As a doctor we are there for the lightest moments and the darkest moments of someone’s life. No one lectures or gives classes on how to tell patients about good news, however “Breaking Bad News” is often the title of our lectures on techniques and tools on how to be that voice of dread. In those moments of preparation before telling patients life changing diagnosis we are left alone with the information and the extensive knowledge of the devastation, heartache, and turmoil our words no matter how carefully chosen are going to inflict.
Setting the atmosphere, telling enough information without overwhelming the patient, preparing for awkward pauses to allow the patient time to process, handling the emotional response, handling no response, the crystal ball question and how to respond, and on and on sessions and
practice simulations with standardized patients; none of it prepares you completely for the reality of the situation. In all the attempts to prepare you not once have I ever had a class or talk or lecture on how to deal with the aftermath as a human being. In school and residency how to be a doctor is first and foremost but in a situation with such devastating impact no one has ever discussed how to handle the emotional rollercoaster you feel as a provider.
In a climate of physician burnout not enough of us attendings are discussing how we balance our scales of life. In residency the beginning of every year the topic that’s talked about is avoiding fatigue and burnout and taking time for oneself. The residency paperwork always includes the Employee Assistance Program (EPA) psychiatrist contact information for 3 free sessions—the rest you are responsible for at a discounted rate. You are introduced to chiefs, given a brief lay of the land, and then thrown you into rotations and your 80 hour work week life begins. A little bit of an oxymoron right? Work life balance is stressed however never taught. We learn how to take care of our patients but not ourselves. We hold on through 3+ years eagerly awaiting the end when our life as an attending can begin all under the expectation that Attending Life will be easier than resident life; and then the sad reality rears it’s ugly head that life is not always greener on the other side. In some respects and some fields yes things might be slightly better however for most of us, particularly those in primary care, the shock comes packaged with insurance coverage, prior authorizations, DME paperwork, billing, etc. We have gone to school to become the glorified secretarial pool of the health insurance world in addition to our role as healthcare provider. This was not the life we envisioned, not the plan we had for ourselves, at least it was not for me.
So how do we achieve the life we envisioned? For each one of us the goal is different because our visions, dreams, expectations, desires are as uniques as we ourselves are; however there are some tenets that I have learned along the way that I employ to keep myself sane and evenly grounded.
Be graceful to oneself
Cut yourself some slack. I have realized that I am not perfect. While I continue to strive for perfection I find the beauty in errors and lessons that I learn along the way.
Break it down before you do
I stay vigilant about my attitude. When I start resenting patients coming for their appointments and/or I start withdrawing into myself, I take a break. Better I take a break than let the system break me. As my dad once told be during a winter snow storm when I was planning on driving to the hospital for my shift…”If you have an accident and wind up in the emergency room they will find someone to cover your shift—right? So you can’t be that essential?”
Accept incompleteness: Its a Marathon not a Sprint
PACE YOURSELF! It’s so easy to keep working and working and working to get all the messages in your in basket completed; however I realized after many moments of disappointment that my in basket will NEVER be 0—there is always that patient about to request a refill of medication or that patient messaging me about a concern they have. It’s a far better thing I do to pace myself to win the race.
Honor your time
No one else is going to honor your time. Where I work patients are to be seen essentially no matter when they arrive for their appointment. This took some getting used to and still does at times. As my clinical assistant tells me often “That is why you get paid the big bucks” (it’s funny how no-one ever mentions the house note amount of debt I am in but that is a different post). Being a salaried employee does mean that you put in hours outside of work to make sure you get the job done; but that does not mean that my time is not valuable. I have set a hard and fast rule of 7pm. I even went so far as to set an alarm that rings on my phone and my watch because it’s easy for me to get caught up in the work. For me all work stops at 7pm and I go home to be with my family, to rest, and to prepare to engage another day. While some of my colleagues work on the weekends I choose not to. Does that mean I get behind in tasks...yes at times I do but my time is precious so I am very deliberate in what I give my time to.
Find your love and connect daily
What is your “Juege” as I like to call it? What do you live for? What gets you up in the morning? For me it’s my family and music. They make me smile and make me happy on the dreariest of days. I like to start off each day with a kiss to my LO and on tough days I make sure I have music in my ears when I enter the office. Hearing my playlist pumps my blood and elevates my mood. I tap into that fun part of myself that can get lost in dealing with minutia and drama. Whatever your juege is connect to it daily and if needed try to make a connection during the day when your days get hard.
Celebrate moments of acting in your calling
I take time to acknowledge when I feel I have made a positive impact in someones health. That is my calling, the reason I because a primary care provider, the reason I’m in hock up to my eyeballs (again another post for another day). On those occasions where I see the manifestation of my calling—I celebrate it! Weather it’s with my happy dance in my office, celebrating with a patient, or calling my best friend to tell her what just happened I take those moments. So much of my work seems to be faxes, reporting labs results, and dealing with the administrative side of medicine that it’s easy to forget the calling on my life so I take moments to celebrate it’s manifestation.
Work smart not hard
“I’m not your superwoman”~ Karyn White (circa 1988). I know I’m dating myself 🤦🏾♀️ but I can’t do it all. I have learned to delegate. I used to have a hard time asking for help and asking others to do something that I know if given enough time I could do. I have had to realize through time that I must work smart not hard and working smart means using ALL resources at my disposal. It does not mean that I am lazy but it does acknowledge that my time is finite and ties directly into—Honor your time
Are these tenets fool proof? By no means! Are there days when it all flies out the window? Yes, but those days have become fewer and farther between the more I adopt these tenets.
Being a primary care provider is not at all what I thought it would be like. Medicine has changed and is forever changing. As technology expands transformation of my beloved career continues to speed up faster than medical training can catch up. It leaves us attendings who are on the front lines of medicine to be transparent to those coming behind us about our struggles, valleys, hills, and achievements. Not only is it imperative that we acknowledge them to ourselves but we must also share with others how we make things work. So often when we have medical students or residents working with us and shadowing us we place a glossy staged photo over the reality of our day to day existence. We must reveal the truth, show the underbelly of our career path and then reflect our imbalanced balancing act so that the next wave have a leg up in blanking their scales of life.
2 things I have learned this week:
Monday while seeing my first patient of the afternoon my lower abdomen felt weird. As any type A doctor does I shrugged it off and continued with the visit. As I was walking out of the exam room with the patient and saying goodbye a severe pain seized me in my lower abdomen and would not let go. Because of where I work had long ago selected one of my colleagues to serve as my PCP. Seeing my pain my wonderful CA (clinical assistant) talked with my PCP’s clinical assistant and got me double booked her schedule. I continued to see patients although much more slowly and with less enthusiasm than I do normally and awaited a break in my schedule. Finally I had one and it was my turn to be a patient. As a doctor it’s weird being on the other side of the computer—trying to accurately describe your symptoms but at the same time not wanting to lead another doctor to any conclusion you may be considering (that is if you have a clue as to what’s going on). It’s even more nerve racking to be on the other side and not have a clue! Which was exactly my position. I had gone through the symptoms formulated a differential diagnosis list but was left with nothing but discards. My exam went as expected and my lab work was negative for infection, electrolytes were stable, and there was no urinary tract infection based on the urinalysis. This left only one next step—imaging of the abdomen and pelvis. I’ll fast forward to the results which were nebulous at best...possible early appendicitis. Therefore nothing definitive. Nothing to hang my hat on. Nothing for my colleague/PCP to hang her hat on. Medicine is as much a science as it is an art and the term practice is hard to put into words. Given her clinical acumen and previous experience she discussed options and I agreed with her a trial of antibiotics; I am in no rush to go under the knife of a surgeon especially since the CT scan read was unsure.
Given my type A nature and work ethic I tried to ignore my pain and I tried to work for a half day and quickly realized that it was a mistake. While clinically I looked fine the pain was very telling. So I have been resting at home taking the antibiotics prescribed and contemplating. I am always acknowledging the role vital signs play in my assessment of my patients but so quick to dismiss them when it comes to personal health needs. I am thankful for those around me who urged me to pay attention. I am also thankful that my physician listened to me and did not dismiss what she could not see or understand. With the advent of technology there is this push to image to see what’s going on inside and while the advent of technology is helpful the lack of noted pathology on imaging does not mean the absence of pathology. As a clinician we must use our knowledge and experience to help guide our plans when technology fails us and as patients we must realize that technology does not always ultimately hold the key, the patients body does.
Embracing my imperfection and striving for perfection through grace.