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Caring About Patients

First day back in this Primary Care clinic. Get ready for some posts reflecting on the experience of seeing patients in this kind of a setting. It’s not that it’s a bad experience, it’s just very surreal.

I know I care about people, I care about the patients who walk in, and I want to use my skills to make them better. And yet everything about the patient interaction seem rigged.

Most visits leave me feeling as though I didn’t accomplish anything meaningful for my patients. And maybe that’s exactly how medicine is supposed to be.

Nevertheless, this feeling of being so ineffective isn’t something I can shake. It’s not something that I can just get over and come to work pretending as though it’s not happening.

“Helping Patients”

To be honest, I don’t even know what my exact purpose is here in a Primary Care clinic. What am I supposed to be doing to help the patient? Ease their suffering? Improve their lab values? Make them healthier? Cure diseases?

Seriously people, I’ve been doing this shit since 2006, 14 years later and I don’t know what my exact purpose is here.

I listen to complaints about the how it’s hard for them to get an appointment to the clinic. They tell me that they couldn’t get their meds at the pharmacy. That they couldn’t afford the last cream I prescribed.

Jaded Doctor

Look, if I was jaded then I wouldn’t give a shit. I’d walk into the room, drop my spiel on the patient and walk out, not caring if they followed my advice or not. But I do care … just that I can’t control the outcome.

Is that jaded?

A jaded doctor would nag and complain about every single patient. They would butt heads with patients and assume all patients are doomed. Or maybe that’s a bitter doctor…

I don’t think jadedness is the problem here. I’m not worn out, I’m not cynical. I simply feel like I’m a waste of a medical degree, standing before the patient not being able to do anything for them other than titrate medications.

Caring About Patients

Caring about a patient means putting in the effort needed to help that person get through whatever health problem they have. Listen to them, help them overcome their barriers, educate them, and rinse and repeat.

Apparently caring is also demonstrating empathy. But to me that’s always been too narrow of a definition.

The essence of caring isn’t to hug my patient and put my hand on their shoulder and shit. It’s caring about their ultimate health – it’s doing the best I can as the expert before them. I got to be the best damn doctor for them.

I don’t have to be their financial confidant. I don’t have to be their punching bag because they have marriage problems. And I can’t do anything about the traffic they faced getting to the clinic.

Instead, caring is going above and beyond. Spending an hour in the exam room, if necessary, and talking about the difficult things with the patient. Tough love, for example.

If I care then I’m gonna be honest with the patient. I’m not going to sugar coat things. I’m going to set realistic expectations while offering them hope and my support.

The Patient-Doctor Relationship

There are those patients who doctor shop. They jump from one doctor to another and they complain and are a drain on everyone’s time.

It’s not like I can be blunt with that patient. I can’t call them out on their bullshit. I can’t interrupt them mid-speak and tell them that I’m not here to play their manipulation games.

But these medical visits are forced. Patients feel as though they have to come to see me because they’ve exhausted their other doctors. They want to be better and all they can think of is to make yet another appointment.

Despite this, they don’t feel that they should be honest with me. They all eat salads for lunch, have fasting blood sugars of 120, and they all take their medications every day.

It’s not fully their fault and it’s not the fault of the doctor. But I have to place some fault with the medical system. After all, they are the ones who butt into this patient-doctor relationship. In fact, it’s a legal definition which the medical industry has constructed.

It’s Easier to Not Care

It’s easier to not care. It’s easier to walk into the exam room smiling, oblivious to the reality of the situation.

The patient will feed me their usual bullshit about how the pharmacy didn’t give them their insulin. And that their glucometer was broke. That the referral coordinator was rude so they didn’t go for their follow-up. I simply nod, tilt my head, and flex my chin.

I want to care about my patients and genuinely do everything it takes to improve their health. But I feel as though the system is designed for me to not give a shit. To just clock in, type a bunch of stuff into the EHR, click on order sets, order meds, and book the next useless appointment.

The Penny Dropped

Maybe I had an epiphany today, maybe the penny dropped. Yesterday was my first day back in clinic after being off for 3 months. Today, on my 2nd day, I’m approaching things 180 degrees differently.

I’ll care as much the clinic cares. I’ll care as much as the medical system cares. And I’ll care as much as the patient cares.

I remember a couple of years ago I wrote another post along this same line. It had to do with antibiotics stewardship and I feel that I’ve not made much progress since that time. So, it’s good that I’m revisiting this topic of “caring” again today.

The Burnout

The problem with burnout in medicine is that it can happen from either direction. You can either be too vested and you’ll burn out or you can burn out from having too little emotional connection with the work.

I haven’t ever recovered from my burnout back in 2016. It left a bad taste in my mouth. Add to that my medical board investigation in 2017 and it’s been a lot to deal with.

But I don’t think anything I covered here today will serve as an antidote to burnout. Instead, this is such a coping mechanism for the work. A way to feel balanced so that you don’t feel taken advantage of but also don’t feel that you’re robbing someone else of their rights.

7 Comments

  1. fmresidentefuente

    Hope you’re ok doc. I’ll be looking forward to your future posts and really am curious to know how your thinking evolves as you get back into clinical medicine. I’m just a resident starting to pick up shifts in the local UC… it’s going well, but I see what you mean. You need to have a balance between caring too much and being checked out. At my fqchc I feel like a useless cog, but feel like an effective clinician at my UC (focused clinical work, easy template based charting, a reasonable number of “interesting” semi-acute situations every shift to keep me on my toes. I’m liking it so far… but obviously you go through different phases in life where your thinking evolves depending on the situation/context. I think I’m jaded but can’t seem to Shake the feeling that the work we do is important for some reason, even if it’s just reassuring someone that all is well. Every day is an adventure. I’m thinking about getting an ebike and rolling around doing house calls for 250 a pop. That would be fun i think. Might do an addiction fellowship, who knows. There are more important things than money, like your health and happiness. How was the travel from Spain? How are you handling the corona virus situation from a medical as well as investment perspective? Could be worse! I’m 300k in debt… but at least the stock market fluctuations mean nothing to me!

  2. Damn dude! I like your thinking.
    I have to be careful about my audience, because I think it’s safe for my fellow attendings to read the shit that comes from my brain but I don’t want to twist your perception of medicine – you who is still in the stages of defining what medicine is for you. I definitely agree with you that what we do is amazing for patients even if we do nothing more than reassure patients. Today was a great example man, I had this 75 yo super healthy lady who came in from discharge from the hospital for diverticulitis. She thought she had cancer because they maybe didn’t explain things to her. She wasn’t eating any of her regular food because she thought it’s gonna cause another bout. Anyway, some education and reassurance was all she needed and she was a new woman.

    I love your idea of going door to door. Find a good neighborhood, be friendly, be available, and be green. There are so many ways to carve the niche for yourself, especially when you start as early as you.

    I like addy medicine, not a bad idea. Also love geri and palliative. These are some of the happiest doctors I’ve ever had as patients and there is so much you can do.

    Investments are great, they are crashing which is a fabulous opportunity for me to buy even more, which is what I’m doing. Just don’t have more cash or else I’d go all-in. I think for you, being that much in debt, it’ll still mean a lot even if you can get $500 or $1,000 into the market. Don’t worry, you’ll have many more such market volatilities in your time to take advantage of. Hopefully you’ll get yourself debt free asap and you’ll see how many amazing opportunities you can take advantage of.

    Spain travels were good. It’s a nice change up being here in LA but I wish I was back in Spain – I think I still prefer the digital nomad life more.

  3. G

    To the doc coming out of residency my bit of advice is to set boundaries early. Your idealism will likely be at its highest point right after training, so just be careful. Medical practice, and nursing from what I’ve heard, tend to eat their young.

    There are plenty of folks with personality disorders who are looking to test the newbie….and I refer to both patients and to those who made their way from clinic into administrative/managerial roles.

    Your experienced colleagues are more than happy to have their life-draining patients join your panel. It sounds crass, but the ability to weed and cull the panel separates the experienced PCP’s from the former PCP’s. If you limit your practice to locums (or find an urgent care that will hire a physician) it’s not such an issue, of course. The pay is not the only allure of ED, rads, anesthesiology, and (maybe) hospitalist.

    Early on you might limit your primary care practice and do some urgent care. There are plenty of unassigned patients coming to urgent care and you could be selective in who you invite to join your primary care panel.

    I suppose urgent care could also work to pick up new patients for an addiction medicine practice…and your urgent care colleagues would probably adore you.

  4. Anonymous

    Dr Mo,
    As one of your RN readers, I find it fascinating that you’ve articulated a concept in the healthcare worker-patient relationship that I see rampant in the great hospital where i work. I never would’ve suspected before getting into medicine that patients were so oblivious to what’s in and out of their health control, and the hospitals. Exercise, diet, attitude, sleep hygiene, and hygiene are treated like afterthoughts to an extent that is mind boggling . While I think Spain and remote living was a terrific salve, I wonder if there are other ideas that also might help.
    Dr. Bryan Sexton has great YouTube presentations on burnout in medicine and possible avenues to address it. Also, I wonder if ideas from athletic programs about embracing the process might be another way forward. Or meditation. Or bouldering. 🙂
    Geoff

  5. Good to hear from you Geoff – thanks for your thoughts. Tell me more about your thoughts on burnout, is it something you experience yourself or something you see in colleagues?

  6. Anonymous

    Burnout is fascinating. I’ve seen many RN describe their feelings of apathy, extreme fatigue, not wanting to show up for work, and not bring able to recover back from that state. Being a less acute floor we have had numerous RNs switch to our floor to attempt to recover from burnout, only to realize that even on our floor the burnout persists. Like you describe once the burnout sets in its very hard to recover.
    I’ve been on my hospital unit 7 years. Certainly, i am jaded when experiencing patients complaints. I’m more efficient with my patient interactions, but sometimes that leaves patients unsatisfied. But overall, I feel like I’ve been lucky and have avoided full blown burnout. I might struggle at work one day, but have a lovely day the next. Maybe because I spend so much time outdoors and have a sense of community and belonging that lives in parallel to my RN work. Also I have a meditation habit that helps keep me in balance. After my last vacations though I did notice a perceptible positive shift in my attitude towards patients, that made me realize I’d probably been overdue for time away.

  7. That’s a great observation. I feel the same in terms of volumes and ratio of time-off and time-on. You might really enjoy the book Early Retirement Extreme – feel that your mind might really connect with his thought process.
    The longer I practice, the more of the patient’s burden I have to take on, the more time I need to recover from an even shorter patient interaction. And as micromanagement increases then that ration of [(on-time/off-time)*micromanagement] has to decrease. In which case, I’m totally happy with every fucking last gov’t agency micromanaging the shit out of me. Investigate me, sue me, add more patients to my schedule … as long as you respect that ratio.

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