I knew Friday was not going to be a good day.
A leak in the ceiling of my family room. A pet who would need surgery. I was already stressed well before Friday.
But at work, the issues started on Thursday with an osteoporotic patient for whom I had recommended Forteo, six weeks earlier. It was denied by her insurer who wanted Tymlos instead. No big deal. We simply precerted Tymlos, but this was also denied. Why? Because she had not received other treatment. They must have missed the part where the patient had taken Fosamax, and not tolerated it. Now, in order to get her medication approved, I would have to do a peer to peer sometime on Friday morning, based on the insurer’s schedule. Needless to say, I was angry that I had to jump through their hoops to make sure my patient got the care she needed
Then came the phone call Thursday afternoon. A patient of my partner, who was on vacation at the time, was being discharged from a hospital where we no longer make rounds. The hospitalist and the patient’s family were not happy that we could not see her in the hospital and wanted her seen on Friday. She had been admitted with an acute inflammatory arthritis and was started on high dose steroids. She was scheduled on Friday morning with one of our nurse practitioners. This would require supervision, which would add at least 15 to 30 minutes to my already packed schedule.
I started patient hours at 7:00 am and was already 30 minutes behind when I started to see my 9:30 am patient. She was a longstanding RA patient with significant joint damage of her R elbow, L wrist, and both knees. She had previously been on Remicade many years earlier, but did not tolerate it, and over the years, was repeatedly unwilling to try another biologic. I was left to manage her with methotrexate alone. She did not want steroids. She did not want surgery. She did not want a biologic. We talked about injections, but she was not really interested. Understandably, she was quite frustrated by the limited options. As I concluded the 25-minute visit, (I was now 40 minutes behind with my partner’s patient and the peer to peer still looming), she then decided that she wanted her elbow injected.
My knee jerk response was, “I wish you had told me that 25 minutes ago.”
Now let me state that I was wrong to say this. Note that I did not refuse to do the injection. In fact, as soon as I said this, I realized my mistake, and offered to do the injection. She angrily declined and stormed out of the exam room, vowing never to see me again. I gave her some time to cool off and called her 2 hours later to apologize. I told her that I had been stressed for time, but that that did not justify my comment. She declined my apology, and stated that I was more interested in getting to my next patient. There was nothing more I could do, but I have been beating myself up since then for having said this.
Fast forward to a week later. Again it is a bad day in terms of time with a full schedule and many complicated patients who require extra time that I provide. I am quickly an hour behind. Remembering the events of a week earlier, the thought that runs through my mind is to stay calm. I remind myself that I am not supposed to be bothered when a patient cannot give me a history that makes sense, gives me conflicting information, or goes off on a tangent, all of which will make other patients wait longer. I am supposed to take in stride the time I waste clicking boxes that have no meaning. It should not matter that I have to ask multiple questions just to determine what number from 0 to 10 best defines their pain. Meanwhile, two other patients are waiting for me, then three, then four. After more than six straight hours of seeing patients, I realize that my bladder will soon explode and that I need to get some food into me. My morning finally ends five minutes before my first afternoon patient is scheduled. However, I need some “downtime” (i.e., checking labs, reviewing messages, etc.) in order to recharge my battery before starting the afternoon. I am exhausted.
So I pose the question, are physicians human? Is it acceptable for us to feel emotions? Is it OK for us to be upset when at the end of the visit, a patient brings up a new problem that will set us back an additional 10 minutes? Are we justified in feeling irritated when a patient shows up late, disrupting our schedule? Are we allowed to be annoyed when we must ask permission from insurers to treat our patients?
There is an unspoken assumption that physicians should be immune to these kinds of feelings. There are tremendous expectations placed upon me by patients, insurers, pharmacies, etc. However, most of the pressure comes from me as I try to be everything to everybody all of the time, even though that is not possible. I am kidding myself if I think that I can resolve every problem that is presented to me each day. All I can do is the best that I can. I must recognize that this will not always satisfy others, but it is all I can do. I must give myself permission to not be perfect. I am going to make mistakes despite my best efforts. I must realize I am allowed to have emotions such as anger or sadness. I am not an automaton. I need bathroom breaks and food. I need downtime. I am human.
And sometimes I am going to say the wrong thing. I must learn to forgive myself when I do. Should I have made that statement to that patient? Absolutely not. I am a physician.
But I am also human. Now all I have to do is convince myself of that. I don’t think I am alone in that regard.
Mark Lopatin is a rheumatologist.
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