Sitting at my parents’ dining room table, I stared at my closed work laptop.
“Why did you say you’d check in daily on your vacation? This is what it feels like to be a hypocrite… so much for actually taking a vacation,” I said to myself as I regretfully opened up the laptop.
“Vacation” mode
I was back home in Michigan to attend a residency reunion in the form of a residency friend’s wedding, as well as to attend my husband J’s grandfather’s funeral – both back to back over the weekend. As I was trying to cram in all the visits with friends and family, nagging thoughts of my work inbox waiting for me interrupted my efforts to present and mindful in our conversations. It was an obsession that would only be relieved by my compulsion to keep hitting refresh on that damn button of the electronic medical record.
Finally, I was face to face with my work computer and loathing every minute of it.
As I sent in the 24 prescription refills, addressed the 35 labs and answered the 37 phone messages that had accumulated over just one day of not being in the office, my eyes settled on the right breast ultrasound I had ordered on my 18 year old patient K last week before going on vacation.
“She only told me about it this week, but she says it’s actually been there the last 2 months!” Mom declared in her posh English accent as she glared at K.
“Whatever mom.. they always feel lumpy. It’s not a big deal,” K fired back.
I could see the prism in K’s glasses as she and her mom continued their staredown. It brought to mind our first appointment 2 years ago when I read “Duane syndrome” for the first time on her new patient intake form. Flashbacks of me frantically trying to read the Up To Date synopsis prior to walking into the room came back in an instant.
“Well, let’s just take a look, shall we?” I offered, breaking through the angry silence.
As I palpated around, I stumbled over a large lump in the lower inner quadrant of her right breast measuring about 3 cm, totally different compared to the smaller, more typical fibrocysts that young women tend to have.
“K, this does feel a little different and a little bigger than the other lumps. I’m really glad you told your mom. You know, this could be nothing, like a cyst, or it could be something. You don’t have a scary family history of breast cancer, but I think we should at least look at this a little more. It’ll make me feel better, your mom feel better.. and ultimately I think it’ll make you feel better since you did bring it up to your mom, so you were probably a little worried about it, right?”
Now I was looking at the ultrasound results – a solid hypoechoic mass measuring 3.5 cm in diameter. Radiologist’s recommendation: Biopsy.
Cool, cool. Who doesn’t want to be the one who tells an 18 year old they have breast cancer?
Just keep moving…
Upon addressing that, I saw my phone message bubble flag red – an urgent message from my medical assistant regarding Baby W.
“Dr. C calling from peds hospital regarding Baby W. In ICU, had bleeding in the brain. Any questions, can call him at (***) ***-****.”
After re-reading it for the 3rd time to make sure I had read that correctly, my breath caught.
I had just seen Baby W for his 2 month well baby check. His toothless grin complete with the most perfect dimple was the last thing I saw as I walked out of the room. I remembered the same dimpled smile on his mom as she and dad met me for the first time when I rounded on them in the newborn nursery, just hours after W was born. I could faintly hear the almost imperceptible sigh of relief and gratitude when they saw a familiar Filipina face greeting them, though I had no other offerings to remind them of home.
I immediately picked up my phone to call the hospital, then quickly routed to the pediatric intensivist taking care of W.
“Hi Dr. M. I’m sorry to be the one to deliver the bad news but I wanted to keep you in the loop. W has bilateral subdural hematomas and presented with an intractable seizure – he had surgery to evacuate the blood last night. Unfortunately, it’s re-accumulated so he is now back in the OR. Of course, we have everyone involved…”
“Including child protective services?”
“Yes. They may be contacting you.”
“… Thank you. I’ll be on the lookout for the updates.”
I slammed the laptop closed and got up. There were a few more things I could do, but I was just DONE for the day. As I stomped around in frustration, J cautiously asked if everything was ok.
“Well, my 18 year patient maybe has breast cancer and my little 2 month baby is in the ICU from likely child abuse. I’m fine but they’re not. Ughhhhh…. this is what I get for checking in to work on my vacation.”
Would it have been better to have waited until I returned to work to deal with this after my vacation, or was it better to spread out the misery? At least I wasn’t trying to run from room to room whilst dealing with this garbage.
Why do I check in on my vacation days?
Because these are MY patients. That is MY 18 year old, that is MY 2 month old. I will take care of them as if they are my own family, because we should expect no less from our physicians.
And when they suffer, I do too.
Dunbar theorizes we can only have 150 true active connections at any point in our lifetime – the people with whom who you are willing to give your time and resources to have shared experiences as we go through our lives.
I wonder how that translates to people who are intimately involved in other people’s lives – therapists, nurses and doctors. People who take care of multiple members of the same family, such as Family or Med/Peds docs, know these people in such an intimate way that is unknown to even those families’ closest friends. We expose their worst fears, hear their unspoken secrets and guide them through their darkest moments.
What is the emotional cost of taking care of 1800 patients? Even if I truly connected on a personal level with just half of them, that far exceeds the 150 connections I’m supposed to have in my lifetime.
As a primary care doctor, I pride myself on knowing my patients and their families on a much more intimate level than if I were just a random doctor they met in the hospital or at an urgent care center. But, this is at the cost of me being fully present when I am with my actual family and friends.
My social capital has been spread too thinly.
My 150 spots have been taken up by my patients and I’m not sure how to reclaim them. Carrying the load of hundreds upon hundreds of people’s worst days has compounded over the last 7 years and my cup is now full.
I’m realizing in order to save myself from burnout I need to get out of primary care altogether and sever these relationships.
There are only so many non-accidental traumas from families I know and love I can take.
***
Photo taken on the path to Wahclellah Falls, Oregon.
Looking at this from a practical perspective, does your group not have a protocol in place for covering the inboxes of vacationing physicians? In my practice, truly urgent results, phone messages, etc get routed to one of my partners. The rest of it accumulates for me, but I certainly don’t log in until I return home from vacation. My partners do the same.
In my younger days, I DID log in sporadically during vacations, and I found that it would always take me right out of “vacation mode.” It’s hard enough for me to get INTO vacation mode, and these holidays are usually not more than one week long. So spending 1-2 days to get into vacation mode, then getting kicked out for 1/2 a day, then trying to get back in…that is suboptimal.
I know you know this, but the point of taking a vacation is to refresh your spirit. You cannot possibly achieve this without disengaging from your EMR during vacation. As you have seen, it is difficult to be fully present with your family and friends when 1/2 of your brain is still obsessing about work stuff. That’s not fair to them or you.
I’ll say something else, and I mean this in the kindest possible way – you’re not that special, and you’re not irreplaceable. It has taken ME years to internalize this truism. My point is that there are other doctors who can care for your patients while you care for your spirit. And if you quit, your practice will find someone to assume your practice, and five years from now, you’ll be a vague memory for many of the people to whom you give too much now.
You can be a great doctor and a caring doctor, and STILL set boundaries when it comes to your life. The patients with whom you have the most intense connections – the ones you feel most responsible for – are also the ones who will understand that Dr. M has a life and needs to live it. I bet they would rather have a healthy, happy Dr. M working, then a burned-out Dr. M who quits.
HD,
The truly urgent matters do get shunted to the physician on call whenever someone is vacation, so I don’t HAVE to log in on my vacation days. I think I’m just a sadist who really enjoys ruining my vacations… or maybe it’s for some unconscious ulterior motive so I can just have something to write about for the blog. Hmm…
Seriously though, I’m trying to determine whether I’d rather be blissfully unaware of work accumulating for me, then bracing myself for the cluster awaiting for me on my day back OR if I’d rather spread the misery over several days. I’m finding my current strategy of spreading the misery is not working, so I will rethink this social experiment 🙂 I’m really bad at establishing boundaries between work and life, and this is something I need to work on.
I don’t take your words unkindly at all 🙂 It’s reminiscent of Mark Manson, an author everyone should read. You’re right, I am replaceable to my place of work and to my patients – I’m hoping I’m less replaceable to my friends and family, therefore you would think I would cultivate life outside of my job a little more. Easier said than done.
By the way, I emailed you back!
Dr. M, excellent post.
Thank you!
M,
HD makes a very salient point, I think that too often we think of caring for patients only in the here and now, but especially in primary care or any longitudinal care setting, it is supposed to be a long term commitment and that requires emotional energy. I like to think of it like one of those grand dams you have up there in the PNW, you have keep the reservoir reasonably full so that when needed, you have the emotional energy to release into the situations that deserve it (like breast cancer and child abuse), in stead of giving the same level of empathy and involvement to every visit, you have to ration it so that when it you really can make a difference – you have it to give.
I recently had a couple of shifts in hospitals that I don’t enjoy working in as much, and they didn’t go that well for me (frustration and irritation abounded), I reread some of the Miracle of Mindfulness and realized that I was trying to get THROUGH the shifts (see quote on washing dishes), instead of being present in them – so I needed to reorient myself to reality, not the other way around. Unfortunately, medical training systematically destroys the skills mindfulness requires by trying to make us do 8 things at once, and so once we are out of training, we have to completely retrain ourselves. We have to get back to beginners mind (see below quote).
“Of course, walking alone on a country path, it is easier to maintain mindfulness. If there’s a friend by your side, not talking but also watching his breath, then you can continue to maintain mindfulness without difficulty. But if the friend at your side begins to talk, it becomes a little more difficult. If, in your mind, you think, “I wish this fellow would quit talking, so I could concentrate,” you have already lost your mindfulness. But if you think, instead, “If he wishes to talk, I will answer, but I will continue in mindfulness, aware of the fact that we are walking along this path together, aware of what we say, I can continue to watch my breath as well.” If you can give rise to that thought, you will be continuing in mindfulness. It is harder to practice in such situations than when you are alone, but if you continue to practice nonetheless, you will develop the ability to maintain much greater concentration.”
“If while washing dishes, we think only of the cup of tea that awaits us, thus hurrying to get the dishes out of the way as if they were
a nuisance, then we are not “washing the dishes to wash the dishes.” What’s more, we are not alive during the time we are washing the dishes. In fact we are completely incapable of realizing the miracle of life while standing at the sink. If we can’t wash the dishes, the chances are we won’t be able to drink our tea either. While drinking the cup of tea, we will only be thinking of other things, barely aware of the cup in our hands. Thus we are sucked away into the future -and we are incapable of actually living one minute of life.”
Quoting: Thich Nhat Hanh, The Miracle of Mindfulness
Such good quotes – thank you for sharing! I really need to read more Thich Nhat Hanh. Actually, I really need to read through the books you had recommended previously!
I agree, it’s really easy for us/me to get sucked into worry or frustration throughout my day. I touch on that in this week’s blog post. But I do find when I actually am able to be fully present in each interaction, it make a huge difference. Unfortunately, I haven’t been able to find the balance between charting and being present at the same time, but that’s another story for another day.
I’ve found I’m pretty good at restocking my reservoir, surprisingly. My issue is the rationing. I’m kind of an all or none kind of person. I suspect most of us are 🙂
M,
The breast mass is almost certainly a fibroadenoma.
VBMD
Yes, looking at it now (and also knowing the path report), of course it was a fibroadenoma. I think it speaks to my state of mind at that time – I was so ready to jump to the worst case scenario immediately. I wonder if other people who are burned out experience that as well.