“I’ll see you in 6 months, ok?” I said as I exited the patient room.
Flashing a smile, I waved goodbye and turned to see my 4 medical assistants huddled around the closest workstation.
All staring at me. Imagery of hunters circling their felled prey before they delivered the final death blow flashed in my mind. Sympathy intermixed with indecision as to when exactly was the right moment to strike.
“What…. ?” I asked, a little disconcerted.
After what felt like an eternity, one of them spoke up.
“C just called to let us know his wife, R, just died from a stroke. He wanted to thank you for everything, but he doesn’t need her appointment now.”
“Oh. Okay.”
Silence punctuated with shocked faces by my curt reply.
“Are you ok, Dr. M?”
Was I OK?
I glanced at my computer screen to look at the schedule – 20 minutes behind. I did a quick mental assessment – did I have time to address whether I was OK or not?
NOPE.
“It’s fine. I’m fine. It was going to happen sooner or later. Can we get the death summary so I can review everything? I didn’t even get the notification that she was in the hospital.”
With that, I ran into the next room.
“Thank you so much for being patient! What can I help with today?”
At the end of my hectic day I finally sat down, eyes settling on R’s admission history & physical and death summary, patiently waiting for me in my document inbox.
It outlined the same things I had listed in my electronic record – an unfortunate woman with a history of myeloproliferative disorder with ensuing bone marrow failure, chronic pain, poorly controlled everything: diabetes, cholesterol and high blood pressure. She was found down in her house with one sided weakness, slurred speech and altered mental status – classic signs of a stroke.
The rest of the death summary read like a familiar novel I had personally written over and over so many times – CT Head showed an ischemic stroke in the middle cerebral artery.
Stroke protocol:
- Allow permissive hypertension, etc, etc.
- Neuro checks every 2 hours
- Check all the labs
- Discuss goals of care
Then the narrative changed – at 2 am, suddenly her heart rate dropped, blood pressure crashed and her breathing slowed. I could feel the blood rush into my face as I pictured the bleeding tide that crashed into her brain as her ischemic stroke converted into a hemorrhagic stroke.
“Husband chose to withdraw care and patient passed peacefully.”
Funny how perspectives change
How perfectly succinct of a death summary. It had all the necessary details without any of the excessive verbiage. It felt like a script I had nearly forgotten after 3 years of being out of residency, but memories of me reciting this half asleep into a 16 hour shift immediately came back to haunt me.
This time felt different as I read it as R’s primary care doctor, the person she had chosen to entrust her healthcare with.
The death summary didn’t include the last 3 years of the back and forth of:
2015
- You need to come in for an appointment. Your last blood pressure was very high and we need to discuss dose changes.
- No show
- I can’t refill your medications unless you come in for your appointment and repeat labs
- Appointment: Please Dr. M, I can’t afford to come in for my appointments or to pay for the labs you want me to do. I promise I’ll do them when I can!
2016
- Your labs showed you now have high cholesterol and your blood pressure is too high! Please come in so we can discuss next steps
- No show
- I can’t refill your medications unless you come in for your appointment and repeat labs
- Appointment: Please Dr. M, I can’t afford to come in for my appointments or to pay for the labs you want me to do. I promise I’ll do them when I can!
2017
- Your labs showed you now have uncontrolled diabetes, your cholesterol is still too high on the meds I put you on and your blood pressure is still too high! Please come in so we can discuss next steps
- No show
- I can’t refill your medications unless you come in for your appointment and repeat labs
- Appointment: Please Dr. M, I can’t afford to come in for my appointments or to pay for the labs you want me to do. I promise I’ll do them when I can!
2018
- Your last labs were done in 2016. This is not optimal care nor is this safe. Please come in to make an appointment.
- No show
A week later, I was reading her death summary.
How did I feel now?
Every lab abnormality felt like a failure.
LDL 153 – You should have just started her on the higher statin dose to begin with.
HbA1c 12 – Why didn’t you just give her instructions to titrate her metformin all the way up instead of fooling yourself into thinking she would come back for a follow up visit when you asked? Actually, you should have put her on multiple oral medications. What were you thinking?
The list went on and on, spiraling out of control until I looked at the time and realized I had been circling the drain, berating myself for an hour and a half.
6:30 pm.
You fail at work, you fail at home. What difference does it make? She’s dead.
I called my husband up, apologizing to him for leaving the office late.
“Everything OK?” he asked.
“I’m fine.”
Not fine
For the next 2 days, I raged.
I was angry at R for seemingly not giving a damn about her own health.
I was furious at the system for making medical care so cost-prohibitive that she probably had to decide between labs/medications/doctor appointments and groceries.
I was irate at myself for not doing more. What if I had just given more medical advice over the phone? What if I had actually refused to refill her meds instead of just throwing out empty threats of refusal? Would that have made her come in sooner?
What if I had begged more insistently that she come in after she no showed her appointment a week prior? Would she still be alive?
“Do you realize how unfair and unreasonable you’re being to yourself right now?”, J asked after 2 days of cajoling me into telling him what was wrong.
“You can’t do this to yourself. You can’t put this much pressure all on you! She made her choices. You can’t fix everything, M.”
Logically, I understand this.
But emotionally, it’s been ingrained in me that if I could just be a better doctor, if I could just connect with people and motivate them in a way that encourages them to take better care of themselves, I can “save” people from fates such as this.
8 years of having this beaten into my head: Just be better.
Might as well tell our young medical students and new doctors,
While you’re throwing out life preservers to everyone else, be sure to tie a cement block around your ankles in a 1:1 ratio.
When you feel like you’re drowning, repeat after me: I’m fine.
“M, I heard about your patient.. I’m so sorry!”, my colleague said to me yesterday.
“Thanks. It’s just frustrating because it could have been prevented. Or maybe not. Who knows,” I replied.
“It gets better, you know. That frustration,” she said.
“Does it? When then, because I’m waiting for that to kick in.”
“Hmm … I guess you just get more numb.”
Perfect. I’ll get workin’ on that.
M I’m so sorry. I know this. I hate this for you. And it would be easier to not blame ourselves for everything if the systems were in place that no patient went without basic care because of financials…..hang in there. And don’t go numb, but don’t beat yourself up either.
Thanks Shannon! It really only lasted for those 2 days, but now I’m over it, for better or for worse. I’m a doctor, not a dictator, and I can’t force people to do what I think they should do… maybe that’s the real issue I’m struggling with 🙂
M, you are a good doctor and an even better person. A great writer and thinker, too. You care…but too much. You need to be kinder to yourself.
Save the caring and emotional energy for your family and for you. Treat your job like, well, a job. Cherish the small victories when you get them, and leave the tragedies for someone else to mull over. Easy to say, but doing these things will make your life and career more satisfying and rewarding.
You are totally right.. I shouldn’t expend all my emotional energy at work. But, I’m having a hard time reconciling the emotional fluff they fed us in pre-med and med school about how this was supposed to be a “calling” and more than a job to where I find myself now.
If I could let that struggle go I would be better for it, but then I get upset when I think of future physicians falling for this bait and switch garbage. I suppose that’s why I’m still writing.
Thank you for still continuing to read and for your kind comments 🙂
Thank you for continuing to share your story. We all struggle when the people we take care of die but we never talk about it. It hurts too much. We are different people from when we started on this journey and seeing the suffering and the death is part of what changes us. Some of us harden or become detached and only refer to a newborn as an “it.” others cope. Some have a harder time.
We need more of this. More conversation about how we have impossible jobs that take too much of us.
I agree – we need to have these conversations out in the open, instead of behind closed doors after a few alcoholic beverages loosen our tongues (which has been my experience, at least). I really couldn’t find that many blogs/social media things that talked about this stuff – everything was too positive! I hate to think of myself as the Debbie Downer in the room, but some things just need to be said. Thanks for the comment!
To piggyback on Vagabond’s comment, you NEED to learn to be kinder to yourself. There are so many emotions, reactions, and hangups wrapped up in the concept of practicing “loving kindness” toward yourself, which makes it difficult for people like us to unpack and internalize it:
You’re too busy to add another thing to your mental checklist. You’re too emotionally drained to add another thing to your mental checklist. You may not have convinced yourself (yet) that you are worthy of your own kindness. You are expending all your kindness on others. It is a (somewhat misguided) badge of honor to care for your patients to the extreme. You’re tired. You’re burned out. You focus on the negatives without celebrating the positives enough.
Listen, I totally get it. I am just a little further along in the journey than you, so take advantage of my perspective, as I’ve already felt everything you feel. At this point, you are in the “dump my raw feelings onto the page” stage. That’s awesome. For every one commenter who commiserates with you, there are probably 20-30 readers who feel the same but just aren’t expressing it. You are giving voice to things many of us go through, and it’s so helpful for others to read it, and for you to know you’re making a difference in other docs’ lives.
The next stage is going to be “ok, I’m ready to figure out how to treat myself better.” This will be a marathon, not a sprint, and you will still beat yourself up sometimes. But it will start to get slowly better. If you don’t listen to Tim Ferriss’ podcast, I recommend listening to the episodes with meditation teachers Sharon Salzberg and Jack Kornfield. Tim is working through his own issues, which are similar to yours, and one of the biggest changes he’s made in his own life has been learning to practice loving kindness toward himself. When you are ready, this can be a game-changer.
I haven’t listened to Tim Ferris’ podcast, but I definitely should start!
A few months ago when I was even worse off than where I am now in terms of my burnout struggle, I started reading Pema Chodron’s books and discovered metta meditation. I admit, I haven’t been as consistent as I should be with practicing that because it was a definite struggle for me. For one, being still is difficult for me as I feel I must always be productive. Secondly, I’m a perfectionist and over-planner, and when things don’t go according to plan, ie my career, it’s hard to accept.
Right now, I’m trying to un-busy my life to allow some space for me to regroup. Hopefully I’ll reach the next stage as you’ve described above! I actually googled “stages of burnout” and it’s all over the map – anywhere from 4 stages to 12. Maybe at the end of this all I’ll come up with my version 🙂
Thank you for your perspective! It is much appreciated.
M, I think that un-busying your life so you can regroup is a great idea. I would note that, once you create breathing room, the path forward becomes clearer. I did not advance much along my own path until I cut back at work.
The trick is going to be maintaining a focus on your personal well-being once things get busy again, which ultimately they probably will. For me, it’s easy to make some time for meditation when I have plenty of time, but when I get busy, it’s one of the first things to fall by the wayside.
When it comes to meditation, I am also just like you. It has taken me a long time, with lots of trial and error, to figure out what seems to work. And I’m still not great at it. But I do it (or try to do it) semi-regularly, because I think it helps. Over time, you will learn that sucking at meditation is part of the process, and you will be able to create some “wins” by learning to bring your attention back to your breath, your mantra, or whatever your focus is. It’s not about sitting still and clearing your mind; rather, it’s about bringing your focus back to the meditation when your mind wanders, which it always does. Heck, you don’t even have to sit still – you can do walking meditations, meditations while running, etc.
If you’re interested, I use a free app called Insight Timer. It has lots of guided meditations, among other types, and it even allows you to filter your choices by how much time you have. I suggest starting with 0-5 minutes, because anyone can meditate for <5 minutes. Starting with a small, achievable goal (<5 minutes 3x/week, for example) helps you create another win for yourself which, for people like us, has the added benefit of making us feel productive!
Hang in there, M. And please keep writing – your blog is awesome.
Thanks HD! Sometimes I hesitate before I publish something because it feels a little like word vomit in written form, and I imagine it can’t be pleasant for anyone reading. Reassurance comes in the form of comments such as yours, as well as the knowledge that I can delete anything whenever I want 🙂
I used Insight Timer for a few weeks until I got overwhelmed by the plethora of options it provided whereas the Calm app was much easier for me to navigate. Now that I’ve gotten more comfortable with meditation, I’ll have to go back and give it another go.
Cutting back and focusing on just one thing at a time needs to be the theme of my life right now – for example, I just realized I currently have 20 tabs open in Chrome! Haha.. minimalism for the win.