“I see you went with the Half Windsor.”
“Yup.”
Looking up to meet A‘s seafoam green eyes, I watched him calculate my smirk.
How long ago was it we were debating the downfalls of the Half Windsor (wonky) versus Full Windsor (too full for a skinny tie) versus the Eldridge which was too much for A to even bear to look at? Before he quit as my scribe 8 months ago, I had tried to convince him to donate to Chuck Norris’ kickstarter for the Go Tie, The World’s First Pre-Tied Adjustable Necktie per its tagline – perfect for today’s momentous occasion:
A’s white coat ceremony.
“You know, everyone else complimented me on the tie. You’re the only one who mentioned the knot.”
Holding back the sarcastic response he was probably expecting, I settled on a compliment instead as I assessed the floral blue tie partially obscured by his brand spanking new white coat. It was his day, after all.
“It’s a nice tie. Looks good.”
The lobby was abuzz with excitement as hordes of short white coats holding flowers and cell phones walked on by. Proud parents with tears in their eyes and siblings posing everybody for the mandatory pictures all seemed to set up shop in the exact amount of space they’d need, lest they intrude on other people’s shots.
Such an interesting social exercise – when did we all agree to these unspoken rules?
I thought back to my requisite photo of J and I, pulled up on Facebook right before A’s ceremony to reminisce while we killed some time.
It seemed so long ago – would the woman standing proudly in that short white coat still recognize the person she’d turn into today? Could she have imagined her swift descent into cynicism, her idealistic self replaced by a physician who would write ad nauseum about burnout 12 years later?
It was surreal being on the other side, now observing these young student doctors actually excited to jump into a free fall, not entirely sure where they’d land but convinced they were still going to make it out intact.
As the event played out, the unease I’d attempted to stuff down on my arrival began to swell. In truth, it started the moment A invited J and I to attend.
“There are so many people who should be in front of me on that list. Are you sure??”
“Now you’re making it weird.”
“OH, I can make things weird.”
“I know you can.”
“…
Okay. Well, thank you for the invite. I’ll be there.”
You’re not supposed to be here, M.
Over the hour of speeches by people with plenty of letters and fancy titles after their names, eye-rolling turned into a churning fury.
“Today, we celebrate the induction of these amazing people before you into the honorable, noble profession of medicine. Today, you enter into a lifetime of public service.”
“Don’t just hear your patients, listen to them. We listen so we can guide and comfort and heal. Be the compassion we need in this world.”
“You are the future – we need YOU to lead the way.”
Did anyone ever stop to think how irresponsible it is to build people up so high, just to push them off a cliff? Or were these people in the high tower of academia so divorced from reality they didn’t realize what they were going to drop these future doctors into? Did they have another speech ready for them at their commencement ceremony?
Welcome to your future, young compassionate doctor.
We are counting on YOU to lead the way. As long as the way is exactly the way it’s always been done.
If you don’t like it, you can leave! Except you can’t, because you probably owe $200,000+ at 7% in med school loans. So I guess… suck it up, buttercup? It’s called resilience. Stop being such a snowflake.
Instead, when you’re feeling down, remember to practice gratitude. You can learn more about a mindfulness, gratitude practice at the conference you can go to during your one day off this week, but here’s the cliff notes version:
You should be grateful for the privilege of being restricted to 80 hours a week during residency – back in my day, those work hour duty restrictions didn’t exist.
Be grateful you even get a mandatory 10 hours off between shifts.
Be grateful you get 4 days off a month.
Remember, this was your choice.
And the speech for new attendings?
Listen to your patients.
Just make sure you finish all your listening in the 7 minutes you’ve been allotted. Because you haven’t met your RVU goals, thus you need to see X amount of patients in X amount of time.
And remember, patients like it when you make eye contact with them. So don’t chart while you’re in the room. Make sure you chart during your lunch hour, or better yet, at the end of your day because we’ve scheduled some very low yield lunchtime meetings for you.
Oh, don’t forget, make sure you document appropriately so you can hit the highest level of billing. For the patients, of course, because they come first. Don’t you remember that from when you got inducted into a lifetime of public service?
But seriously though… why aren’t you hitting your RVU goals? Maybe we need to start double-booking your schedules. For the patients – how else are they going to be seen?
FYI, we actually double-booked your appointments starting tomorrow since your colleague quit. They just weren’t resilient enough.
But you are! It’s because you haven’t forgotten your passion to help people. And because you haven’t, you’re going to come in on your off days and convince your peers to open up their schedules as well because you’re such caring and loving individuals.
Be the compassion you wish to see in the world!
As I mentally rolled out my play by plays in concert with the speeches, I couldn’t help but shake my head at the darkness in me mocking the joyfulness of this event.
Look how far you’ve fallen, M. And you’re still not sure where you’re going to land.
“You’re just waiting for the day to say, ‘I told you so’,”
A jokingly said as he bounded down the hiking trail behind me just a week prior, before his invitation.
The sting in his comment took me by surprise – how could that be so hurtful? Grateful to have my back turned to him, I took a second to collect myself.
“That’s not why I’m here. I want you to do well and be successful. And your experience is going to be completely different than mine – different school, different people. You’re older than I was, you’ll have the support and mentorship that I didn’t necessarily have…
Plus, you’re going to go into surgery, NOT primary care. As long as you don’t do what I tell you not to do, you’ll be just fine!”
When all else fails, use humour to deflect… but he already knows you do that. Did it work this time?
“You’re right… it will be different.”
Suppressing the urge to either grab A by the shoulders and shake some sense into him or wrap him in a protective bear hug, I instead focused on the trail.
A was already on his path whether I feared for him or not. All I could do now was maybe help him sidestep all the bullshit and pitfalls he was going to encounter without any fluff or woo, if he was still willing to listen.
Would that be enough?
Or would he find himself in my place 12 years later, tallying up the costs to his life, still unsure what his end game was going to be?
You can’t make these choices for him, M. You can only choose to walk with him.
With that, a memory of standing under a soft, orange glow on a street corner came unbidden. A night I had desperately tried to hold on to routine and the comfort of friendship by going to my weekly run club, just when my stress level was at an all time high.
The night before my last day in primary care.
“You’re going to be great, M.”
Words of reassurance given long after he’d found out about the blog, despite my best efforts to keep my friends from revealing it to him.
After dropping the charade and letting him peek behind the curtain of what my attendings had probably tried to shield me from during my own training.
After Dr. M became just M.
Who else had a backstage pass to my struggle to cling on to the vision of the doctor I’d wanted to be, just to be pulled under by a tide of cynicism between each patient encounter? How many deep sighs camouflaging my desperate gulps of air to stay alive had he witnessed before we’d step into the next patient’s room? Or glances locked as he realized there was so much more inner monologue behind my pleasant demeanor?
Who else reconciled pieces of their own personal experience with my harsh rendition on the blog, realizing I was nowhere close to the person he thought he’d be following?
No, instead I made him sit through monologues on how to fake the empathy when you have nothing left to give, revealing the cracks through the ever-smiling, compassionate mask I had worn with my patients for far too long.
Admitted to him the dark, unspoken reality of always putting the patient first – giving all your care to people who were more than happy to take it, just to find it would never be enough. The exhaustion of your reserves leaving nothing for yourself, so much so you’d prefer to starve than make one more damn decision about what to eat for dinner.
Because no one in med school or residency tells you to protect yourself against developing a savior complex, that there are too many people who need help and you can’t and shouldn’t expect to help them all.
Gave him unsolicited advice to find his compass like I had in J, to lead him back to the person he wanted to be during those times he’d become an asshole. And he WOULD have those times, despite his best efforts.
Because even the most resilient of us can break from all the brokenness we’ve seen, like when you realize you just spent the last 30 minutes looking into the eyes of a man who sexually abused his daughter, just to lose it when you rush into the next patient visit to listen to them complain about their 20 minute wait for you to take care of their stubbed toe.
Piece by piece I tore apart the rosy picture A might have had about this profession, and yet he still cheered me on as I stepped into the unknown as a hospitalist 6 months ago. Now as he shared his personal victories with me from the little things – like geeking out over his overbuilt Thule backpack with a thousand hidden compartments he’d found on sale – to his med school acceptance email forwarded the very day he received it, how could I deny him the same?
Taking a breather, I looked up at A and smiled.
“You’re going to be great.”
As much as I see so much of myself in him, A’s already better than me in countless ways. His ability to set boundaries against bullshit in combination with the annoying optimism I once thought was his fatal flaw may be enough to set him on an entirely different, joyful path.
Maybe that’s the only way to keep hope moving forward – to support and equip people who are bound to succeed where you once stumbled.
Bear hug it is, then.
***
Thank you to whoever shared my post Death of a Primary Care Physician’s Career: Act One around UMass Memorial – it got quite an unexpected bump in traffic last week! Since I launched it into the internet almost a year ago, it has been read and shared the most of any of my other posts, nearly 16,000 times. I swear this is not an attempt at a humble brag, but rather is spurred on by an email someone sent me after he described himself as a “lurker”.
Most people don’t comment publicly for fear of outing themselves – as someone who’s trying to stay anonymous, I get it. But I want to say if any of this stuff I’m writing about burnout resonates with you, you are not alone. If you’ve been afraid to reach out and email/DM me privately (I’m most active on Instagram), I assure you – it’s not weird. I get multiple messages a week from other people like us who are trying to find their way.
Anyway, to the lurkers out there – thank you for reading and sharing. I hope you continue to find something of benefit here.
***
Photo taken of J surveying Crater Lake, OR from Wizard Island.
I was thinking about this exact conundrum the other day. Everyone says we need more compassionate, humane doctors in the profession, I agree. On the other hand, is it fair to go out and find compassionate, humane people and convince them to join a profession which is currently set to dehumanize as efficiently as possible? I am really struggling with it. In the current environment, the callous survive and thrive, the compassionate are crushed. Is there anything we can do?
I started reading “Man’s Search for Meaning – Viktor Frankl” the other day(I know, another book, right?). His basic premise is that life is suffering and what makes it bearable is the meaning we find it.
In the same way, practicing medicine is suffering and what makes it bearable is the meaning we find it. I think part of the burnout phenomenon is a disconnect between what our training tells we will find meaning in and what we actually spend on our time. Call it moral injury, dehumanization, etc, whatever you want to call it. In the end, the meaning we were supposed to find in the suffering isn’t there, because the system has taken it away – because it gets in the way of RVU generation.
I am thinking about a blog post in more detail on this idea, but I haven’t finished the book yet…
Who says you need to finish the book to formulate your thoughts? I think you laid it out really well here. You’re right – RVU generation has become the end-all, be-all of what we do. It’s measurable, you can create metrics out of it, make comparisons amongst your peers, etc. But the meaningful work I do isn’t in the RVUs – it’s in the comfort I give to patients and their families by knowing we have a plan moving forward, or just by the mere fact that they feel they’re being seen and heard.
Perhaps moral injury occurs during the transition point between compassion and callousness. I see myself wavering between the two constantly. Survival of the fittest though, eh?
Great post here. I’ve always appreciate your honesty writing these posts and can’t help but think this would help many others feel part of a larger community suffering some of the same fate. I admire you standing up for yourself and not being bulldozed by the system. I’ve learned that can happen by default these days unless you stand up for yourself. Your friend is lucky to be able to hear the truth from you and be able to pick your brain about how you would do things differently knowing what you know now. Keep up the good work and continue to chart your own course. That’s the best we can all do, but you deserve not to be treated like a replaceable pawn in the larger system. You are better than that, and always will be.
Best,
Primary Care Doc
Thank you for your kind thoughts!
I’m not sure I’m being entirely effective at standing up for myself – most of these thoughts are just part of my inner monologue. But, I am making sure if things come down to it that I will be able to mobilize and move out out of these less than ideal situations – that’s the beauty of the FIRE/minimalism movement.
The best part of the blog has been hearing from other people who also feel the same as I do – this community is much larger than I had anticipated. Hopefully at some point WE will mobilize and make changes; either to the system or build something anew altogether.
I hope you’re still surviving primary care – I admire you for staying.
M
Do we become Tom Sawyer entrapping others to whitewash the picket fence when we encourage their interest in medicine despite our cynicism?
Tough call. Brings to mind the quote attributed to Churchill: “Democracy is the worst form of government, except for all the others.”
An acquaintance from my premed years, now a neurosurgeon of some renown, came from humble beginnings in a family of migrant farm workers. He recounted that his grandfather counseled him early on that he could either earn his livelihood with his back or his brain. My guy chose the latter, worked his tail off, but has no regrets. He looks at his cousins, injured backs and industrial accidents and gnarled hands at young ages, and feels he’s had the easier path.
It’s clear from your writing you have moments where you love the work you do, and you do it brilliantly. Perhaps doing less of it, on your terms, while minimizing the cost to the higher priorities in your life is how you rediscover that love again. Perhaps its folly to think it can be recovered.
You get to ensure your protege goes in eyes wide open, but you are in no way complicit if he encounters disappointment where he sought a calling.
Love reading you do what you do best,
CD
CD,
I’m not sure he’d take too kindly to being called my protege.. haha. Especially since I’m not too sure I’m doing him any favours – it feels like I’m stomping on his dreams most of the time. It is a weird balance to strike, and quite honestly, I just want to be a good friend, not necessarily a mentor.
At any rate, to your point I’m still working on figuring out how to cut back. I’ve started just giving away shifts without any expectations of a trade to get my shift balance to exactly zero. Not trying to ruffle any feathers or draw any notice to it, but they made it abundantly clear they’re not going to work with me, so I’ll just be more proactive. We’ll see how this goes!
M