Building our care team made me lonely

I began practicing cardiology a decade ago caring for a cadre of young adults with congenital heart disease. I got to know their families (parents often still accompanied them to office visits), and I learned about their lives in addition to their hearts.  “How do you remember the patients so well?”  trainees often asked me.  “Because I remember their story as a person and then the medical journey follows,” I would respond.

My practice flourished, as more children arrived in adulthood with congenital heart disease and as their parents aged and sought general adult cardiac care with me as well wanting to “keep the family’s care altogether.”

As the program grew, we hired another MD, a nurse, a nurse practitioner to help see patients, a social worker, and finally an RN program coordinator. We were an outpatient care machine. It was exciting to share patient stories, successes, and challenges.  It was reassuring to have a support system to help cope with the rare and usually devastating losses at a young age.

At the same time as our outpatient unit was expanding, the hospital instituted an inpatient coverage model. Physician burnout was growing and each physician rounding on her own patients every day was challenging. There were other drivers of this systematic change which had been demonstrated in comparable academic institutions as well.

About 18 months into our growth trajectory in the inpatient and outpatient setting, it started. This deep-seated unrest each time a patient said, “Your other doctors saw me; I spoke with your nurse; gee you must be pretty successful now as you are so busy.” I prided myself on the doctor-patient relationship, and these comments irked me. A few weeks later, I noticed myself being surprised by patients who came with their new baby or when the nurse had to remind me that a patient had lost a parent in the intervening months between clinic visits. Recalling those details was my role. The background noise which was irritating me now became a dull roar.

For the next two weeks, I stepped back and watched my own daily interactions. I was busy, moving from patient to patient, listening to presentations, teaching and precepting. I was still hugging patients, taking the time to sit down and connect, but I had both history with the patients and had gotten facile enough to connect in a minimal amount of time. I hoped that my patients felt we still connected, but noted that many commented on how systems of care had changed and we were now practicing team-based care.

I had support, for the electronic medical record, patient calls, and paperwork.  I had more time with my family, and vacations during which, for the first time in a decade, I actually signed my pager out. It was in this cocoon of protection and camaraderie that I became lonely.

Precision in defining emotions is essential. If I wanted to use the phrase of the day, I would say I suffered from “physician burnout.” But that is not accurate. I spend fewer hours inpatient (or at least those hours are now consolidated), I have more control over my schedule and layers of people assisting with patient management. I should not be burnt out. But I am bereft of something. I am lonely without my patients.

Many of us become physicians for similar reasons. Those of us who see patients in the outpatient setting five days a week do so because we relate to people. We thrive on the excitement of discovering someone new and their story, and are honored that our profession is one of the few where within an hour you are welcomed into the inner recesses of another human’s emotions, hopes, and fears. Often, you are in fact asked to be their navigator.  A large and steady volume of that level of emotional connection is perhaps too much for many and can lead to burnout, one of emotional exhaustion.  However, for individuals who thrive off of that responsibility and connection … take it away, and there is a gaping hole.

Looking back, I see that my subconscious saw this coming. A few years ago I began doing televisits (Skyping with patients) and enjoyed it immensely as these visits were limited to my patient (often their family) and I, talking about their health goals and their course moving forward. Connection, individualization, and navigation are my trinity, and I achieved that in the televisits.  Earlier this year I began to use a virtual scribe system and started to see patients on my own again without a trainee or colleague.  A few times a month I would ask a perfectly well-trained fellow to shadow me.  Those visits were an opportunity for them to watch an interaction that was entirely mine to engage in.  Then, I started calling patients back myself. Even if I wasn’t the first call back, I wanted them to hear my voice, and perhaps, I enjoyed hearing theirs.

I suspect there is a balance: Teaching trainees, working with nursing colleagues, and seeing patients independently. I would never give up the team model; I do believe it improves quality, access, and accuracy of care. They are also my new family, one that makes me enjoy the workplace and have pride in the care we deliver. As an individual, the past decade has been a journey of better understanding which parts of being a physician appeal to me, and how I retain those in this ever-changing world of health care delivery. For me, being the consummate caregiver means retaining my human connection with patients, whether by old or new means. In congenital heart disease, I am fortunate to provide lifelong care to my patients and their families. As in any relationship, they also see my journey. It is they who shape me as a caregiver. I suspect that many of them will recognize that it is also they who will make me whole again.

Ami B. Bhatt is a cardiologist.

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