Category: Uncategorized

During the third year of medical school, students are released into hospitals and clinics to interact with actual patients, doctors, and medical systems. On our first day as third-year medical students, my classmates and I each received a key card. It was a light shade of grey, had an uneven surface on one side, and easily slid into the sleeve that held our identification.

The hospital administration admonished: “Keep your key card in a safe place. Do not lose it.”

The key card unlocked all of the doors in the hospital. Just 24 hours prior—when I was a second-year medical student—I had to register as a hospital visitor and wait for people to guide me through the building. Now, things had completely changed.

After tapping the key card against the electronic panel outside of the trauma surgery ward, the lock on the door disengaged. I pulled the door open and inside were patients with various limbs elevated, wrapped in gauze, with metal rods and screws sticking straight out of their flesh.

The heavy doors of the intensive care units automatically swung open with the tap of my key card. The sighs of mechanical ventilators and various beeps from heart monitors greeted me. I spied silent, yawning people sitting by unconscious patients. Tubes jutted out from their slack-jawed mouths and numerous clear tubes trailed from their bodies to the IV poles towering over them.

The key card allowed me to step into the maternity ward. No one cast a wary glance at me when I peered at the rows of newborn babies in the nursery.

With that key card I learned that the entire hospital, with all of its sacred spaces, was open to me. I felt both terror and delight. Did they not know that I had no idea what to do? Couldn’t everyone sense that I did not belong there? I avoided eye contact with all other human beings and hastened my gait to assure everyone I was not loitering. I didn’t want to give anyone the impression that I was trying to take care of patients.

No one noticed. In some instances, I used my key card to open a door, took literally two steps into the area, then walked right back out again. Doctors and nurses seemed to look straight through me.

At the end of the day, I used my key card to leave the hospital through an unofficial exit. The heavy heat of the July evening immediately walloped me, along with a humbling realization: Now that my classmates and I were allowed into these sacred spaces, we had power and privilege.

Doctors often forget that patients can invite us into the sacred spaces of their lives. They share their physical and emotional vulnerabilities with us. We learn about their health, illnesses, fears, and hopes.

We, however, do not automatically receive key cards to patients’ lives when we first meet them. We can only earn these invitations through respect, professionalism, and competency. We must remember that, as with hospital key cards, we should do our best never to lose those skills.

Mr. Smith tolerated the surgery well. The anesthesia wore off quickly. One of the wheels of his gurney clattered as the orderly pushed him down the hallway towards his room. His mother, wringing her hands, wordlessly rushed towards him when he entered. She cried.

That night, his mother slept on two chairs next to his bed, as if she was guarding the wound.

Mr. Smith said little about the amputation of his left leg. He commented that the car accident was just that—an accident—and, now, he wanted to look forward, not back. The doctors and nurses marveled at his serenity. They wished all of their patients were calm like him.

The next morning, his sister came by. She brought a box full of family photographs with her. While Mr. Smith watched, his sister and mother taped them to the window. The photos formed a large “S” that occupied the entire pane. He was pleased with their handiwork.

The visitors began to trickle in that afternoon. Some were teenagers; others were about to retire. A few came in wearing tailored suits, but most were in jeans and tee shirts. Nearly all of them came alone. They told the clerk that they were Mr. Smith’s friends. The clerk often had to ask them to wait because there were already too many people in his room. Most spent less than 15 minutes with him.

A nurse turned off the lights in his room that night. Mr. Smith objected. He said he could sleep in a lit room. If he woke up, he wanted to see who was coming in. The nurse turned the light back on.

A few visitors came later. When the nurses told them that they could not see Mr. Smith, some of them became angry. They had travelled far to see him. Couldn’t the nurses make exceptions? When the nurses instructed them to come back during visiting hours, they muttered obscenities.

This went on for two days.

Meanwhile, some of the nurses noticed that the dressing around the stump of Mr. Smith’s left leg was often loose. While rewrapping the gauze, they told him to let them know if he noticed the dressing was falling off. To help the wound heal, it should be snugly wrapped at all times. Wincing, Mr. Smith agreed.

On the afternoon of the third day, screams and shouts came from Mr. Smith’s room. Nurses ran in and saw a male visitor leaning over the bed. His fist was over Mr. Smith’s head.

The nurses demanded to know what was happening. Mr. Smith said nothing. The angry man said nothing. The two other visitors in the room stared at the floor. The angry man abruptly left.

Twenty minutes later, four police officers burst onto Mr. Smith’s floor. The nurses chased after them, loudly asking for the reason for their visit. The police said that they wanted to arrest the man in the room with the S on his window. The nurses protested.

Mr. Smith was sleeping when the police surrounded his bed. Doctors arrived. His mother fled. The police asked the doctors to remove the dressing from his wound. Mr. Smith, calmly looking around, asked if it could be done later. The police insisted.

And this is how everyone learned that in the wound of his amputated leg was a stash of cocaine that he was selling to his visitors.

Antidepressants, like other medications, cereals, tee-shirts, and frozen vegetables, come in trademark and generic varieties. What is the cost of one month’s worth of generic medication? How about one month’s worth of trademark medication?

The generic name for Prozac is fluoxetine:

According to drugstore.com, 40mg of fluoxetine costs $40.99 per month. 40mg of Prozac costs $398.49 per month. Prozac went off patent in August 2001.

The generic name for Paxil is paroxetine:

Paxil went off patent in 2003.

The generic name for Zoloft is sertraline:

Zoloft went off patent in 2005.

The generic name for Celexa is citalopram:

Celexa went off patent in 2003.

Here is a comparison of the costs of trademarked antidepressants:

Lexapro (a cousin of Celexa) and Cymbalta are currently under patent. No generic forms are available at this time.

Why does Prozac remain expensive? Why is Lexapro relatively inexpensive?

If doctors knew the costs of these medications, would they change their prescribing preferences?

If patients knew the costs of these medications, would they ask their doctors more questions?

(All price data above are from drugstore.com. Patent expiration dates come from a variety of business magazines. I created the graphs using Google Docs.)

How did you first notice the lump in your breast?”

The sadness in her face momentarily disappeared. She laughed.

“My husband found it.”

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.”