Okay M… you can do this. Live just one little checkbox at a time.
I looked at the 63 med refills waiting to be addressed on this Monday, marveling how quickly they accumulated after just 2 days over the weekend.
Just batch them per patient.. now magically 63 refills become just 30!
Shaking my head at the mind games I had to play to keep myself from slamming down the laptop screen and walking out, I started to diligently go through my checkboxes:
- Open med refill request
- Make sure request is accurate
- Check if labs are current
- Check if patient is due for an appointment → If not, open phone encounter to ask them to come in
- Lather, rinse, repeat
20 minutes of your “lunch” gone, M. You know, you’ve just created extra work for yourself… now you’re forcing 10 people to come back in for an appointment, and you’d better believe they’re not going to be happy about it…
“Hi P.. is there anything you’d like to discuss before I start going through my spiel for your physical?”
“Well, you know, you made me come in so you’d refill my meds, but I guess I do want to talk about my blood pressure now that I’m in here.”
P handed over a yellow piece of paper with the words BLOOD PRESSURE written out on the top in tidy block script.
“I’ve been logging my blood pressures and they’ve been high, even for me.”
Looking at the numbers, they seemed to range from 150-160/90-100, well above the goal of 140/90. Then, I spied a few 180/110’s scattered around.
“What’s going on here when the top number goes up to 180?”
“Yeah… that’s my blood pressure after work. You know.. after a frustrating day of meetings and conference calls.”
“So this is every day? Even with taking the 4 blood pressure lowering medications you’re on?”
“Yeah, it’s just normal stress. It gets better when I settle in at home.”
I sat back in my rolling chair and regarded him. For the last 2 years, we had been going back and forth with his medications:
“No, I don’t want to start a new med for that doc, I know how to lose weight and I’m going to do it!”
Scanning P’s vital sign trends prior to entering the room, he never could seem to break below 350 pounds despite all the promises of changes.
“Tell me about your salt intake.”
“I never add salt to anything! And, you know, I’ve been really good with my lunches – I eat a salmon salad every day. I don’t know why I’m not losing weight. Well, I do… I just can’t find time in the day to work out, just a little walk to let the dog out to do its business. I mean, working 10-12 hour days makes it very difficult to find time for that. You should know what that’s like – you’re a doctor!”
“And how many times are you eating out a week now?”
Sheepishly, he replied,
“3 times a day during the work week, and probably once a day on the weekends. But I’m in sales! I need to wine and dine the clients, you know?”
As a swell of frustration started to rise in me, I resisted the urge to massage away the furrow forming on my forehead.
This is not how a healthy diet works! You can’t just eat a salad at lunch and forget about the other 6,000 calories you’ve consumed over the course of the day. Furthermore, you would never be able to burn off those calories solely by picking up your dog’s turds once a day.
What are you doing, M? Stop banging your head against the wall. He’s not ready to change. Just throw him another pill, talk about his immunizations and colonoscopy and move on with your day.
Let it go. You don’t always need to have the last word.
“You know your job is killing you, right?”
Startled, P’s back stiffened, gaining him another 2 inches of height as he sat up straighter on the exam room table.
Gah!! What is WRONG with you!? You don’t have time for this pandora’s box today. You’re not Dr. Now from TLC’s My 600 lbs life! Ugh.. fine. You’re in too deep now.
“You’re eating out three times a day, which I guarantee has way more sodium and calories than you think it does, you can’t exercise AND it’s causing dangerously high blood pressure elevations for the majority of your work day. Your body is throwing up red flags, but you’re just ignoring them and powering through.”
“Well.. here’s the thing though, doc. They keep raising the productivity expectations, and as a senior sales person, it’s up to me to set an example and set that bar. I’m in charge of a large territory so I have to be in my car a lot and I can’t exercise. I run meetings and do presentations in front of hundreds of people, so that takes a lot of time to work on outside of my regular work responsibilities.
My daughter’s in college so I have to keep up this pace! And my wife is expecting another 3 week trip to Europe next year for our anniversary.
There is absolutely no way for me to cut back. Maybe in a few years once I’m closer to retirement. You know what they say… sleep is for the dead!”
Same old tired excuses
Stepping back from my frustration, I realized what rankled me so much about his pleading monologue.
The self-importance.
The need to be needed.
The willingness to put one’s health on the line in service of others.
The unwillingness to make a change.
P was just me in a 55 year old man’s body, spouting off my same old tired excuses to my face. Now he was waiting for my blessing to continue on his road to self-destruction.
Do I give him a pass in order to make my day easier, or do I just go for it?
There’s no going back now…
M, sometimes the hardest things to say are the most necessary.
“So what I’m hearing from you is there is absolutely nothing you can change.”
As I sat waiting for his response, I wondered what his inner monologue was telling him. Was he struggling the way I would when someone shines the light on my bullshit? Was he thinking,
Who does this person think she is? Telling me how to live my life?! She has no idea what I go through. She only made me come back to tell me how fat I am. I’m never coming back again!
And still I waited.
I could hear A, my scribe, shift uncomfortably behind me.
The creases on P’s face mapped out his discomfort. Lips pursed in response to words that died on the tip of his tongue. Eyes shifted away to avoid contact with mine.
Finally he responded with a quiet fury,
“Well, I can try to change my food selections, but I’m just stuck. I think until I can figure things out, you’re just going to have to give me another pill.”
I nodded my head. He wasn’t ready. And it was far easier to direct his anger at me right now than to be mad at himself.
His maladaptive coping mechanisms are even the same as yours, M. You can’t even be frustrated with him right now… he’s you!
As I finished up the rest of the appointment and worked to send in his prescription electronically, I couldn’t stop myself from getting the last word in.
“P, I just want you to understand… this is your fourth blood pressure medication, really, the 5th since one of them is a combo pill. We don’t have a lot of wiggle room here.
I really want you to think about what you want your life to look like in 5 to 10 years.
Are you going to spend your retirement with a bunch of medical problems that you’ll just have to keep coming back to see me for, or are you going to live a life in which you can walk those European cobblestoned streets with less pain from carrying all the extra weight, without having to bring all your meds with you, without having to worry about how to store your insulin? Because at the rate you’re going, this is what you’re looking at.
What do you want your life to look like?”
P got up with a troubled look on his face, muttered an empty word of thanks and stalked out of the room.
As I watched him hobble down the hall, I felt a pang of regret.
You feel better about yourself now, M? Was all this “tough love” worth it? You pushed him too hard… he wasn’t ready yet. This is what happens when you allow your frustration to spill out into the open.
Seeing my 55 year old male self round the corner, I measured the years and decisions between P and I.
Had he sold himself the same old excuses so many times they now defined him? At what point did he buy into the story he was making up about his life? Was it a conscious, monumentous decision or did reality die by a death of a thousand cuts?
Where, along the next 23 years of my life, would I fall along the same path?
Was this the person I had to look forward to? So caught up in my rationalizations, rendering me unable to see the outcomes of my decisions even if they beat me across the face.
When the patient teaches the doctor…
Some people need to make their own mistakes to learn life lessons.
That’s not me.
I’ve been fortunate to glimpse into thousands of lives as a doctor, pulling truths from experiences I will never own. Lifetimes of mistakes and regrets have been shared with me, rocking me to my core. How could I squander these little nuggets of truth offered to me in the most sacred of trusts?
I refuse to find myself in my doctor’s office, 23 years from now, hiding my fear of change behind my excuses.
I am willing to make the changes that need to be made.
I cannot redirect my fury at my unhappiness to anyone other than me.
I won’t continue being a bystander in my life, watching myself get pulled into a million directions because I wasn’t ready yet to be an active participant in my own life.
Just because you’ve made a change doesn’t mean everyone will, M.
No… they won’t. But they’ll think long and hard about it because I made them feel something.
Even anger is better than walking around feeling numb to our own existence.
Maybe that’ll be enough to just plant the seed.
***
Photo of M overlooking the captivating Columbia River Gorge, shot from Wind Mountain, WA.
Slowly but surely, I’m teaching J how to take photos! For more of our photography escapades, like that time I made J paddle me out to the middle of a lake in our inflatable kayak to take some awesome bridge/autumn shots, follow me on Instagram!
You hit it right on the head. We’re often as bad as our patients when it comes to making excuses for our bad habits. Between shiftwork and 3 small kids I can always find an excuse not to exercise. I’ve never got off a night shift and craved celery. If we can’t make the right choices knowing all we know, how can we expect our patients to do any better? Good post!
Thanks for reading! Sometimes we feel invincible when we think we know everything, as if knowing is the same as doing.
With that being said, I’ll be the first to say I’m the WORST patient. The only time I’ve gone in to be seen is when I was literally dying from anaphylaxis (which I wrote about here –> https://reflectionsofamillennialdoctor.com/2018/01/25/millennial-doctor-patient-brush-death/).
Otherwise I’m more than content to google at home solutions to fix all my problems like everyone else 🙂
I couldn’t help but think of FI when ‘P’ was talking about the college expenses, fancy trips and expensive lifestyle he “has” to maintain. He crafted a life that demands too much of him and he can’t see any other options.
This is one of our why’s of FI and why some think FI is a remedy for burnout. Having the option to cut down on work and pursue ourselves may be how we can save the mid and late career future us.
FI might not be the cure all if you are burning out as a young doc since there are still loans and a giant pile of money that needs to be accumulated, but living far below your means may give us the opportunity to take a part time job for a bit or at the very least be able to leave a job that is terrible in pursuit of another.
M, your writing is again inspiring. You can do it!
Thanks for your vote of confidence Kpeds!
I 100% agree you! Seeing patients who are running themselves ragged by trying to live the high life is one of the reasons I’m running toward financial independence! It makes no sense to me to trade the quality and health of my life just to fill my life with more things.
What is FI?
Oh, my friend, thank you for asking.
FI stands for Financial Independence and there is a large movement of us who are paying down debts, living a life well below our means (my personal approach is minimalism but others do it via frugalism), amassing wealth, doing side hustles – all in an effort for us to no longer be beholden to our jobs in order to live our lives.
I think most of us started off with the White Coat Investor (whitecoatinvestor.com) and there has been an explosion in other blogs:
– Physician on Fire (physicianonfire.com)
– The Physician Philosopher (thephysicianphilosopher.com)
– Pediatrician Finds FI (pediatricianfindsfi.com)
– Xrayvsn (xrayvsn.com)
– Side Hustle Scrubs (sidehustlescrubs.wordpress.com/)
– Crispy Doc (crispydoc.com)
– Miss Bonnie MD (missbonniemd.com)
There are so many more out there, but these are the ones I read more regularly.
I hope this answers your question, and if you have any more, please feel free to reach out!
It is sad as doctors who tell patients one thing but can’t follow their own advice.
How many doctors do you know smoke? Eat poorly? Sleep too little? Barely exercise?
If a patient came into you office with any or all of those traits you would be reprimanding them. Everyone says doctors are the worst patients and it is true.
It is very easy to excuse these bad habits with work schedule etc but regardless of excuse we are doing done serious damage to our bodies that will eventually manifest itself
Absolutely! I am just struck by the feeling of helplessness that we all feel when we’re in these situations, such that we stay in these horrible working conditions for longer than we need to.
I’ve just decided that cutting back/changing my work is what I need to do to design the life that I do want. I understand the hesitation and fear when it comes to doing something like that, but the alternative is much worse.
You have a great voice, Dr. M. I’ve been reading the autobiography of Oliver Sachs, and your writing is a bit like his – immediately engaging.
*
In reflecting on your patient, I was thinking of the complex equation of money, life demands, and time. I’m not too far off the age of your patient, and am now finding that I’m starting to value my time a bit more than potential earnings.
Perhaps the same realization will come to your patient some day: preserving health may become more important the making more sales.
Thank you for giving me another book for me to check out! The trick is trying to find the time to read all the books on my growing list 🙂
I find myself pondering if maybe I’m just an old soul inhabiting a millennial’s body – my time has always been precious to me. And I am willing to forego earnings and money to protect my time.
Perhaps the generational disconnect of thinking millennials are lazy is really just us saying we don’t want to get on this hedonistic treadmill that has been modeled for us by prior generations. We see what it does to them, and the value add is not deemed worthwhile.
Thanks for the comment, Friendly guy!
M,
I think you have managed to maintain compassion for your patient population much longer than I ever would have. I find it much easier to maintain empathy and compassion for heroin addicts, schizophrenics, and the other cast-off souls of our society than for the work-and-stuff addicted upper middle class.
I have so little tolerance for transactional medicine.
“I paid my co-pay so you owe me a prescription.”
No investment on either side, no shared work. I feel that is what most people expect from a primary doctor nowadays. It is so unsatisfying and in the end – useless. So many of us strive and work so hard only to receive a paycheck.
If it weren’t for student loans, I would probably be working about 2/3 as much. It might be different if we spent out days actually addressing people’s suffering and problems. But rather, I used to spend a vast amount of time talking people out of anesthetizing their consciousness.
Oh my goodness.. you’re just speaking to my soul here.
I do spend an inordinate amount of time trying to convince people they don’t need to numb themselves out of existence, but it’s easier to numb with food, alcohol, screen time or expensive play things and trinkets than to embrace the suck and find a reason to change the way they live.
With that being said, if I can’t find the compassion in what I do even for the first world problems, it hurts me more than it hurts them. I wouldn’t be able to find purpose in my day and would become ineffective. It’s taxing but I do it to maintain my sanity, at least until I can pay off my loans and really cut back on work.
There were so many excuses I would hear from patients that would make me internally roll my eyes until I realised that I made the same excuses. I think somehow I’d subconsciously thought of my situation as being unique and different when in actual fact it really isn’t. And this post just reiterated that a 1000 times.
Haha.. yes, it’s much easier to point out others’ flawed thinking than our own. Fortunately I’ve surrounded myself with people who do that for me with compassion and love, otherwise it would be too easy for me to cast aside their valid points.
When I turned 60, I finally started to take my own advice. I changed my diet, lost 30 pounds, joined a gym and exercise regularly. Its been 5 years and I have to say, that I wish I had done it alot sooner. I feel better than I ever had in my younger life. I can now be a real life example to my patients. I cannot tell you how nice it is to see these same patients at the gym. I feel like they trust me more when they see me practice what I preach!
That is awesome! I am a big advocate of healthy habits and I talk about it at every physical. I hate feeling like a hypocrite, so in order to avoid that I try to practice what I preach! Great job on carving out that time and effort to focus on you!
All too true. I make a stress assessment at every annual physical with my patients. I make it a point to look them dead in the eye and tell them “stress will KILL you” and we talk about ways to compartmentalize, mitigate, and discharge that stress. My patients get healthier, they inevitably come off some of their meds…word gets out and now I’m in “high demand” and I’ve got my practice manager breathing down my neck to see more patients, open more availability etc…. you’re damned if you do, you’re damned if you don’t. And do I find the time to take my own advice?! I barely have time to take out the garbage before I crash and wake up at 5am and do it all again. If it weren’t for my 3 days off a week I’d be crispy fried with burnout. I feel you brother.
I absolutely hear you! I filled my practice within 10 months of starting out after residency and every week the front staff messages me, begging me to please accept one more patient. I then increased my hours to 4.5 clinic days and my work schedule ballooned up to 60 hours a week, putting me on the fast track to burnout which I’ve been struggling with for the last year and a half. I went back to 4 days earlier this year because I realized if I didn’t take care of my personal self, there would be no way I could take care of others.
If you don’t look out for yourself and set boundaries, administrators and the system will take EVERYTHING from you. I hope you can find some ways to create breathing room for yourself to see what you can start saying no to. If you listen to podcasts, the Brave Enough Show Podcast (https://www.becomebraveenough.com/podcast/) has been my newest favourite find – it is geared toward women, but I think there is benefit in there for everyone. She has actionable, practical steps that you can start doing today.
Please give yourself permission to cut back even more, especially on the things that don’t bring you joy.
Beautiful piece, nicely written, and I think we can all identify with it . . . but probably most of us have not done as good a job in confronting their patients (or ourselves?). But I have been in a situation where I felt my family medicine job was killing me . . . took the plunge, left a regular employed practice (after having thrown in the towel after many years in private practice), and went in to an employed direct primary care position, which I have been in for 4 years, and I could scarcely be happier. No real time pressures, no productivity pressures, just sensible quality incentives, which are realistic when every regular visit is 30 minutes (an hour for an annual visit). I”m not trying to sell anything to anyone but DPC really is the way to save your life if your job is killing you.
When I was at the height of my burnout struggle, I seriously considered DPC, bought Doug Farrago’s book and devoured it in one sitting. It’s still not completely out of the cards for me, but I will be moving on out of private practice into something else (don’t want to do a spoiler alert but it will be in an upcoming post in a few weeks!). There aren’t any employed DPC options out where I’m working, so I would have to start a practice from scratch and that just isn’t feasible with my insane amount of student loans left. In an ideal world though, I would totally open up my own DPC practice and wave goodbye at all these productivity pressures, insurance nightmares and checkbox ticking for the sake of ticking checkboxes.
Thanks for reading and commenting!
Nice job communicating our routine.
At 56 I’ve recently reduced to 3 days per week. EMR crap was eating me up. Still is but 4 days away is a huge relief. I was never so angry and frustrated in my life as when EMR was forced upon us. Talk about unhealthy, I have to do some things like billing corrections in small doses as I can feel my blood pressure and pulse rising.
I’ve been investing in rental homes to supplement my income and facilitate an early retirement. I plan to pull my 401K and do more of this as the return is more than double.
I think sharing in a forum such as this is very positive. Helps to see how others deal with it. If I were just starting, it would for sure be DPC. Too late now, I can’t abandon all the patients who have been with me for years. I will, however, bail out early. I hope there are better things to come for your generation.
Thanks for your comment Arlie! I didn’t realize how common this was among practicing physicians until I started struggling with burnout and looked for ways to get out as a young attending. I devoured everything in the physician FIRE space and after finding The Happy Philosopher’s blog (a radiologist who decided to go part time), I decided to start my own because we need to start having more of these open conversations.
I’m hopeful my generation will have a better time of things, but I’m also a realist and in this current climate, I’m not holding my breath.
This Tuesday, I’m actually participating in a 4-way cross collaboration post to discuss medicine through the generations, from the Boomer’s, Gen X, Millennial and Resident Physician’s perspective, so stay tuned! It will be really fascinating to see everyone’s different takes on this.
Just a small point –
Why are all the refill requests coming directly to you? Have a nurse review them all first, and then you OK them.
Or did all the nurses get fired to pay for the EMR?
Great question – I was told there was too much on our MA’s plate to have them take first jab at our inboxes and refill requests. So it now falls to me. I have set up some systems to where the nurses will triage my web/portal encounters first, but I’m the only physician in my practice who “dares” to do so.
Part of it is a control issue on the physicians’ part in my practice, the other is that the system here is not set up to support the physicians well. It’s maddening.
Wow.
So the docs are there to support the MAs?
That’s what EMRs have brought us to.
Honestly, we have no one to blame except ourselves.
It’s definitely death by a thousand cuts leaving us with the question: Which cut do we address first to fix this?
I’m not sure what the answer is.
From a Boomer to the Millennials:
As an FP, I was always amazed at the oncologist I knew who had mastered the knack of claiming one remission out of the last 10 patients he had seen, and could call it a good day at the office. When I saw the stats on smoking cessation, that the straightforward recommendation from a trusted primary care provider greatly increases the chances that a patient will quit, still low but much better, I began to understand.
When it came time for me to relocate my family for good reason, and go through the painful process of saying goodby to long established patients, I got many unexpected thanks from persons I seldom saw anymore because they HAD taken my advice, and became much healthier. The ones we see more often we tend to feel are our failures, but as a mentor told me nobody bats 1000 in this job. It is our duty to plant seeds, it is up to our patients to water them. I had to realize that some seeds take longer to germinate than others. Resist the thought that your sincere words are wasted, and keep planting seeds.
Thank you for your wisdom. It’s true – selection bias is totally at play as the people who do take me up on my advice and recommendations end up self-selecting out because they don’t need to see me anymore, while the ones who don’t come back. Mostly because I make them come back in order for me to refill their meds!
Everything these days is about instant gratification – seeing healthy habits play out over several years is a slow process.
Thank you for your comment!
I think you pick your battles. Since I recently took a hospital employed job I see lots of GYN ER follow ups. The number of patients who bleed to the point of needing blood because they are 450 pounds is startling. I used to think it was rude to bring up obesity as a cause of problems but no more. I really think of it as suicide by food. As a side note I am 61 and one thing that is different is that few physicians smoke. When I first started lots of them did. It is hard to be a “role model” if you smoke and weigh 250+ pounds in my opinion. No one will protect your time unless you stand up for yourself. Being Financially independent gives me the ability to refuse to do some things even as an employee. Since I ran a private practice for many years I understand how to delegate and so far I am able to do it. I am definitely a cat who will not be herded.
I will aspire to be a cat who will not be herded as well 🙂 I try to practice what I preach as it would be unfair for me to ask my patients to do things that I choose not to. I’m getting better at picking my battles to reserve some of that emotional and bandwidth for the rest of my day, but it feels akin to giving up on people. But, I know that patients need to move that needle for themselves – I can’t do that for them.
Thanks for commenting!