Month: February 2011

Dr. Erdoc happened to look up when the internist walked into the emergency department.

“Oh no,” he murmured under his breath. The consulting psychiatrist was sitting next to him, typing a note. She looked at him and raised an eyebrow.

“I hoped it wouldn’t be him. Unlike his colleagues, Dr. Internist seems to have a deep loathing for us emergency docs,” Dr. Erdoc explained as he stood up. Dr. Internist was frowning as he approached.

“Dr. Erdoc,” Dr. Internist opened, “why are you admitting cellulitis to the hospital? Didn’t they teach you how to treat a bacterial skin infection during your residency?”

“Yes, they did,” Dr. Erdoc said. “They also taught us when someone with cellulitis needs a hospital admission.”

“This man has schizophrenia,” Dr. Internist went on. “Why can’t he be admitted to the psychiatry unit? The medicine consult service can see him there.”

The psychiatric consultant glanced at Dr. Internist, though kept typing.

“Because psychiatry has already assessed him—twice—and they don’t think he has any urgent psychiatric issues,” Dr. Erdoc said. “I agree with them.”

“Twice? What do you mean, twice?”

“If I had a chance to tell you the history, you’d already know,” Dr. Erdoc curtly said. “He’s a 43 year-old homeless guy with hepatitis C and schizophrenia. He came here four days ago with a hot, painful left leg and was diagnosed with cellulitis. Psychiatry saw him then. He was sent back to the homeless shelter with oral antibiotics, but he returned today—”

“His schizophrenia must be affecting his ability to take the antibiotics as directed,” Dr. Internist cut in.

Dr. Erdoc cleared his throat. “He was sent back to the shelter with oral antibiotics, but returned today because the cellulitis has gotten worse. He brought in his medications—including the stuff he takes for schizophrenia, which psychiatry looked at when they saw him today—and the expected number of antibiotic pills are gone. To prevent—”

“Did you call the shelter staff to get more information? Like if he actually swallowed the antibiotics?” Dr. Internist interrupted.

Dr. Erdoc looked blankly at him before replying, “No.”

“Why not?” Dr. Internist demanded. “You didn’t get a detailed timeline of events.”

“Because that wouldn’t change my management. To prevent the cellulitis from getting worse, he needs IV antibiotics, which means he needs an admission to the hospital,” Dr. Erdoc said.

Still frowning, Dr. Internist continued, “Did you draw blood to see if his body is mounting an attack against the infection?”

“Yes, but the results aren’t back yet.”

“I’d like to see them before I admit him.”

“Dr. Internist,” Dr. Erdoc said, taking a step towards him, “his cellulitis isn’t getting better. They did teach you in your internal medicine residency that you don’t need to draw blood or do x-rays to diagnose someone with cellulitis, right? It’s a clinical diagnosis.”

Dr. Internist looked darkly at Dr. Erdoc, but said nothing.

“The best thing for the patient is an admission to the hospital so he can receive more aggressive treatment for his cellulitis,” Dr. Erdoc continued. “Your dislike of emergency medicine docs isn’t going to make patients get better. Now, we can continue to stand here, argue about this patient, and waste our time, or you can do the noble thing and admit this man to your service so we can all move on with our lives.”

Dr. Internist glowered at Dr. Erdoc.

“Fine. I’m doing you a favor,” Dr. Internist said before walking away to see the patient.

“No, you’re doing your job,” Dr. Erdoc muttered.

Sighing, Dr. Erdoc walked back to the computer where he was typing his note. The psychiatrist was finishing up her work.

“The contempt he has for us is fascinating,” he said.

The psychiatrist gave a small smile before commenting, “Sure, though the reasons why he dislikes emergency docs may be much more interesting.”

From Karen Pryor’s excellent Don’t Shoot the Dog (the first sentence runs long):

In order to maintain an already-learned behavior with some degree of reliability, it is not only not necessary to reinforce it every time; it is vital that you do not reinforce it on a regular basis but instead switch to using reinforcement only occasionally, and on a random or unpredictable basis. This is what psychologists call a variable schedule of reinforcement. A variable schedule is far more effective in maintaining behavior than a constant, predictable schedule of reinforcement. (page 21)

---

“Honey, you’ve been playing the slot machines for over five hours. Aren’t you hungry? Can we go eat somewhere?”

“Okay, just a few more minutes,” he replied, plucking another quarter from the plastic cup between his knees. After feeding it into the machine, his eyes watched the spinning fruits, jewels, and 7s.

Cherry. Cherry. Cherry.

The lights began to flash, synthesized music filled the air, and a shower of quarters clanged onto the metal dish below.

“WOO HOO!” he exclaimed. A small smile crept onto his wife’s face.

“I’m almost even! Things were slow for a while, but I’m back on a roll!”

(Behavior: Putting quarters into the machine and pulling the lever. Reinforcer: Lights, music, jackpots.)

---

“I know he’s bad for me, but I can’t help the way I feel,” Jennifer said.

“He’s terrible for you,” Lisa said. “This is the third time he’s gone behind your back with other women in the past six months! He’s not thinking about you, he’s thinking about him! Why do you put up with him?”

“Because when he’s around, he’s so good to me. Remember when we first met? He visited every day. He took me out. He bought me stuff. He was so nice.”

“Yeah, and now he doesn’t do any of those things.”

“That’s not true!” Jennifer exclaimed. “He’s done some wonderful things! Like four months ago, after I found out about that first woman. He said he was sorry and he showed it, too: He made dinner and bought that expensive necklace—remember that?”

“Right,” Lisa said. “And then he hooked up with another woman one week later.”

“He said he was sorry! He even cried. He said it didn’t mean anything. I believe him. To make up for it, he somehow bought us great seats at the sold-out concert.”

Jennifer sighed. Lisa rolled her eyes.

(Behavior: Jennifer’s tolerance of her boyfriend’s behavior. Reinforcer: Her boyfriend’s attention, bling, etc.)

---

These same principles could also apply to blogging. Discuss.

I just want to go,” the man said.

To the left of him were two medics. One of them had driven the ambulance to the emergency room. The other medic had sat in the back with the man. The medics looked at each other and smirked.

The man got up and started to walk towards the exit. The handful of patients in the waiting area watched him. The tattered hems of his oversized jeans stuck to the heels of his shoes. Stains of different colors and sizes were splattered over the front of his sweater. His shoulders were hunched forward and his dragging pants added scraping sounds to his shuffling steps. He hadn’t washed his hands in days; he looked like he was wearing dark gloves.

The security guard quickly walked in front of him and blocked his path.

“Hey. You can’t go. Just wait for the doctors to see you, okay?”

“I just want to go. I don’t want to be here,” the man said. He looked blankly at the security guard and took a few steps back.

Nurses walked by, scribbling notes onto sheets of paper. A patient was reclining in a stretcher, holding his leg tightly. When he gingerly let go, the pads of gauze in his hands were soaked with blood. He grimaced.

“There’s a gun shot wound coming in,” the medic commented to his partner. The other medic nodded. The man started walking towards the exit again.

“Okay, Gandhi. Just wait, Gandhi,” the security guard barked. The man stopped and his shoulders rolled forward.

“Oh, are you Gandhi today?” one of the passing nurses said. “I thought your name was Moses.”

“It’s Gandhi today,” snorted one of the medics. The nurse chuckled. The man looked down.

“Oh, you’ve been Moses, too?” the security guard laughed.

Still gripping his leg, the man on the stretcher craned his neck to see who they were talking about.

“We see you all the time, Moses. Why are you Gandhi today?” the nurse asked.

“I don’t know, I don’t care,” the man said to the floor. “I just want to go.”

“Hang on, Moses. We know you’ve parted the Red Sea in the past, but you can’t lead an exodus today, okay?” the nurse said, pointing to the row of chairs in the waiting room.

“Come on, Gandhi,” the security guard said.

The medics, nurses, clerks, and security guards snickered at him. The handful of patients in the waiting area watched him return to his seat.

“The gun shot wound will be here in two minutes,” another nurse called out.

“… and the patient is blind,” the medical assistant said as she passed the chart to the physician. He nodded his thanks and walked into the room.

“HELLO, MRS. CALAHAN!” he said. She turned her head towards him and smiled. She seemed to be looking at his left ear.

“Hello, Doctor,” she said. He pulled the stool from under the table, rolled it as close as possible to her, and sat down.

“HOW ARE YOU?” he asked, trying to speak directly into her ear.

“I’m okay,” she said, leaning away from him. “I’m here for an annual checkup.”

“GOOD! GOOD!” he exclaimed, leaning further towards her. “WHEN WAS THE LAST TIME—”

“Doctor!” Ms. Calahan interrupted. She raised her hand and turned her palm towards him. “I may be blind, but I am not deaf!”