“I’m going to get you a Starburst, Dr. M.”
“No, you really don’t need to do that.”
“Ok.. but what kind of Starburst do you want?”
I shook my head at my scribe, A.
“You’re really sweet… but I’m good. We just need to make it through the morning.”
I took in a deep breath, steeling myself for the onslaught of questions from a woman who was pretty sure she had a brain tumor. After a long exhale, I entered the room with A trailing behind me.
Tears, so many tears.
So many anxious fears dumped into my lap, waiting for me to reassure each one of them away. 40 minutes spent, reviewing the normal CT Brain scan and neurologic exam. Reassuring her if she stopped her overuse of tylenol and ibuprofen, her headaches would get better. Reviewing the importance of sleep hygiene and getting a full 7 hours of sleep a night. Repeating this cycle 3 or 4 times until it seemed she was finally mollified.
Just as I was about to get up, the real reason she was in became apparent.
“My husband has dementia… and I just can’t take this anymore.”
More tears. I watched them trickle down her cheek, dripping off her chin into her lap, not making a single attempt to wipe them away. All 3 of us sat in silence as she released the pent up emotion that had been building up in her, trying to pound its way out of her head. Now it was out in the open, threatening to suffocate me.
Where is your empathy, M? Don’t tell me it ran out at that 40th minute…
No… it ran out before I even made it into the room.
I discreetly glanced at my watch. 15 minutes late.
Who knew how much longer she was going to cry?
Why does the truth always come out at least 10 minutes into the next appointment??
Taking in another deep breath, I mustered the last of my emotional reserves, hoping my frustration wasn’t becoming apparent.
Reaching out for her hand and handing her a box of tissues, I finally responded,
“This must be so hard for you. What would be the most helpful for you at this time?”
Regroup
“I got you an orange Starburst… and a left and right Twix!”
Despite myself, I smiled and took them from A’s outstretched hand.
“This is a poor coping strategy. But thanks.”
Clearly he was picking up on me being emotionally tapped out, trying to help me release some serotonin by inducing a sugar rush.
Damn.. I thought I was hiding it better.
Electing to go with the Starburst before the chocolate, I popped the candy in my mouth and allowed myself to savour the artificial orange flavour.
This counts as practicing mindfulness, right?
Peeking at the schedule with dread, I wondered who’s appointment I was going to rush through in order to make up for those 30 minutes I’d fallen behind.
- Follow up depression
- Follow up anxiety
- Discuss abnormal mammogram
- Follow up ADHD
- Follow up depression
- Follow up chronic pain
- Follow up labs (FYI – Wife died)
The front desk officially hates me. They literally want me to walk out today. No time like the present, M. It would be better to cut your losses sooner rather than later…
“Ready for the next one?” I forged ahead with forced cheerfulness.
“Always,” A replied.
Is it just me, or is his enthusiastic smile starting to crack? On to the next…
Debrief
At the end of the day, we settled into my office to finish the last few notes. A seemed to plop down into the squeaky office chair with a bit more of a thud today.
“How are you doing, A? Today was a little… heavy.”
“I’m fine. What I want to know is how are you doing? You’ve eaten more candy today than I’ve ever seen. How do you keep doing this every day, patient after patient and still keep saying the right thing?”
A thousand thoughts raced through my mind.
Do I demure and say what I’m supposed to say?
Oh, this is all just part of being a doctor! It’s such a privilege to be allowed to enter into someone’s fears and emotions. Everything is awesome. Just living the dream.
Or do I say,
I’m fine. You’re fine. We’re all fine. Please stop asking questions for which you’re not prepared to hear the answer to.
Or perhaps the truth,
I’m actually not fine. Thanks for asking. The only thing that’s allowing me to make it through the day is that I’ve formulated an exit strategy, because I can’t take this anymore.
Master Of Deflection…
“Have you ever heard of the NURSE acronym for empathy, A?”
“No… what is it?”
“It’s what I learned in med school to be a better listener for my patients.
N stands for Name. You name the feeling that you’re sensing from the other person.
U is for Understanding. We say, ‘I see why you feel that way.’
R…”
“Wait, wait… I don’t think I really want to hear this.”
Curious, I turned to actually face A and caught his faith in me crumbling as he realized this wonderful, caring doctor he’d been following for the last month was merely following a script. My stomach lurched from my free fall from grace.
“Look, it’s not… it’s not that I use this all the time. I mean.. at this point, it’s become second nature. But sometimes you need to go back through the process, you know?”
Lies, M. You’ve had to go “through the process” more often than not recently.
“… Ok. So R?”
“Respect the Patient.
S is for Supporting whatever decision they choose to go with.
E is for Explore the emotion further. Usually that’s when I say, ‘Tell me more about x, y or z’.”
Silence
Again, I tried to study his face, but this time he was much more guarded. Finally A responded, each ensuing word dripping with more and more disappointment.
“Thinking about today’s visits… I can see where you do this. It’s actually pretty much the same thing every time. That’s how you’re so consistent.”
Salvage this, M.
“When I first learned about this in med school, I thought it was garbage. That I would never need to learn something like this. I always prided myself in being a good listener.
But when you’re on your 18th of 21 straight days working in a row during residency, or 16 hours into your 24 hour shift as a senior resident and it seems like your interns are on a mission to kill everyone on the list, or you haven’t seen your husband or wife for 2 weeks despite technically living in the same house because you’ve been on night shift and your schedules don’t line up, this NURSE acronym becomes your lifeline.
Because you’re not going to care anymore about the complaints of 16 people you’re going to see that day. You might even want to snap at them and tell them their first world problems are the least of your concerns. Or you’ll hold it in and take it out on the people working around you.
But you’re not going to. Because you’re going to fall back on this script.
At the end of the day, it’s not about how WE feel in that moment. It’s about our patients and there is healing in feeling heard, even if that’s the only thing we can offer.
So remember this conversation, A. Don’t be that jerk.”
After digesting my unexpected monologue, A finally stated,
“If it makes you feel any better, I would never have been able to tell. You’re very good at what you do.”
On my drive home that day, I wondered how many of my adored mentors and attendings during my med school and residency training found themselves where I am in now.
How many of them had been faking the empathy? How many of them were burned out?
Who else had dreaded going into work every morning because one night, or even a full weekend was not nearly long enough to replenish the well? Who else would have deflected instead of answering a probing question?
Was I even in a state of awareness that my brilliant, fearless leaders weren’t the superhumans I wanted them to be?
This is why no one ever “sees it coming” when a physician chooses to take their lives. We just fake it even harder, scraping the muck from the bottom of our wells, offering up the last of our reserves to someone else because we mistakenly think they need it more.
Was I doing A a disservice by letting him glimpse into this world? Or would he be better off for having this conversation?
You knew this was a mistake from the very beginning, M.
You had no great words of wisdom to impart on this person who wanted to follow in your steps without stomping on his dreams. Did you really expect to be able to hide from someone who’s been studying your every move for 40 hours a week? Now he’s going to be on the lookout for your tells.
Let him look. He might just save you from yourself yet.
At the very least, he’s another obstacle preventing you from walking out that door.
As a former engineer (like your scribe A), former high school teacher, and current radiology resident, I can’t begin to tell you how valuable your mentorship is for A (but will briefly try). We all have preconceived notions of what certain careers are supposed to be like, and a mentor who “tells it like it is” rather than following the script is not only super helpful providing guidance, but also provides validation for when we, the mentee, become a mentor ourselves and ask the same self-doubting questions you ponder on this blog.
So, thank you for “keeping it real”.
Wow.. you’ve lived so many more lives than I have 🙂 The more time I’ve had to think about this post, the more I wish I did have that mentor who was real with me. I also am realizing perhaps I was walking around with blinders during my training, and it is only now that I’m in search of my flawed heroes.
I’m not sure if I’m ready to be that for someone else, but I guess that’s what I’m doing with this blog. There’s so much forced positivity out there that doesn’t allow for real conversation… this is why I continue to write.
Thanks for reading and commenting!
The answer is “yes”. Those who we looked up to in high school/college/med school/residency as mentors, teachers, wizards, and prophets, are all human beings, just like we are. Just like we go to work and put on acts and aires, so did they.
Perhaps physician work conditions have deteriorated over the last generation, such that the theatrical skills that we possess need to be greater, we adapt, and they are.
At some point, our calling becomes a job, our passion becomes drudgery, and we are just trying to get through the day. There are occasional pleasant surprises that make it worthwhile, even enjoyable for the moment, but then we move on to the next work unit. Our doc heroes of yesteryear did the same.
I’m going to be honest… your response devastated me a little. But you’re absolutely right, of course.
It does feel like the majority of my job is showmanship. Sometimes it feels like I’m a glorified used car salesperson, which is annoying because I’m trying to sell people a healthier life, or at least a pill to get them by.
The portrait of a “doc hero of yesteryear” as you put it does not leave room for self-doubt or wanting to be seen as more than just a person who was put on this earth to serve others, even if they may have felt these things personally. This is what I struggle with – the need to identify with that and the reality of having lost my calling and purpose.
Honestly, M, I try and just be honest with my residents. When it sucks, I tell them. When I love my job, I tell them. When I need options, I tell them that, too.
It opens up paths for them to vent to me, too, because they know I’m not just some solider on the field who is gonna tell them to “shut your mouth, and do your job” like others.
There is nothing wrong with giving A a glimpse. It’s probably more wrong not to.
Just be you and be honest. Let A decide what he thinks.
Like Vagabond said, we are all human. It’s okay to show that.
TPP
And this is why you got your wonderful teaching award 🙂
I am not a person to sugar coat things, but I also say a lot of things internally than never make it out to the open. I think my hesitancy to let A see into these thoughts stems from feeling the need to protect him from all this darkness. But you’re right – it’s probably more wrong to do this.
He should know what he’s getting into.
Nah, I just paid ’em all 🙂
You seem like an incredibly thoughtful person. I have no doubt your holding back comes from a good place in protecting A.
Don’t beat yourself up!
I think we got empathy wrong. People don’t need your empathy, they need compassion. They need someone to listen, feel heard, and validated. They want to walk away from talking with us reassured.
They don’t need us to experience their suffering.
I think we’ve done ourselves a great disservice by focusing on empathy. None of us can be empathetic for ever. It is a well that runs dry and needs to be replenished and that replenishment takes time.
I heard Paul Bloom talk about some of these ideas and his book, Against Empathy: The Case for Rational Compassion, on Sam Harris’ podcast. It was a good listen.
The NURSE acronym is a marvelous tool to show compassion and be attentive to their needs while saving your sanity.
p.s. I prefer to practice mindfulness by delighting in haagendaz belgian chocolate chocolate ice cream. Way better than Starbursts 🙂
Ah yes, the empathy vs compassion debate. Academically, I see the merits of rational compassion, but on a day to day basis, I personally have a hard time teasing out the empathy from the compassion. These days, it seems the compassion is only getting me so far as I deal with people who are quite content with being bystanders in their lives rather than being active participants, and I just can’t validate that. Mainly my adult patients. Should’ve just done peds 🙂
I too would much prefer Haagen Daaz but that’s harder to hide away in my super secret candy drawer at work 🙂
Another powerful story. It is good that A is seeing the real struggles of a day to day practice in medicine.
It is much different than what people see on TV. If you are going to make the big sacrifice you need to make sure you know what you getting into to. He is getting a lot more experience being thrust in the front lines and seeing what you deal with.
I could go on forever about all the new medical dramas on TV, but it would be an incoherent ramble I won’t subject anyone to.
I’m hoping I’m giving him an authentic experience since I’m all about being real and genuine, but letting people into the struggle in real life is much more difficult vs doing it online when you can edit, then re-edit your thoughts.
This is a really good blog post – thank you for sharing.
When I read your list of upcoming patients, I was struck by how many follow-ups had strong psychological aspects (I’m not dishing these; I teach psychology).
What I wondered is whether what makes your job so draining is that you end up being all things to all people. Essentially, you are the only person many can open up to, so patients seek you not just for medical complaints, but also for personal problems and even social contact.
Thank you for reading and commenting!
When I’ve commiserated with the other docs at work, we all have said the same thing: If we knew how much psych we would see in primary care, we probably would’ve chosen something different. There is a shortage of psychiatrists nationwide, access to therapists/counselors is dismal in my area and finally, the stigma surrounding mental health is still very strong.
If people come to their primary care doctors to get their mental health meds, in their minds it stays a “medical” issue rather than a mental health issue. It’s easier for people to say, “I’m going to my doctor” rather than “I’m going to my therapist”. I do believe there is a strong psychosomatic link between chronic medical problems and mental health, and I rarely find it helpful to only focus on the medical aspect of things because that doesn’t inspire change.
But you’re right – this ends up being very draining – it only took me 3 years to get to this point and I’m looking to get out.
We have the same dearth of mental health professional availability in our area. One source that many patients and providers may overlook is an EAP (employee assistance program). If your patient happens to work for a medium to large employer, there is a pretty good chance they can access a mental health professional, either in person or by phone free of charge. Just another possible tool in the (nearly empty) bag.
Maybe not so strangely, I have found my own ability to empathize or be compassionate has increased with age. Perhaps because I’m near retirement 🙂 or because I’ve experienced more loss, personal setbacks etc. than someone in their 30’s, giving more perspective.
I certainly empathize with your situation M and hope you can find your way to contentment.
Thank you for the suggestion! I always forget about EAPs as an option.
I sure hope my ability to be more compassionate/empathetic improves with age as I’m told pretty much everything else goes downhill after 40 by my older patients! All joking aside, I do think if we were allowed more space in between every 15 minute visit to just regroup, that would make a world of difference. Unfortunately, there is that constant push to squeeze more in throughout the day – one more phone call, one more ear check, one more form to sign; taking a mental health moment seems too self-indulgent.
I will be leaving this hamster wheel for something else that will allow me to take a breath when I need it, so we shall see what happens! Thanks for the comment!
M,
I tell all aspiring physicians that unless you don’t see patients( i.e. Diagnostic Rads or Pathology) that all Medicine is about 80% psychiatry. This is because we deal with people, who are by definition emotional rather than rational beings. I think the idea that we can hide from psych and still see patients is dangerous or at least undermines our efficacy as clinicians – because as you said, “medicine” doesn’t inspire change.
I did a rotation with an adolescent psychiatrist at a partial hospitalization program in residency who had wanted to do primary care. She realized that pretty much most of primary care is actually Psych, so why not just do that so you can actually focus on it and hopefully be given the time to deal with it. It retrospect, that was some legit wisdom that I wish someone had laid on my plate earlier.
As far as empathy vs compassion, I always feel more fulfilled and connected when I have legitimately been empathetic and connected with someone. It is also draining, so I I can’t do it with everyone. I have to choose when to decide to connect. Otherwise the well does go dry. So, I don’t think it is either/or, but which and when.
Ah, again such wise words. Rationing the empathy/compassion is something I struggle with, as if holding back some for myself is a selfish gesture. The only truly effective way for me to do this without the guilt was to cut back on my hours entirely, but then again, working the standard 55-60 hours/week that physicians work is just ridiculous to begin with.
There are so many pieces of wisdom told to my younger self that I just wasn’t in a place to fully hear and understand them. But, pondering the road not traveled is not helpful, so I’ll take your wisdom now 🙂
Physicians are selected because you can beat the crap out of them and they will actually show up the next day for 5:30 rounds 100% of the time. It’s our “feature”. Physicians are trained to be the one who doesn’t lose their mind while everybody else has the freedom to lose theirs. It’s un-natural but necessary. This is also what we get paid for. It is not an act and it’s not phony. Burnout is when a person who has a natural 2.5 standard deviation skillset tries to perform at a 3 SD level ALL THE TIME. The system has been designed by the MBA’s to burn you out. You’re the Rocket Woman burning out your fuse up here alone. You are not alone by the way.
Solace is a clear understanding of who you/we are and the system you are forced to engage. The solution is to move out of the tail, up from 3 SD back to 2.5 SD. Nothing more radical than that is needed. You don’t incur guilt by being who/what you are. Instead you shed the situational dishonesty and pretense and that is healthy. An old man told me once “dare to be average”. I dared to be average instead of perfect, my life got better.
Your writing is beautiful by the way
Thank you for reading and for your comment!
As a self-declared perfectionist, I have struggled with the concept of “average” and “good enough”, but now that I’m getting older and seeing what little return on investment that gets me, I see now that 2.5 SD is perfectly acceptable.
Putting that into practice, however, is an entirely different matter.
I stumbled here 9 months later…. Beautiful writing. Your patient list for the day made me shudder. I don’t think that much empathy exists in the world. I’m not sure that I can explain this as beautifully as you explain your feelings, but here it goes:
My job is to allow a patient a safe space to get to what is bothering/concerning/frustrating/impeding them. That all too often comes after the allotted appointment time is over, but that is the most valuable moment of the visit. The moment they say, with honesty, this is where I am and what is bothering me. I win most of the time and open myself to letting them explore this with me. I don’t win too often. I’m behind, I’ve given you too much already, I have other patients….
Win more often than you lose, be the best doctor you can be. You will never be perfect and none of ‘us’ expect that of you. You don’t have to give pieces of you away to help other people, you just have to be open to sharing their experiences.
Hope that makes sense!