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There's often something else in the background. A weird platelet count, a low sodium level, a little anion gap--something that might be easier to ignore than to try to figure out how it fits into the clinical picture. I'm assuming that I'm going to at least notice these annoying details. That is, I'm already assuming that I'm vigilant.

Vigilance makes a doctor good. A good doctor will diagnose the pneumonia and treat it. Curiosity makes a good doctor better. A curious doctor will be driven to figure out why these other lab values are a little off because, it’s true that there could be all sorts of silly explanations for an out-of-range test result, yet the doctor's job is not only to figure out what's not wrong, but also--when the dust settles--what is.

Like any other job, medicine can become routine. The evidence that we have been accumulating on medical and surgical interventions has to some extent standardized our practice. Data have helped to define the 'standards of care' for investigation and management of many diseases. Some of these well-studied diseases for which there is more or less widespread agreement on management include heart attack, heart failure, diabetes, many infections, and certain kinds of trauma, to name a few. The purpose of evidence-based medicine however is not to make the job of the doctor easier nor is it to make sure everyone gets the same treatment just for equality's sake, but rather to apply particular medical decisions that have been shown, hopefully in high-quality experiments, to be effective. The medical community decides that interventions that improve outcomes should become standard because they're better.

The word that doctors use is not 'standard,' though. It's 'guideline.' This is not because doctors think that they're better than everyone else and that rules shouldn't apply to them. Rather it's to make room for judgment because it is impossible to study every intervention in every population of potential patients, and because even effective interventions are rarely effective for every eligible patient. We have therapies that may approach 100% efficacy (eg, penicillin for syphilis), but they are few and even they're not perfect. We think that preventing death in only 1 out of 42 people treated with a beta-blocker for two years after having a heart attack is pretty good. In addition, accepted algorithms for investigating disease will not include every possibility, so the doctor needs to have an index of suspicion for diagnoses that may not be on any algorithm.

So, is this science or art?

Everyone knows that doctors like to say that medicine is as much art as science. My own quibble with this has nothing to do with medicine (nor with art or science for that matter) but rather with the public's perception of these things. The word 'science' evokes--in most people I think--accurate, precise, and reproducible results. But science is nothing more than approximations and arbitrary constants, especially in the practical application of physics, chemistry, and biology. Engineers have to compromise and allow for some inaccuracy and imprecision in their end design ('tolerances') because they have to live in the real world where mathematics has to be a little looser than it is in the classroom.

At its heart, science is built on hypothesis-testing. Who comes up with hypotheses? People. Observant, curious, creative, artistic people. If hypotheses could be generated based on precise formulae then we could just build a science machine and let it figure out the secret to life, the universe, and everything for us. We know how that would turn out.

Science, like art, requires creativity (neither science nor art are sui generis things). I'm not going to pretend that I can define art, but maybe besides creativity it might include some element of perception by an observant person. At its simplest, then, art is a creative person's response to an observation synthesized into some form (canvas, performance, sculpture, music, prose, poetry, speech, hypothesis--whatever). Science is the same thing I think. Isaac Newton observes that an apple falls from a tree. It's fair to say that millions of people have seen this happen before him but he is curious--inspired--enough to design unique and creative experiments to calculate the rate at which it falls. He is finally able to synthesize his data and determine the gravitational constant (which is an estimate). Newton's laws are works of art. Da Vinci's sketches are science.

The doctor is a scientist, but the scientist is an artist and the artist is a curious human. The uncurious doctor is a mediocre one because he is just a human who is happy with what he knows and doesn’t care about what he doesn’t.

Quiet hour

Mr. Peterson has a pulmonary embolism--a clot in one of the blood vessels going from his heart to his lungs that threatens to keep his blood from picking up oxygen. It most likely came from somewhere lower down in his body, sliding up his vena cava and into the right side of his heart. While there isn't much that we can do about it now, we need to prevent the clot from getting bigger and new clots from getting started in the first place--he needs heparin. Because everyone responds a little differently to heparin, we have to make sure that his blood gets tested every few hours (around the clock) and adjust his dose until he is in the therapeutic range.

I am the 'night float' intern; I take care of patients like Mr. Peterson (which is, of course, not his real name) overnight while the three day teams get whatever sleep they can. It's quieter at night, and with only the occasional beeping of infusion pumps, telemetry monitors, and pulse oximeters all just out-of-sync, I'd even say it's soothing. So far I've been too terrified of something going wrong in the hospital to go to sleep, but I've become used to sleeping during the day. Not so for my patients.

I should say that I've never spent a solid amount of time in the hospital at night before this, my first month of internship. As such, I'd never really thought about how care continues through the night. I never considered that, when I ordered a test or a medication to be performed or administered 'q6h'--every six hours--patients would at some point have to be awakened from sleep during at least one of those instances. And, of course, worse for q4h orders, and so on. I just never thought about it.

Now, I am sitting in a call room and waiting for 4 am when I am to draw another tube of blood from Mr. Peterson. Just a few hours earlier overnight, I had woken him for the first tube and the result showed that I needed to increase his heparin infusion rate because his blood was still clotting too quickly, which I did. Now, I need to wake him for more blood and I know that if I don't, and his response to the increased heparin dose was not adequate, the complications could be disastrous. His clot could get bigger, or a new one could materialize and shoot up his veins through his heart and into another pulmonary artery. Pulmonary emboli can be fatal.

Often, with busy day teams trying to get through their mounds of work, little thought goes into how much sleep patients might need. I mentioned this in an off-hand comment to a colleague and he said, "Patients are always in bed and have nothing better to do than sleep!" But what about the quality of that sleep, interrupted as it is without fail for this blood pressure or that blood draw, sometimes barely an hour apart and not usually more than four or five? It's not surprising that patients--even the most positive and pleasant ones--quickly tire of being in the hospital. Insomnia and irritability go hand in hand.

Although many researchers have discussed the importance of sleep, including in critically ill patients, none have actually studied the effect of its deprivation on hospitalized patients and hospitals do a poor job of promoting good sleep hygiene. In the hospital where I work, a large academic medical center, there are signs posted at the nurses' stations telling staff and visitors that between 2 am and 3 am our patients are asleep and would appreciate quiet. Nurses, doctors, and phlebotomists walk into patients' rooms at all hours of the night for any number of reasons--urgernt or not--turn on the light, poke around, and sometimes forget to turn the light off or close the door when we leave. Alarms, chatter, and beeps puntuate the dark hum of the hospital at night, and they would certainly keep me awake. Sleep is clearly not a priority here, nor is it at any hospital where I've trained so far. How could it be? This is not a hotel; these people are sick and we are working tirelessly and at the expense of our own sleep hygiene to get them well again.

But sleep does matter. Several pre-clinical and clinical studies have shown us that deprivation of sleep, and particularly REM sleep (thought to be the most 'restful' phase of sleep, and the most fragile), affects all sorts of brain and body systems from memory and mood to the heart and general health. In one study, rats were shown to be more sensitive to pain the less REM sleep they got. In many other studies, shortened sleep cycles have been associated with obesity and diabetes--in humans. In a very recent Chinese study, also in humans, sleep deprivation increased inflammation and blood clotting--both involved in stroke and heart disease. And pulmonary embolism.

So what is the right thing to do? In Mr. Peterson's case the decision is simple: I'm going to wake him up. His life is on the line. But what about Ms. Simmons in room 436 who's getting routine (that is, not urgent) lab tests at 5 am--the time designated for AM blood draws throughout the hospital--despite having been kept awake until after midnight in our busy ER awaiting admission to the ward? No one really stops to think about how little sleep this poor sick woman has had last night and how important it might be to her recovery here. We have far too much else on our minds.

Anyway, it's time to go wake someone up. This time I have the luxury of not agonizing over the decision. It's not always this easy.

Watching the road

Sometimes I think I'm the only person who doesn't know what he wants, which is a silly thing to think. Often, I think that maybe I'm just not picky enough. Less often, I think that I don't think about it enough and so haven't proactively developed a taste for anything. Rarely, I think that I just haven't yet encountered anything resembling something I would want. But I don't really believe that. I've exposed myself to plenty. To plenty in excess of plenty multiplied by wastage of time raised to the power of whatever.

It turns out that I have been thinking and that I know more about what I want than I knew I know now, nearly new as the knowledge is. Call it maturity or inevitability, but maybe the sum of all indifference is truth or even wisdom. Well, I'm eleven years short of forty so let's not get carried away just yet. Instead, let's call it 'about freakin' time.'

Is this about a woman? No, it's about my job. Somehow I've made a decision about which I wasn't aware until I heard myself say it and--oddly--it made so much sense! I talked about what I've been looking for with such confidence and eloquence that the stuttering, indecisive, impassionate person in me put down his spray bottle of bleach, pulled off the rubber gloves, and, for the first time, let some dust settle. I'd been so busy fretting about the order and congruity of everything in my life that I wasn't experiencing my experience, just cataloguing it and shelving it neatly, plenty in excess of plenty multiplied by 29 years. I'm glad that someone was watching the road.