Thread by @medicalaxioms

Like most doctors of my vintage, I was taught to be two doctors.

Doctor One was for innocent victims of their disease. Good, respectable people who took their medicine and had a ride home at discharge. 1/20

Doctor One was textbook perfect. He took everyone at their word. Two beers a week meant 2/wk. Complaints of pain were taken at face value and met with concern and treatment. Intentions were never questioned. Extra time was given. 2/20

Doctor Two was for bad people. These patients had made themselves sick with character flaws and bad judgment. This doctor was a skeptic and doubted ever word. 2 beers per week meant 6 per day. “Pain” meant “drug seeking.” Visits were quick. And painful. 3/20

Deciding which Doctor to be was easy in the mid-90s. Everybody knew how it was done.

You were Doctor Two for
“Drug addicts”
“Criminals”
“Weird people”
Patients nobody could diagnose
People with chronic pain

… and anybody else you felt like you could get away with it. 4/20

Doctor One came out for VIPs, fancy people, your parents’ friends, people like your parents’ friends, doctors, local dignitaries, clearly rich people, and mostly everyone else who seemed kinda legit. 5/20

Lots of people taught you how to be Doctor One. Your professors, atrendings, nurses, your parents, your role models. It was written down, taught in class, shown on videos, practiced in role play.

It was the default. If you weren’t sure, be Doctor One. 6/20

Doctor Two was not taught in class. This wasn’t in the syllabus. It was the code you learn to live by on the streets.

It was taught by residents and nurses. Taught at night and on weekends.

Learn the code. No snitches. 7/20

It all might sound quite fantastic. Unless you were there. If you saw it, you know it. 8/20

The innocent among you might wonder, “Why did we let ourselves get intimated like this? Why did we play along?

That’s because you don’t know about the punishment. 9/20

Let’s start with the easier mistake. You show up as tough Dr. Two for a “VIP” patient.

The family is upset. They don’t like your doubt and skepticism; don’t like your insinuations. They complain to the attending or the administrator.

You get yelled at and apologize. 10/20

These were easy. You apologize for being tired and being short. You promise never to do it again and get in your best Dr. 1 behavior. Everybody forgets in s few days. 11/20

The mistake we all made back in the day was showing up as shiny happy Dr. 1 for a patient who clearly deserved a Dr. 2.

“Fuck around and find out” as the kids say these days. 12/20

The story went like this:

Clueless Newbie goes into the room, takes a careful history and concludes the patient has chronic pancreatitis and is suffering from 10/10 pain.

He walks out and writes orders for all kinds of IV opiates.

Big mistake, Newbie. 13/20

First the nurse says “What is all this for?”

“For his pain?”

“He doesn’t have pain he’s here all the time.”

“Oh I see.” 14/20

Next Newbie goes to his resident and explains the situation.

“He’s not in pain he’s a drug addict.” Explains the resident.

“Oh I see.”

“Don’t give him drugs he will stay forever.”

“Oh I see.”

“… and don’t be nice to him. He’s a drug addict.”

“Got it.” 15/20

At this point Clueless Newbie asks for a little more guidance. He’s only ever been taught how to be Doctor One. The nice guy. So he asks his resident.

“Oh hey what do I tell him?”

“Go tell him he’s not in pain and he gets one Tylenol every 6 hours. Regular strength” 16/20

“Got it.”

So Clueless Newbie goes into the patient’s room and delivers a good quick Dr. Two speech.

Later on that night the nurse sees him in the hall, “Your patient is curled up in a ball, crying.”

“I see.”

“Nice job, Newbie!” 17/20

The cost of not learning how to Doctor Two was ridicule. Ostracism.

“Whose side are you on, anyway?”

Being nice to “bad patients” was naive. And bad medicine.

“Can’t you tell he’s not in pain? He was watching TV comfortable before you walked in.” 18/20

Merging 2 doctors into one who can face each next patient with a balance of curiosity+a little skepticism, gentleness+a little hard truth is harder than it sounds.

The lessons you learn on the street stick harder than the ones you are taught in the classroom. 19/20

I work hard to remember no patient deserves to be sick. Nobody “brings this on themselves.”

I still slip up sometimes and Dr. Two shows up, at least for a moment.

I try hard not to teach the 2 doctor style. I fail sometimes at that too. 20/20