“I love my doctor! She’s the best.”
“Aww.. thank you! You’re going to set some unrealistic expectations for him from the get-go… see you next time!”
Turning to A, my new scribe, I pondered out loud after exiting the room,
“I don’t know what it is about having you here, but all of a sudden people are coming out of the woodwork saying nice things. It’s to fill the awkward silence of having someone new in the room, I think.
This is not typical. AT ALL.
You can’t ever let this stuff get to your head, because it just makes the bad days worse.”
Watching A nod his head, probably in an effort to patronize me, I couldn’t silence the inner monologue.
You’re just teaching him foreboding joy*, M. Don’t pass on your maladaptive coping skills way before his time.
I should lean into the joy of hearing that people appreciate what I do for them.
But in my mind, all I hear is Admiral Ackbar,
I can’t take the compliments. Why should I accept these little participation trophies for just doing my job?? If I’m being honest though, it’s probably just another variant of imposter syndrome (s/n: of course, since I’m an overachiever, I’ve dealt with all 5 varieties of imposter syndrome at some point over the course of my life. Go me.)
Whatever it is, it’s a character flaw that probably doomed me to burnout from the very beginning of my career in medicine.
Now it’s compounded exponentially as I try to resist the outstretched hands pulling me back into my primary care career while I seek an escape route into a new job.
Stay strong, M. You already committed to an interview.
Just Keep Swimming
Looking at my schedule, I spied the next chief complaint.
Patient K: Low back pain
Going through K’s chart, I couldn’t place his face or his name. In my last note from the year before, we had talked about his sciatica and increased alcohol intake. Still, nothing rang a bell.
Perturbing.
I pride myself in knowing my patients. I know if they exercise by walking their dogs or if they do Crossfit. I know if they hate veggies. I know if their teens are lying to them (PSA: Assume they’re lying to you at all times).
Upon entering the room, it bothered me I still couldn’t place his face.
“Hi Dr. M! It’s so good to see you! I hate to come in for my sciatica again, but I just can’t seem to get it to calm down with yoga like you told me. By the way, are you still doing Yoga with Adriene? She’s great!”
Oh shit.. he remembers way more about me than I remember about him! And I write notes about our visits!
“Yeah, I’m still doing Yoga with Adriene.. but now I’ve transitioned to the Down Dog app! Tell me about your sciatica.”
“Well, I went to PT which improved things, but now it’s going down my leg again despite the exercises. My mom who’s a doctor told me it’s probably time to get an MRI.”
After doing my exam and hashing out the details, in an awkward moment of silence while I was putting in orders, K addressed A, my scribe.
“So my mom tells me scribes are usually people who want to get into the medical profession! Are you working toward going to med school?”
“Yes, I’m actually applying for next year,” A replied.
“Well… you couldn’t be following a better doctor.”
Uh… what’s this now?
K continued.
“Last year… I had one of the hardest conversations I’ve ever had in my life with Dr. M. I came clean about my drinking and because of what she said… well, it changed my life. If I was coming in with like an anxiety level of 10/10, she brought me down to a 2, instantly. I really liked her approach of the SMART recovery… just her approach in general.”
Turning his gaze toward me, K said,
“You know, I walked out of here with tears in my eyes after that visit. Even though I didn’t believe I could quit drinking, I knew you believed in me. I knew you had my back. You didn’t judge me or try to make me feel bad. You just wanted me to do well.
And… I’ve never looked back since. My life is better, because of you.”
Words of protest died at the tip of my tongue as the guilt came rushing in.
I didn’t remember this conversation happening
I couldn’t even place his face, the one looking so earnestly at me as the angel who saved his life.
That was just a standard Tuesday.
But for him, it was everything.
Blissfully unaware of what was going on in my mind, K returned to A and spit out chokingly with tears in his eyes,
“This doctor… she’s the best. You’re lucky you get to learn from her.”
Make it stop!
The entire following week I was left in a tailspin trying to undo the damage done to my future plans to leave my clinic.
Who else has listened to my monologues about self-care?
What if I haven’t given enough time in primary care to see this through?
What if I just need more time to see the effects of my counsel?
What if looking for a different job was a mistake?
Am I really prepared to walk away from this?
It’s a trap, M.
But what if…
It’s a trap.
___________
*My first time learning of foreboding joy was through binge-watching all of Brene Brown’s TED talks, specifically: The price of invulnerability
If you don’t have time for the full 16 minute video, Brown summarizes in one of her books,
“When something good happens, our immediate thought is that we’d better not let ourselves truly feel it, because if we really love something we could lose it. So we shut down our ability to completely enjoy so that we can also shut down our capacity for feeling loss.
…
In moments of joyfulness, we try to beat vulnerability to the punch.
If you cannot tolerate joy, what you do is you start dress rehearsing tragedy.”
Guilty as charged.
***
Photo taken at the Hoyt Arboretum in Portland, OR. Welcome to Fall.
Like you I am guilty. Guilty of forgetting most of the names and faces of the patients and parents I interact with.
I know I must have an impact on their lives, their kids are in the hospital. Yet once they leave I download the info into the discharge summary and somehow my mind does a mental delete and they are gone.
Sometimes it saddens me, mostly because I don’t have any healthy long term Dr-patient relationships. I enjoyed that part of my residency clinic.
Sometimes it is super weird when I see them on the street near the clinic that my office is across from. I recognize that I should know them but it’s in that deja vu kind of way. Lots of confused looks on my part.
But usually it doesn’t bother me that much. Maybe it is a coping tool, if I’m blissfully unaware of them then nothing bad can happen after they leave right?
P. S. Hold on, there are 5 types of imposter syndrome….
Haha.. yes! 5 types of imposter syndrome.. pick your flavour, or all of them if you’d like. When I first read that Fast Company article, I was a little devastated. I was so sure that wasn’t me, but lo and behold, I was nodding my head to the description of ALL of the types. Fortunately they didn’t all happen at once, but definitely over the course of the last 20+ years.
When I was in residency on my hospital rotations, I also was able to do a memory purge and be totally fine as soon as I walked out of the hospital. The recurring contact in the clinic over time has worn me down. Not only am I taking care of the 18 patients I’m seeing in clinic that day, I’m also responding to phone encounters for things that happened earlier in the week, or reviewing labs that I may have ordered 2 weeks ago that I need to revisit, reading consult notes from specialists that I send referrals in for 2 months ago, etc. I counted up how many patient charts I touched daily, and it went anywhere from 40 to 100 for the week I was tracking.
It’s not just recurring contact in person, it’s also the micro touches in between those appointments that keep me checking in with my patients. It’s nice because I know my patients really well for the most part, but it’s also exhausting.
Definitely wouldn’t be too harsh on yourself, you see 1000s of patients between annual visits it would be hard pressed to put a name to a face from reading from a chart (I always wondered why docs don’t have patients take a small headshot they could then attach to the folder to jog memory better).
As a radiologist I never have this problem btw 🙂
And I think you do need to relish on the positive feedback when it comes your way and take it at face value without thinking of it as a trap. It is these things that will help slow the flames of burnout.
Our EMR takes the headshot from the patient’s driver’s license and attaches it to the chart. Now whether that picture actually looks like them is a different story 🙂
My struggle with this patient was that we clearly had a very impactful conversation that I just could not recall. If it were simply a sinus infection I had seen him for last time, that wouldn’t have bothered me at all. Plus, I’m that awkward person that remembers faces and small details that always makes other people feel uncomfortable when I recognize them but they can’t reciprocate. My memory failed me on this one.
As for the positive feedback… I think I’ve just been burned by too many people who probably had borderline personalities. They love you when they love you, then turn on you when things are no longer going their way. I definitely do need to reset that thinking, but it’s so hard.
The VagabondMD second rule of Interventional Radiology (and everything else) states the following:
“Things are almost never as good or as bad as they seem.”
Ultimately, this draws from common sense and the innate radiologist ability to hedge, in this case hedging one’s emotions. I am not sure why this is my weekly comment on your blog, but for some reason it seemed to fit.
Until next time!
Haha.. I think your comment was quite apt! I try to live my life in the middle by hedging emotion as you put it, but am finding while it limits experiencing the bad emotions, it also stunts joy.
I can’t stop talking about Brene Brown, but she puts it as “living a disappointed life” as a form of ineffective personal protection.
Anyway, I would love for you to find a way to work in “Recommend clinical correlation” in future comments. That would just make my day 🙂
M,
You write very well. In my 32nd, and hopefully, last year of primary care, I’m in a wholly different position then you are. There is no question that the practice of medicine has undergone huge changes during my career, most to the detriment of providers. Enemy #1 is the EMR followed closely by the “patient portal”. I can totally empathize with younger physicians and what the are facing, particularly in primary care. Increasingly, I see younger colleagues planning for the earliest possible exit.
The one thing in medicine that does get better with time is expertise and confidence. This makes practice less demanding mentally as I worry less and rarely second guess myself. I’ve become much more adept at reading patients and can easily say “No” when necessary. Unfortunately this takes a long time in primary care – more so than with sub-specialties, IMO. Good luck with your career decision.
Thank you for your kind words, Topdown.
Even with just a little over 3 years under my belt, year 3 was infinitely easier than my first year out in practice. I don’t know if I have an additional 30 years in me to see just how much easier it gets though 🙂 Much like your younger colleagues, I am planning an early exit and will hopefully be done by the time I’m 45, just 15 years out of residency.
As for saying “no”, I actually found this accelerated my burnout. Just today, I said no to filling out a PA for a medication that wasn’t needed and would cost the patient $14 if she paid out of pocket. What ensued was a 2 hour kerfuffle with an irate patient that ended up getting escalated to my office manager and me being forced to do it.
The expectations and demands placed on primary care are bordering on outrageous, and I won’t be around to wait to see how far things will go before the pendulum swings.
M,
I think too often we refer to the “art” of medicine being the hand holding, the compassionate words, the displays of empathy. Those are all important. But it is like calling a palette and a brush the “art” of painting. That moment when that man felt your presence and believed in himself, which lead to change and actual health is the art of medicine. The outcome of the art is health, not a less negative outcome of disease, or a favorable odds-ratio thereof, but actual health and wellbeing.
Unfortunately, it is not quantifiable. And like all artists, there is an entire industry built up around us to profit off of our art. Healing doesn’t have an ICD-10 code.
I think experiences like this are why a lot of people hold on in primary care, because those moments can be fantastic. Unfortunately, they seem to be getting fewer and fewer in between. At some point, they cannot tip the scale for everyone. Only you can know where your balance is at any one time – and it changes throughout our careers. I hope you have good luck finding something closer to your “good enough” point. Maybe it is cutting back to part-time primary care and taking hospitalist shifts to help pay the bills? Maybe it is being a hospitalist – maybe it is doing something radically different? Who knows?
Sometimes I think this whole FIRE concept is just physicians being medical students again and trying to make it to the next thing. Instead of a promotion, or making partner, or some other career notch, it is FIRE (which is a symptom of how disenchanted we are with medicine). I think it is harder for physicians to work to find satisfaction in the here and now than it is to dig in post more RVUs in pursuit of FIRE or whatever other financial goal one may have. Until we can live in the moment, we will always ask ourselves “now what?” when we get there. The system spent 11-15 years shaping our psyches to fit its gogs, it is our job to reclaim our humanity.
“Healing doesn’t have an ICD-10 code.”
First off, when are you starting your own blog?? Every time I read one of your comments, I walk away so much better for it. I should just collect all of your responses and make it its own post, but I think that would border on plagiarism.
Anyway.. I’m already well on my path to securing my next job. I’m just dragging it out on the blog to see who’s going to make it to the finish line with me 🙂
I agree with your comments about FIRE – I do think there’s an appeal of attaining mastery of something you haven’t focused on before, plus there’s the happy side effect of having enough money to do whatever you want. With RVUs, you’re at the whim of an insurance company or healthcare system, but the thought of being able to control your financial destiny by something you did is exciting.
Really, I think for me it’s about gaining the ability to diversify my life. I’ve been so one singular with my career goals that when I got there I did end up asking, “Now what?” and couldn’t come up with an answer. I still don’t know if I have or if I’ve fully reclaimed my humanity, but not being beholden to my student loans and therefore my job will allow me to step back and regroup.
Funny you should ask about the blog thing. I have been in the process of building one over the last couple of weeks and just got it started. Bear with me…navigating the right amount of personal disclosure is tricky. I should thank you, reading your blog in particular and commenting has been a large part of the impetus for it. Hopefully, it is worthwhile.
I am glad you are making your way to something different. I increasingly believe mastering the “strategic retreat” is an important life skill that isn’t taught in traditional settings. I like to and try channel Chief Joseph: https://www.nps.gov/nepe/learn/historyculture/1877.htm
I’m so glad you’re starting one yourself! Your story is one I’ve thought about many times over, and it’s equally devastating every time. It WILL be worthwhile, and hopefully will help you process in a different way.
Figuring out how to overshare in the right way has been a challenge. I’m not sure if I’ve really got it down, but hey, I’m anonymous-ish so I can say whatever I want! I have crafted this online persona who is a lot more open than I am in real life, so the comments from friends who read the blog have been laced with a lot of surprise. I may just suffer from multiple personality disorder or whatever they’re calling it these days, but it has been a strange process.
Really insightful comments from everyone. I just want to add that I, too, have found it harder to accept compliments due to the frequency with which I encounter borderline personality disorder. Although I have many patients with whom I’ve had a great relationship for years – and I can accept their praise – when I have a newer patient who is effusive, I am put on guard. Granted, I often suspect BPD before even going in the room, given the chart review I perform beforehand. So the pump has been primed – I’ve already got my game face on, both externally and internally. But this really does put a damper on what could be a more heartwarming interaction, when the person is genuine and free of a personality disorder.
I also wanted to speak to Brene Brown’s assertion that we can’t let ourselves enjoy something fully, because then we fear we might lose it, and that would be painful. I have found that, of the tenets of Stoicism, the one that absolutely doesn’t work for me is envisioning the worst case scenario to protect myself from the devastation of eventual disaster. This is precisely because Brown is right: I can’t enjoy the amazing things in my life, as I start obsessing about their loss.
Perhaps I’ll convert you to whole hearted living a la Brene Brown vs Stoicism! Instead of an immovable statue, you can be a walking hug. Just think about it 😉
Per Up To Date, BPD prevalence in psych outpatient clinics is 9.3% and the ratio of females to males with BPD who present for care is 3:1. Since it seems I’m doing mostly psych rather than IM/Peds and I’m a female provider who sees mostly female patients, I would say some days it feels like dealing with that takes up 50% of my day, if not more.
Lots of landmines to navigate… it’s been safer to assume compliments coming my way will just open the door to more injury down the line.
I saw your post when I was on XRV’s site. I have done primary care in Canadian for almost 25 years now. It is very difficult for women in primary care. The patients expect much more of you. You are a woman and somehow are suppose to “get it”.
Primary care is also very hard to do if you are a sensitive person.
I am not a very sensitive person and I am more an efficiency machine. But I also really enjoy the patients.
Borderlines do not tend to stay with me since I am not very accommodating to them. I have very clear boundaries. My attitude was always to allow those ones to leave so that I would have more energy for those who really needed help.
I learned very early on to say to patients “I don’t think I am the best physician for you.”
I hope you will enjoy your career whatever direction you choose.
I’ve never really seen myself as a sensitive person either, and I’ve prided myself on my efficiency.
These last 3 years out of residency have challenged these previously held notions of mine.
Maybe it’s the burnout. Maybe it’s getting to know my patients on such a deeper level than one time visits that I had in residency, so much so that I emotionally invest in their well-being. Maybe it’s figuring out people will buy into what you want them to do if they feel you genuinely care about them, and I’m such a bad liar I wouldn’t be able to fake it.
I’m not sure how patients are in Canada, but I never anticipated the amount of entitlement, opposition, bullying and flat out disrespect I encounter on a day to day basis, and not just from my borderline patients. I’d move back to Canada (I grew up in Toronto btw) in a heartbeat to practice medicine if my husband were willing, but alas, he is not.
Many of my female colleagues understood they did not enjoy primary care and went on to work in insurance companies, workers compensations medical advisors, hospitalists, emergency medicine, the list goes on.
My own husband did not enjoy primary care. We took a 90% pay cut and allowed him to go back and retrain. And I was pregnant with my second child during this time.
If he did not enjoy being a surgeon after his training, I would have encouraged him to stop as well. Nothing was off the table for consideration.
Both of us being docs knew the score. We would never have allowed one another to continue working at anything if there was a better way. We promised to catch the other during our many falls and fails.
I have also found people are generally the same everywhere. The observation you have made of difficult patients are mirrored in Canada as well.
Best wishes for your journey.
Having a supportive partner is key. I have been so fortunate to have an amazing husband who has been with me through undergrad, med school and residency, and is still encouraging me to find my way, even now.
I have seen other colleagues struggle with relationships in which they didn’t have that support, and to me, it would almost be better to just walk this path alone.
Thank you for your good will!