If you missed Act One, click HERE for the first part in this three part series.
***
“Soooo.. I got the contract today.”
“And… ?”
“Well, I couldn’t just sign it at lunch without you there, of course.”
“Ok. So what’s stopping us from doing it now?”
You, M. You’re standing in the way of progress.
“Well… we’re walking the dogs currently. Can’t do it right now.”
J shook his head knowingly.
“You know, you’re being that annoying prodigal daughter you used to complain about in residency. The one who wouldn’t let her estranged parent go until you came in as the hospice queen and convinced her to pull the plug.
Your current job is already dead, you’re just keeping it alive for some reason.”
No preamble. Just straight to the quick.
Taken by surprise by J’s atypical allegory, I laughed out loud.
“Oh, that one landed?!”
“Yeah.. it was short and effective. Real impactful.”
“M… what’s stopping you from signing?”
In the span of a few moments, the yawning void between us grew wider and wider.
To me, it was simple: my emotional self hadn’t caught up to my logical self quite yet.
Sure, I could logic my way through all this. Could peel out the facts from my emotional cesspool. By all accounts, this new hospitalist job was going to be better for me, for how J and I wanted to live our lives, for our future goals.
And yet, here I was, unable to DocuSign my name on my cracked iPhone screen – ironically, another perfect example of my analysis paralysis as the thought of selecting another phone to replace this 5 year old relic proved to be too much for me to wade through.
Much like admitting to J just how illogical the swirling thoughts in my mind were these days.
How many more new and interesting ways can you ride the struggle bus, M? When will you let it be over?
“I just… I just need til the end of the week. It will be done by Friday.”
“Will it?”
“Yes, it will be done. I just need a few more days to think.”
J sighed.
“Ok. Well, I’ll just have to plan a little celebration for the end of the week. Because we should celebrate, M. You’ve put a lot of work and thought into this.. stop overthinking!”
But that’s what I do…
The Show Must Go On…
“What can I do for you today, K?”
“At work, we do this lab screening stuff, and.. it says I’m diabetic and they told me I have high cholesterol! I don’t want to go on any meds – and I know you’d help me with the diet and exercise stuff. That’s your thing you’ve been harping on for the last 3 years!”
So you were listening… hmm.
“A, can you print my handout? We’re going to talk about healthy habits!”
A, my scribe, smirked as he handed over Dr. M’s infamous 4 page #howtoliveyourbestlife DIY handout. He had heard my “healthy habits” talk so frequently it had become a trigger phrase for him.
That’s why you say the phrase “healthy habits” these days, M. Just to get under his skin. You know that’s the only power those words hold nowadays.
Going through the motions of my script, I recited the lines from muscle memory:
- Walk me through your typical day in terms of what you eat – we can start trouble-shooting from there.
- This is your healthy food plate – I want half your plate to be fruits and veggies, cut your carbs back to just a quarter of your meals and try to limit red meat to just once a week.
- I’d like you to start walking 30 minutes, 5 days a week. Push yourself to the point where you can have a conversation, but slightly out of breath.
- Ideally everyone should be sleeping 7 hours a night, uninterrupted sleep. Any concerns for sleep apnea? If you’re not sleeping well, you’ll have more difficulty losing weight.
- Remember – baby steps. It takes 21 days to make a habit. I want you to make 3 goals and work on them one by one in 21 day increments. Systems, not willpower!
How many times had A witnessed this speech before he saw through my disingenuity? How many iterations had he seen before he realized I no longer had faith in my preventive medicine crusade?
Scribbling out K’s 3 top goals on the back of my handout, I finally handed it over to him with my patented encouragement smile.
“It took you a while to get this weight on, so it’s going to take a while to get it off. But I know you can do it.”
Do you though, M? How many times have you recited this just to be disappointed when they gain 15 lbs by their next appointment? You can’t will someone to success. Your encouragement smile isn’t enough to hold their feet to the fire, but go ahead, keep on smiling.
“I know you probably say this about a thousand times a day, doc. And I know you probably think this is falling on deaf ears since I haven’t listened to you before. But I’m ready now, and I’m excited to do this! I just wanted to thank you for spending the time… for everything.
Unexpectedly, the timber of K’s voice broke. He quickly glanced down at the handout, but the waffling of the papers betrayed his emotions.
“I knew you’d be the doctor who’d support me without pushing meds first. You’re going to help me change my life.”
As I watched K struggle to contain himself, I wondered about the journey that brought him to this point.
How much courage does it take for someone to open up his entire lifestyle to be dissected and critiqued by someone who has never walked in his shoes?
How much trust had he placed in me, knowing full well I could’ve just as easily ridiculed his baby steps to health rather than support his goal to start walking 15 minutes a day?
Had he ever allowed himself to ponder what life could look like without an additional 100 lbs weighing him down? Is this what was spurring the tears he was attempting to hide?
Don’t let him pull on your heart strings, M. You can’t go down this road right now… you aren’t even planning on sticking around long enough to see the end of his journey, remember?
“You’re going to do all the hard work, K, so remember to give yourself some credit! I can’t wait to see how you do. Let’s touch base in 3 months and recheck some labs then, okay?”
Guilt rushed in as he shook my hand before heading out the door.
3 months, not 4, eh? You didn’t want to push him out onto someone else’s schedule? Are you doing this for him or for you, M?
“You ok, Dr. M? You need a Starburst?” A asked intuitively.
It’s becoming harder for you to hide from your shadow, M. Time to deflect.
“You know, A, for as many times as you’ve heard my healthy habits spiel, I thought you would’ve picked up on the lack of candy on the healthy food plate by now.”
I softened the rebuke with another neutralizing smile on demand.
“I’ll see you after lunch!”
Today’s the Day
As I sat down to eat my woefully hypocritical lunch, scrolling through emails I came upon a friend’s latest message.
“I hope you’ve signed your contract by this point. If so, congratulations?”
This was the deadline you gave yourself, M. Today’s the day.
But… what if I just haven’t given this enough time? Is 3 years really long enough to see if the seeds I’ve planted will start coming to fruition? What if I start having more successes like this?
You won’t. The healthy ones will filter out, and then it’ll be the same shit, different person on a different day. You know this already, M! Just sign the contract already!
J’s voice echoed in my head.
“M, what else do you need to do before you sign? We went through this when you signed the letter of intent. You already had someone look at the contract and they thought it was reasonable. We’ve spent weekends looking at all the neighbourhoods for us to move to, hours on Zillow looking at houses! You’ve been looking at different jobs for months.
What else is there?”
What other options had I not unearthed? Had I left any stones unturned?
I tallied up the hours of research had I already done: Direct primary care, fellowship, joining another primary care clinic, locums in New Zealand or Australia, fleeing to Canada, hiding in the remote jungle so my student loan lenders would never find me.
I had made my pros and cons lists, wrote then re-wrote blog posts that would never see the light of day in an attempt to organize my thoughts and when that failed, agonized on the blog ad nauseam.
I reached out to would-be mentors, spent hours in quiet mindfulness meditation, read so many books on the scripting of our lives – all in search of a moment of clarity. Trying to imagine what I actually wanted my life to look like, I could only come up with,
“I don’t know… but not this.”
Despite all this, when all was said and done, I still found myself in this moment. Unable to make the commitment to my future. Still trying to hang on to my estranged career – because of… love?
No, M. Because of guilt. Because of fear. And they’re not good enough reasons to stay.
You can sit with your emotions, but you can’t let them get in the way. You know what needs to be done.
Let go to let grow
I took out my phone and poorly scribbled my signature in Docusign across the broken cracks of my screen.
Looking up, the sharp, bright edges of the computer screen blurred as my logical self leapt forward into the future, proclaiming as she left my emotional self behind,
It’s done, M. The headstone is complete: 8/2015 to 2/2019.
The four beige walls of my windowless office closed in as my emotional self shuddered down in a moment of silence.
You’ve got 3 minutes to mourn before your next patient, M. Make it quick, if you must.
The tears blurring my vision finally spilled their way onto my lap.
Time’s up, M! Pull yourself together – you still have another 3 months of this.
The show must go on.
Click HERE for Act 3
***
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Photo taken of light breaking through the clouds over the Columbia River Gorge at Fort Cascades, North Bonneville, WA.
The guilt is real. The guilt of leaving your patients and a job unfinished (or is it unfinishable. impossible?). The guilt of “giving up.” But guilt will give way to the excitement of a new adventure and knowing that you are doing the right thing for you!
You’re totally stealing my thunder for Act 3! But, the guilt is very real. It was especially hard when I was scheduling people out 6 months for follow up, knowing full well I wouldn’t be there. But, I was sworn to secrecy by my clinic to not tell patients until they were ready for that to go public.
Your clinic seems like it is run but a bunch of turds
Said like a true pediatrician 🤣
There are many ways to fix a broken world. Your next chapter will introduce you to broken people who need you just as desperately. And if the new job hurts you a little bit less than this one? Take the small victory and remember to be grateful.
Thank you for your sage words! Gratitude is something I’ve been trying to practice more, but I haven’t figured out how to make it cover up my guilt yet. Perhaps the answer is to be found elsewhere.
Death is a part of life. It’s also part of a medical career. When you’re a young naive medical student you have this idea of what medicine is going to be like. As reality sets in, your reasons for staying will evolve.
PCPs are saddled with many things, including guilt. For ER docs there is no fork in the road where we need to decide between idealism and practicality. The closest we come is deciding to move the meat for $x/hour vs moving the meat in academics for $0.5x/hour. Don’t beat yourself up for picking a job with better pay and better lifestyle.
Be true to yourself. The worst case scenario is you don’t like the hospitalist job and you go back to primary care after negotiating yourself a raise. I look forward to seeing where this journey goes.
I’m looking forward to it to, because I really don’t know where I’m going!
I suppose there’s something liberating about not having a specific destination in mind and allowing myself to meander for a bit. I’m consoling myself by telling myself I can always return to primary care at any time – it relieves the pressure of having to make this “perfect” decision.
We shall see.. apparently people I trained with always saw me as a hospitalist, not a PCP. I was perhaps too stubborn to see myself any other way,
Wow, actually teared up at K’s comments. I wasn’t expecting that. :/
It doesn’t sound like you’re entering this decision lightly — completely the opposite; in fact, as far opposite as a person can get from that. Haha. But coming from someone who religiously pro/con lists absolutely everything, I think you will have a deeper peace knowing that you left no stone unturned.
Wishing you all the best!
🤣 Well… I’m not known for doing anything half-baked. If I’m going to analyze something, you better believe it’ll have arrows, flowcharts and unnecessary spreadsheets to go along with it.
You’re right though.. I will be emotionally better off knowing I searched every avenue before committing, but in the meantime there is a lot of angst that could be avoided.
Oh well.. this is just my process and I’m stickin’ to it 🤷🏻♀️
M,
Good luck! New isn’t always better, but different can be a reprieve. Your comment on meandering resonated with me. It has felt really freeing not to have a rigid career plan and just let myself have a job for a while. Since my contract is measured in hours, not years, the perceived freedom is a huge boost – even if the day to day isn’t all that different.
I have noticed many references to the emotional labor of your work trying to make people feel not the way you feel. Or, maybe the way you feel like you should be making them feel? I am sure some of that is creative license. Do you think the emotional labor of denying the emotional experience in visit after visit has a lot to do with burnout?
Absolutely it does.
The thing with most people is that we’re emotional creatures, and we make decisions based on emotion most of the time, then support it with logic. I found I was most successful when I reached people in that way, rather than just coming down on them with hard facts and statistics. For example, everyone logically knows we’re supposed to diet and exercise, but the reasons why people don’t do it are usually emotional in nature.
I, for one, try not to emotionally imprint my feelings onto my patients and that can be difficult to do when they divulge such vulnerable things. So, I just put it onto the blog 🙂
Absolutely agree. I didn’t learn about narrative medicine and the like out of a personal interest. I am actually not inherently all that empathetic – I hate being ineffective. I tell my wife that when I am speaking in emotional terms I am speaking a second language, which takes twice as much effort. Learning how to relate to people’s emotions about their experience and translate those into action is how you are effective in medicine. But it takes time.
I for one think saying, “I gave them my reccomendation, if they do it or not is up to them.” Is a total copout – it is a way of blaming the patient for outcomes and the line used by doctors that seen 30+ people a day.
I think the line between letting people see that we are human, that we too bleed and not emotionally dumping on your patient’s is a very fine line. But I think it is a more healthy relationship when people know we are human too and have limits. I know my patient’s were far more appropriate in expressing care, sympathy, and support when our daughter died than my partners were.
Was working part time not an option? I negotiated working 3 days a week in the office but full call coverage as a family physician in 1991 as a woman with a toddler. No one was offering this, but I understood the need to pace myself and yet be available to patients and cover colleagues. I increased my time clinically as my family matured.
My career has taken many turns and bumps with reinventions. However, even with a period of burnout the choices never felt like selling-out.
Now I have the experience and seniority to call the shots. Everything from 5 weeks on and 3 weeks off to 4 days a week with the understanding that I can leave for 30 days a year to do expedition/humanitarian medicine, as a medical director.
I hope your future choices are as positive and career building as mine have been.
I was working 4.5 days a week for a time, then went down to 4 and still found myself burned out. Part of it was my panel was approaching 2000 patients, so I was just cramming more things in less time, and when that didn’t work, I was logging in on my off days. 3 days a week would have been optimal, but unfortunately I still have student loans to pay so hospitalist medicine it is…
I suspect I’m older than you since I became a physician after being a nurse for 20 years, but we finished residency at the same time. You lasted longer than I did- after 18 months I negotiated out of my contract and opened a DPC practice down the street. Now 18 months into this venture I am tired but in a vastly different way. The connection with my patients is stronger, too strong at times. I’m working on boundaries. But I love that I am in control of this whole process. What I would say about guilt is it’s a useless emotion- sucks power from you, leads to self-harm on many levels. I think our profession self selects people who can create tons of guilt! I’ve been envisioning my next few years- right now I’m wondering how much it would cost me to hire someone to work for me every 6 weeks for 2 weeks (instead of 5/3)! That’s the greatest idea I’ve ever heard.
Congratulations on opening up your successful DPC practice! I really considered doing that for a long time – had even thought about going to the Nuts and Bolts conference in November. DPC would best fit my personality and the way I want to practice medicine. But, I’m just too financially insecure to do that right now, with my student loans still looming over me and whatnot.
In the meantime, contending with the amount of guilt I’ve had with “abandoning” my patients has been difficult – my words, not theirs. I actually write about that in this week’s post. I agree with you – guilt itself is useless, but it is also a marker of how much I still do care and that is reassuring in and of itself to me (how pathologic is that?!)
Everyone is swimming in the same ocean trying to avoid the sharks, if we can be strong and say no to 15 minute visits and write our daily script according to both our needs and the patients, we can slow down the dehumanization and “ I quit “ this chaos milleu. DOCTORS, not administrators need to orchestrate the symphony. The worst of it is that the patients are paying big premiums in the entire fiasco of medical care.
100% agree. Now how to make this happen in this current environment, that is the question.
M., I’ve been in practice for 13 years in a rural community and in September decided I could no longer be an army of one. So, after being in this community for 25 years, I am going to take a Locum Tenens position in Ct.. I have decided to leave my MA here while I am gone. She will hedge the issues. All my patients know I am going, having started to prepare them in October. I have told them I am a phone call away. This new position is for 4 months, hopefully enough time to reassess where I want to go and how I’m going to get there.
I understand and empathize with your angst. It is hard to separate from people who have become like family. In fact, I see them more than I see or talk to my own family. But, one thing I have learned over my 27 years of doctoring, there are always people who need healing. Wherever you go, you will be met with gratitude. You have a gift of knowledge and compassion. While you seem to feel it has become a thankless task of repetitiveness, there are going to be many times you say to yourself “I saved him- now I can die”. I live for those moments. You will too. Every time you make a correct diagnosis, catch a cancer in Stage 1, diagnose CHF in someone who has been told they have a cold, or see that LAD blockage on an EKG, you should pat yourself on the back; for you have saved a life. That’s why most of us became doctors.
The BS that the insurance companies and the government have buried us in should never negate the good work you do. You have to play the game, but no one says you have to play it their way. I love a good fight with the insurance companies. They count on us to get defeated. I get angry and release the wrath of Julie on them. It’s very cathartic. I take their names and tell them I am putting it in the patient record so they can be listed in the lawsuit. I never roll over and play dead. I guess you could say I let my protective side, the mothering side, come out swinging. My staff get the popcorn out when they know I’m going to call. They love the show. And I love to win.
Yes, it is tiring and frustrating- and not at all what I thought a practice was going to entail. But it is all about saving lives- one way or another.
So, M., cry if you must, curse when you need to, but always remember to pat yourself on the back. You, my dear, are a healer.
Thank you so much for your kind words.
The office also enjoys when I fight with the insurance companies – the claws definitely come out. But, after so many fights I came to realize I was just participating in little skirmishes but still losing the war. We are so many little armies of one – if anything is going to change, we need to come together and evoke change.
I don’t know when that’s going to happen or how, so I’m hoping to use this career shift to create some breathing room and space so I can plan my next moves. I wish you the best in your future endeavours and I hope you also find your peace.
Best.