I usually don't cross-post from my personal blog, but this recent piece seems to have really resonated with fellow residents and physicians in general. People have approached me in the hospital to talk about it, and as a result, I have had a lot of honest, wonderful conversations with my colleagues -- about their love for medicine and for their patients, about the traumas of training, and about the systemic problems that make their jobs less satisfying than they had hoped they would be. These conversations have reconnected me with my own deep motivation to serve patients and have inspired me to fight for a better system. I look forward to hearing from fellow MiMs about your experiences and hopes and ideas for how to better heal our patients and protect ourselves from burnout.
* * * * *
I am on retreat with my residency class. We are in an otherwise empty
hotel on the Jersey Shore whose just-an-average-hotel-ness is
intensified by the lonely quiet of the off season. I can imagine the
bustle of summer filling up the space -- trails of sand from little feet
tracked in from the beach, brightly colored umbrellas stacked up on the
deck, all the various sounds that people can make from within hotel
rooms -- but in the emptiness of winter the rooms seem tired. Why are
hotels decorated in brown and beige? Are there people who are offended
by color? Or is it just to mask wear and dust and dirt? Is the bored eye
less likely to see?
There are few opportunities in my life to
sleep in but today I could have slept until 8:30am, which as all parents
of toddlers can attest, is the new noon. I went to bed early last
night, in fact, because I wanted to experience the sensation of
restedness this morning, the feeling of waking up out of readiness
instead of necessity. But because the universe has both good wisdom and a
good sense of humor, my eyes opened at 5:45am -- the very time that my
alarm will ring tomorrow morning -- and I couldn't go back to sleep. At
first I was filled with a familiar sense of cynical irritation, the "why
me" and "well isn't that always the way" that residency has brought to
my life despite the comforts and advantages that I enjoy. But then I
thought to myself, how often do I get a chance to walk on the beach as
the sun rises? According to weather.com the sun would be rising at
7:01AM. I put on several layers and slipped out of my shared room,
through the muzak in the lobby, and out towards the ocean.
There
was no one else in sight. I walked toward the ribbon of pink spreading
up from the horizon. The hard, frozen sand up near the beach grasses
gave way to the satisfying sink of each step into the wet shore. Several
gulls circled and dipped. I looked for shells to bring home to E -- not
too small, not too sharp -- and came across some of the odd hints that
the ocean delivers up to us about itself. Cracked orange crab shells and
dismembered legs half buried in the sand. Plant fronds of various
colors and textures and widths. A foot-long brown spear that widened up
to what looked like the end of a bone with some white and yellow flesh
still attached -- tooth? spine? tail? Breaking the smooth contour of the
shoreline, a sudden small pile of sea sponge. I walked for an unknown
distance. The sky became lighter and lighter beneath and around the
layers of cloud. I wondered to myself when the sun would rise and what
would mark the sun's rising. I looked at my watch and it was 7:13,
already past the appointed time. The part of my legs between the top of
my boots and the bottom of my coat began to tingle and sting with cold
and I turned to walk back to the hotel as the daylight continued to
bleed into being around the edges of the sky.
* * * * *
How
should I say this? I am worried about the state of health care. I am
worried about the state of my own heart. I am worried about the way
doctors are trained. I am worried about the way health is defined. I
have been in and around hospitals for almost a decade at this point and I
feel like I know less and less about how to help people achieve
well-being. I feel like I'm getting better and better at keeping people
alive and less and less good at helping them live well. I am maybe a
little depressed or to use the somewhat more socially acceptable term,
burned out.
I
went into medicine with a desire to be with people in life's most
terrifying and difficult and potentially ecstatic moments. I wanted to
understand the body, to understand more about life and illness and
death. It's a cliche but a deeply felt one: I wanted to be of service. I
also wanted financial stability and the ability to provide for my
children. I wanted a job that would be meaningful even on the worst
days. But mainly I wanted to form deeply satisfying therapeutic
relationships -- it's what I wrote my residency application essay about
and it is still what I aspire to accomplish, somehow.
Now, almost
ten years later, I spend more than 90% of my day in front of a computer.
Sometimes the computer is actually physically located in between me and
my patients and I have to crane my neck around its unsleeping eye to
see them. I type through the majority of my clinical encounters. During a
typical day on the wards, I see my patients for -- at most -- 5-10
minutes per day each. My day is filled with entering and reentering
orders on the computer, writing endless admission notes and progress
notes which recapitulate information that is already recorded elsewhere
in the medical record, waiting on hold to talk to primary care doctors'
answering services, calling pharmacies and insurance companies for prior
authorization, calling subspecialists to address each of the body's
organ systems, and coordinating the complex behemoth of a large tertiary
care center to get tests and studies done for my patients. I work up to
28 (actually more like 30 but shhhh don't tell) hours in a row every
fourth night which wouldn't bother me except that of those hours I spend
at most 2-3 in total with patients. Patients turn over so quickly in
the hospital that I might be responsible for the care of over 100
patients during a given week. During clinic hours I am perpetually beset
with anxiety at how far behind I am, unable to get through a well child
visit meaningfully in the 20 minute time frame allotted for this
purpose and because of the fragmentary nature of residency scheduling, I
often do not see these patients again. I want to form relationships
with my patients, but at times it feels like talking to patients just
takes time away from the tasks that need to be done for them. It's
crazy, but it's true.
Some of these issues are unique to
residency, which is time-limited (though formative), but surveys of
post-residency physicians suggest that as a group, we are in trouble. In
a much quoted and discussed survey of 24,000 physicians by Medscape in
2013, only 54% reported that they would choose medicine if they had it
to do over again. Fourty-nine percent of physicians surveyed reported at
least one symptom of burnout and 40% reported that they were burned
out.
On the receiving end of medical care both as a patient and as
a loved one advocating for sick family members, I know what it's like
to receive care from a system of overwhelmed and/or burned out
providers. Test results are not communicated. Small details are missed.
You wait 7 hours to speak with the doctor, then that person does not
know some of the basic details of your case. The care you receive
addresses a symptom or a part of the problem, but rarely the whole
problem, and rarer still, you as a whole person. I fear being that kind
of provider yet I have been that kind of provider despite my fervent
desire to avoid it. There are just too many patients, too many data
points, too many notes to read and write. There is so little time for
relationships to form. There is no magic there.
Doctors are a hard
group to sympathize with. Once we finish training (it's long, but let's
face it, life is longer) most of us land in the top 10% if not the top
5% or 1%. Training is hard and the hours are long but we choose this
life with full knowledge (as much as you can have full knowledge) of
what we are getting into. We hold a lot of societal and political power
and on an individual level, in hundreds of thousands of exam rooms
across the world, we have the power to examine, to question, to
diagnose, to prescribe, to get it right and heal or get it wrong and
harm. But if we as a society want to get the kind of health care that
not only cures but heals, we are going to have to look at how doctors
feel, how they are trained, how their work-life is organized, what we
ask of them, and how we support them in their work.
* * * * *
If
you work around sick children long enough, there will be a death that
crushes you, that doesn't let go, that you can't let go of. Little O
came into my care last month and a few hours later passed away under the
most difficult of circumstances. Oddly enough, I don't remember her
name -- perhaps because the intensity of our efforts to keep her alive
and the adrenaline coursing through my body erased it from my data
banks, perhaps because I have been afraid to reopen her chart. I think
of her as little O, the little O of her mouth, the round moon of her
little face which I saw for weeks every time I closed my eyes. If I will
it, I can hear her mother's screams in my mind's ear as vivid as the
sounds of my household humming around me as I write: "No es justo! No es
justo!"
I
want to make contact with her family, to tell them that I feel for
them, that I think of her, that even though our lives touched for only a
few short hours, I feel the weight of their loss. I have never done
such a thing before and I'm not sure if it is even appropriate. Who
should I ask? Do I need to get permission from my program director? Do I
need to run it by risk management? In the end, the question comes down
to one of the nature of my relationship to that baby and her family. Was
there one? And if so, what was it? I have been training for many years
but have received no apprenticeship in this most important aspect of my
profession.
So
many hundreds of children pass through my life and I through theirs and
we are like ghosts to each other. There are so many layers between me
and my patients, layers of bureaucracy, legality, scheduling,
vulnerability and power traded back and forth in a complicated dance.
Was this always so? Sometimes I fantasize about becoming a small-town
doctor, about being part of the community I serve, of knowing my
patients and allowing them to know me.
I
will likely never send a card or see little O's family again, but this
is what I would want to tell them: I will hold your daughter in my heart
forever.
* * * * *
Meanwhile,
back at retreat, I am surrounded by the loveliest people. My
co-residents are intelligent, accomplished, funny, and kind. To a person
they are motivated by the desire to be of service. They are scientists
and humanitarians who hold as sacred the trust placed in them by
children and their families. They are also spouses and parents and
children and friends who struggle to balance the commitments they have
made in so many domains in their lives. I feel lucky to know them and I
think children are lucky to have them as their doctors.
What
I wish for them and for myself as doctors, what I wish for myself as a
patient, for my patients, and for my loved ones who are someone else's
patients, is a system that allows us to be healers, that helps us to
heal. I want a system that allows me to express my compassion, that
gives me the space and time to care for people in a meaningful way.
Unrealistic? Selfish? Possible? I hope to find out.
