It has been a slowly dawning realization for me - I don't love medicine.
It's not Emergency Medicine, either. It's medicine as a whole. I'll give you a few examples:
48 year old male, chronic back pain, wants narcotics. Angry he's waited for 3 hours to be seen. Even angrier that I'm not going to give him his fix. Both of us walk away upset from our interaction. I don't enjoy playing bad cop, but I do it about 10 times per day.
35 year old female, morbidly obese. Smokes 2 packs a day, comes in because she "can't breathe right." Lungs sound like ash. I give her some breathing treatments and steroids, she gets a bit better. Goes home to smoke more.
10 year old male, BMI of 40.8. Mom is upset that his pediatrician wanted to start him on antihypertensives and comes to me - an emergency physician - for a second opinion. I can't argue; his blood pressure is 160/95. He's eating a cheeseburger.
85 year old female, completely demented at baseline, dropped off by nursing home completely unresponsive. Third time this year. Family nowhere to be found. Despite my better judgement, I intubate her because I'm supposed to. Feel guilty afterwards for not just letting her pass peacefully.
I know there are patients out there who really, truly need me. They are few and far in between, however. Modern medicine, for better or for worse, now treats first-world problems. We "care" for nursing home patients because families can't be bothered. We write prescriptions for vicodin because we can't bear to fight with 5 people in a row today about whether or not they need pain pills. We prescribe antihypertensives and statins and diabetic medications for people who don't fill them and then go eat at McDonalds.
The truth of the matter is, I just don't feel like I make a difference any more. My fellow emergency docs know how frustrating it is to go through a pelvic pain workup on an 18 year old girl, just to find out that she only came to get a pregnancy test. The ER, you see, is cheaper than the dollar store. Or the drunk who just needs a place to stay for the night and complains of chest pain to get a "free" bed. Or the dialysis patient who smokes crack, forgets to dialyze for a week and comes in dying.
There has been a lot of discussion in our journals lately about physician burnout. It's been labeled as an epidemic of sorts, one that is getting worse. There are a lot of reasons why. Here are a few of mine.
1) There is constant pressure to never make a mistake. Some of this is legal - screw up and you get sued. I like to think most of it is humanitarian, though. You don't want to miss something and have someone get sick and die. It's very personal. Your mistakes are your own.
2) Patients can be miserable. Especially in my field. For instance, I go through phases with drug seekers. Sometimes I'm easily able to blow them off. Other times it really bothers me. I never wanted to have to spend every minute of every day being suspicious about human motivation. Now it's part of every workday for me. For better or for worse I've developed an incredible sixth sense about when I'm being played. It's not a skill I ever really wanted.
3) You can't help someone who won't help themselves. I think this one is the worst. The vast majority of what I take care of is the patient's own fault. Smoke too much, get COPD - come to the ER when you can't breathe. Eat too much, get diabetes - come to the ER when your sugars are too high. Drink too much, get cirrhosis - come to the ER when you get a GI bleed. And then get upset at me when the wait times are too long, or I can't get you back to normal.
In the end, the easiest insulation is to just care less. That way you don't get burned when the oxygen-dependent COPD'er blows off his own face by smoking with oxygen tubing. Or the full workup you just ordered on your chest pain patient ends up being a waste of thousands of dollars because he was just trying to scam you out of vicodin. Or the family of the diabetic you're treating for high blood sugar brings her an Oreo Blizzard from DQ while she's hooked up to IV fluids.
I've spent the last 7 years really, really caring about what happens to my patients. I still do, but it's wearing on me. For every great save I make, there are eight more patients for whom I was a momentary speed bump in their fast lane to destruction.
It's tough trying to hold on to the good things I do. A kid almost died after an inhalation injury a few days ago. I intubated him and saved his life. He's back at home now, normal, with his family. At the beginning of residency, I would have been excited about that for weeks. Truth of the matter is, I don't really get a rise out of it any more. Just one more patient out of thousands.
And so, I'm looking for a reason to keep going. One that spans beyond a need to pay off loans or make a paycheck or not to throw away 7 years of miserable training. I know things will get better. For now, though, it feels like I'm a tiny brick in a massive dam that is trying to hold back the constant flood. America is getting sicker.
I'm getting tired of fighting.