Rounding the corner back to my office, I spied A with his black rain coat on and immediately felt burdened with a heavy sense of knowing. His smile (or was it a grimace?) seemed forced as our eyes locked.
“Leaving?”
“Yeah.”
“You have all your stuff?”
I glanced at the Bates’ Guide to Physical Examination and History Taking textbook clutched in his hands.
“Here, take this,” I said as I handed A the old relic from my first year of med school. “This will help you understand how I organize my questions and exam when you scribe.”
“Are you sure, Dr. M?“
“Yes, please take it! I don’t even want it back – I haven’t opened it in 10 years. It’s just been sitting on my shelf to make me look smart.“
Now it was going to a good home to live a second life. Minimalism FTW.
Moving my gaze over to his computer station, I now spied the empty spot where the Post It note listing A’s future unborn children’s names had once been displayed. 8 inside jokes that would never be understood again.
“It’s only 4! Where are you going?” S, the phone nurse poked her head out of her little work station.
“I’m headed out… and I’m not coming back. It was a pleasure working with you, S.”
“What? What happened?”
“There was a… disagreement between the office manager and I. I’ll just say this has been the most poorly managed business I have ever worked for. But you were great.”
As I watched them shake hands, I didn’t know what to say.
How do you say goodbye to someone who unexpectedly brought joy back into your work life, just by the mere fact that everything was new and exciting to him?
How do you send someone off who learned how to read your tells in a matter of 3 months when it takes most people years to peel back the layers?
How do I tell someone how much I appreciated the rarity of meeting a person who shared my love of classical pianist Ludovico Einaudi’s Nuvole Bianche, Netflix’s Big Mouth and mutual hatred of Christmas consumerism and music all rolled into one? That every orange Starburst and right Twix that magically appeared at my workstation after difficult patient interactions gave me the strength to resist the urge to run out of the clinic, even as I lectured him about finding better coping mechanisms?
Remember you supported him with this decision, M. This is how it had to happen. Don’t get all sappy now.
“So I guess I’ll see you at run club then?”
“For sure. I’ll be there.”
“Ok… well, I’ll see you when I see you.”
So many words left unsaid, but this was neither the time nor the place for it.
Watching A walk away for the last time, S quietly stated,
“Well… there goes 46.”
“46?”
“Yes. 46 people who’ve come and gone since I’ve been here, and I only started a few months after you Dr. M. That’s a lot in 3 years. That’s a lot for a place that employs less than 20 people.”
Tallying up the numbers in my head, I was confounded when they added up. I personally had been through 9 medical assistants. NINE. Not to mention the 5 front desk people who once had been assigned to me.
“Wow, S. You’re absolutely right.”
“Isn’t it awful? That’s why I just keep my head down, do my job and head out. If you think about it too much, it just gets you all sorts of mad.”
Another One Bites The Dust…
I haven’t really talked much about my toxic work environment as a cause of my burnout, not because it didn’t exist at my clinic but because this seems to be universal in all of healthcare at all levels. What else could I possibly add to this discussion?
This is the reality of the world we work in.
Fear based leadership. Seeing people as cogs in a machine, to be spent in any way deemed useful to the organization with no concern for the actual person. There will always be another you – don’t forget, you are easily replaceable.
Toxic Work Environment
In my love for click-baity listicles, I came across Bustle’s 19 Signs Your Work Environment Is Toxic & Affecting You Negatively a while ago. I tallied up the number as I found myself nodding my head while reading down the list: 17 of these signs resonated deeply with me.
How did I get to this point? 3 years in and only now was I willing to take the blinders off!?
As I saw this Humans of New York post make its rounds on social media, I realized the conditioning starts early on in our careers:
Residents and med students are trained to just keep our heads down, do our jobs and not make too much of a ruckus, lest we be called disruptors. We are discouraged from taking a stand against abusive behaviour. No one wants to be that person making too many waves, especially those of us who prefer to be known as collaborators.
This continuously reinforced behaviour results in us putting up with toxic work environments when we get out.
In place of malignant attendings, in the attending world we now have healthcare executives, administrators and sometimes even patients to fill these roles. And still we stay silent as a learned response.
A had the perspective of someone who worked in an entirely different industry – engineering – and was appalled by the toxic state of my clinic. After 3 awkward showdowns where he drew his boundaries of what were reasonable expectations at work, he voted with his feet and left after a major disagreement with the office manager.
On one hand, I worry about A’s ability to tolerate a future in healthcare as this toxicity is prevalent everywhere. Yet on the other, it gives me hope that future generations will no longer have the tolerance to put up with this shit we’ve been putting up with for so long.
Keeping my oath of silence
My first year in private practice was a honeymoon period – anything was better than residency. As time went on, however, I slowly allowed myself to see the true colours of my office manager: a Professor Umbridge with a sickeningly saccharine exterior covering up the most villainous personality.
Unbeknownst to me, the clinic had a revolving door installed the day she was hired on.
While S has continued her countdown to 46 departures, there has not been one question from the practice owners and office manager. No self-reflection on what could possibly be causing this. We’ll just hire another has been the overriding sentiment from management.
The fact that they’re not even asking any questions indicates they aren’t ready for or even care to hear my input on this glaring problem.
And why should they?
Since I announced my departure, I have seen the tide turn against me. I am no longer part of their doctor tribe – I am now “just” one of the office staff and as such, the veneer of caring has vanished.
I have become “poison” to their organization and with A’s quick arrival and departure, this only serves to vindicate their stance as they fully turn against me.
However, what they fail to see is the other employees are now confronting their complacency and learned helplessness while they watch both A and I leave in rapid succession. There is no need for me to add more fuel to this dumpster fire of their own creation.
They will eventually reap what they sow.
Keep your head down…
Private practice, the thing that was supposed to save medicine from corporatization, is not immune to the traps of bureaucracy and poor management.
In this more intimate setting, the betrayal feels much more personal as I’m being openly pushed out by the community I had longed to be a part of since I was a child. At least with healthcare corporations, my overlords could remain faceless names. Now I navigate landmines daily with every interaction with my colleagues as I serve out the rest of my 120 day sentence.
The thing about A being by my side was that I could make believe for a moment that I wasn’t alone here.
Now as I retreat down the empty hallway to my office in silence, in my head this mantra plays on repeat:
Keep your head down.
Do your job.
Head out.
22.5 more working days left.
***
Photo taken of J, Oliver and Ernie walking under Spanish moss at Trillium Lake, OR.
I’m sorry your colleagues turned on you. That is a betrayal that most cut deep.
I work with a few people who seem incapable of having a normal human conversation. Their cruelty is the casual and indifferent sort. It is sad to see how their begavior effects those around them and even sadder to see these happy smiling interns get crushed by the weight of it all.
Medicine is in desperate need of a culture change from the top down.
I agree – a culture shift is necessary. The thing that saddens me the most is seeing physicians turn on their own colleagues. I was wooed by their advertisement of a “family feel” to the clinic, but it ended up being one of those families you avoid like the plague at forced family reunions.
A supportive work culture is just so much more effective and it’s really not that difficult to not be a jerk.
I think this will be something I’ll never be able to wrap my mind around.
The medical office and hospital environments are as dysfunctional as thet are toxic, and these two negative attributes seem to feed off one another. It takes nearly everyone to go above and beyond the call of duty and well outside their job descriptions, everyday, for the system to function even at such a pathetic level.
I suspect that your office pays poorly, in addition to ineffective leadership. That amount of turnover is not the norm and likely, indirectly or directly, contributed a great deal to your professional dissatisfaction.
The pay is often cited as the reason people leave the clinic, but for those who remain we all know what the real reasons are.
I personally view my medical assistants/nurses/scribes/front desk people as an extension of me. They represent me whenever they interact with a patient, pharmacy, etc – why wouldn’t I want to give them the tools/skills/pay for them to be successful?? But apparently the practice overlords don’t see it in that way.
There has been such an “us” vs “them” mentality, one that is unnecessary and ultimately hurtful to our shared goal: to provide good care. Maybe I’m just naive and don’t know how to properly run a practice, but I definitely know how NOT to run one based on these last 3 years.
M,
This really resonated with me. Before I left my old position, the place I worked had lost a doctor (not including me), dietician, 2 office managers, 2-3 nurses, my MA left once she knew I was going to leave, several other office people, a DON and there were more. It was obscene. I felt like I was on a sinking ship screaming about the water pouring in through a hole in the hull while everyone else (literally) argued about color schemes.
To the one of my coworkers, I literally used the words dumpster fire to describe the situation: you know you’re millennial when?
I actually increasingly believe creating and maintaining a healthy work culture is extremely difficult and requires discipline and focus, otherwise they would be the norm, not the exception. Few people have that level of discipline – especially managers and admin people, and doctors aren’t trained in leadership – though we should be.
It is bleak out here sometimes.
😢 I agree with you – many people in leadership are poorly suited for these roles. Often times it seems their credentials are more highly rated than their actual effectiveness as leaders.
However, if the RIGHT people are in these roles, people who are consistently leading from their values, who aren’t afraid of having real conversations in difficult situations, who stay curious when it’s proven that they’re wrong and are willing to admit they may have blind spots, maintaining a healthy work culture should come as second nature because that is just a natural extension of who they are. A good leader empowers people to work to the fullest extent of their abilities, not to jam people into a box of preset criteria that stifles their potential. A good leader inspires, not mandates.
What I’ve encountered with different bosses/superiors over the years is that when someone has to keep saying they’re the boss, it usually means they have zero influence, thus they rely on fear based tactics to get what they want. This is unfortunately the norm in healthcare, and one that is counterproductive.
But, we can do better. I, for one, am really excited to read Brene Brown’s Daring to Lead book – it’s my Christmas gift to myself 🙂 I highly recommend you check it out! Perhaps it is your turn to try your hand at leadership!
I am sorry to hear that everyone at your office has to go through this. While there are things that could be better where I work, it is not nearly as toxic as yours.
You are absolutely right to leave, and I cannot wait to see what the future brings! I applaud you for not being a bystander who keeps their head down. And I encourage you to tell them exactly what you think upon leaving. Maybe it’ll make it better for those left behind?
TPP
Perhaps! Or if my feedback isn’t well received it’ll be like walking away from an explosion. I’m sure it’s as glamorous as they make it out to be on TV 🙂
I hope you find your way through your own toxic stew at your workplace – hopefully they’re more receptive there to change.
To quote the assistant football coach in Dazed & Confused, “OTSS. Only the Strong Survive!” That’s pretty much the mentality in our profession and it’s very pervasive.
Put up or shut up.
What doesn’t kill you only makes you stronger.
It’s time to move on from these tired notions, but they’re so deeply ingrained, that I’m afraid it could take a generation or two to effect meaningful change.
Best,
-PoF
Yes, most changes occur with generational shifts.
I see my generation starting to challenge these previously held beliefs and and voting with our feet by walking out. In order for the medical machine to survive, it will have to adapt or it’ll be replaced.
M,
I was conversing about this very topic with Doc G and some other bloggers last night – I think that more physicians reaching financial independence is going to be turning point for medicine becoming less toxic.
Right now we are interchangeable widgets, but our learned helplessness is essential to maintaining our downtrodden state. We are in debt. We spend. So we need those W-2 jobs, and save for the occasional unicorn groups, medicine is now a corporate gig with little chance to own your business. Most jobs suckle at the teat of Corporate Medicine.
Envision a day when financially literate physicians, docs who live a more values-driven life with lower spending, decide to say no, I will not accept your crappy job. I will not work an inordinate number of hours. I will not accept your substandard conditions. The system depends on the financial servitude of the physician-worker bee.
Once we reach a critical mass, where the system needs physicians far more than physicians need the paycheck, the job either gets much better or it doesn’t get filled.
You may say I’m a dreamer, but I’m not the only one…
Fondly,
CD
CD,
As I read your inspiring words, I imagined that this is what it would have felt like to watch Braveheart give his uprising speech prior to going into battle!
In order for your dream to become a reality, I think the first step needs to be changing the culture of what “full time” work is to physicians, which is why I’m always excited to read another one of your posts of Doctors Who Cut Back. As a young attending, I didn’t really have any models of physicians limiting work to 40 hours a week to emulate, so I fell into the pattern of the typical “full time” doc working 50-60 hours a week. Once we can wrap our minds around working a 40 hour work week as a profession, the next natural step in that evolution is to find a way to make that work financially.
America’s economy in general is dependent on consumption and the ensuing financial servitude of its worker bees, as you put it. I think Xrayvsn had done a recent post about how the world would end if we all decided to FIRE 🙂 I do think though, we would all be better if we could all live a values-driven life, which is why I am a big advocate of minimalism. You definitely aren’t the only dreamer 🙂
Thanks for dropping by and I hope you have a wonderful holiday!
M
I’m not sure I would say “Healthcare workplaces” are toxic. MBA’s are toxic. Physicians already run themselves at 2 SD above the mean levels of effort, MBA ‘s try to whip an extra SD (3 SD) level of performance out of you. The energy expenditure going from 2 to 3 is enormous even if you possess the natural ability to do 3 SD. Many of us are not 3 SD. The solution is to be who you is and understand the game that is being played.
You speak of fear based management, what’s the fear? They won’t like you? They’ll think you’re not good enough? You’ll get fired? Guess what you’re leaving anyway. In the first century, Seneca said, “We suffer more in imagination than in reality.” Here’s the 411 they don’t make money without you, them’s the facts and that’s your feature, no need to be bullied. This place you work is a toxic place to work, so go work somewhere else. Today you’re smarter than you were yesterday because of your experience. Tomorrow you’ll be smarter still. I did medicine for 35 years and always had a hamburger to eat a car to drive, a roof over my head and so did my wife and so did my kids. You’re pretty much bullet proof. You already did all the hard part, so go make your life into what pleases you.
Words to live by – if you could give a pep talk to all of my peers who struggle with learned helplessness, they would be better off for it.
I had a toxic work placement really early on in my training and I attribute that period of time as the beginning of my growing cynicism towards medicine. Like you, I resolved to count down the days until it ended.
Good luck M.
I have 2 countdowns going – my calendar date countdown app and my number of working days left! It’s a little obnoxious, but it’s what keeps me going some days.
For me, remembering the impermanence of things is helpful. This too shall end, one way or another… I’m just trying to make sure this is an ending of my choosing 🙂
At least in primary care, what patients want and what partners/administrators want are in conflict.
Patients want their list of various concerns addressed fully at each visit. They want 30 minutes or longer. They want convenience, especially if it’s free: phone time and/or emails-preferably not with an advice nurse or other “non-provider.”
Partners/administrators want numbers; ideally 4 patients per hour, seen in clinic, for 36 hours per week. Preferably such care is delivered by a provider “working at the top of their license” who can be paid at the lowest rate without violating scope of practice issues.
There also will be conflict with “value-based” care. A patient’s concept of value is different than that of an expert reviewer. It may be easier to pass a camel through the eye of a needle than it will be to get 5 stars from Press-Ganey while “Choosing Wisely.”
It is so fascinating to see what’s happening in medicine – I think most of us would say we went into medicine to help people. Most of us were told in medical training, “Patients first”.
Then, you walk out as an attending and realize you will actually spend your entire career torn between doing what your patients want and what admin wants – it is completely demoralizing and sets people up for failure. It’s no wonder so many of us are burning out.
Thank you for sharing your experience. I am currently going through a similar situation and found it extremely helpful and comforting to read your words as well as the comments. I was also sold the small group/close family dynamic until I realized how dysfunctional and toxic of a family it was. Things did not go well when I raised my concerns and asked to set boundaries. And now, after quitting, I have certainly become the enemy and retaliation (in the form of increased workload, new PTO rules, and non-disclosure agreement) is rife. It is certainly not how I envisioned my first job to have played out but here I am…..just keeping my head down and counting down the days….
I’m so sorry – I wish I could say your dream job is waiting for you out there, but 2+ years after writing this post, I’m still hard pressed to believe it. BUT there are less toxic jobs out there that buy you a little more breathing room until you find what you’re looking for. Baby steps are sometimes all we need.
M