Thanks to the human heart by which we live,
Thanks to its tenderness, its joys and fears,
To me the meanest flower that blows can give
Thoughts that do often lie to deep for tears.
— William Wordsworth
Three decades with Kaiser Permanente. Half my life! The concept is both amazing and sobering. It is hard to fathom it was 30 years ago when I walked through the door and signed on the dotted line. After so much time, it is natural to pause and reflect. How did the years pass and what did I learn? What follows is not a comprehensive assessment, but rather random thoughts and reflections on my experience being a physician. I write these observations primarily for myself. If any of these musings resonate with you, well and good, but there are no lessons here. Just some notes from the practice.
We physicians are assigned a singular and mythic role by society. Humankind has delegated to us the job of chief guardian of the people’s health. This is a sacred charge which requires that each day we summon the energy and fortitude to recommit ourselves to care for, treasure, guide, empathize with, cultivate, listen to, nurture, speak meaningfully with, and value every patient we see. We need to do so with wisdom and compassion, talent and grace. Of course, we physicians are imperfect. We, too, are human. But we must strive to do the best we can. When we tangibly aim for that goal, our patients will see that we have tried.
Despite my best efforts, I have made mistakes, far more than I would have imagined 35 years ago when I innocently strolled away from the halls of medical school. These mistakes haunt me every day of my life. They live deep within my soul, an omnipresent shadow. Integral to the role I play as physician is the fact that people place the life and their fate into my hands, naively trusting me to know what to do. But there were times I failed. While it was never deliberate, and sometimes not foreseeable, I betrayed the trust and fumbled the responsibility. And at times these missteps were directly or indirectly fatal. I tell myself that to err is human, but knowing I am personally responsible for the deaths of people who would otherwise be alive today is inescapably humbling.
I cannot be a physician alone, a savior unto myself. My job would be impossible without the close support and meticulous work of dozens of other professional caregivers — medical assistants, nurses, receptionists, psychologists, social workers, physical therapists, pharmacists, pharmacy techs, housekeepers, respiratory therapists, x-ray technicians, cafeteria workers, laboratory staff, managers, administrators, and many others — everyone who works under the roof of the medical center. Bar none. The single most profound influence on my ability to survive the workday and feel I actually accomplished something is how well my teammates do their job and how well we work together. They can make me. Or they can break me. Our interdependency is immutable.
In the same vein, my colleagues profoundly influence my professional satisfaction. I admit it. I am dependent. I am needy. I depend on my colleagues and I need them to be collegial. It is the rare patient I can care for alone for decades on end, without seeking the help of other physicians more knowledgeable than I in the secrets of urology, the mysteries of the skin, the back roads of the lungs, and the byways of the endocrine system. When a colleague adroitly accepts the baton, we all finish the race more quickly. When the baton is dropped, we look like fools.
And, critically, how I function impacts the staff and my colleagues. I am impatient with the staff, if I raise my voice, if I am Mr. Grumpy, the staff rebel or woke they’re in a mudpit or both. Game lost. Or if I refer a patient to a colleague without first completing the best workup I can, without deploying my knowledge of medicine on behalf of the patient before I refer, then I make my colleague’s day gloomy and I stir up back hallway chatter about how primary care docs and just high-paid triage artists. I need to do my job also. Game on.
Resisting compassion fatigue is one of the hardest yet most important parts of the job. It is difficult to always seem interested and engaged, patient after patient, year after year, decade after decade. It is extremely challenging to show empathy for how bothersome each symptoms is, especially when one has heard the same thing thousands of times. It is nigh on impossible to listen carefully and gently to each patient’s story, since they don’t know how to present a coherent and cogent history, they don’t know what is important and what is chaff, and they don’t know when to stop. Especially when I am running 25 minutes behind and have four patients registered and waiting. But fighting against the attrition of compassion is crucial. It is second only to maintaining and developing one’s knowledge base of the science of medicine. First, know the science and know it well. Second, engage intimately with each patient. Validate and acknowledge their concerns, no matter how mundane. As hard as this is, we fail as physicians if we disinterestedly mumble our way through our days. Even if we think we’re smart.
Small things often loom large. I had not fully appreciated this truth until recently. This point hit home when I began saying goodbye to my patients over the past several months. So many patients recalled single sentences I had spoken 10 or 20 years ago, and told me how much impact these statements has made in their lives.
- “You’re doing good with your blood sugar.”
- “You’re looking a lot more energetic today.”
- “Congratulations on your daughter getting into Harvard.”
- “You’re doing so well, I think we can make your visits every 6 months instead of every 3.”
This is scary, since many of the comments were passing phrases I gave little thought to in the moment. But to the patient, they lodged deep within and served as touchstones they returned to over and over. More than anything, this shows the profound power we physicians exert. We need to be aware of our choice of words, our tone of voice, and the silent but weighty cues of our countenance. Yes, it can seem like we’re walking on eggshells every time we walk into the patient’s room. Sorry, but that is the clout we wield.
Illness is frequently random and unfair. While much disease is indeed due to lifestyle choices made by individual patients or to unavoidable genetic influences, far too much is indiscriminate, unreasonable, and unjustified. I, for one, grew sick and tired of having to make those heartbreaking phone calls to perfectly nice people who had never done anything wrong. I always cringed when I had to drop a cluster bomb in the middle of what was a perfectly normal life and a close and loving family. I hated it, I tell you. Unfortunately, I became very adept at assaulting the innocent, but it is a skill I wish I had not acquired. This was the single hardest thing I had to do and despite repeated practice, it never came easily.
Family and community can make all the difference, good or bad. Individual patients are never individual patients. They are members of families, of workplaces, of communities. In sickness and in health, individual patients both affect their various social circles and these social circles affect them. When the family or the community is supportive during a devastating illness, miracles are possible. When the support is lacking, all the physician’s magic is for naught.
When patients or their families got angry with me when I had to deliver bad news, it cut me to the quick. I did understand the anger. I knew I should not take it personally. But I did. Even though I was only a messenger, messengers have feelings.
Losing colleagues is exceedingly hard. I know I keep referring to the hard parts of this job. There are indeed many wrenching aspects to being a physician, and one of the worse is losing a comrade. It often feels like a military campaign, this work we do, fighting disease. And when a colleague is felled, especially when they are still on the battlefield fighting the good fight, it is a tragedy without parallel. Why di the physician have to die in the middle of the war, at a young age, for no good reason? Physicians should have a pass on this, but clearly we do not. So those of us left standing must simply soldier on.
There are so many things I never accomplished. I could go on for days about the myriad goals I set for myself which remain unfulfilled but it is getting late, so I will mention just a few:
- I never cleaned up my office.
- My handwriting never improved.
- I never learned how to inject trigger fingers.
- Call me old school, but I never figured out how to get patients to feel that watching an internet video about managing their back pain was just as good as coming to the office and letting me put my hands on their body. Sorry.
- I never figured out to park in the right spaces in the garage to avoid dings in my side panels. For those of you searching for a deeper meaning or metaphorical slant to this last statement, there is none. Just look at my car.
- I never learned when to keep my mouth shut nor how to play the game. Yes, there is deeper meaning to this one, but that is for another dy.
- And, most significantly, I never learned the secret of how to grow old gracefully. If I could just mast this last challenge, I would feel my life’s work was complete and I could retire in peace.
Despite the frustrations, this job is ultimately rewarding like no other. These past 30 years, I have laughed and I have cried. I have been totally exhausted with the bone weariness of the long distance runner and I have been more energized than an Olympic medalist. I have slogged my way through days that seemed they would never end and have sped my way through days that vanished in the blink of an eye. I have had patients yell at me and I have had patients hug me with the grip of a vice. But now that I am getting close to laying down my stethoscope and contemplating how much longer to subscribe to the New England Journal of Medicine, I must say I have no regrets. The years have been amazing and I would not trade these past 30 years for anything else.
The last several months of the practice have been especially rewarding, as patients have one after the other expressed their gratitude. This has been a moving and profound testament to the role a physician can play in the life of a patient and their family.
One of the most unexpected and surprising goodbyes came from a patient I saw for the last time about a month before I closed up shop. I will call him Mr. Morgan. He was one of those patients whose name I dreaded seeing on my schedule. For 20-some years, Mr. Morgan had done nothing but complain. Each visit he brought in a litany of varying, irresolvable symptoms with an underlying implication that I did not really care about him and was not thorough enough in my evaluation. Perhaps you have some patients like Mr. Morgan? On this final visit, true to form, he had his soliloquy ready. But this time it included to complaints. Instead, he wanted me to know that I had not only saved his life but I had also saved his marriage. I will note that he had never had any serious illnesses nor had I ever met his wife or discussed his marriage. But Mr. Morgan described at some length how important and meaningful our interactions had been over the years. He said that his marriage would have failed without my help, he would not have kept his job, and his life would have been totally different. I sat before him, speechless. For decades, my heart had sunk whenever I saw his name on my schedule. And now to hear how he had viewed these interactions was stunning. I started tearing up, because no other response was possible.
This small vignette captures a crucial element in the practice. There are clear — and, for the good physician, unavoidable — frustrations in being a doctor. These run deep and wide. I had loathed seeing Mr. Morgan’s name on my schedule for over 20 years because of how difficult each visit was for me personally. Even if I could rewind the tape and replay each visit in the context of knowing what he would say at his final appointment, I would feel the same way. His visits were hard; they sucked my energy and drained my emotions. What had happened had happened and was real, in its time and in its place. But I apparently masked my true feelings sufficiently at each visit that my very limited interventions had evidently been therapeutic. Hearing his heart-felt words and reflecting on how our interactions had positively impacted his life took my breath away.
Fortunately most of my patients’ visits over the years were not unpleasant. I enjoyed hearing about their life experiences, cheering on positive lifestyle changes, staving off illnesses where that was possible, and encouraging them to accept the shrinking borders of the country called aging, with its contracting realm of possibilities. Fortunately, the reward and gratification from most patients was more immediate than was the case with Mr. Morgan. But I will briefly climb on my high horse to say this: the litmus test of how well we function as physicians is how we each handle our own Mr. Morgans. It is easy to take of the easy patient. It is hard to take care of the hard. But we each need to “doctor up” and do our job, competently and compassionately. Especially with the tough patients. OK, I’ll climb down from my horse now.
I am not naïve. I know and understand the practice will continue to have its frustrations. Some are intrinsic to the work, unavoidable and inevitable. And some are extrinsic, frustrating, and unnecessary. But I do believe that for every physician, when we walk out the door for the last time, the good will far outweigh the bad. And that is what I wish for you as I conclude my notes from the practice.
(September 2011)