A few months ago I was paged by a medical student in the emergency room at ten o'clock. I had just changed my clothes, and before my pager went off my attention had been squarely fixed on the newest Jack Reacher novel.
You can usually tell when someone is going to ask you to come into the hospital from home, because there are two or three apologies before any details about the case come out. Eventually she got to the part where the patient was bleeding in his mouth, so I called my attending to give him the story and we decided to go in. He offered to stop by my house so we could ride in together, which I accepted because that made it feel like a road trip and he has better parking than me.
I got dressed and grabbed my coat and stethoscope. It was nice weather so I went outside to wait. My friend across the street was letting his dog out, and threw a sympathetic look when he realized why.
'When does this stop?' he asked.
I thought it was a funny question because he works at least as hard as I do: usually leaves his house by 6 am to get work done before the rest of his office shows up. I think by 'this' he meant the unpredictable schedule and surprise visits back into the hospital that are an inescapable part of fellowship and I said, 'Probably never'. He responded with a half-smile, more solidarity than mirth. My attending pulled up and I stepped into his passenger seat.
'Home by midnight,' he said as I buckled my seat-belt. He was either trying to reassure me or himself.
We got to the hospital and saw the patient, who was not in extremis and was a little bemused by our sense of urgency. We admitted him to the inpatient service and started treatment and he went home a few days later. It's nice when treatment works. We were home just after twelve.
When does this end?
Recently, I've read too many articles about how burned-out doctors are these days. Why being a doctor is the most miserable profession and Why doctors commit suicide and how burn-out is unavoidable for physicians for various reasons.
In response, could I please respectfully ask my colleagues to take a deep breath for a second? I'd like to opine some context.
Applying to medical school is competitive, so I think it's safe to presume that most doctors went to a good college. We were probably academically successful while there. The importance of 'well-roundedness' was also mashed into our heads by our pre-med advisors, so we usually have some interests other than science. So: good schools, did well, probably even enjoyed ourselves some of the time.
Yes, we spent extra time in the library and we were very stressed (but as most of my own college classmates would observe, much of this was self-imposed) because the troll of rejected medical school applications always lurked somewhere under a future bridge. Still, we were doing what we liked to do. I know this because there were many who realized they didn't like it, and stopped doing it (or they realized there's more to life than how many *pi* bonds in a CO2 molecule, but that's a **very** specific inside joke).
Then, all we doctors eventually made it to medical school. I personally was stunned and can still remember pulling my car to the side of the road when I opened my acceptance letter. I felt lucky. I definitely did not feel oppressed.
Here's where I depart from generalizations and stick to my own story.
Medical school starts, and me being an observer of my friends' successes, I applied to combined MD/PhD programs because they seemed like so much fun. I showed up on campus a few months earlier than the other first-year medical students so I could start in the lab. That rotation began a six-year process of discovering that I am not a basic research scientist. Despite suspecting this fact around week two of that first lab rotation, I stuck around ultimately defended a PhD thesis, repeating in my head the whole time:
Hard work pays off,
Hard work pays off,
Hard work pays off,
If you say this to yourself a sufficient number of times, it starts to feel true (even though I can distinctly remember a professor saying it once and silently responding 'you totally don't know that, Guy-Who-Already-Finished-Medical-School, you just know that you got lucky').
When the classwork years end and the clinical rotations of third- and fourth-year start, you again find yourself the most junior member of a team. To be fair, you don't bring a lot to the table other than an eagerness to learn something, and you learn that as long as you never look idle or let your attention drift while someone senior (i.e. anyone) is trying to teach you something, then people will think you're doing your part. You're working hard and believing it will pay off. Proceeding through residency (and in some cases fellowship) you navigate the transition from learner to learner/teacher then to learner/teacher/leader.
Here's where I've seen it go badly for some of my compatriots.
In the United States, the minimum requirement to sit for a board exam is a residency of some type. Residencies range from three years (for example, internal medicine) to roughly one thousand years (for example, plastic surgery or neurosurgery). It's common these days to do a fellowship of some type, which is more sub-specialty training depending on which residency you did.
So, then we finally reach the end of training, those many years of grinding work and missing family weekends and working on holidays and maybe getting beat up in the cardiac intensive-care unit one time (I'll tell that specific story someday if anyone's interested) and you get to tell all of your friends who have been asking you, 'When does this end?' that it ends now!
Except...as opposed to college graduation, when the books go away and you don't have to take exams any more and there's a sense of completing something and moving on to something else, when you finish residency or fellowship training, life usually gets harder rather than easier. Now you have to deal with administrative responsibilities and insurance companies who make medical decisions with actuarial tables and the fear that you might do something (or not do something) to hurt someone and there's no other attending physician's signature to crouch behind.
I suspect this is where a lot of the frustration in medicine comes from. We told ourselves for so many years that 'hard work pays off' and many are experiencing that it just means a transition to harder work.
Many of the articles I've read raise good points. Unfortunately, money factors largely - most doctors start their professional lives with a lot of debt, so when they start to get the higher salary they postponed for x years, it's as if they're also paying for a house they don't get to live in. Hospitals are businesses, complete with executives and support staff and Boards of Trustees. Executives tend to make a lot of money and employees down the corporate chain make less. Physicians are a few tiers down and compensation is commensurate.
But here's another thing: many of those articles talk about medicine being a job that its practitioners don't want to do anymore, and the problem with that is, medicine is not just a job.
Medicine is a belief system.
This is not to say that it ranks as highly one's spiritual beliefs or life-philosophy system, but to reduce the practice of caring for patients to a job has no possible outcome other than to guarantee that it will be a job that people hate. The stakes are too high. Very early in medical school, a few of my professors (independent of each other) were very up front about this: if anyone is here because you want to make a lot of money someday, leave now, for your own sake. Your money is somewhere else.
It's not necessarily a standardized belief system, but there are a few commonalities.
People who pursue medicine believe that life in general is worth something. Often, life needs maintenance and people should receive help irrespective of the other details of their circumstances. A sick person's pain takes precedence over my fatigue, someone else's fever is more important than my sense of overwhelm, because at this moment I have the training to deal with those things, and the moment after this one, I get to leave the hospital and be with my family and not everyone has that privilege.
If medicine is reduced to just a job, then it just becomes math. My fatigue is in the debit column, and someone else's nausea is in the credits, and when they don't balance then the question becomes, is this job worth it? And if it's just a job, then the answer's an unequivocal 'no'. In the moment, it's too demanding and thankless and the level of investment is too high.
Not only that, but it's also difficult to ignore the simple fact that most doctors work in an environment where illness is the norm, and whether you acknowledge it consciously or not, it really tends to reframe your perspective of the world. Since we can't really be upset at the sick people for being sick, we look for other reasons to be upset, and they're not hard to find.
Anyone who practices any element of medicine (nurses, doctors, the person who answers the phone), needs to be a shokunin (disclosure: I pulled this straight out of Jiro Dreams of Sushi). I think it's the only way.
The most miserable profession? Perhaps sometimes we are the source of our own misery. If we are expecting our co-workers, our executive bosses, or, possibly worst, our patients to deliver to us our sense of value, we are begging to be miserable.
I personally can't claim to have mastered the alternative, but I'm trying to stay on this road as I hit the home stretch in training. We're not only building a knowledge base, we're learning a craft. Which gesture is most reassuring when a newly-diagnosed cancer patient starts to cry? How can I most respectfully conclude a well visit so I'm not late for my next clinic patient? What is the most helpful thing I can do for a colleague who is clearly bearing the emotional weight of the suffering that cancer is inflicting on his patients?
I wonder if the most misery is born when we substitute these micro-issues for macro-problems over which we as individuals have no control. From my current vantage point, I cannot fix the potential system breakdowns instituted by new federal legislation. I cannot restructure the reimbursement system that ensures fewer doctors are practicing primary care (perhaps the most essential branch of medicine?) every year. I cannot stop people from getting sick.
I can spend a little more time each day learning about the thousands of diseases that fall under the purview of hematology and oncology.
I can try to stop worrying about why some medical specialties are reimbursed higher than others or, worse, why some industries in the United States offer far better lifestyles and ten times the compensation.
I can remember that I chose to pursue a profession that means sometimes I'll have to go into the hospital at 10 o'clock at night because that's the hour that someone happened to get sick. That I might have to deal with paperwork that I consider ridiculous because it means the difference between a patient getting the medication she should have rather than the one the insurance company wants her to have. That I have to learn to cope with the persistent reminder that we human beings cannot out-eat, out-supplement, or out-lifestyle our vulnerability to any number of awful diseases, and that no one is exempt.
This might mean that I'm not always home by midnight.
That's part of learning the craft.