Jayma Anne Montgomery
THE COST OF THE CALLING
I have been battling extreme exhaustion for the past few days. I came off of an especially tough five-day stretch at the hospital three days ago and can’t seem to find a posture of rest. It’s more than just physical weariness that is plaguing me, which is likely why sleep can’t seem to cure it. You become accustomed to managing a few disasters at a time in this line of work. Something is always on fire, about to catch on fire, or is a fire that was recently put out. This week, just about everything was on fire all at once and there was no option to call for backup. What else is there to do in that situation but keep the hose pointed at the flames and try not to get engulfed by the flames yourself? Then, after the building is a soggy, charred mess with shingles hanging by a nail and blackened floorboards emanating billows of smoke, you go out and find what your version of “shawarma after saving the world” looks like. For me, it looks like binge sleeping for several days in a row, reading my favorite authors, writing, and spending some much-needed time with my family. For others, it looks like wild parties, binge drinking, recreational drugs, random hookups, and any other pathological means of adapting to stress that you can think of. I am well aware that there are versions of life where things aren’t constantly burning but I have no idea what that is like or if it will ever be possible for me. I can smell the smoke no matter where it is or what I’m doing because I never want it to find me unprepared. Now that I have beat my fiery analogy to death, I am ready to get to the point of this particular blog post. (You see what I did there? A smile or a chuckle here would be greatly appreciated.)
As I was saying, I’m losing the battle with emotional fatigue. Perhaps it’s the unexpected death of one of my patients overnight that I wasn’t at all expecting. I had reassured her daughter and granddaughter the day before that she would be just fine after we treated her heart failure and COPD. It wasn’t a promise but I still feel like I unintentionally gave them false hope. It could also be my cancer patient who kept bleeding profusely into her lungs. Every day was a sprint to stay ahead of her dwindling red blood cell and platelet count with one blood transfusion after another. Her chest tube was putting out more than 2 liters of bloody fluid per day and she could still hardly breathe. She was the patient I feared would die at any moment. Or perhaps it’s my other patient with a new diagnosis of cirrhosis from an unclear cause. Her limbs had an unnatural, inflated appearance and a sponge-like recoil. Her pattern of lab work was suggestive of leukemia. By my fifth day on service, she was entrenched in battle with a syndrome that causes both dangerous blood clots and catastrophic bleeding. All the while, she remained unfailingly kind with a delightful sense of humor. She was evidence of the widely held belief by many of us in medicine: that it’s the sweetest patients who seem to suffer the most. I had some sleepless nights worrying about her for sure. There’s more to tell but I will save it for another blog post. I’m preparing to shift gears into a particular direction.
There are many difficulties that are expected and unavoidable in this line of work. We doctors know this from the very beginning when we apply for medical school. Those who don’t are in for a rude awakening when they start their clinical years and either don’t finish or stick to research. We make the wise, good, and hard decisions in the best interests of our patients because it’s our duty to do so. But there are many hard things that aren’t expected and, frankly, are not our responsibility that are frequently shoved onto our laps. Policing people seems to be a daily responsibility that has been thrust upon physicians despite the fact that we were never trained to do it and it’s not part of our job unless we are in appointed a directorship position. Patients and family members can essentially behave in any manner they see fit with next to no consequences. We are asked to tolerate harassment and verbal abuse practically daily. If a patient is making threats or throwing things, the immediate response is to call the physician on duty. What is five-foot-one little me supposed to do to mitigate that situation? I’m pretty feisty but I’m not about to physically wrestle a hostile patient to the ground. Not my job.
I have faced off with family members who felt it their personal duty to nitpick every single thing that anyone even remotely associated with the care of their loved one did. They harass the nurses so much that the nurses, in turn, feel pressed to harass us. Upon entering the room, we are made to endure snide remarks and baseless accusations of negligence simply for not being at their beck and call. Then, after spending more than ample time in the room appropriately addressing all concerns, the family members want to have a separate discussion with you outside of the room pertaining to things that were already adequately addressed just moments before. They conclude by handing over a list of siblings, cousins, and other distant relatives whom they expect you to call and provide updates to as well. This is real life, folks. There seems to be no awareness that I may have anywhere from 19-23 other patients to care for. There certainly is no level of concern for the mental drain that these endless demands are placing on my finite mental resources. Since most hospital systems are narrowly focused on patient satisfaction to the detriment of their personnel, I propose they begin hiring people to act as personal concierges to these entitled patients and their families/significant others.
I ranted about a patient whose wife cussed me out over oxygen that he didn’t qualify for just a few weeks back. He was back in the hospital with fluid in his lungs and I was assigned as his attending physician. He was briefly on oxygen and then, just like before, he was weaned off quickly after he completed a session of dialysis. I refused to engage with this irrational woman again so I turned his care over to one of my colleagues. At some point, my colleague was busy with another patient and the nurse contacted me to tell me that this patient’s wife was cussing her out and making threats. Would you mind coming to talk with her? I could tell she immediately regretted asking me that question. I absolutely DID mind! I instructed her to call a security escort to see her out of the building. This was the same directive I gave when she was refusing to take him home just weeks ago. I later found out that this same woman has cursed out two other doctors, a nurse practitioner, and a number of nurses and nurse’s aides. And yet, she was permitted to casually walk in every day as if nothing inappropriate had taken place the day before. If she behaved that way in an outpatient clinic, she would have been dismissed from the practice. It is beyond me why this woman was not banned from hospital grounds for her ludicrous behavior. I suppose if she escalates to the point of physical violence then this may be reason enough. I don’t know about you, but I find this totally unacceptable. And yet, this is the reality that I and many of my colleagues find ourselves in.
When I hear about physicians like Dr. Robert Lesslie, Dr. Tamara O’Neal, and Dr. Katherine Lindley Dodson being slaughtered in their homes or their place of work, I am devastated and hurt, but I am never surprised. We are expected to tolerate abuse as a natural consequence of our role as custodians of health. Who says that it has to be this way? Certainly not us. It’s the hospital executives, business people, and administrators who rake in astronomical salaries and bonuses all while being insulated from the gritty, hands-on work of patient care. If I sound embittered, it’s because the part of me that is willing to sweat and bleed in the best interest of my patients who are in need is growing increasingly dissatisfied.
On a final note, I just want to say that I’m genuinely puzzled by the way many patients and their families have come to view hospitals. Back in the day, hospitals were a place for sick people and the people taking care of them. Now, it seems to also be a place for accommodating needy families and friends, the demented or unwanted elderly, the homeless, the drug seeking, and the worried well. The time that I spend tending to this group of ‘non-hospital level patients’ is valuable time that I am unable to devote to my genuinely sick patients. There are times when a 40+ minute family meeting is necessary but that time is not daily. It’s not my job to usher patients into an assisted living, nursing home, or rehab hospital. That’s the entire purpose of employing case managers and social workers in the hospital setting. It’s not my job to convince the worried well that they are medically appropriate for discharge. Sir, this is your fourth day in the hospital after a completely negative chest pain workup and Cardiology has cleared you for discharge. Now you are breaking out into a shingles rash on your chest which, incidentally, is likely what was causing your chest pain all along. I have just spent 30 minutes at your bedside explaining the plan of care, ordering your medications to start before you leave the hospital, and ordering the remainder of those medications to your local pharmacy. Twenty minutes later when the nurse comes in to discharge you, not only do you act as if this conversation never took place but you tell her of your intent to appeal the discharge. This is the equivalent of being hospitalized for pink eye or a hang nail. Am I now supposed to take up even more time negotiating with you about the fact that this is a condition regularly treated in the outpatient setting? Hard pass. When I write a discharge order, if the patient doesn’t agree with it, then that needs to be handled by a third party. My job is to tend to your ailments, not your paranoid delusions of catastrophic illness or hypochondriasis. I have long proposed that medical facilities need bouncers in addition to security. This is precisely why.
This is the modern medical workplace for physicians everywhere…a never-ending face-off against the myriad legitimate and illegitimate issues that impede you from doing your job well. Somehow, after 65 hours or more of this over the course of five days, I am supposed to have ample energy reserves left to be an attentive wife, mother, an active member of my local church, good neighbor, and custodian of my household. I also additionally choose to stretch myself even further by writing regular blog entries, completing my book, and starting this Master’s program in January. If you want to know why I sometimes come across as a crazy person, this is why. There is no conceivable way to do all of this well at the same time. I have to settle for being ‘ghost’ mommy and wife while I am wearing my doctor hat and then unplug as much as I can from work on my days off. If the nonsense isn’t mine to fix then I’m not going to try. When patients or their families bring the shenanigans, I have no time for it. When institutions and support staff have no concept of what my actual role is in the medical infrastructure, I am very quick to remind them. If I didn’t believe that I was called to do this and that it pleases GOD for me to serve my fellow humans this way, no amount of money could tempt me to keep at it.