Fabulous Prizes II

As brothers our troubles are 
Locked in each other's arms
And you'd better pray
That they never find you
'Cause your back ain't strong enough
For burdens double-fold
They'll crush you down
Down into nothing.

-Townes Van Zandt

There is no alternative to black humor at the county hospital.  Rather, there is no survivable alternative.   If you are too sincere in your pursuit of the monster, you might actually catch it, and then you would have it in your arms.  This is clearly what happened to Townes in the epigraph above.

Morbid jokes supply an artful way of perverting the awful clarity with which you might see your patients, their situation, and your implication in it.  There are better and worse ways of executing this caper, this feigned stumble in pursuit of truth.

One of the worse ways to do it is to make jokes at the expense of patients - to mock the loud demands of the drug-seeking patient for i.v. Dilaudid (tm) or his implausible claim that he's allergic to the oral preparation.  I try not to do this, because in addition to being prima facie disrespectful, people who develop a facility for these jokes become calloused and uncouth.

A better way is to find the joke - this is the equivalent of dumpster-diving veal.  You're not actually paying for the calf to be shut up in a box; likewise, you're not actually mocking suffering, you're just noting its occasionally intrinsic comedy.  You can enjoy the surplus products of institutional cruelty without financing it.  You just need a morality which is more concerned with contingency than with essence.

Anyway, I found the best awful medical joke I have yet discovered in a chart in clinic the other day.  It was so good, in fact, that after close review by the Committee the author has been awarded another of my unsolicited prizes, the widely coveted "Most Concise Argument for Healthcare Reform" award in the Medico-Legal Documentation category.

I was seeing a patient for a colleague on leave, and I came across the following sentence, which she had written without any apparent irony:

Pt is a resident of the US but could not wait for appt with Adult Medicine so he went to Korea for diagnosis.

But this is not quite the best part - it's wildly hilarious, of course, that the waiting list for our clinic is so long and the private hospital alternatives so expensive that somebody would fly to Asia to avoid both.  But what swayed the Committee was the fact that the diagnosis the patient received in Korea was one of papillary thyroid carcinoma in situ, which is to say that he had a very dangerous tumor in his thyroid gland which had not yet spread.  The difference between papillary carcinoma in the thyroid only and metastatic papillary carcinoma is the difference between a minor operation and probable death.  He was smart to go to Korea; he waited "for appt with Adult Medicine," he might well be getting palliative radiotherapy right now instead of enjoying his cancer-free life with his wife and young children. 

He returned with his diagnosis and had his operation here, although I'm not entirely sure why.  He was taken a little more seriously when he presented his pathology report from the Seoul University Medical Center.  I'm thinking of advising my uninsured patients who can afford the initial investment to take their health problems to Seoul.  As a matter of fact, when I finish residency and lose my employer-mediated health insurance, I may join them. 


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