Things that Get in the Way

I recently picked up a dusty book from the overflowing self-help shelf on my bookcase: The Gifts of Imperfection by Brené Brown. I’d had a rough week at work, so much so that I left early one afternoon before I impulsively gave my 90-day notice. It wasn’t just one thing that pushed me so close to the edge, but a cumulative storm of events that built up until I felt crushed by the pressure of it all. I know better to not make life altering decisions when in the throes of emotion, so I went home, took a hot tub, did some journaling, and eventually got some support from a trusted physician friend. I returned to work the following days, thankfully without the constant voice of “I need to quit my job” blaring through my mind.

Brené Brown’s book was just what I needed to read; it was the right words at the exact right time. I read the following line and it got me thinking about what I needed to return to work.

“If we want to live and love with our whole hearts, and if we want to engage with the world from a place of worthiness, we have to talk about the things that get in the way—especially shame, fear, and vulnerability.”

I immediately thought about all the things I believed were affecting my ability to be a compassionate physician, the “things getting in the way.” I made a long list of all the non-clinical aspects of medicine that interfere with direct one-on-one patient care, but are inexorably tied to modern healthcare—documentation, staffing shortages, insurance companies, patient satisfaction surveys, administrative micro-managing, and constant pressure to do more with less. The more I thought about it however, I realized that my dissatisfaction was less about the external factors, most of which I have no control over anyway, but more related to internal factors. I was unhappy with and ashamed about how I was responding to the things that were happening at work. After some processing time, I rephrased the insightful line that had moved me so powerfully.

“If we want to show up at work in healthcare with love and compassion in our hearts, and if we want to engage with our patients and their families with kindness and acceptance, we have to talk about the things that get in the way—all the things that we are afraid of, the things we are ashamed to talk about, things that will make us vulnerable.”

So, what am I afraid of? I am afraid that I will not be able to stay in clinical medicine for much longer, even though I so love taking care of patients. I’m afraid that I won’t be able to remove myself out of clinical care because of my student loan debt and need to save for retirement. I’m afraid that I will become burned out once again, leading to more unpleasant interactions with patients and their families. I’m afraid that I will wake up day after day thinking “I don’t want to go to work today.” I’m afraid that I will fall into that 80% category of people who don’t like their job. I’m afraid that my calling and career will become a job, something to do to just pay the bills.

So, what am I ashamed of? I’m ashamed that I sometimes have minimal compassion and get irritated by my patients and their families. I’m ashamed that I sometimes wake up and don’t want to go to work. Afterall, being a physician is such a privilege, I have no reason to complain. I’m ashamed that I got quite upset after several interactions with family members last week. These interactions, and the resulting shame, is why I felt so close to walking away from all of it.

One patient was a young female with stage 4 metastatic cancer. She wasn’t making the functional progress required to stay at the rehabilitation hospital, with large daily fluctuates in how much assistance she needed to do things as simple as standing up. I sat down with her spouse and told him that she wasn’t making progress and would need to discharge. I recommended she go home on hospice and explained what that meant and would look like. Her spouse then started arguing with me about how she was doing with therapy, arguing with me that she was making progress, and refused hospice because that meant the patient could no longer get any further radiation treatment. Even though I knew his lack of acceptance and denial of her dying was his own emotional defense mechanism, I left the room frustrated, feeling as though the choice the spouse was making was not in the best interest of the patient.

Several hours later I then called a patient’s family member to let her know her daughter was ready to discharge. Again, the family member argued with me, going over every single slightly abnormal lab value she saw that morning in the medical record. No matter how much I tried to reassure her mother that her daughter was medically cleared for discharge, she came back with a reason her daughter needed to stay. After having a circular conversation for at least 20 minutes, I left the room again with frustration, feeling that once again, the family member was not doing what was in the best interest of the patient, which was to take her daughter home. As I headed to my office I was thinking, “I can’t do this anymore!” and “I did not train for this!”

I’m not sure what led me to do what I did next, though in hindsight I suspect it was because I was not in a clear mental space. Instead of going back to the safety of my office, I went to my leader and tried to get some support over these two challenging cases. He was not helpful and in fact, said some things that only added to the shame spiral already building momentum. I rushed to my office close to tears, pushing them away so that I could complete my documentation, chastising myself for trying to get support from someone who I knew from past experiences was unable to provide it. When was I going to learn?

A nurse then came into my room just as I was finishing up my notes, with a simple question about a patient issue requiring clarification. I don’t remember my exact words, but it went something like, “Unless the patient is dying and this cannot wait until tomorrow, I am unable to help you. I need to leave right now before I do something impulsive like give my 90-day notice.”

He looked at me in shock, stating that in the five years he had worked with me he had never heard me say anything like that, had never seen me so upset and at my wits end. Alas, I fell off my pedestal. But there I was, at the bottom of a cliff, all stirred up, frustrated, sad, and ashamed. I needed to express myself, all the disappointment about working in healthcare and dealing with families. He was the right person at the right time, safe to share my frustrations with. He validated my experience, allowing me to release what I was feeling so that I could move forward. He understood where I was coming from, reminding me of his own struggles when it came to taking care of patients and their families, and for that, I am so thankful.

Thankful I have not only him, but also one or two other colleagues at work that can listen to me when I’m having an off day. Co-workers that do not put me on the pedestal of the perfect and endlessly compassionate physician, one that never gets frustrated, one that always says and does the right thing. No matter how much I strive to be that way every day and with every staff and patient interaction, I too am human. I have bad days when I am not my best self, days when I can’t remember why I went into medicine in the first place, days when I wish I could go back to serving espresso. The support I received from this nurse and my close physician friend who I talked to that evening eventually filled up my emotional gas tank, so I could return the next day, ready to face whatever came next.