The physician’s paradox of healing

Physicians across all levels of training are familiar with the widely recognized truth that our medical system is broken. This damage is evidenced by a paradox; perhaps it will become the great paradox of our time – physicians who were driven to a profession by a desire to help others are now the same doctors who secretly hope they don’t have to help you.

It is 9 p.m. on a fairly average call day. My fellow sends me a text message to let me know that he just added a patient to our team’s list. He proceeds to describe her as a “hot mess” who is being directly admitted to the hospital due to concerns expressed by her primary outpatient physician. I know the hospital has no open beds. In fact, we actually have negative bed spaces available. So I cross my fingers in hopes that she will not be admitted during my 28-hour call shift. As 6 a.m. creeps around, I feel a sense of relief and near joy wash over me. I narrowly missed an interaction with this patient and family that would have inevitably taken up hours of my night; An interaction that, on the basis of my fellow’s description, I expected to be negative. However, this patient needs to be hospitalized. Due to her comorbidities, she relies on intravenous nutrition and is currently experiencing significant electrolyte imbalances. I know she needs close management, yet I am happy that she was not admitted while I was still at work. And just like that, I find myself celebrating failures in the medical system that have any chance at making my shift go just a little bit smoother.

My unsettling contentment is cut short because I have another patient who acutely decompensates and requires immediate assessment. I call the critical care team, and they agree that she is growing increasingly ill. This patient ultimately requires escalation of care from the acute to the intensive care unit. In the aftermath, I cannot help but feel pleased. On the one hand, I reflect on my intervention and conclude that it was timely and appropriate. However, I also catch myself pleased with my “success.” If the critical care team had not seen the need to transfer her, it would have reflected a more stable clinical status for my patient that might imply a shorter or less complicated hospital course. However, my clinical intuition is validated by the transition of care, and I am almost grateful that this is one less sick child I have to actively worry about.

I return to my computer to document what just happened. As I detail what led to the transfer, I discover that a different child was discharged last week without a prescription for the antibiotics he needs in order to treat a central line infection. Admittedly, I am driven by sheer instinct to look at his chart and confirm it was not me who made that mistake. Having satisfied my selfish sense of relief, I then proceed to react in a manner that could actually serve to rectify the situation; I am not quick to help the patient first and foremost.

In the hours that follow, I am left wondering, how did all of this happen? As residents, we are always on. We work long days and long nights. We are physically, psychologically, and emotionally exhausted. And we accept the system—the long hours, the seemingly endless lack of control over our schedules, and the hurt that comes with feeling perpetually undervalued. We are complicit in this abuse for several reasons, not the least of which being that we are told our desire to help others is noble and that we are good people because of it. We smile for as long as we can and resiliently bear the weight of our work. But it is not without its consequences; sooner or later, something breaks.

In a profession where healing lies at the crux of our job description, we are beginning to lose our drive to help if it means more work, more excruciating minutes spent being yelled at by a patient or their family, more inevitable moments of self-doubt and questioning when headed home after a long day. We are slowly losing our personal accountability in doing right by our patients. And in turn, doing right by ourselves. Our medical system is broken. I can attest to this truth, because it broke me.

I am sorry. To the girl whose mother had to sit at home awake all night, worrying that her daughter’s medical issue was not being addressed properly while awaiting a call to notify her that a bed was finally available. To the father who witnessed a swarm of providers talking over him about the worsening clinical status of his daughter and then had to tearfully walk by her side to the ICU. And to the mother who had no idea that we sent her son home without antibiotics; I do sincerely hope he is OK. But perhaps, most importantly, I owe myself an apology. I am sorry for letting the stress, the hours, and the doubt chip away at the compassionate and driven individual I was proud to be—leaving in its wake a person who is starting to secretly hope she doesn’t have to help you.

I know this feeling, however concrete or fleeting, is neither who I am, nor who I want to be. In fact, my most consistent motivation to go to work every day is being able to connect with patients, treat them with respect, and build trusting relationships. These qualities are predicated upon a deep-rooted desire to help, despite everything. As such, I am almost certain that my figurative scars will fade. But removing myself from the strain that broke me is not a solution. Furthermore, normalizing the damage only perpetuates a culture that will go on to hurt others. I do not want to play into the paradox. I want to greet challenging patients with the same fervor as I did on my first day of intern year. I want to contribute to a system that tirelessly cares for its patients, just not at the expense of their medical providers.

The authors are anonymous pediatric residents.

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