Agraphia Medical Tragicomedy



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.



"Hey, brotha. I need help. Look, I'm not gonna shit you, I'm an alcoholic. I'm homeless. I've got back pain. You can help me, you're a doctor. I need Ativan so I don't go into DT's and some Percocet for my pain.  Please, brotha,  I lay myself at your feet."

Before me lies an emaciated husk of a man, frost-bitten, his bleach-blonde hair pulled into dirty dreadlocks. The room reeks of alcohol, the tang of shitty beer lying uncomfortably in the air.  His bloodshot eyes track me as I walk over to examine him.

This was my first introduction to our resident frequent flier. He's famous; every ER doc in the city has treated him for everything from alcohol withdrawal to blood infections.  Among other things, he's an asshole, a florid alcoholic, and an abuser of the system (a news article estimated his ambulance rides, ER visits, and ICU stays costing the taxpayer more than $10 million).

Unsurprisingly, my exam is unremarkable. It's freezing out, and the ER is a refuge for a few hours from the biting cold and the unforgiving streets. I prepare myself for his discharge, and give him his papers.

"Your exam is normal today. I can't find a reason that your back hurts. I'm sending you home."

"Fuck you, man. I can already tell, I can't change your mind. I know your type. Yea, I'll fuckin' go. You know how cold it is outside? Yea, I'll fuckin' go. I'll go, you privileged sumbitch. You have no idea what it's like to be homeless."

He leaves without much fuss. A nurse claps me on the back for handling him well. She thinks my no-nonsense attitude approach will serve me well as an ER doc.  All the same, a small voice in the back of my head wonders if I should have been more compassionate.

The rest of the shift goes uneventfully, and as I drive home, I notice it's cold out, cold enough to freeze the windshield on my car. I run inside my heated house and crack a beer. Life is good.

"You have no idea..."

Out of guilt, I throw on a sweater and my overcoat, and shuffle outside. It is bitingly cold; I start shivering instantly. The stars are frigid, beautiful, and unforgiving, the moon austere behind a single veil of cloud. He was only wearing a sweater and some thin pants when I discharged him. He must be freezing right now. I last all of 5 minutes; my teeth chatter so hard I fear I'll break the enamel. I rush inside, the warmth enveloping me like an old friend.


Trapped and Free

4:55 AM, and I was dragging. My 12th day straight in the hospital, leaving a string of three call nights behind me with one left to go. Twenty patients to see before grand rounds at 7AM.

My knee has been hurting. I suspect it's from the miles and miles I've been putting on my body 14 hours a day, 90 hours a week, running around the hospital. I've been taking the stairs everywhere in an attempt to remain in better shape, but this morning it was too much. No coffee yet and too little sleep. I gave in and took the elevator from the 3rd to the 11th floor.

I leaned back in exhaustion against the side of the elevator, eyes closed. It whirred into life, and I let the tug of gravity pull me to the ground. The elevator reached the top floor and *dinged* quietly. I stirred, mentally preparing to start rounds.

And then, the door made a few feeble attempts to open, and quit. Servos whined to a halt. I was stuck in the elevator.

Funny, how things can change. Any other time I would immediately panic. What if I have to go to the bathroom? What if the cable breaks? What if the call button doesn't work? What if I can never get out?

Instead, pure, unabashed relief washed over me. I couldn't work while trapped in the elevator.

Zac, why haven't you finished rounds yet? The situation played out in my mind, There's so much to do today! We have to get on it!

Sorry sir, I quietly replied, I'm physically trapped in the elevator on the 11th floor, there's really not much I can do from here.

Well, I suppose you've got an excuse then. Take the day off.

I sat there for a few minutes, relishing the solitude. I planned out my entire day of rest, mapping out every delicious hour I would spend in each corner. Perhaps I'd take a nap right in the middle of the floor. I smiled. It was going to be a good day.

Then the elevator *dinged* softly again, and my hopes sank as I traveled back down. The door opened on the third floor. A tech stared at me in surprise, papers stuffed in my pockets, hair askew, sitting on the floor of the elevator.

"You alright, man?" he asked.

"Not really", I responded. I stood up, knee hurting, as I limped off towards the stairs.



Well, it's struck again, the dreaded apathy.

It's interesting, as I look back through my med school career. At first I remember being totally excited to learn, to understand, to really study our coursework. Anatomy, neurology, physiology... that was the stuff I loved in college, and being able to study it and apply it to other people? What an honor, what a privilege!

The grind slowly caught up with me. I studied too much, took the "work hard, play hard" mantra too much to heart. I would sit on the couch with a beer, a sleeping pill, the TV blaring, and my computer fired up simultaneously just to relax. I started making jokes that I used coffee as an upper in the morning and beer as a downer at night... but I wasn't joking.

I finished Boards - god knows how - and thought to myself finally the long hours, the stress, the constant feeling that I should be doing something productive would stop.

3rd year rolls around and you realize that for all the studying you may have done during years 1 and 2, you still don't know shit. Attendings pimp you on arcane knowledge from their specialty they've been practicing for 40 years and are shocked when you don't know it. End-of-rotation exams are brutally hard and require you to diagnose, treat, and manage 100 patients in about 120 minutes.

On top of it all is the knowledge that everyone you work with... interns, residents, attendings... are all going to grade you subjectively on how well they thought you did. So you put on your smiley face, pretend like ophthalmology is the most awesome field EVER and go to work every morning, starting on average at 6AM and finishing around 5PM.

It is brutal, and exhausting, and sometimes honestly I wonder if it wasn't a huge mistake to go to medical school. I'm not asking for sympathy here, by the way, but instead hoping that some of you nod to yourselves while reading this and go "yeah, I know where he's coming from. I've thought the same thing to myself from time to time".

Listen, sometimes you get that patient who comes along and just makes it all worthwhile. But sometimes you punish your body, mind, and soul for some asshole who treats you like crap and expects you to FIX EVERYTHING WRONG WITH ME even though he's not fixable.

I'm a person too, folks. I like sleep, and food, and friends, and family. I've lost a lot of that these past 3 years... and sometimes the field of medicine just isn't rewarding enough to make the sacrifice worthwhile.

I suppose the reason I write this now is that I have really, really been enjoying internal medicine- I like the diagnosis, the management, the primary care aspect. But I see my interns and residents getting no sleep every 5th day (and if you aren't a meddie, imagine that for just one second. No sleep every 5th day for the next 4 years of your life... plus little sleep the rest of the time) and frankly, I don't know if I want to do it.

So, here I am again, thinking about the decision between doing what I love and doing something where the lifestyle doesn't suck. There's a damn good reason people go into pathology, anesthesia, radiology, and dermatology. You work real people hours, and you get paid a decent salary.

After all this time and energy, don't you think we deserve that?