After my work related lunchtime rant last Friday, I arrived home and made a beeline for my fridge. Waiting for me were delicious Kona Koko Brown Ales, ready to embrace me with open arms. As I popped open the top and took a sip, I pushed away intrusive thoughts,
“You know, doctors have high rates of alcoholism. You don’t want to start a pattern.”
“Think of the calories!! You were doing so well with your salad lunches!”
My husband J looked cautiously at me as I proceeded to plop on the couch with my beer in hand, all while forcing the dogs to cuddle with me.
“… So you had a good day, huh?”
After 8 years of dealing with my ups and downs through med school and residency training, he knows the tell-tale signs.
After 2 and a half beers in, I promptly passed out at 9:30. Drinking in your 30s is way different than drinking in your 20s.
The next morning I woke up grateful that my aged body had taken over and blocked me at the pass. Drinking my frustrations away and dealing with the resulting hangover would steal precious weekend time from me. This was not the way.
Time to re-equilibrate
Over the weekend, I jammed in a flurry of activities – a 21 mile bike ride, multiple dinner dates with friends, dog walks with Mt. Hood and Mt. Saint Helens scenic views, yoga – and yet, I still couldn’t stop myself from continuing the rant into Sunday.
As I was recounting my frustrations, J said to me,
“Have you thought of just not caring that much? Your patients come to you for medical advice, so you should give it to them. But if they don’t take it, it’s not on you. Maybe you shouldn’t care as much.”
I pooh-poohed away the notion quickly – that’s not why I became a doctor. I care, end of story.
But, later that day as I was painting my nails an unnatural color of blue in another attempt at self-care found by reading some fluff article online, I couldn’t get our conversation out of my head. Did he mean it facetiously? For those that know J, it’s known that’s kind of his thing. Or was he saying it because he’s the one that directly suffers when I am experiencing compassion fatigue – I have nothing left for him at the end of my day.
What if I didn’t care as much?
What if I started treating my job as a doctor as more of a consulting profession as J had suggested? People come to me for medical advice, and I give it – end of interaction.
No more motivational interviewing. No more searching for people’s reasons for wanting to change. No more getting them to buy into what I’m selling – my vision of what their healthy life should look like.
Truth be told, isn’t it arrogant of me to think I can change someone’s lifelong habits in 20-30 minutes?
It’s not like people don’t know smoking is bad for them – they don’t need me to tell them this. It’s not like people don’t know that over-eating leads to diabetes, high blood pressure and high heart disease. They also don’t need me to tell them their BMI is approaching obesity levels.
Conversely, people don’t need me to stop smoking. They don’t need me to start dieting or exercising. Weight watchers is way more cost-effective and has better outcomes long term than several office visits with me to help manage their cholesterol and blood pressure medications. Walking outside is free.
No, by the time people come to me in the clinic, they’ve already made their choice, intentionally or unintentionally – they don’t want to make any lifestyle changes. Sure, they’ll pay lip service to me and say they do, but really, deep down they want me to give them a pill so they can carry on with their lives without any inconvenience to them.
If people wanted to change, TRULY change, they’d make it happen – with or without my input.
If I could accept this, I would no longer feel like I’m banging my head against a wall. I wouldn’t be personally upset when I spend the extra time to talk about diet and exercise for an additional 15 minutes, making me late for the rest of my day, just to have them return on the next visit having gained an additional 10 pounds.
“I don’t know how that happened, doc!”, they say.
Yes, yes you do.
And I do as well – I failed to understand that I can’t be your sole source of motivation. In order for people to change, they need to want to change. And I can’t instill this in people.
That’s not my job.
My job is to diagnose and treat disease.
G came to me last week for a follow up visit for his diabetes, high blood pressure, high cholesterol and chronic pain – all things perpetuated by his BMI of 50. A month prior, he had begged me to put him on phentermine, a weight loss medication that works to help suppress appetite. He was gaining 5 lbs a month and if he continued on this trajectory, he would be unable to work or even walk in a year. Despite my misgivings since phentermine could worsen his blood pressures, I gave in but told him this was just a tool to help with weight loss – he would have to do the heavy lifting with a plant based, low carb diet and walking.
Just before walking into the exam room, I peeked at his vitals and saw it again – a 5 lbs weight gain, not loss. I shook my head and opened the door.
“Before you say anything, I know I gained weight. The pill you’re giving me isn’t working! I told you you shouldn’t have started with the lowest dose first. We need to go up.”
“I’m not comfortable doing that – your blood pressure is higher than I would like it to be, and I think it’s due to the phentermine. Tell me what other things you did to help with the weight – what did you do for your diet and walking?”
“… I didn’t really change anything. It’s too difficult – I don’t cook so I have to order in or do take out, and I work a lot so I don’t have time for exercise. This pill was supposed to work!”
“You know, there are a lot of resources to help you learn how to cook online. And they have frozen veggies you can just heat up…”
“I don’t like veggies. Anyway, there’s something I need you to do for me,” G said as he handed over a packet. “I need you to fill this paperwork out so I can sit down for work. It hurts my knees too much to stand all day. And you don’t need to say it again, for every extra pound I gain, I know it puts on 4 pounds of additional stress on my knees.”
“You’re putting on an additional 20 pounds of stress on those knees a month, 100 pounds every 5 months. Isn’t that reason enough right there to eat those veggies?”
“I just don’t like them.”
As I finished out the paperwork begrudgingly and handed it to G, he said,
“Thanks doc! You always take good care of me!”
I wanted to scream,
“I can’t be the only one who takes care of you! Take care of your own self for goodness sake!”
When I went into primary care, I had dreams of being able to prevent disease. I had dreams of doing my part to help this broken, expensive healthcare system – chronic diseases directly attributable to obesity make up 80% of healthcare spending in the US. If I could just catch deadly habits before they caused harm and set people on a better course, I could do so much good, I told myself.
What I didn’t take into account was for this to work, the people I took care of would need to also buy into this dream. Tragically, by the time they come to me and are willing to make changes, it’s already too late. I just diagnosed a young man only 6 years older than me at 38 who was having a heart attack in my office. When he returned to discuss his hospital visit and how to make changes, the damage was already done – his heart function was abysmal and he had a long road to recovery ahead of him.
People don’t see the outcomes to their habits like I do. They understand some concept of a heart attack or stroke, but that’s an abstract notion that will never happen to them. Until it does.
Do I keep banging my head against a wall, trying to convince people of a lifestyle they don’t want to buy into, to prevent a future they’re in denial of happening to them?
Do I continue to emotionally invest in people’s care when they’re not putting in the same effort for their personal selves?
Do I reserve my compassion and care for people I deem “worthy” and high-yield for my efforts, and how do I go about this in a way that’s not detrimental to my psyche and dehumanizing of my patients?
Do I keep trying to combat compassion and empathy fatigue by vainly painting my fingernails and practicing mindfulness to help push out unwanted thoughts, which really are the brutally honest truths I am unwilling to utter?
I don’t know what the answer is.
But right now, what I do know is painted nails are NOT an appropriate form of self-care, for me at least. Too much upkeep.
*Photo taken at Falls Creek Falls, WA.
All that I hear is frustration and pain here. You are such an authentic person who could not care any less than you do. You would probably leave the profession before giving your whole self to the care of others.
Your writing is good to relieve and express the stress and the questions you have. Is there a network of doctors you can share with- a more experienced doctor who can give some input?
Something I noticed in your article- you reached for the same escapism that your patients often go to- just that your medical brain kicks in- your fitness brain kicks in- your patients don’t have that basis of maturity???(not the right word)
Bottom line- I wish you were my doctor. You’re awesome!
Before giving less than your whole self to the care of others. Yes that’s what I mean.
Does that make sense??
Yes, that makes sense, and I think you’re right. I don’t think I can doctor any other way than I’m doing now. I have reached out to other people and have unfortunately found many others in primary care are in the same boat – burned out and fantasizing about quitting medicine. I think the general public should know this but we’re all very hush hush about it.
As for my attempts at escapism – I was grasping for anything at that point, and a chemically induced escape via alcohol seemed the easiest. But, from seeing my patients do that with alcohol or xanax or opiate medications, I just know this not a thing I should be doing. I should be addressing the problems that are causing me to want to escape my life, so writing is therapeutic for me. I do have my lapses though – I am only human! Thanks for reading!
First, thanks for being a doc. It’s hard work and we need you.
I’m an older pt here with a serious heart condition and all that comes with it (genetic, don’t blame me!). I read blogs and twitter and see how miserable my docs are. I cope by asking as few questions as possible, only raising one issue per visit even if it means multiple copays, and I avoid contact through the mychart system. being in the hospital treated by a hospitalist who doesn’t know me is a nightmare; office appts are rushed and just a source of anxiety.
Pts are as unhappy as you are but we don’t have a choice to opt out other than to die early and I’d rather not!! I hope you and your colleagues can carve out some relief. Your pain becomes our pain. We want you to be happy. Strongly suggest that you put in writing a list of suggestions for all pts and explain some of the constraints on you. Help us help you. Making believe it is 50 years ago isn’t working for any of us.
Thank you for your thoughtful comment! I think it’s tragic so many things interfere with the patient-physician relationship, especially in your case. In an ideal world, doctors should be able to answer more than one question during visits, and patients should feel like their concerns are being heard and addressed. We all feel the time constraints of the current system, with our schedules being more and more compressed for the sake of “productivity”.
As for your comment about “opting out early” – once I’m done with all my student loans and other financial obligations, I will eventually come to the point where I could decide to opt out of medicine. Although I often fantasize about it, ultimately I don’t think that’s a decision I will make because I still want to help people, and I have a particular skill set that will allow me to do that.
So, I just need to keep trying to figure out how to make this work for me in the meantime! Thanks again for reading!
I have been feverishly reading through your blog regarding physician burnout. WOW, so very real and true. I know a physician that needs to work part-time yesterday! Primary Care in general today is an absolute nightmare scenario that physicians seem to not be able to get out from under, especially female physicians. Once children come, if they do not have a strong mate to allow them time off to heal or are swamped with debt, soon are in crisis mode where anything and everything bad seems possible.This primary care doctor / mom / single point of failure is absolutely unsustainable. Please share if you have found an alternative to being a full-time female physician.
Is there such a thing as part time primary care work?
Thank you,
D
D,
From my discussions with people who go part time, it never is really “part time”. Sure, you’re not in the office seeing patients, but the paperwork and patient calls are pretty much the same because you get them every day. It builds up and on the days you are back in the office, you get even more slammed with work. But, of course your salary goes down so you’re actually being compensated less for doing that administrative work.
Because of this, I don’t think there really is “part time” primary care work. It is possible in shift work, ie urgent care/hospitalist jobs because once you’re done with your shift, you don’t have to bring that home with you. I think this would be the alternative to being a full time primary care female physician, and one I’m actually strongly considering at this time.
As for your comment about kids, this is one of the reasons I have been very intentional about not having children at this point in my life, especially since I am still paying down my student loans. I can’t imagine returning to work at my current frenetic pace after going on maternity leave – the stress of a decreased paycheck for the 6-8 weeks I would take off would compound the stress of paying off my loans. I am fortunate to have an amazingly supportive husband who would be willing to stay home with kids, but losing his income would be detrimental to our financial goals.
Money aside, I don’t want to even fathom not being emotionally available for my children because I left too much of myself at work. I suppose I could get better at juggling the two, but I’ve seen what happens when you don’t do it well, and it’s just not a situation I want to deal with right now.
I wonder if other people really take a long look at their future life choices in this way… perhaps it would be better if I didn’t overthink everything! But, that wouldn’t make for a good blog post 🙂
Thanks for the comment!
I know a doctor who works part time in primary care. She does some unpaid administrative work on days off but still is at under 40 hours
That sounds fabulous! I think in an ideal world we would all work 30 hours a week, but I just don’t see how the medical system would allow physicians to do that. Just today when I logged in to start my Monday, I had 20+ medication refills, 30+ labs to and 20+ documents to review, all up from 0 when I left at 6:30 pm on Friday. The workload is never ending, and I would feel compelled to log in on my off days to address all of them.
Things keep piling up every day – that is the nature of this beast. Perhaps if I could get over the guilt of making patients wait for me because I need to have this “work/life/balance” thing, it could work…
Half time is about 30-40 hours a week of actual work. It isn’t half time but the money is decent and it is certainly doable. You do have a gift. I read what you say, what you tell the troubled teen, how you anguish over the baby. I would have loved for you to have been my child’s physician through those many hospitalizations. It is hard, really really hard, I still grieve when I see the grandmother of my lost patient in the grocery store. That is part of what we do though. And it does matter. More than you can imagine. The real art of medicine is in the meeting point of the knowledge, the skill and the caring. Thank you. You are good, And it does matter. Keep your faith in yourself. Please
Thank you so, so much for your kind words. After writing this post, I ultimately realized I can’t practice medicine without caring. It would be impossible for me to separate out the two.. either old habits die hard, or it’s just built into my nature. If I’m not doing this for the benefit of others, then what is the point?
I’m not leaving medicine just yet, but I am searching for a way to reshape the way I work so it’s not such a drain to my personal life. Thank you for commenting, again 🙂
Wow. This could have been me (but doing a much poorer job than you are doing).
When I entered medical school, I wanted to do primary care for the same reasons you mention – I wanted to preach lifestyle change, and help patients eat better and exercise, instead of just pushing medications. And then I rotated in family practice with a doctor much like you. Someone who was very good, and compassionate. Someone who preached lifestyle changes in the 15 minutes allotted, and then prescribed medications anyway. And after the encounter, showed me the previous 4 encounters with the lifestyle change sermon and the lack of change.
Eventually you have to treat with medications, because the patient isn’t going to change.
I saw that there was no way I could handle that. So I went into a different specialty that I liked. One where I could sit down with a patient, discuss our plan of care, and then I implement that plan without relying on patient willpower at all (Anesthesia).
If I had gone into primary care, I would have been a terrible doctor, because I know myself, and I wouldn’t be able to care any more after a short period of time of interacting with patient after patient who didn’t care enough about themselves. And I would have hated myself for my ‘shortcoming’.
You are amazing, both in your capacity to care, and the clear-eyed view to see it fading and work to protect yourself and your patients by doing whatever it takes to relieve that burnout. Even if that means cutting back on the number of people you can help.