Tuesday, February 11, 2014

Evidence of things not seen

I usually don't cross-post from my personal blog, but this recent piece seems to have really resonated with fellow residents and physicians in general. People have approached me in the hospital to talk about it, and as a result, I have had a lot of honest, wonderful conversations with my colleagues -- about their love for medicine and for their patients, about the traumas of training, and about the systemic problems that make their jobs less satisfying than they had hoped they would be. These conversations have reconnected me with my own deep motivation to serve patients and have inspired me to fight for a better system. I look forward to hearing from fellow MiMs about your experiences and hopes and ideas for how to better heal our patients and protect ourselves from burnout. 

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I am on retreat with my residency class. We are in an otherwise empty hotel on the Jersey Shore whose just-an-average-hotel-ness is intensified by the lonely quiet of the off season. I can imagine the bustle of summer filling up the space -- trails of sand from little feet tracked in from the beach, brightly colored umbrellas stacked up on the deck, all the various sounds that people can make from within hotel rooms -- but in the emptiness of winter the rooms seem tired. Why are hotels decorated in brown and beige? Are there people who are offended by color? Or is it just to mask wear and dust and dirt? Is the bored eye less likely to see?

There are few opportunities in my life to sleep in but today I could have slept until 8:30am, which as all parents of toddlers can attest, is the new noon. I went to bed early last night, in fact, because I wanted to experience the sensation of restedness this morning, the feeling of waking up out of readiness instead of necessity. But because the universe has both good wisdom and a good sense of humor, my eyes opened at 5:45am -- the very time that my alarm will ring tomorrow morning -- and I couldn't go back to sleep. At first I was filled with a familiar sense of cynical irritation, the "why me" and "well isn't that always the way" that residency has brought to my life despite the comforts and advantages that I enjoy. But then I thought to myself, how often do I get a chance to walk on the beach as the sun rises? According to weather.com the sun would be rising at 7:01AM. I put on several layers and slipped out of my shared room, through the muzak in the lobby, and out towards the ocean.

There was no one else in sight. I walked toward the ribbon of pink spreading up from the horizon. The hard, frozen sand up near the beach grasses gave way to the satisfying sink of each step into the wet shore. Several gulls circled and dipped. I looked for shells to bring home to E -- not too small, not too sharp -- and came across some of the odd hints that the ocean delivers up to us about itself. Cracked orange crab shells and dismembered legs half buried in the sand. Plant fronds of various colors and textures and widths. A foot-long brown spear that widened up to what looked like the end of a bone with some white and yellow flesh still attached -- tooth? spine? tail? Breaking the smooth contour of the shoreline, a sudden small pile of sea sponge. I walked for an unknown distance. The sky became lighter and lighter beneath and around the layers of cloud. I wondered to myself when the sun would rise and what would mark the sun's rising. I looked at my watch and it was 7:13, already past the appointed time. The part of my legs between the top of my boots and the bottom of my coat began to tingle and sting with cold and I turned to walk back to the hotel as the daylight continued to bleed into being around the edges of the sky.

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How should I say this? I am worried about the state of health care. I am worried about the state of my own heart. I am worried about the way doctors are trained. I am worried about the way health is defined. I have been in and around hospitals for almost a decade at this point and I feel like I know less and less about how to help people achieve well-being. I feel like I'm getting better and better at keeping people alive and less and less good at helping them live well. I am maybe a little depressed or to use the somewhat more socially acceptable term, burned out.

I went into medicine with a desire to be with people in life's most terrifying and difficult and potentially ecstatic moments. I wanted to understand the body, to understand more about life and illness and death. It's a cliche but a deeply felt one: I wanted to be of service. I also wanted financial stability and the ability to provide for my children. I wanted a job that would be meaningful even on the worst days. But mainly I wanted to form deeply satisfying therapeutic relationships -- it's what I wrote my residency application essay about and it is still what I aspire to accomplish, somehow.

Now, almost ten years later, I spend more than 90% of my day in front of a computer. Sometimes the computer is actually physically located in between me and my patients and I have to crane my neck around its unsleeping eye to see them. I type through the majority of my clinical encounters. During a typical day on the wards, I see my patients for -- at most -- 5-10 minutes per day each. My day is filled with entering and reentering orders on the computer, writing endless admission notes and progress notes which recapitulate information that is already recorded elsewhere in the medical record, waiting on hold to talk to primary care doctors' answering services, calling pharmacies and insurance companies for prior authorization, calling subspecialists to address each of the body's organ systems, and coordinating the complex behemoth of a large tertiary care center to get tests and studies done for my patients. I work up to 28 (actually more like 30 but shhhh don't tell) hours in a row every fourth night which wouldn't bother me except that of those hours I spend at most 2-3 in total with patients. Patients turn over so quickly in the hospital that I might be responsible for the care of over 100 patients during a given week. During clinic hours I am perpetually beset with anxiety at how far behind I am, unable to get through a well child visit meaningfully in the 20 minute time frame allotted for this purpose and because of the fragmentary nature of residency scheduling, I often do not see these patients again. I want to form relationships with my patients, but at times it feels like talking to patients just takes time away from the tasks that need to be done for them. It's crazy, but it's true.

Some of these issues are unique to residency, which is time-limited (though formative), but surveys of post-residency physicians suggest that as a group, we are in trouble. In a much quoted and discussed survey of 24,000 physicians by Medscape in 2013, only 54% reported that they would choose medicine if they had it to do over again. Fourty-nine percent of physicians surveyed reported at least one symptom of burnout and 40% reported that they were burned out.

On the receiving end of medical care both as a patient and as a loved one advocating for sick family members, I know what it's like to receive care from a system of overwhelmed and/or burned out providers. Test results are not communicated. Small details are missed. You wait 7 hours to speak with the doctor, then that person does not know some of the basic details of your case. The care you receive addresses a symptom or a part of the problem, but rarely the whole problem, and rarer still, you as a whole person. I fear being that kind of provider yet I have been that kind of provider despite my fervent desire to avoid it. There are just too many patients, too many data points, too many notes to read and write. There is so little time for relationships to form. There is no magic there.

Doctors are a hard group to sympathize with. Once we finish training (it's long, but let's face it, life is longer) most of us land in the top 10% if not the top 5% or 1%. Training is hard and the hours are long but we choose this life with full knowledge (as much as you can have full knowledge) of what we are getting into. We hold a lot of societal and political power and on an individual level,  in hundreds of thousands of exam rooms across the world, we have the power to examine, to question, to diagnose, to prescribe, to get it right and heal or get it wrong and harm. But if we as a society want to get the kind of health care that not only cures but heals, we are going to have to look at how doctors feel, how they are trained, how their work-life is organized, what we ask of them, and how we support them in their work.

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If you work around sick children long enough, there will be a death that crushes you, that doesn't let go, that you can't let go of. Little O came into my care last month and a few hours later passed away under the most difficult of circumstances. Oddly enough, I don't remember her name -- perhaps because the intensity of our efforts to keep her alive and the adrenaline coursing through my body erased it from my data banks, perhaps because I have been afraid to reopen her chart. I think of her as little O, the little O of her mouth, the round moon of her little face which I saw for weeks every time I closed my eyes. If I will it, I can hear her mother's screams in my mind's ear as vivid as the sounds of my household humming around me as I write: "No es justo! No es justo!"

I want to make contact with her family, to tell them that I feel for them, that I think of her, that even though our lives touched for only a few short hours, I feel the weight of their loss. I have never done such a thing before and I'm not sure if it is even appropriate. Who should I ask? Do I need to get permission from my program director? Do I need to run it by risk management? In the end, the question comes down to one of the nature of my relationship to that baby and her family. Was there one? And if so, what was it? I have been training for many years but have received no apprenticeship in this most important aspect of my profession.

So many hundreds of children pass through my life and I through theirs and we are like ghosts to each other. There are so many layers between me and my patients, layers of bureaucracy, legality, scheduling, vulnerability and power traded back and forth in a complicated dance. Was this always so? Sometimes I fantasize about becoming a small-town doctor, about being part of the community I serve, of knowing my patients and allowing them to know me.

I will likely never send a card or see little O's family again, but this is what I would want to tell them: I will hold your daughter in my heart forever.

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Meanwhile, back at retreat, I am surrounded by the loveliest people. My co-residents are intelligent, accomplished, funny, and kind. To a person they are motivated by the desire to be of service. They are scientists and humanitarians who hold as sacred the trust placed in them by children and their families. They are also spouses and parents and children and friends who struggle to balance the commitments they have made in so many domains in their lives. I feel lucky to know them and I think children are lucky to have them as their doctors.

What I wish for them and for myself as doctors, what I wish for myself as a patient, for my patients, and for my loved ones who are someone else's patients, is a system that allows us to be healers, that helps us to heal. I want a system that allows me to express my compassion, that gives me the space and time to care for people in a meaningful way. Unrealistic? Selfish? Possible? I hope to find out.


  1. Related paper recently in JAMA IM;
    Not sure what the solution is to any of these problems.

    1. Interesting article -- thanks for passing it along. I found it interesting that the control group still fared better than non-participants -- just having one extra hour in a given week makes people feel better about their worklife.

  2. I'm in tears (which sucks because I'm on call tonight and need and tears are frowned upon). But thanks for saying this. As I get further and further into residency I do indeed start to see some light at the end of the tunnel, some increased semblance of relationship building and ownership over the gift of trust that patients entrust us with, but it is still buried in inquiries from coders and instructions to re-write, re-dictate, use this word and not that one which often makes the medical record un-interpretable for the actual medical provider and completely devoid of actual useful information. I love my patients, I love this work. I love the gift of operating on someone who entrust you to their care - I respect and have reverence for this honor. I want to join in the fight with you. We are a new generation of doctors - complex and difference in our own ways - why not take back ownership of this field we desperately want to love and serve. I'm in!

    1. Hi Cutter,

      Thanks for your words! Let's fight together and take back the role of healer! Still trying to figure out the details of how to do that, though :-).


  3. Thanks for this beautiful blog. I am an MS2, married to a PGY3 in peds, and we have an 8-yo son. I see many of these things you describe above happening, with my husband and doctors around me, and while it makes me sad, it doesn't make me less hopeful for my future career (in what specialty, I have no idea). I am at the beginning of discovering how wonderful patient care can be, and I cannot wait for 3rd year for many reason, one of the most important being not only that I get to care for patients, but that I know that this year will be when I get to really spend the most time with patients and have the luxury of taking my time (compared to future clinical years that is). I think having a realistic outlook on my future in medicine is a gift, and is one of the reasons I love this blog. You guys all help me to see what is wonderful about medicine, what is difficult about medicine, and what to value the most as time marches on.

  4. This is one of the most beautiful things I've read online. I'm an MS3 with a toddler trying to navigate which specialty to choose. I want to provide great care to patients but it's hard not to get discouraged by the how burnt out the residents and attendings I work with are. As a student, I get to spend so much time with patients while residents spend 90% of their time charting and it wears on them.

    I do also want to say that I've experienced moments with residents and fellows where they advocate for patients despite the BS of the system in which we operate. These moments are too few and too far apart but they serve as important reminders of why I chose to do this. For now, I'm choosing to be optimistic.

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  6. What a beautiful and touching post, thank you. As a MiM it really helps me to hear perspectives from people at different stages in their careers so here are my two cents. I am on the threshold of graduating from fellowship and starting out into practice. I'm trying to avoid saying "real job" because, though they have not paid very well in comparison to my debt load, all of my experiences to date have been "jobs", jobs in which I invested tremendous effort and which resulted in personal and professional growth.

    Choose a field within medicine that matches your soul. One in which you enjoy working both with your patient population AND your colleagues. If you find yourself in a culture or situation that does not support your own health, professional growth, and well being try to change it. If you can't change it, WALK AWAY. Find another environment or job that honors your personhood and allows you to be well. Realize that some amount of pain and suffering may be necessary evils for example residency training but be sure you find ways to recover from these necessary evils. Admit your own flaws and don't be afraid to show your own humanity and weakness and you will attract people who value that in you. Find brilliant minds and ask them to teach you. Find others to support you, get as many mentors as you can. Mentor others. Make non negotiable ways to spend time with those you love and to take care of yourself. Pay for, borrow, and accept as much help as you can. Give as much help as you can (both emotionally, time-wise and financially).

    Above all else preserve your love of humanity. Do whatever it takes to preserve that. If that means you write a crappy progress note so you can spend 20 minutes sitting at the bedside of a dying patient (or whatever else it is that brings you joy and meaning in your work) do that. This plan has worked for me so far. I'll let you know how the next 10 years goes.

    And oh yeah, SEND THAT CARD even if you have to dig a bit to remember her name and find her contact info. If you wait a year it will be harder to find the contact information for her family and you'll regret it.

    Yes, lets heal ourselves and be healers. I'm in.

  7. Thank you for sharing your thoughts. As a mother and career-changer starting the med school application process, I have been doing much reflection on the reasons why I am motivated to become a physician and what the healthcare landscape I envision looks like. My perspective closely matches your residency app. I am encouraged to know there are strong women ahead of me with such a determination to influence the system in the direction of compassion and healing.


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