Agraphia Medical Tragicomedy

12Sep/1223

Disillusioned

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.

Comments (23) Trackbacks (1)
  1. Have you considered transferring to somewhere else, or even out of country (I am not sure how feasable that would be)? Or even doing aid work for awhile in a country that doesn’t have enough trained physicians? (Again, I’m sure your loans may not allow it, and you’ve probably considered it all before, but still)

    I enjoy your posts when you update, from all the way back when you were in med school. What about writing a book?

  2. As a patient, it breaks my heart to read this. I really feel for you as you try to work through all of these vexing situations and still practice good medicine. I would never want to tell someone to engage in a profession that makes them unhappy, but I so hope you (and other doctors) can find a way to handle it all without feeling numb or worse inside.

    I have a rare metastatic cancer. It took several months to properly diagnose it, and I have seen dozens of doctors and surgeons along the way. I appreciate the efforts of every one of them, even the ones who may have missed something important. It was clear to me that they each tried their best and valued my well-being to a degree that truly humbles me. Please don’t lose sight of the fact that there are legitimately sick people who adore their doctors and rely on them. I am constantly amazed that there are people like you who trained so long and hard just to be ready to someday handle a very freakish case like mine. I can only thank you and your colleagues for your kindness and expertise and willingness to go the distance. I’m sorry about all the bizarre non-medical reasons people wind up in an ER. They have problems that clearly go way beyond what any individual doctor can address. For now, I just want to send you a bit of cheer and gratitude.

  3. I’m a medical student with a Path/Pharm/Microbiology test tomorrow…stop scaring me.

    Thanks for writing this blog

  4. That’s too bad man. As an M2 I’ve always told myself I’d never get disillusioned, but I can definitely see how it happens. How have older ER docs handled similar experiences? I know the field of ER is highest for burnout and has the shortest career span of all the specialties.

    Keep us updated on how things go and I wanted to say thanks for writing one of the most inspiring medical experiences I’ve ever read – hopefully your experiences will be more like that.

    http://www.agraphia.net/the-moment-ive-been-training-for/

  5. Ive practiced Internal medicine now for 29 years. I have worked emergency room,provate practice, clinics and now as a hospitalist and i want to assure you that the people you do good for make it all worth while. I want you to do something for me . Take a tally sheet of your patients for one day. You will find that the patients you described are the exception ie 4 out of the 48 patients of the day. Unfortunately the 4 rob you of your emotional energy but the tally sheet will give you perspective

  6. Do a research fellowship. The NIH has loan repayment plans. See patients 20% of your time instead of 100%.

    Also, how’s your life outside the hospital. I know you broke up with your gf a while back and moved to a new city. Perhaps that’s part of the problem too? For me it takes about a year of living someplace new to really settle in and have it feel like home, with new activities, routines, and friends.

  7. While I am not a doctor, I am almost a nurse (6 weeks!), and I also work in a hospital. I agree that these patients are frustrating; for me it’s the nursing home patients who are a&o x0, no family and have no quality of life who are full codes. I’ve read your blog for awhile and I think you’re an amazing writer and an amazing doctor. I hope that you can find your way to over come this, or find some awesome way to repair our broken system. I agree with the poster who suggests working abroad, it’s so important for us to give back, and to realize why we do what we do. Good luck. I hope you’re able to find your love of medicine again.

  8. Maybe the problem is that you deal with the burden of this yourself now as opposed to being a resident, where you got to dump some of the frustration onto your attending. As an R2, it scares me to hear you say these things, as I am still catching myself near daily remarking at how much I love this job. But part of the love, comes from the shared experience with the other residents, bitch sessions, crackin’ jokes about the stupid things our patients do and say, or the crazy stories they make up all in the name of percocet. I’d imagine that being the new attending, with new peers in a new city, has taken away a lot of these outlets that maybe existed before. Maybe over time as a new support network of colleagues and peers develops, your frustration will wane. I hope so.

  9. Hey, all – I just want to say thank you for your kind comments. I never would have figured my readers to be so supportive. Yesterday was kind of a rough day for me; I had just switched nights to days, had a miserable shift beforehand and was particularly grouchy.

    Never fear, I still love what I do. Good times and bad times come in waves. Med students, don’t worry. You’ll have highs and lows. Sometimes you just have to tough it out.

  10. Hey Zac,

    I’ve been a quiet reader of your blog ever since Ariel turned me on to it. But I have to comment on this.

    I can’t even begin to understand how hard it is for doctors to practice the craft they love in the midst of bureaucracy, politics, lawsuit potential and just general idiocy of humanity. But if it weren’t for doctors like you, my still young (51 year old) mother would not have had the chance to meet my daughter. Just days before I had my baby, my mom was who visiting us had a really hard time breathing. We forced her to go to the ER, where she coded twice. Her BP was 197/122. She was asystolic, and later we found out that she had around 2% chance of recovery. If we had done what she begged us, which was to just let her go home, she would have died on the way. Those ER doctors saved her life and touched the lives of many different people in the process, including my baby, who will get the chance to know her wonderful grandmother. We are encouraging my mom to take better care of herself, eat better, exercise more, and get preventative treatment so that needless trips to the ER can be avoided in the future.

    I can tell that you love what you do, otherwise you wouldn’t be so disappointed in people. Just don’t forget that for every 10 cases that will make your faith in humanity waver, remember that there is one case that really truly makes your job worth it. So thank you.

    Val

  11. As a first year med student, I obviously can’t give you much advice. That being said, my physician mentor gave us one really good tip, which is to lower your expectations. Concentrate on the small victories, like the stroke patient that gets some function back, or the child with an earache that you can fix and send on her way. It leaves you feeling like you came out ahead, even on your worst days. Always try to fix the problem, but realize that only sometimes you will succeed. It’s easier said than done though, especially for compassionate people like you and I. Best of luck.

  12. I left internal medicine for anesthesia almost 25 years ago, and have never looked back. There is satisfaction in accomplishing more limited goals (go to sleep, good operative conditions, wake up, pain controlled, nausea controlled or absent). You may need a different venue, less big city, more small city or town. Or an ambulatory clinic where you will see big stuff now and then still, but don’t get all the aggravating stuff.

  13. As one of those shitty drug-seekers I would like to say “I’m so sorry”

    I really am. I wasted a lot of people’s time and a lot of other people money trying to get high. And I did feel embarrassed. And ashamed.

    It just took me a while to realize what I was doing to others while trying to make myself feel better.

    Thanks for helping out those who sincerely needed it while putting up with everyone else.

  14. Doctors without Borders. If you want to make a difference, do it and stop complaining about it.

    • I think he has made a difference in plenty of people’s lives wherever he has been practicing in and out of residency. Don’t have to go to another country to “make a difference.” And for many of us, a blog is a method of coping or dealing with what we are feeling. It isn’t complaining. Dr. Zac has made a difference in my life, so think before posting and telling a tired EM doc to “stop complaining.”

      Dr. Z, check out this post by another EM doc who focuses on finances. Was a pretty good read, and it came out the same day as this post: http://whitecoatinvestor.com/avoiding-burnout/

      Thanks again for the great guest post, let’s work together again soon.

  15. Dr Zac, I have been following your blog for several years (invited you to our home in Atlanta, asked you to post ” If it’s to be…it’s up to me” on your mirror when you were in College. I want you to know that your post made me feel so guilty that I went upstairs and got 2 large bars of semi-sweet chocolate and discarded them. You made me realize that I was not only hurting myself (which I didn’t care about) but my Doctor too. My Metformin and Januvia was right beside it in the drawer. I don’t know why My Dr hasn’t given up on me. Thanks for the post. I won’t let him, you or me down again.

  16. Look, I hear ya. I’m a non-traditional (read: old) first-year, and I thought a lot about the things you’re describing before jumping into medicine. But consider this: your pain and frustration comes from judgment. Yes, people cause many of their own problems. But, like everybody, they are trying to get by the best they know how. Life is fucking hard. If the only thing that feels good in a person’s life is eating or drinking or smoking, well, it is what it is. You probably don’t feel bad about working on, say, an athletic injury, because to you, that particular overindulgence is in the “good” category, compared to eating a box of donuts, which you deem “bad”. Maybe you could learn to let go of that, and see yourself as helping people live the lives of their choosing. The messy, sometimes extreme, and sometimes short lives that they know how to choose. Which is hugely beautiful and valuable, even if people make different choices than you think you would in their shoes. Just a thought.

  17. Great thoughts, FDW. I try to remove myself from judgement as much as humanly possible for a lot of reasons. Otherwise I think I’d honestly lose my ability to practice; the vast majority of things I see are due to poor life choices.

    And the idea that other people live different lives than I do – and that it’s hugely beautiful and valuable – I wholeheartedly agree with that statement.

  18. I guess my point is, maybe they aren’t “poor” choices. Maybe they are just choices? And maybe reframing it that way wouldn’t help you, I don’t know. Regardless, the beautiful and valuable thing I was referring to was the care that you give people. I love your blog, and I look forward to being in your shoes. :)

  19. I can totally relate. I am a recent grad and I feel like I couldn’t have written this better myself. It is nice to hear that other people have felt the same way at times. Sometimes there are good days and good saves, and other days, well are just taxing. Thanks for the writing. Keep on keeping on… sounds like you really are a great doc.

  20. Thank you for writing this blog. It gives me a lot of insight of a doctor needs to go through, and I am trying to find out if I should pursue this career.

  21. Hey Dr. Zac.

    I’d just like to say, you’re a tremendous inspiration. I’m in my final year studying right now, and just had a mega crap discouraging day. Then I found your website.
    I’m going to right back and hit those books, but I just wanted to thank you. This particular post is about how you’re on a downer, but you sound like a great guy, and a terrific doctor to boot. So thanks. Thanks for the little pat and shove. I’m sure I’m not the first or the last person to have gone away reassured.. And isn’t that the hallmark of a great doctor?

    Hope you have a good one!
    -Cookie

  22. I have a rare metastatic cancer. It took several months to properly diagnose it, and I have seen dozens of doctors and surgeons along the way. For now, I just want to send you a bit of cheer and gratitude.


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