Just get over it

During my first year of practice, I was told over and over again that I should "just get over it”, that things get better in 5 years, that what I was experiencing was normal.

 When I noticed that I was diagnosising at least 5 cases of cancer per week, I confessed to a friend that I was concerned and a bit freaked out. She told me to get over it. That's what family doctors see and do all day. (It's not, especially not in a small rural practice, but I guess surgical residency makes you cynical). I was also told by a colleague that I should expect lots of cancer in my first few years because I will be seeing people who haven't been reviewed in years. But then he walked away.

 I missed a few cancers because I was so far behind on my paper work. They came to light and the patients will survive despite me. This concerned the hell out of me. I asked for extra staff to help me stay on top. I was told to make my staff I already have work faster. My staff that is already overworked with the difficult set of patients we have. There are parables about beating overworked animals, I definitely wasn't going to add to my staff's excess burden.

 When I received my second death threat in 8 months, I told my colleagues. They laughed and told me that I was a real doctor now. (Apparently two of them had received one threat in the past 15 or so years. The rest had received nothing.)

 There was a tragic, horrible, incident on my watch. Then, my colleagues surrounded me and offered help. Looking back, I do wonder how much was because they were worried I'd get the yips and need to stop working the ER. They did do a good job though.

 Seeing patients with more mental health concerns than years in their lives, listening to stories of horrific childhood trauma, being manipulated by personality disorders and drug users was exhausting. When I brought it up I was told to fire these patients, to not ask them questions (I didn't, they offered me their horrific stories on their own), to not let them speak. This advice suggests that I completely ignore my values and put my license in jeopardy.

 I burned out very early in my first year of practice. Looking back, reflecting on the times I asked for help and the lack of actual help I received, it's fairly obvious to me why. I expected my fellow family physicians to care about people enough to care about me. Now I see that I was making a mistake. Everyone has been working for themselves and doing what they can to keep their heads above water, even my good friend. No one is able to help someone else when they aren't able to handle themselves. This is why I now have a therapist. It's also why every new doc needs a dedicated mentor. Someone who has time carved into their schedule just to help the new doc and answer all their questions, let them know what is reasonable and what is not. Knowing at least one person will listen and not tell you to just learn to deal with it is vital to keeping your new docs in practice.

Screw it

I’m just so tired of having to be persistently pleasant while at work, in the grocery store, on email. If I’m not, I’m seen as a bitch. Other (read male) physicians are allowed to be as moody, rude, blunt, cruel as they want to be. If I’m not smiling constantly and holding peoples’ hands I’m the bitchy doctor. 

Screw this. Screw gossipy nurses who still treat me like I’m not a physician. Screw the backwoods attitude that men are held to a lower standard and that women are supposed to be soft, pink, and fluffy 24/7. Screw “business feminists” who write crappy leadership literature that perpetuates these ideals. Screw jackass patients that don’t like hearing the truth. Screw the parts of my professional life that are unprofessional and make me lose my temper. 

Soft skills

I’ve become part of the medical culture that minimizes the “soft skills”. Before the brainwashing cult of medical school, I almost worshipped those soft skills. The culture I’m embedded in has made me loathe much of what makes me a good doctor. In general, the men I’ve been working with have little respect for the areas I excel in - palliative, psychiatry, geriatrics, and pain management. They think that patient centred methods are not something any physician should aspire to.

 This has rubbed off on me. Now I think that the areas that I am strong in are not worthy of being considered real medicine. It’s something I’ve been struggling with since clerkship. On all my evaluations, I was lauded for excellent communication and advocacy skills. I never took these seriously because the hidden curriculum taught me that my soft skills aren’t real medicine. I wished that someone would say that my cardiology skills were amazing, or that my physical exam skills are exemplary.

 If these skills are so soft then why do so many physicians have a hard time with them? Maybe there needs to be another name for them. Making a list of possible alternatives, I think about collaboration, organizational, conversational skills, but I imagine these as also being diminished as being too “pink” to be considered real medicine. Could try something like supratentorial skills but given how frequently we use that as code for somatization, that also wouldn’t be treated seriously. Even people skills are “pink” - something we expect those who work in retail to have to learn by watching videos in a break room.

 These “soft skills” are not gained that easily though. Yes, we can learn them through videos and work, but the best of them are learned by experience. By watching what our mentors do well and emulate the people skills they display. We learn them through collaborating with our allied providers and seeing how they advocate for patients. There are no textbooks to show us how to be the best at advocating, listening, collaborating, communicating, organizing, and generally being patient centred. We need to shed tears, sweat, blood, to get to that point.

 These skills are not obvious and difficult to describe, maybe the opposite of concrete skills? Abstract skills? That might work.

 But then again, what is so wrong with calling them soft skills? As long as we start to acknowledge the efforts made to learn them. There shouldn’t be anything wrong with the pink skills that are associated within the soft skills. All physicians should strive to be the best doctors they can. That means practicing their concrete skills, (clinical skills, rote learning, anatomy) as well as their abstract or soft skills. To be a fantastic doctor, one shouldn’t have to hire another MD to provide bedside manner. We should expect it of each other to want to be a complete physician who is able to provide all a patient needs from their specialist or primary care provider.

 If female providers are better at the abstract skills, we should be congratulating them rather than acting like they have done something wrong. I’ve been told several times that I care too much, that I am too passionate. This is ridiculous.

 I want a doctor who is passionate about their job. I want a doctor who cares. No, I don’t want my doc taking their work home with them, spending their night going through all the coulda’ woulda’ shoulda’s. They shouldn’t cross boundaries to make my experience better. But, that doesn’t mean that they shouldn’t cry when they feel like, argue with specialists who refuse to take my care, give 100% during office hours.

 If you think my passion and caring is the problem, I think it’s safe to say that you are the problem. The concrete thinking physicians with a limited view of medicine should really just get the hell out of the way of the physicians who flex both soft and hard skills and are kicking ass. Those are the physicians who are asking the questions in research, are pushing the boundaries of what we are able to do to make our patients’ lives better. We need to repair our culture to catch up with what patients expect from their physicians, and what we expect from our colleagues. The concrete thinking docs need to be called out for being the dinosaurs that they are.

How could I be mad?

When at the end of my 24 hour shift my patient’s epigastric pain changed to a STEMI? As I explained to him and his wife what was going on and how dire the situation was given his prostate cancer? As I told them the high risk of bleeding to death on our way to the city to see the cardiologist? As he kept sneaking his thumb over to touch my hand that was on his leg while I talked to him? Tough old coot was scared at the odds I gave him, worried about his wife, worried about his chest pain, worried. 

These are patients who are used to the doctor just telling them what to do. I won’t do that. I’ll present the options as I see them, and likely bias the discussion one way or the other, but I ask them to make the decision. Sometimes the decision is to let me decide, then I check if they are relieved or distressed with that decision and adjust accordingly. Not by the book med school ethics, but patient centred. Luckily my patient’s wife was able to decide for all of us. 

I’m worried too. I hate sending my patients to the city with another doc but I’m not safe to still be caring for him. Very happy I kept doing serial ECGs though and trust my gut when I think something is wrong. 

Not gone. Dead.

I love when I’m working emerg and my next patient is someone I already know. It makes it so easy to get to the bottom of what’s happening and get them feeling better.

Unless they come in VSA. Then it just sucks.

Especially when they are young and their kids aren’t ready to be an orphan in high school.

Especially when they’re your own patient.

Especially when the family thinks, because of a diagnosis you magically pulled out of your ass that you walk on water.

Especially when no matter how many of the Hs you cross off the PEA list, he just doesn’t come back. His pulse never returns. He doesn’t have another joke, or jab, or hug. He’s just purple and bloaty and looking nothing like you’re guy anymore. His brain stem hasn’t caught up to his heart and doesn’t realize he is dead so keeps telling his lungs to breath horrific, agonal breathes and you have to explain to his children that he is dead.

Not gone. Not done. Dead. Without those words his kids can’t move on.

But they need answers. Why? How? What did I do wrong?? Who can I blame? Maybe I didn’t love him enough? I just want to hide and cry. Because I have the same questions and no answers.

It’s an honour to say that I fought valiantly to save his life. But would be a greater honour to say I had actually won.

My current patronus is Lewis Black

I am furious. So angry. Yelling at people angry. I never yell at people.

The group of middle aged men I work with has described my work as less than medicine. They are suggesting that as someone who practices patient centred medicine, I am not a real doctor.

I work my ass off all day every day, and their interpretation of my work is that a middle aged man could easy double the patients seen just by not being nice.

Protecting these men’s reputation is more important than caring for patients. Slagging patients is ok as long as I don’t question a man’s clinical judgement. As of Hallowe'en I am done here. Until then I will try to avoid hurting anyone. And destroying my reputation.

The Rural to Urban Transfer, a Primer for Urban Docs

1. If the report starts with "...is a horse and buggy Mennonite, and called an ambulance to arrive here at...", know that whatever comes after means this patient needs to be transferred out ASAP. These patients will do everything they know how to do at home, waiting until the very last minute to come to hospital. If they are willing to splash out on an ambulance, there is something very wrong. Same goes for any Mennonite that shows up the ER on a Sunday. Just seeing them there on a Sunday makes my pulse race.

2. Don't assume that we have the same resources that you do. For example, I have an RT that comes in some Wednesday mornings. There is an anesthesiologist who comes in a few days a month. I do the difficult airways. I figure out the ventilator settings. When I show up to the ICU, you have more people waiting in that room to receive us than we have in our entire hospital, usually at least 3x as many. Please ask what resources we have before repatriating a patient who requires more than we can give, or assuming we can handle the case that is being consulted on.

3. We work 24+ hour shifts. I am acutely aware of the time that I am calling you at 4 in the morning. If I say that I need to discuss a case, please be sure that I really do. I've either exhausted all my internet and paper resources and need help, never seen what is in front of me, or am having a hard time organizing my thoughts after a particularly stressful day. Rural docs are proud. If we are asking for help, assume it's legit.

4. During that 24+ hour shift, for the most part, we are it. Any and all codes are run by us. I've run several in the same day plus delivered babies, saw 30+ sore throats in the ER, and talked down psychotic patients. Not every day is like that, but give us credit for being able to handle all of that and keep going. We do this because we love our communities and are dedicated to keeping our hospitals open, we love medicine, and we are masochistic idiots.

5. Nothing makes me feel more validated than having staff ready when we show up. If I tell you it's a difficult airway and you have an anesthetist and RT waiting for us when we arrive in the city, it seriously makes me feel incredibly relieved. I know that you believe us and will treat my patient well.

6. We get attached to our patients. We see them again and again in our hospital, and in truth, I may be the family doc of the patient I am transferring. I will do everything I can to keep them in our tiny hospital. When it's time for them to go somewhere else, I will fight like a dog to advocate for their proper care. You would too.

7. Rural docs are "real docs". We are generalists who are constantly studying and upgrading. After every code, every transfer, every good and bad event, we talk to each other to learn about what went well and how we can make things go better in the future. Consult notes that belittle us and derogatory comments on the phone are entirely unnecessary. We are counting on your expertise to help us in our practice, but also on your civility.

In case I forget to thank you because I've been hand ventilating a patient for 3+ hours when I finally see you during my 27th hour on call, please assume I do. I am incredibly grateful that you have chosen to work in the city in ICUs, surgery, high risk obstetrics, etc. Without you, I couldn't have the brilliant job I do.

Too much

A few weeks ago, my class song started playing. Usually I don't just sing along, I bang my head and call all my med school friends. 

This time though, I did nothing. But I did realise that I was in trouble. It became clear that what was going on in my professional life was affecting my personal life. 

This is what burnout looks like to me.