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A doctor’s struggle for patient care

“I maybe have a tiny shred of compassion.”

A doctor I know wrote this in reference to a person they’d never met, a person who had been verbally abusive to many health care professionals. A person who was a prospective patient.

A tiny shred of compassion. Maybe.

I had met the patient in question, was the physician caring for them in the hospital. I was trying to find a PCP who would take care of them after discharge. They were a person of color and they were poor. They were living out of their car but too proud to admit it. They had a low paying job doing hard, honest work that took a toll on the body. They were not physically well. They often needed doctors and nurses to take care of them, but whenever they were in a hospital or clinic, they saw health care villains, not health care heroes. I didn’t know my patient’s whole life story but imagined they had reason to distrust people, institutions, and systems. Distrust as visceral as theirs must be rooted in a lifetime of lies and betrayals. No matter how well justified, their mistrust was not serving them well. When my patient was sickest, when they were most vulnerable and scared, their fear was compounded by suspicion of all those trying to help them. It was a threat to their life if it caused them to delay or reject lifesaving care. My colleague was considering whether to accept this patient into their practice after discharge. I thought about how much empathy they used to have, that is before the daily grind ground it out of them. I figured they were burned out.

Moral distress and burnout are frequent topics of discussion in health care circles these days. Administrators send out surveys, hand out candy on hospital units, and offer well-intentioned words of affirmation … all while asking medical staff to keep doing more than is safe for them to do. I am burned out and I am distressed, morally and otherwise. A Kit-Kat and a kudos are not going to change that. What I want is to drive home at the end of a shift and feel good about the care I provided that day. I want to provide my patients with the health care they deserve, the high-quality care I know I can provide if I have the time and resources to provide it. However, I can’t control the electronic medical record or the number of patients I have to see; I can’t control documentation requirements or the frequency of interruptions.

Learned helplessness has taken root. The American health care system is a reflection of our culture—that is to say, individualistic, profit-driven, and short-sighted. Rather than reflect the superficialities and pitfalls of our culture, doctors are expected to embody the best of it. We embrace this challenge and in turn expect the stature and respect bestowed on those of unimpeachable integrity. But too many of us too often fail to hold up our end of the bargain. We go through the motions, cash our paychecks, treat patients as commodities while resenting the commodification of our profession. The culture within medicine is changing and it’s long past time it did. More and more, doctors are encouraged to embrace their humanity, acknowledge their limitations, and talk about their emotions. We’re not Supermen and Superwomen. We’re human. Atul Gawande tells us so. I support all of that and believe me, I am plenty in tune with my faults and limitations. At the same time, I don’t want to be seen as an ordinary person. I don’t want patients in their hour of greatest need to look up and see just another dude. I didn’t spend all those hours in the library or all those sleepless nights in the hospital so I could do ordinary things. I wanted to be part of something powerful, something beautiful. As cliché as that sounds, it was true before, and it’s still true now.

My brother asked me years ago, “Isn’t being a doctor just a job?” I told him no, it is a passion and part of my identity. In recent years, it has been just a job, and that’s why I’ve been so miserable. I need to put those years behind me. My patients deserve better than someone who treats improving their health or saving their life as just another job. They deserve my attention and focus, deserve to be heard and not judged, deserve to feel safe and cared for, deserve to feel confident in their doctor. They deserve to trust. It is magic, trust is, and the moments of connection it allows—when a wall comes down, a secret is shared, a fear expressed, a tear shed. Individual doctors cannot control “the system,” but we can connect with patients, earn their trust, and challenge colleagues to do the same. It’s about time we stop playing the victim.

We can hide behind “the system” and many overworked, overscheduled days we’d be justified in doing so. There is so much we cannot control about our day and our job but the system will only take our humanity if we relinquish it. If we expect to be held in high esteem we must act in a way deserving of it. We cannot wait to be treated as selfless professionals to start acting as such. Our professionalism cannot be conditional on being treated as a professional. I am not satisfied by the number of patients I have to see every day. Metrics don’t fill my passion bucket. I am through with throughput. The triple aim can kiss my ass three times over. I will not mimic my employer by measuring my work and my worth as a bean counter would. I am going to ignore the buzzing phone in my pocket, ignore the utilization reviews, and ignore the RVUs, JOAs, and P4Ps. All those things can wait. In fact, they’ll have to wait because I am staging a sit-in, one where I sit down and focus wholly on the person in front of me.

So I was driving home a few nights ago. It was very late. Exhausted and spent, I was listening to Ben Folds’ “The Luckiest,” and I was crying. That day I had connected with the abusive patient who was supposedly incapable of reasonable human interaction. With a nudge from me, my colleague’s heart had softened and they agreed to take on the patient no one else would see. They even reached out to the patient with a simple act of kindness. The patient was overjoyed, and more than that, they were relieved. Their shell of anger cracked, along with their voice, when speaking to a case manager that day. They said they had finally been heard and could let go of their fear—their fear of not getting care.

I don’t pretend to have the riddle of career satisfaction solved, but I do know fulfillment does not lie in the approval of my employer. I am going to serve my patients because it is through service to them that I serve myself. The ultimate performance incentive is human connection. The sooner I recognize that, the sooner I recover a tiny shred of hope. Maybe.

The author is an anonymous physician.

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