“Dr. M… so glad I caught you before you walked into that room! Be prepared for A LOT of questions about vitamins and supplements in there. Husband hasn’t stopped complaining about all of the ‘horrible food’ at the hospital since you left the room yesterday.”
Suppressing a sigh, I tried to barricade yesterday’s hour long discussion about how we were all trying to poison his wife from ruining my day. Again.
“You are literally asking us to decide whether or not we want to inject poison into my wife’s body, as if you people know what you’re doing to preserve health! I mean look at this menu! French fries, hamburgers and pasta at a “health” institution?! This is such a joke! The system is doing all it can to turn us into repeat customers.”
I mean… he’s not wrong, M. You actually agree with that statement 100%. Now, do you engage or not? How much longer do you want to go round and round in circles and still not accomplish anything? You will never change their minds. This is the definition of NOT high yield.
Preparing to guillotine this conversation, I fell back on my reconciliatory smile.
“You’re absolutely right. The food here is not the healthiest and it’s a shame. And you’re also right about the chemotherapy the oncologist talked about for your wife’s leukemia. It is literally poison. It will wreak havoc on her body and a lot of healthy cells will be collateral damage.
I guess the question you have to answer for yourselves is: Is it worth the extra time you’ll have together? Is it worth the months or years this could buy you? And I can’t weigh that decision for you. I can only tell you what your options are… the choice is yours to make. You don’t have to choose right now. I’ll be back tomorrow, ok?”
Now tomorrow was here. And it seemed he was fully prepared to pick up this conversation where I had tried to leave it. An hour of my life from yesterday I wouldn’t get back.
How much time would they take today?
Walking into the room, I was distracted by the glow of reiki crystals scattering the light as they perched on the windowsill. The purple hue covering his shoulders was quickly cast off as he popped out of the chair to greet me, list of things to address clasped in his hands.
“I see you have a list for me this morning!”
Tone down the forced cheerfulness, M. You have to make this believable.
“Yes, well, after our discussion yesterday about nutrition I wanted to run a few things by you. As you know, my wife simply cannot drink that Boost or Ensure garbage. It’s not even real food. So, would it be alright if we bring in our own vegan protein powder to add to her smoothies? It has Vitamin C and E for the antioxidants which I’ve been reading is really important for her…”
As he pulled each supplement and natural remedy out of his reusable cloth bag to show me, outlining the benefits of each item, I wondered how long he had spent standing at his pantry last night.
Carefully selecting and researching how these things could help his wife.
Trying to do his part to help in her healing.
Trying to take back control of this shitty situation.
They had spent their entire lives avoiding the big bad healthcare system. They had believed if they just ate the right things, walked their 10,000 steps a day, had monthly visits with their naturopath, they could exert some control over when death would come for them.
And now it was here in the form of a white blood cell count of 290,000. Crowding out the rest of her blood cells, causing profound anemia requiring multiple blood transfusions and IV sites to ooze and bleed because her platelets were so low.
They believed their naturopath when she promised these personalized tinctures would heal her bone marrow. Back when her white count was 30,000, then 100,000 then 200,000.
Even in the face of this glaring failure, he was still reaching for these remedies, emphatically showing me the labels as if to prove to me that they tried.
And they were still trying in the best way they could.
They weren’t ready to give up.
Taking a seat next to his wife’s bed, my actual patient, I regarded her for what felt like an eternity. A pale, tired woman with a line of dark red blood infusing into her right arm. Was it was sustaining her or sucking her life force away? In the last 4 days, she could barely muster the energy to express herself, so weighed down by her illness and uncertainty of the path I was leading her on.
“Have you made your decision yet? No rush, but it does help us determine which path we’re going to pursue. If you choose chemotherapy, you’re certainly not strong enough to go back home – we would then look into the different facilities you could go to. If you choose hospice as we’ve discussed, we could help you find the best fit for you and maybe even get you home.”
“I… I don’t know.”
I watched as the tears from her left eye dripped down across her nasal bridge to meet up with the pool of tears in her right. Every day I saw her in the same state – curled up in the fetal position on her right side. Did she even remember a time when the world wasn’t sideways?
Her husband approached the opposite side of the bed and fiddled with the tape holding up The Lord’s Prayer plastered on the side rail. How had I never noticed this before? The dissonance between the familiar verse and the purple reiki crystal pulled me out of her grief, if just for a moment.
Just long enough to know it was time for our moment together to end.
“That’s alright. You’re still going to be here for at least another day. But I did want to tell you today’s my last day. Tomorrow, Dr. T will be taking over and he is a wonderful physician. He’ll take good care of you. But, he’s going to ask you the same questions I asked you today, so I want you to be prepared for that.
I do wish you the best of luck, no matter what you choose to do.”
Nodding in assent, she unexpectedly reached out to me with her frail hand.
“Thank you, Dr. M. Thank you for your care and for your time. And for listening. This… this is not what we expected our experience with the medical system to be. And although we hate that we’re here, I’m glad we started off with you.”
Unsure of my response, I took her hand in mine and gave it a gentle squeeze.
“… Thank you for saying that. Take care.”
Walking toward the door, I could feel the tears that would never be shed burning a trail behind my eyes.
Tears for her as she continued to struggle against the knowledge that her entire life’s philosophy had failed to prevent the thing she couldn’t predict.
Tears for them as they fell for my act of compassionate doctor, blissfully unaware of the cynicism in my mind essentially writing her off before we even started today.
Tears for me because I could feel myself being sucked back into medicine even after deciding I was done.
As I arrived home that evening, I spied another hue of purple glowing near the windowsill. A 4 month old thank you gift from one of my old clinic patients that I was determined to keep alive.
“Thank you” flowersEvery day, the flowing script reminds me of the doctor I had wanted to be. The one I still pretend to be as the compassion is leeched out and overtaken by something much more sinister.
Every thank you, every handcrafted stained glass memento or Disney princess painstakingly colored by an enthusiastic kiddo pulls me back into the profession I fantasize about abandoning.
Do they know how their little gestures have me trapped? That I would do anything – endure someone reading a label to me or watch the tears roll down their face – just to capture their fleeting moment of gratitude?
It’s not healthy.
But this is why we stay, isn’t it?
***
Some apologies are in order… if you’ve been checking in every Wednesday to read the newest post but have only been met with crickets, sorry!
I’ve all but given up on trying to get my posts out on a regular schedule. I tried to make you my accountabilibuddy, but things like going for evening walks with my dogs and husband, catching up with friends IRL and trying not to eat garbage food just get in the way. Apparently self care takes time – and I encourage you to take time for yourself as well!
I guess I’ll just make the announcement now that new posts will come out every week-ish. Like Wednesday or Thursday. Ish. Which also includes Friday.
If you want to keep checking in randomly throughout the week, please continue to do so!
But if you’re all about maximizing efficiency and being in the know when new posts come out, sign up for the weekly-ish newsletter here ↓
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Photo taken of a random gnarly tree somewhere in the Pacific Northwest.
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Thanks M for sharing this.
So it did look like your days as a hospitalist are over. Are you transitioning to another medical job where you practice as a physician or are you transitioning out of medicine completely?
Keep us in the loop.
I think she meant her last day on service before her mini-break – not last day as a hospitalist.
Yup. Although I did fantasize about it being my last day as a hospitalist!
Haha.. but how am I supposed to keep up the suspense to keep you reading??
I promise I’m not stringing you along, I just have no idea what I’m doing. Which I’ve decided I’m going to have to be ok with for now.
This hospitalist chapter will be short lived but it’s not over yet. I’m trying to figure out my next move and until then, I can make this work to pay the bills/student loans. At this point, it’ll still be something in healthcare but I don’t know what that looks like yet.
In an ideal world, I’d be that doc who helps people get off their medicines like in Forks Over Knives, but I just haven’t seen an actual practice model that does this successfully. We shall see!
M,
I read somewhere the root of burnout is a felt/experienced lack of efficacy. How we get that sense of efficacy is individual to us all. The EMR, Assembly-line Medicine, and a culture of entitlement all undermine our efficacy. The question becomes, are the small tokens of thanks enough to support our sense of efficacy? To make us feel like all our work matters? Are there other ways to feel more efficacious over which we have more control and influence? That are less codependent?
I think when we can sit down and have those conversations you had with patients without feeling like we are cynically pretending to be someone else, that helps. It is difficult to find that energy and time in Assembly-Line Medicine.
The only way I have found to make space to feel genuinely present in those moments is to work less and in a less frantic environment. This way, when someone needs that from you, you have the sincere emotional reserve to offer them.
But, the system doesn’t want to “waste” such a valuable resource as your RVU generating time.
I hope that your time away from the hospital is bearing the fruit of the life you have been trying to rebuild after medicine.
That has been the one benefit of the hospitalist gig – the chunks of time off. However, they had me scheduled in chunks of 2-3 shifts then off 2-3 days, rapidly alternating days and nights for most of the spring which was awful. For as much time as I used to spend counseling my patients on the importance of sleep when I was a PCP, I was doing the exact opposite of that.
It’s unsustainable and the RVU production model is unsustainable as well. I’ve just come to a point that I’m going to spend the time when I see fit, and if I don’t hit their inane metrics, I just don’t give a shit. Because we don’t generate “products”, we take care of people.
To your original point, I’m more effective if I take care of people. So me getting all the little bubbles to green in Epic or making sure I organize the problem list in level of priority is just not where I spend my time. We’ll see if it sustains me for the rest of my contract, or at least until I can pay off the rest of my loans and run out the door.
The EMR is cleverly designed to take advantage of the physician personality need to be thorough and perfect. Behavioral Psychology at its most devious. At some point you have to say fuck it.
As far as the cynicism vs compassion and “pretending.”
I like to remind myself if light can be both a particle and a wave, I can probably hold 2 or more seemingly diametrically emotions within myself, multiple times a day or even within the same minute.
Oscillation is the nature of the universe (metamodernism).
In that vein, I wonder if, in fact, you actually are the deeply compassion, caring person that you “pretend” to be for patients. And, the cynicism is an armor you’ve been using so long to protect yourself from the vulnerability of feeling your patient’s pain that, out of habit, you have come to feel it to be your true self and the compassionate words as the falshood.
Compassion – from the latin: cum(with) + pati (suffer). True compassion is, by definition, painful. It would only be natural to try and protect ourselves.
I’m going to have to sit with this for a while.
Not only am I having flashbacks to physics which I absolutely hated, but also because there is a certain comfort to identifying with being cynical having been that for so long, that the thought of me being compassionate at baseline is difficult to swallow. Not sure if that makes sense… it’s definitely something I will ponder.
M
You’re young in your career, I’m old. Getting old does something it gives you wisdom perspective and resources. My practice was Anesthesia with some Pain on the side so I had a clinic as well. In the course of my time in town I did about 25,000 anesthetics and 25,000 pain procedures. The point of that is over decades I touched a lot of lives and a lot of families, some I knew but some family members I didn’t. I was out one day at the UPS store and a girl a couple people back was whispering to her friend “that guy was my anesthesiologist and gave me my epidural when I had Cloe”, I glanced back and she asked “do you remember me? Of course I did but I shot back I don’t know: turn around! Totally cracked her up. Another time I was at a party for my friends Dad at my Church. There were about 50 people there. I glanced around the room and realized I had at some point cared for 48 of them including her and her Dad. I attended the birth of their children, took out their gall bladders, pinned their broken bones, and treated their pain syndromes. One day around when I was retiring I was in Walgreens. I rounded a corner and there was a guy holding 2 bottles of tylenol. One version 3 bux more than the other because of some special disolveing or something. He caught my eye and said HEY DOC WHICH ONE???? I dutifully took the bottles saw which was cheaper and said THIS ONE and gave them back. I didn’t know this guy from Adam. I had probably taken care of his Mom or sister, and because of that he knew exactly who I was. I was someone he could trust. I was someone who devoted his life to fighting against the chaos in my own particular way. You want to know WHY? This is why. It takes time to make a measurable difference, but for any given patient a difference you do make. Yes there are personal costs, BFD. There is plenty of gain as well.
There’s so much great stuff in this post, but I want to shine a light on something you said toward the end: “…they fell for my act of compassionate doctor, blissfully unaware of the cynicism in my mind essentially writing her off before we even started today.”
I think doctors and patients alike should embrace – or at least accept – the fact that compassion and cynicism in medicine are not mutually exclusive. My whole blog is actually predicated on that concept, so I know of what I speak. For me, some readers understand that my harsh tone comes from a place of caring, but reflects my frustration with quacks who hurt people and patients who stubbornly continue to hurt themselves. Others write me off as an a*hole, not appreciating the existence of nuance in my approach.
The point is, you can be cynical and compassionate at the same time. I understand that you feel like you’re faking the compassion part right now, but I wonder what the split is on fake/real. Maybe 80/20? 90/10? Or maybe you’re closer to 70/30? The fact that you still want to make these sorts of connections with people speaks to the possibility that you’re not 100/0.
In the immortal words of Jim Carrey’s character in Dumb and Dumber, “So you’re sayin’ there’s a chance!”
I actually get your reference this time! But would it surprise you that I’ve never watched that movie in full?? Sacrilege, I know.
Anyway, your point reminds me of that Meredith Brooks song (B*tch) from middle school – I think you may recall that from med school, actually 😧
I suppose my problem is I view the compassion and cynicism as dichotomous in nature, when I really should allow myself to be all these things rolled up into one. The split between fake and real is a very fine line and I waffle between the two constantly, so I’m really not sure what the ratio is. You can’t truly connect and have meaningful conversations unless the other person feels real compassion there, so I would be completely ineffective if real was at 0.
Not sure how other people operate, but that’s just me.
Yes, it sounds like you really need to give yourself permission to feel whatever you’re feeling at the moment – whether it’s compassion or cynicism – without thinking you have to conform to some idealized expectation of how a doctor should be. I think you’re too hard on yourself.
Very informative post about the history of doctors . I read in this article the things i didn’t know before. Thanks for the wonderful sharing!
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