My providers have been encouraging me to return to work as soon as next week. My department leaders consistently advise me to take my time and not rush back. I’m not sure where I land between these two extremes. My instinct is to stay out longer, because I’m not yet desperate to return to work like I was toward the end of both of my parenting leaves. At the same time, I don’t want to take advantage of the system, so if I am able to return, I think I should. Then there’s a part of me that wonders if I should return at all.
In the last couple weeks, two major periodicals (The Atlantic and The New York Times Magazine) have published articles about
physician burnout. Both touch on the exact problem that led to my leave: the
ever increasing administrative burden placed on physicians. Taking 5-6 weeks
off will not solve the problem, which is why I was hesitant to take the leave in
the first place.
In particular, I appreciated Dr. Xu’s analogy to a chef in a
busy restaurant:
To understand how burnout arises, imagine a young chef. At the restaurant where she works, Bistro Med, older chefs are retiring faster than new ones can be trained, and the customer base is growing, which means she has to cook more food in less time without compromising quality. This tall order is made taller by various ancillary tasks on her plate: bussing tables, washing dishes, coordinating with other chefs so orders aren’t missed, even calling the credit-card company when cards get declined.
Then the owners announce that to get paid for her work, this chef must document everything she cooks in an electronic record. The requirement sounds reasonable at first but proves to be a hassle of bewildering proportions. She can practically make eggs Benedict in her sleep, but enter “egg” into the computer system? Good luck. There are separate entries for white and brown eggs; egg whites, yolks, or both; cage-free and non-cage-free; small, medium, large, and jumbo. To log every ingredient, she ends up spending more time documenting her preparation than actually preparing the dish. And all the while, the owners are pressuring her to produce more and produce faster.
It wouldn’t be surprising if, at some point, the chef decided to quit. Or maybe she doesn’t quit—after all, she spent all those years in training—but her declining morale inevitably affects the quality of her work.
Do I want to quit? Part of me does. Last week, I remembered
the first time I told my husband that I didn’t want to be a doctor anymore. I
was midway through an 80 hour week supervising the hospital service. We had
admitted a patient with a pulmonary embolism, a blood clot blocking the flow of
blood to the lungs, reducing the amount of oxygen that could be delivered to
the body. We started our patient on blood thinners to prevent the clot from
expanding and requested appropriate monitoring so we could detect clinical worsening
as quickly as possible. I also asked the team to order ultrasounds of both
legs. “Why?” they asked. “We are already giving the treatment we would use for
clots in the legs.” I asked them to imagine what they would do if the patient
came to see them in the office three months from now with leg pain and
swelling. Especially given the recent history of PE, they would consider the
patient to be at higher than average risk of blood clot elsewhere in the body, and
would appropriately order a leg ultrasound. “Let’s say a blood
clot is detected at that point,” I asked. “The patient will be on blood
thinners for this PE for the next 6 months. If they develop a new clot while on
anticoagulants, this has long-term ramifications: they will need a longer
course of a more expensive medication, potentially lifelong. If we can document
the leg clot now, then we would know if that clot identified in 3 months is new
or the same one that was present at the time of the PE.” I learned this from
working with hematologists over the last decade, and it was really a joy to be
able to pass the knowledge on to the young physicians I was supervising.
I was awakened by my pager that night at 11 pm. The resident physician
in radiology had just reviewed the leg ultrasound and wanted to report that
indeed, a clot had been found. He had called me because my name was on the
order as the attending physician of record. He did not see the note from the
resident asking that questions be directed to our Family Medicine resident
pager. He did not review the clinical record to see that the patient had a
known PE and was already on treatment. I was exhausted and overworked, needed
to get up the next morning to get to the hospital by 7 am, and I had been woken
up by something completely non-urgent. Fortunately my husband was still up
working and I was able to cry about it until I was calm enough to go back to
sleep, but that was the first time I questioned whether I am getting enough out
of this work to be worth the inconvenience and the expectation that I would be
always available.
Then I think about why I decided to be a Family Doctor, and
what I value most in my work. I come back to two factors which are central to
my practice and to what I want to provide to my patients. The first is maternity
care, and caring for families. I have now had the opportunity to help many
young women navigate contraception, then when they are ready to start a family
they choose me for their prenatal care. I very rarely miss my patient’s
deliveries. Often I am asked to be the primary physician for the new baby. I
become very connected to these young families as women are asked to come to
prenatal visits every 1-2 weeks in the last three months of pregnancy, and
babies are seen quite frequently in the first months of life. It isn’t uncommon
that the new mother realizes her partner hasn’t seen a doctor in a while and
they ask if I can be his or her PCP as well. I am also asked if I can take my
patients’ parents into my practice, or their children who are aging out of
pediatric care. I am honored by these requests and welcome the opportunity to
care for multiple generations within the same family. Since residency, one of
my dreams for my career is to eventually be involved with the birth of a child
of a patient whom I myself delivered. As my oldest babies in Vermont are about
5 or 6 years old, this will be a while in coming, but it is a strong reason for me
to stay in the same practice for 20 more years.
In addition to care across members of a family, the second
factor that is important to me is to be able to provide a great depth of care
for each person. This includes maternity care and family planning, but is also
why I try to stay as current as possible on management of chronic illness. I
work hard to provide the best initial care I can, with a good understanding of
when I need to ask my patient to see a specialist in their condition, and of which
specialist might be the best match for this specific person with these specific
concerns. I have also become a buprenorphine provider, and it has been
incredibly meaningful for me to be able to create a safe space for patients to
talk about their difficulty with substance use, then offer a pathway for treatment
that brings them back into our office for maintenance therapy.
A good friend and colleague recently told me that what she
sees as remarkable about my style is that I am able to provide care without any
sense of judgment. This is actually something I have cultivated as a priority,
because I want patients to feel safe and honored when they come to be seen.
Generally people have a lot of stuff they would rather do than come to the
doctor’s office. A front office staff member at my first practice out of
residency told me that she would always try to be as kind and helpful as
possible on the phone and at the front desk, because just about anyone coming
in was suffering in some way, and she saw her role as making their day just that
much less miserable. In my fantasy world, all of us in health care have this
approach. So many people have experienced trauma of some kind, and for
self-preservation they are on guard against further hurt. I want people to
feel, as soon as we start to talk to each other, that I respect them and want
to find a way to help them move forward, however is most important to them. I
may be an expert in primary care medicine, but they are the expert in their own
lives, and by approaching our relationship as a partnership, I hope we can
achieve the best outcomes. This approach seems natural and instinctive to me,
but based on what I have heard, it is not universal. I think it must be a gift
that I have that I am able to provide nonjudgmental care to everyone, and the
more marginalized in society someone is, the more I want to create that open
and safe space. I do not want to turn my back on this gift. I want to continue
to see the families I have watched develop, and to help more people through
recovery, so I know I will return to my practice.
I’ve thought a lot about what it will take for me to return.
My leave has triggered increased attention to the well-being of all staff at
our office and in our department, as well as awareness of where our support
staff might be able to do a little bit more to reduce the burden on providers.
This will definitely help but I don’t think anything done locally will solve
the bigger problem in the health care system described in the recent articles
linked above. My request for my return is to reduce my panel size. Based on a
metric that was distributed to us as the vision for Primary Care in our health
network, I have over twice as many patients as the goal. I don’t know how we
will make this work – how will we decide whom to cull from the list? Whom will
they see instead, as all of our providers are stretched thin with more patients
than the ideal metric? I guess as I recover I need to let my department figure
that stuff out and focus instead on taking care of myself. This will mean a lot
more saying no. I think I will only accept new patients if they are household
members of current patients, and I’ll need to keep an eye on the numbers to
make sure I’m not moving toward overwhelm again. Over-commitment has been a
challenge for me since high school, and I guess I finally met my limit.
Thank you to everyone who has offered me support and
affirmation. It really means a lot.
