episode trying to transfer this patient to another service, an act that is known in medicine as:

The Turf.

The turf has long been touted to interns as one of the keys to success in hospital-based medicine. Learn how to turf your patients to other services and save yourself some pain, says the conventional wisdom. The concept existed before the book House of God, but was no doubt immortalized because of that book. HOG (which contains such “golden” rules as “GOMERs go to ground,” “They can always hurt you more” and “The only good admission is a dead admission”) was only following its own rule (“Rule #5: Placement comes first: Your absolute first question should be: ‘How am I going to TURF this patient?’”) when it provided very specific instructions on the best methods for turfing patients, including raising the bed to heights where your poor, confused aged patient is likely to fall off and experience trauma as a result of the fall. There is “orthopedic height” (Fall and break a hip, get turfed to ortho) and “neurosurgical height” (fall off, head bleed..turf to…well you get it). Of course, these days, patients with these problems stay on the hospitalist service with only the briefest of surgical consults, so such escapades are no longer beneficial to the primary team (and they were, ahem, never beneficial to the patient). More often than not, it’s hospitalists who complain that surgeons turf to medicine. It’s common practice for surgeons to refuse to take a patient onto their service because of “complex medical issues” (i.e., comorbid diabetes or hypertension).  Despite the grumbling about surgeons refusing to care for their patients, however, there is a practical side of this: surgeons are busy operating and taking care of post op patients and they don’t always have the time or knowledge to take care of the medically ill. In fact, I have recommended in my own institution that hospitalists should volunteer to care for most of the patients in the hospital, with surgeons only consulting-which frees the surgeons up to be in the OR. Of course, the danger is that hospitalists end up perennial interns, always taking care of somebody else’s scut and never getting any respect. Plus, I don’t think there’s any way hospitalists would be paid for this service directly-the hospital would have to figure out dollars saved by adding extra surgeries-which they’ll never, ever do. Hospitalists are already criticized for “Not making the hospital any money” and even "costing the health care system too much" (just like palliative care never makes money-until you figure that they talk to families and convince them to take terminal patients off ventilators days, weeks, or even months earlier than if the palliative care team wasn’t there. But nobody ever counts that cost saving as income), so I can’t imagine hospitalists caring for the entire hospital would be a popular option. But it makes clinical and, thinking out of the box, even financial sense.

After multiple TURF attempts, George finally discharges the patient to a nursing home.

There was one pretty good line that I am too PC to ever use but still made me chuckle:

Chief to nurse administrator: “Don’t you speak nurse?”

And, finally, the moral (just to irk those who don't like morals):

“No matter how hard we try to ignore or deny it, eventually the lies fall away, whether we like it or not. But here's the truth about the truth: It hurts. So we lie.”

Saturday, September 10, 2011

Episode 22: Begin the Begin

This is the birthday edition of the Miracle Cure. Yes, I turned 37 last week. 37 is not quite old, but is certainly no longer young. I think one could make the argument that 37 years is the beginning of middle age, making it not much of a birthday to celebrate. When I started this blog, I think it was my fear that I would reach this birthday single, childless and with minimal job security. On the up-side, I’m no longer single.

On a happier note, a big birthday shout-out to Dr. McAwesome, my favorite surgical intern!!!! (I think she may now be 25. Or maybe 26). Congrats on getting through your first three months.

“Fresh starts. They happen every year. Just set your watch to January.”

This is Meredith’s introduction to the Grey’s version of the 80-hour-work-week. The chief touts it as a needed intervention to reduce errors, although the New York Times recently reported that reducing errors and improving quality in medicine is much more complicated than reducing work hours alone.

What the show seems to miss is that 80 hours is still a lot to work, and doesn’t usually involve leisurely, untired mornings off. No, 80-hour-work weeks usually just mean that most days are a regular 8-10 (and sometimes 12) hour-work-day, twice a week is a 16-hour (or longer) day, and one day a week is 24 hours off. I worked 80-hour-weeks for two years of my residency, and I found I was at work during most daylight hours. When I finally got home at night, I was freakin’ tired, just able to eat dinner and watch bad TV. Far from leaving residents with many leisurely daylight hours free, the 80-hour-work-week turned residents from complete zombies with swollen, haggard faces and a confused, psychotic look into normal tired people who could occasionally go out to dinner. (Although, as my friend who is a program director said to me, "Even with the 80-hour-work-week, intern year does a number on these folks, that's for sure. We see the class pictures of the interns versus the second years and there is a significant difference. The second years have aged. Of course, we don't tell them that.")

In stark contrast, the Grey’s residents in this episode appear to working a 20-hour (or even 10 hour) week, because their new schedule lets them live the lives of stay-at-home-dog-owners and freewheeling retirees. They do laundry and bake things and go jetting across the country on a whim (well, Cristina jets off with Bailey to Idaho to get a heart for a transplant. Meredith runs into McDreamy during a leisurely morning at her mother’s nursing home. Meredith also does laundry and makes muffins.) This depiction is, of course, ridiculous and may have contributed to the belief held by a large number of attendings who insist that residents “can’t learn anything” in 80 hours. To me, working 80 hours a week for 3-7 years in a structured training program should teach a person how to be a doctor. If it doesn’t, there’s something wrong with the training program, not something wrong with the hours.
The Grey's version of the 80-hour-work-week=stay at home dog owner, spending leisurely mornings doing laundry
Or, perhaps, living the life of a jet-setting retiree

In other Grey’s news:

The dog is not working out. He barks, urinates, and tries to mount George from behind.

Addison hates McDreamy’s trailer.

Burke still wants Cristina to move in. Cristina is still deciding. (I am so sick of this ridiculous plotline)

A patient who is awaiting a heart transplant hits on Izzie. He looks pretty realistically pale and puffy but not quite short of breath enough. I found that I couldn’t stop wishing he would be a little more short of breath so he would just stop talking. Spoiler alert: he doesn’t get the heart.

Bailey seems unhappy. It may be the 80 hour work week or may be the fact that she is very pregnant. She’s one of these “'work hours ruined medicine' people.” Her stance reminds me of a residency interview I had with a very tired and scary-looking chief resident in Seattle. It was before the 80-hour-work-week was around, but some programs did have “caps” on admissions. This meant that after a certain number of patients, a resident was “capped” and couldn’t do any more work. In the course of my interview, I asked, “So do you have an admissions cap here? Or how does this program limit the residents’ workload?” It was a pretty benign question, but the woman suddenly developed a facial tic and loudly and forcefully announced, “Any program that limits the number of admissions is a program where you will learn NOTHING!” Needless to say, I left the interview feeling like the program was not a good fit for me.

A man ate his book and needs it to be surgically removed. “I ate the whole damn thing. Every last piece of that unmitigated crap.” It comes out of his gut in the OR as a bloody lump, but the patient remains ill. Alex somehow figures out that the man has mercury poisoning. Good catch, although unlikely that you would have figured it out, particularly given the fact that you didn’t even know about central pontine myelinosis.

Poor Jamie Lee. Constantly with the gender rumors and she has to do those commercials touting yogurt for chronic constipation.
This episode also raises the age-old question: Does Jamie Lee Curtis have a Y chromosome? Well, let me rephrase. Jamie Lee Curtis is not mentioned in the episode at any point, but a patient in this episode presents with a disorder that Jamie Lee is rumored to have: Androgen Insensitivity Syndrome. This syndrome occurs in people with XY chromosomes who are unable to respond to androgens, so despite the male genetics and the presence of testes (and the resultant androgens these testes secrete), the patients appear phenotypically female. The patient in this episode was raised a girl but she is supposed to be a tad boyish-if you've seen the episode but are still slow on figuring this out, I will clue you in: the patient's boyishness is indicated by the fact that she insists on being called “Bex,” she doesn’t have a boyfriend, and she wears a winter hat at all times. 

Winter hats: indicator of gender identity questions?
Addison biopsies a “growth” on Bex and pathology (always available minutes after the surgery!) reveals it is an undescended testes. In response to this finding,  Bex’s parents don’t want her to know, but George reveals the secret to Bex, and by the end Bex is cutting her hair short. (Because short hair and gender identity issues go hand in hand, right?).

Or is it the short hair?
Once again, this plot line isn’t supported by evidence. There’s no evidence that patients with androgen insensitivity who are raised as women are more likely to be transgendered or gay-which means Bex’s testes probably aren’t doing much to contribute to her gender identity problems (although it could be an independently occurring event, I guess. True, true, unrelated, as they say. Or could the hat be causative?). In one of the more interesting moments of the episode, George gives Bex a lecture, advising her that her issues with bullying at school will end when she goes to college. His point? “It gets better.” This episode was broadcast long before Dan Savage et. al. created “It gets better,” making me think that that Dan saw this episode and unconsciously incorporated its message into a website he created 5 years later. So thank you, Grey’s writers, for (maybe) saving the lives of a few sad gay teens. Although…George is played by the one gay actor on this show, T.R. Knight. Our friend T.R. was reportedly bullied on the set by the actor who plays Burke, Isiah Washington

So sometimes it gets better and sometimes, even when you grow up and many of your dreams come true, you still have to deal with complete assholes at work.

ER actually had a patient with androgen insensitivity syndrome as well, although they presented it in a slightly more sensational manner, ending the scene with an attending surgeon saying to the resident (after she informed the family of the situation), “You handled that very well...... but you should have told them they're going to have to change their daughter's name from Barbie to Ken."

Uh, except they’re not and that statement is totally offensive. Annoying.

Last note: I was coming back from a conference today, Saturday, September 10th, and I happened to take the train, which meant that I got to see the best view I ever get of the Manhattan skyline. It reminded me of the first time I saw the skyline after September 11th-a moment in which I suspected that I would never again see that view without my first thought being that the towers were gone. 10 years later, that is still true. Weirdly, as the scenery whizzed by, I also happened to be listening to this Death Cab for Cutie song (yes, I know, DCFC is so 2005. My IPod was on shuffle.) which seemed so fitting: 

“I wish we could open our eyes
To see in all directions at the same time
Oh what a beautiful view
If you were never aware of what was around you”

Death Cab for Cutie, Marching Bands of Manhattan