Sometimes I feel like Sergei, my devoted Russian wolfhound. No, I don’t mean that if I had a pig ear and dog bone, I would consider life just about perfect. I am referring to the notion that just as I really would like to know what’s going on between his furry long ears, I get the feeling that patients wonder what I and most other doctors think about. Sergei cannot speak the King’s English, but I have the distinct impression he is continuously processing the things he sees and hears and has a point of view worth listening to, if only he could wrap his long tongue and deep throat around a few vowels and consonants and just spit it out. I don’t know how profound it would be, but it surely would be a unique perspective to say the least. While he rarely will give me the time of day, my wife seems to be able to make some verbal communication with him as he almost answers her questions. She will call his name and he will look at her and point his ears. She will ask a few simple questions in succession; and with each one, he will become progressively more animated and eventually will begin to make high-pitched, brief barks, which evolve into more complex howling phrases. I am sure he is trying to answer the questions put to him. Finally, he will shake his huge head as if to say, “I can’t put it any clearer, you guys must be dense.” He will then return to his world. We have tried to get his opinion on mundane topics such as his food, his new companion canine, Max, and how he has been feeling lately. I have at times asked his opinion regarding more complex matters such as his political views. I cannot be certain but I think his positions on the Iraq war and health care are about as clear as those of the candidates.

Further discussions of Sergei’s views on political and other matters will have to be pursued at another time, as I want to spend a few moments considering what occupies the thoughts of most doctors. In an effort to provide some order where their may be none, let’s just ride a full day of the brain waves inside the hard skull of a regular, rank-and-file doctor of medicine and see what makes most of them tick – and at times ticks them off. If I appear to leave some thoughts out, just assume they are just like yours. For simplicity of presentation, things that come to mind are presented using the “universal I”; indeed, some of the thoughts are from physician-colleagues and I cannot claim any ownership.

Most doctors arise early and must physically and mentally prepare for what is a very long day even by today’s standards of a very over-worked society. While taking a morning shower at 5:30 AM doctors will likely consider several things. “God, am I tired. I went to bed at a decent hour and slept well. I must be getting old. I hope nothing is physically wrong. The shower feels great. It should wake me up. It darn sure better because I have a very long day ahead of me. I love the shower. It is quiet and I can think. Why the heck do homes that cost a small fortune still have only a 5 X 5 shower stall? Stalls are for horses for heaven’s sake. Maybe I am just a horse and am running in another race. First, I have to go to St. Joseph’s ICU. Mrs. Smith is still short of breath. I hope I gave her enough Lasix. Her lungs are a mess. Her son is a critical SOB. He seems to be sure we are all fools and just might sue me if mom dies. I will see her first.” When doctors are in a quiet place and left to their own thoughts they consider the cases that led to lawsuits, cases that could be lawsuits, and cases that should have been lawsuits. Doctors review cases over and over in their minds and try to recall what led to mistakes in past years and seek to avoid making the same or parallel mistakes in this day at work.

It is the beginning of a regular day. It begins with the stress of considering their sickest patients for whom there may be no easy way to improve their health. Dressed and leaving the house in the dark, I think, “It would be nice to see the kids before I leave. I didn’t get to the high school football game last Friday and only saw them briefly over the weekend because I was on call. I will call them when I get to the hospital just to say ‘Good Morning.’” Finishing ICU rounds, the doctor heads to the office. On his desk are three messages; two from patients at home who wish to be seen that day, and one from another physician seeking to have his patient seen as soon as possible at the hospital. Also on the desk is the office patient list for the day. Twenty-five names appear on the docket. Some are known, some are new patients. “Lord have mercy, I have to see more patients daily every year just to meet the overhead of the office. The days when fifty percent of the revenue could pay for the office staff and other overhead are long gone. It is now close to seventy percent. The academic literature is full of advice and the most common is to spend more time with each patient. I know that is true, but the costs of running an office, paying malpractice premiums, purchasing new and demanded information systems are becoming massive these days. Doctors in private practices are becoming nearly extinct as they are pushed to leave private offices and work for hospitals, massive group practices, or industry. Some just quit and do something else just to stay independent.

Let me put on my white coat, don the stethoscope and begin the day.” “Mary, call Mrs. Jones and see what the problem is. Crystal, page Dr. Jones for me. I’ll be in room 1.” Mid-day, “I’m hungry. I have had only three cups of coffee and it's 1:00 pm. I can eat a sandwich in my office and it will take only five minutes. I am one of the highest paid professionals on the planet and I get only five minutes for lunch. There is something wrong here. I remember how it was twenty years ago when Doctors would take Wednesday or Thursday afternoon off and play golf. This is now history. That’s life”. End of day, the doctor takes a few minutes to open the mail. “Letter from a law office. God, what’s this? Cripes, only a request for records for a disability application. Why do law offices do that? Wouldn’t it be nice if the letter had the following note on the envelope, “Don’t worry, this is no big deal.” Of course it would never happen, but I never like opening letters from law offices. Over a one year period, I have a thousand patient contacts and I am never sure that each and every case is free of the risk of a lawsuit. Law offices must make money by owning Xerox stock. They request records all the time for less serious matters but it still is a hassle. Now they want the records for Mr. Thompson. He has been a patient for fifteen years and the chart is over two hundred pages. That will tie up a secretary for several hours. How nice, the lawyer will pay all of twenty-five dollars for the copy. Thanks a Bunch! What’s this? A card in longhand from a patient thanking me for taking good care of her during her hospitalization last month. If patients only knew how much it means to get a note like that. It does make it all worthwhile.

Office hours over at 5:00 PM. The doctor heads to the first of three hospitals for evening rounds. “If I finish at the first hospital by 6:30 PM., the second by 8:30 PM and the third by 9:30 PM I can get home by 10:00 PM. I have to stop by medical records and sign charts and dictate a discharge summary or two. No, I’ll do that tomorrow morning if I can get to the hospital by 6:00 AM. I am behind in the records at the hospital and am told I will be suspended if I don’t get the damn things done by tomorrow night. They can’t be serious but they are.” Home by 10:00. I kiss the kids and the wife. I have dinner and watch some of Monday Night Football. “All those people in the stands. Do they have day jobs? How can they get away to a football game on a week-night? They must be hospital administrators, independently wealthy, or they did their hospital records last Saturday. I will do mine next Saturday. Sergei, my boy, how was your day?”

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