Heal thyself before others

Alice wept in my arms as she described her father’s last days. He died of metastatic prostate cancer. She felt lighter as she shared beautiful memories of him. It will never be the same for Alice, nor will it be for me. I was running behind for my next patient, a healthy 86-year-old woman. I apologized for keeping her waiting. She did not mind; she knew I would give her the time she needed. She held my hand as she unburdened her recent challenges caring for her husband after his vascular surgery. As dictated by her insurance carrier, she had minimal services. To my frustration, I could not in my power, get her the help she needed to care for him and the session ended in disappointment for us both, though she didn’t show it.

My next patient was not as understanding. She was new to me, a 26-year-old with a host of physical complaints, looking for an immediate fix. To the best of my ability, I was able to decipher through her physical symptoms and explained that a pill would not treat them, but instead offered stress management strategies. She left the room clearly unsatisfied with no intention to return. This one will go down on my Press Ganey survey.

I dismissed the last appointment, and was still preoccupied with what Alice said. She was lucky to be by her father’s side when he passed away. Sadly, I did not have that opportunity with my mother, and Alice’s comment brought back a world of hurt. I was only two hours into my clinic session; I did not have time to think about this. I had to keep moving — remaining present for each patient, oblivious to my own needs.

The remainder of the day was filled with visits of varying complexity, including rushing a patient by ambulance to the ER for unstable angina, amongst other clerical tasks which did not allow for a pause until 9 p.m. when I was able to get back on EMR to complete the charts and attend to other important messages and lab results that awaited.

This is not an atypical day for a primary care clinician.

It is widely acknowledged that physician burnout is on the rise. My specialty in primary care is especially susceptible to this raging epidemic as we are at the front line of access to care. We take the Hippocratic Oath as graduating medical students, which includes the line, “May I always act so as to preserve the finest traditions of my calling and may I long experience the joy of healing those who seek my help.”

Becoming a physician is a calling. We go into medicine fully acknowledging all the scarifies we will make for the sake of patient care. Various aspects of our lives will be placed on hold, as we will race on a speeding treadmill with no end in sight. The sleepless nights and sheer exhaustion in residency are just the start. The endless pings of pagers, texts, practice alerts on EHR, patient calls, consultation interruptions and prescription refills will keep our stress response system chronically activated. The expectation of physicians has been that we can work endlessly. We, too, feed these expectations, setting physical and emotional limits impossibly high, but at what cost?

With the current health care system demands of primary care clinicians to increase productivity, meaningful use, and meeting metrics, the demands are only getting worse, while there is simultaneously decreased reimbursements only further leading to devaluation of clinicians.

In order to survive the hamster wheel of endless administrative tasks, while losing control of our days, we become mechanical in our all our operations including the clinical engagements which were once meaningful. Regimenting medicine has taken away the joy and purpose of this noble profession.

Physician burnout can imply the lack of a physician’s ability to deal with stressors. While I agree that immediate self-care for physicians is vital, I do not believe it is enough to prevent this epidemic. We need to shift the culture and expectations holistically and go back to the foundation of what makes a doctor great. We need to look carefully at how priorities are formed and maintained throughout a doctor’s tenure as a caregiver.

I am encouraged by the commitment leaders are taking on to find a solution to this problem including reducing clerical responsibilities, promoting team-based care and most importantly bringing back the joy of medicine.

I hope our future generations of doctors will continue the work to amend the Hippocratic Oath: Heal thyself before others.

Shalu Ramchandani is an internal medicine physician.

Image credit: Shutterstock.com

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