Since being out of residency for the last 3 years, I have marveled at how much my training didn’t prepare me for the real world. Most of my medical training was hospital based – I know how to manage someone’s high potassium levels so their heart doesn’t stop, how to stabilize someone’s ulcer from bleeding them dry and how to adjust insulin levels on a sliding scale.
In the clinic setting, these are not my primary concerns. I have had to learn how to distinguish what is truly pathologic and what is just the worried-well. I navigate people’s unspoken concerns and expectations daily like a tarot card reader. This skill is more important to me now than remembering that calcium gluconate, albuterol, insulin and dextrose rapidly drops high potassium levels.
The biggest lesson of all is this:
The reason people give for their appointments to my scheduling staff is almost never the real reason why they came.
Last Thursday, L’s name popped up in my schedule unexpectedly.
Chief complaint: Chest pain
Chest pain??
She was my age – a young woman in her 30s, a whole food nutrition fanatic, athletic, smart and intentional with every word she spoke. Pretty much everything I aspire to be packaged neatly into her statuesque, well-manicured frame.
The perfect patient.
Clearly she was not the typical person to have chest pain from heart disease. My mind went through the “differential” – all the possible causes of chest pain in a patient like her: pneumonia, costochondritis where the connection of the ribs and cartilage is inflamed, reflux or anxiety.
But what would she have to be anxious about?  She lived a perfect life – in fact, she and her husband just bought the house of their dreams at her last physical. I smiled at the memory of her excitement to make it their own.
As I stood outside her exam room door and glanced at her vitals, I was surprised to see her blood pressure slightly elevated – not to crisis levels, but definitely higher than her baseline.
“Interesting,” I thought to myself. Quickly my differential changed. “Maybe it is heart related chest pain.. or maybe renovascular hypertension? Glomerulonephritis? Lupus? Everything is lupus.”
I was about to inject some excitement into my otherwise dull day of strep throats and colds.
I stepped in to the room and locked eyes with a woman I almost didn’t recognize. Her whole demeanor had changed – what was once a confident woman had been replaced by someone who had shrunken into herself. Neck and shoulders hunched over to conceal a face that had clearly been crying for days. Her attempts at hiding the dark circles under layers of makeup just highlighted her transformation.
But it was her eyes that were the most striking – they had been stripped of the joy she usually had in spades. They were just… empty.
“Hey! What’s going on?” I asked.
“Hi, Dr. M. I’m sorry to come in for something that probably isn’t going to be anything…”
“No need to say sorry. What can I help you with today?”
“Well, I’ve been checking my blood pressures, and they have been super high. Like 150s for the top number, and I read online that it should be closer to 120. But, I’ve been tracking it and if I’ve been good about yoga and meditating, it seems to come back down to normal.”
“What’s happening when it’s up in the 150s?”
“Well.. that’s when I get the chest pain. So I figured that’s a good time to check.”
“Are you moving around when you experience chest pain? Or is it when you’re sitting or laying down?”
“Usually when I’m sitting down and not really doing anything. It’s really quick, just maybe 30 seconds, but then I’m able to breathe through it and it goes away.”
My dream of diagnosing a new case of lupus was quickly fading away. Sounded like another case of anxiety and panic attacks. I quickly ran through my laundry list of red flags – shortness of breath with activity, irregular heart rhythms, leg swelling, etc. – all resounding no’s.
Finally I decided to just bite the bullet.
“What’s wrong, L? You’re not yourself today. What’s really going on?”
Tears and mascara started cascading down her face as the words tumbled out.
“Last week, before my husband was re-deployed … he just came at me. And he wouldn’t stop. He just kept pushing, grabbing, pushing and grabbing and shoving his hands down my pants and I tried to say no and told him to stop but he wouldn’t listen! Finally I was able to get away and he snapped out of it. But then he turned around and blamed me.
Of course it’s my fault! It’s always my fault.
And I’ve been putting up with this for so long. I’m just tired. I’m tired of this. So I’m leaving him. And every time I think about it, I have this chest pain. Because how am I going to do this on my own?
I’ve hidden all the guns and unloaded them just in case. I opened my own bank accounts and have been slowly putting money in there so he doesn’t notice. But he’s coming back in 3 months.
I thought I was stronger than this… I don’t understand how I could let this happen to me. But somehow I let him cut me off from all my friends and family. I have no one to turn to.
Just you and my counselor.”
It all seemed simple back in medical school.
X + Y = Z.  All the possible answers were available in multiple choice: A, B, C, D or E.
But I wasn’t warned of these times – the space between the question set up and the answer.
Clearly L needed to continue going to counseling. She needed some legal advice. She needed other assurances of safety like the YWCA women’s shelter.
These were the 3 options I could offer her.
But what was the right thing to say in this very moment?
What could I possibly say to her that could provide healing?
The right answer on paper is to send her back to her counselor. But unlike the standardized exam setting, I can’t just select option (C) and be on my merry way to the next patient.
I was trained to think of the differential – the possibilities of potential diagnoses and the next steps thereafter. In contrast, I had almost zero training in how to handle these moments other than a simulated patient encounter on how to break bad news in a zero stakes scenario.
Keeper of stories
During my short medical career, I have collected thousands of patients’ stories, most of them tragic and horrific – this is what I signed up for, after all. To be part of someone’s worst day, potentially every day of my working life.
Most people can’t handle hearing about awful things within their own inner circles. However, over tens of thousands of times in our working lifetimes, doctors find themselves in their patients’ inner circles.
We are allowed to hear and see what most people hide. We carry their stories with us, the good but mostly the bad. We are the keepers of their worst fears.
Nobody tells you how to carry the weight of these moments.
Nobody tells you how to steel yourself.
How to prevent their trauma from becoming your trauma.
It is a privilege.
It is a burden.
It is wearing me down.
After I gave her the county’s domestic violence resources and the contact information of the local YWCA, L said to me,
“I don’t know what I was expecting, but I knew I’d feel better after talking to you. Thank you for reassuring me it wasn’t my heart.”
“L… just because your chest pain isn’t from heart disease, doesn’t mean your heart isn’t breaking.”
****
If you’re dealing with domestic violence concerns, whether they be physical or emotional, please know there are resources out there to help you. Please to go to The Domestic Violence National Hotline or call 1-800-799-SAFE. You can also go to your local YWCA chapter for help.
Photo of South Falls, Trail of Ten Falls at Silver Falls State Park, OR.
Thank you for your care and concern for L. Thanks for having built that relationship with her that she could be authentic with you.
And I thought about you on your holidays. how di you manage the holiday- and the call to keep abreast of work duties?
I just found this comment in the spam section – so sorry!
My holidays were wonderful – in fact, I was able to sneak in two holidays since you posted this comment! Lots of time with my sister as I had a sister trip to explore San Diego, California and then this last weekend I was able to participate in my sister’s wedding which was amazing!
It was easier to let go of work the second go around – I mean, there will always be work, but she will only get married once! Pretty confident in that statement 🙂
This is the albatross we are “privileged” to carry as physicians, but most particularly in primary care. It is a privilege, but also this great burden, and it needs to be unpacked sometimes, and it can’t be unpacked in 15 minute visits 25 times a day, 5 days a week. It is too much for any reasonably emotionally intelligent person to carry. I did a lot of reading on this subject in residency because the psychological trauma that we were exposed to in our primary care clinics (many people with severe severe persistent mental illness complicated by heroin/meth addiction and life on the street) was immense and no one seemed equipped or focused on teaching us how to deal with these problems. Vicarious trauma is a real thing, btw, even if doctors don’t want to admit it as it regards themselves. Ex: current physician suicide rates.
In residency, I started reading ethnographies of medical culture, because at some point you are so deep in the culture of medical training you have to read it described from the outside to remember what the culture of the average American is like. I highly recommend “The Illness Narratives,” (https://www.goodreads.com/book/show/312248.The_Illness_Narratives). More than anything this book changed how I practice in my clinic setting. As someone who appreciates a good story, you might also want to look into Narrative Medicine (Rita Charon at NYU is sort of the founder of the discipline).
I think in some ways we are victims of our own success at convincing people how important and powerful we (the medical profession) are and now are being asked to deal with problems that are inherently non-medical (though they absolutely have bearing on the medical problems we treat). In “Medicine, rationality, and experience” the author discusses how all human cultures have a need to address suffering, the purpose thereof, and its relationship to salvation. In our current culture the author observes that, “In a civilization deeply committed to biological individualism, one in which the spirit is ever more a residual category, the maintenance of human life and the reduction of physical suffering have become paramount. Heath replaces salvation.” Ex: current opiate and benzodiazepine epidemic.
When were trained to deal with that shit?
The answer is we were never trained to deal with that shit, and no one ever told us the trauma it would leave on our psyche and souls.
I think a lot of us were attracted by the fact that we could “help” people, then we entered into a profession that asks us to keep giving and giving more of ourselves at the expense of our mental health. On the flip side, when you run from room to room in primary care and don’t feel like you can adequately address someone’s suffering, that’s almost worse than giving too much of yourself.
Talk about being between a rock and a hard place! This is definitely not the kind of medicine I envisioned myself practicing. And, you’re right, sometimes you get so entrenched in the culture you can’t see the filth you’re standing in until you force yourself to look at it from a different angle. I am fortunate to have a husband who is non-medical and keeps things in perspective for me. He’s actually been encouraging me to find something else for a while as I’m more miserable now than I was in residency.
At any rate, you’ve given me another excellent book recommendation! It seems like something that should be mandatory reading for those in training, probably more than those resiliency lectures I was subjected to 🙂 Thanks so much for your thoughtful comment!
Oh man, don’t get me started on resiliency lectures. They are masterpieces in victim blaming. “What can YOU do to be more resilient?” Never mind that the system is holding you hostage with debt and slowly turns the dream of your lifetime into a prison and expects you to make it a profit for them. Resiliency is your problem, not the system’s. Sounds a lot like those old PSAs about what WOMEN need to do to protect THEMSELVES from sexual assault, instead of addressing the system that breeds the problem.
Every resiliency lecture I have been to is basically a laundry list of extra shit you should add into your day to try and make you more resilient (leave it to doctors to think the solution to every problem is to do MORE). Again, ignoring the underlying issue, which is that maybe you are being asked by the system to do too much and that saying NO and having boundaries might actually be answer. But the system doesn’t want anyone to hear that, because then it would make less money.
I too was more miserable in my first practice than I was in residency. Sure, I was tired in residency and wanted to work less, but felt like I was doing something meaningful and had a great community to lean on. “Real life” was very different. As far as doing something different, I now do contract work with a group called Docs Who Care in fly-over country. Work as much or as little as you want, paid by the hour – but you have to travel. In communities that really need you and are largely appreciative for your presence. It isn’t perfect, but it is a nice way to still get paid while reassessing what you want to do. They mentioned possibly starting to do some work in WA, but I don’t know if they have any options there currently. I also looked into doing hospitalist work with this group: http://ruralphysiciansgroup.com/locations/ Longer shifts – 5-7 days away at a time, but still total control over your work schedule and good work-life balance.
Just found this comment in my spam filter! Sorry for the delayed reply. I will definitely have to look into those two groups.
I’m finally ready to jump ship from my clinic, but since I’m such a planner and really risk averse I’ve been spending a lot of time exploring every possible option, even to the point of looking into doing locums in New Zealand! It’s a little fantastical thinking but at least I convinced my husband to look into going there for our 15 year anniversary next year!
As for your comments about resiliency, I’m with you 100%. People who see and hear what we expose ourselves to on a daily basis are quick to identify the stench of corporate bullshit when we’re accused of not being resilient enough. But, we don’t do enough to push back, myself included. I mean… I am blogging anonymously, after all. It’s one thing to complain without any fear of retribution; it’s totally another to say it when there’s risk of repercussions.
I have reached my edge though, especially last week after I heard through the grapevine that my office manager was making comments about how Dr. M doesn’t “want to work, like every other millennial.” I may just kamikaze that shit and take the clinic down with me – there’s no non-compete clause in my contract and I know for a fact if I leave, the clinic will be in dire straits financially.
Again, fantastical thinking but sometimes it’s nice to get lost in dreams.