Making a Difference
Issue: July/August 2020
Author: Andy Mayer, MD FAAEM
Editor-in-Chief, Common Sense
Let’s think back to when you opened that envelope and learned that you had been accepted into medical school. You dreamed of saving lives and helping people and making your mother proud. No matter where any of us ended up in our medical career, I think all of us at some point were idealistic and thought that we could “make a difference.” The typical path to becoming board certified in emergency medicine begins in grade school and progressed through a seemingly endless stream of pyramid schemes of advancement. At each step, you could look back at people left behind and feel relieved that you had reached that next ledge on the climb up the tall mountain which took us to the age of 30 or beyond to reach. Whether just finishing residency, or a grizzled old veteran, you can remember walking out onto the floor of your first shift as an actual emergency physician with the dueling feelings of sheer terror and incredible pride of having made it to the top of the mountain. You were finally the person who on your own could save lives, help people, and make the world a better place.
Then of course, you picked up your first chart who was a patient with metastatic fibromyalgia with a completely positive review of symptoms and already threatening to complain if you do not admit them for their well-deserved dilaudid coma. The shock and horror that the patients are not easier to manage when you are an attending and that you alone have to decide who stays and who goes hits you right in the face. I have seen this reaction many times over the years and have noticed a pattern in what I think of as the battle between idealism and acceptance and it often soon emerges. Most new attendings seem to do well when first out. They are excited to finally be getting a big paycheck and work more reasonable hours. There is occasionally the real save when a patient fibrillates in front of you and are shocked once back to a normal neurologically intact middle aged father with three teenagers. Who among us does not go home feeling better that night knowing that we actually did save a life just like you had always thought would happen numerous times a day. Your family might have also thought that your career would be like their favorite medical drama on television with an endless string of incredible lifesaving events on a daily basis. Their expectations of what your career would mean can also lead to this conflicted sense of our careers and what we actually do during our average work day. The shifts seem longer and the problem patients start to outweigh the saves. These new attending emergency physicians certainly don’t want to appear to be weak, slow, or lazy. They use their lifelong endurance skills which have been hard won and which helped them get there in the first place to mask the often-bitter turmoil inside their heads.
The first cracks I usually see are often expressed with negative comments about the quality and integrity of the patients during their shift. We all know that we think that our hospital has the worst possible assortment of patients and think that our emergency department is the epicenter for the treatment of cyclic vomiting, fibromyalgia, migraine headache, low back pain, or whichever is your least favorite chief complaint which makes your grimace when you pick up the chart. I remember thinking about a year into my career that the belligerent drug seeking patient had actually come to the emergency department purposefully at 2:00am to torture me. Learning that the patients usually have no intent to torture you, specifically, but rather are just trying to get what you want even if their methods are bizarre and sometimes cruel and manipulative. How many of you have sat worrying about a problem case you are working up, thinking of all the diagnoses which you as a young emergency physician do not want to miss. It is only on the fourth time you go into the room that it all becomes clear why the patient is even in your department when they ask for a work note for a week off.
This frustration can come to a head and if capped off with a bad early malpractice complaint can be fatal to a promising young career in emergency medicine. You probably know someone who started out strong to only end up after just a few years deciding that an urgent care or other venue for their career is right for them. Some of these young, well-trained, and caring physicians even leave medicine altogether. This is a real shame. I am not condemning these doctors or minimizing the stress and turmoil which led them to these difficult decisions. Some people did pick the wrong career and realized it too late. However, I think that these doctors did not fail, but that we as a profession and as a society have failed them. Obviously, most young emergency physicians stay in emergency medicine and have to learn a method to deal with this internal paradox.
This is why I want you to consider the idea of “Making a Difference” and that this phrase could have different meanings. Obviously, it is important for us to feel like we are helping the sick and dying in our careers. A sense of altruism and empathy for our patients is certainly a laudable and expected part of our professionalism. It is our core value which we need as a profession to hold sacred. However, I want you to try and see the other types of differences which you make in other aspects of your life which are facilitated by your emergency medicine career. I ask you to try to use those positive results to help you build some armor for the trials and tribulations which you will face when you walk into the next weak and dizzy ninety something year old’s room. What can protect your well-being when explaining to the three 70 something children that you did not find a realistic solution as to why their ninety something year old mother is so weak and that no you cannot just admit her for her to build up her strength?
In the end, despite issues we have a great job, which is well-paid, and in which you can actually help people and save lives. For a moment, try to forget all of the other baggage related to CMGs, government regulation, EMTALA, midlevels, etc. Consider that you might use the positive aspects of our job to improve and balance the other aspects of your life. Making a good living and having a set schedule allows you to get home, hug your kids, have a hobby, exercise, fish, or whatever. Use the positive to create wellness in other aspects of your life which then can splash back onto your career. In previous articles, I have encouraged all emergency physicians to have a non-clinical and usually unpaid or ill paid medically related activity. I use AAEM for this personal professionalism building activity, but I am also involved in hospital committees, etc. which allow me to feel like a doctor and a professional. It is great to think of yourself as a “doctor” and not a provider.
If you are not interested in this, maybe consider focusing on the joy which your emergency medicine career can shine onto your daily life. Maybe you are an exercise junkie who enjoys the set schedule and can plan the long bike rides, hiking trips, exercise classes, or whatever consumes your free time that a general surgeon in private practice might long for, but can never obtain. Maybe you and your significant other are travelers and you like the opportunity which your emergency medicine schedule allows for you to be off for frequent short or long trips which our internist friends long for in their dreams. It might be our salary which allows you to provide your children with a great education which will bring an increased sense of fulfilment into your life.
My point is that even if your professional and hard earned emergency medicine career is not bringing you the sense of self-actualization that you had hoped for, does not mean that it is necessarily a bad career. Even if you do not feel that your emergency medicine job is making you happy you can still take pride in and focus on providing excellent care while meeting all of the seemingly endless and mindless benchmarks or quality measures during your next shift. You can do so knowing that while at times tedious and frustrating, your job can provide you with the tools you can use to provide happiness for both you and your loved ones. Hopefully, you walk out the door at the end of your next shift and then smile to yourself that your shift is done, you did good work, and you can get on with the things which really bring a smile to your face. Your emergency medicine career can make this possible. Making a difference to yourself and your loved ones may be the skill which will allow you to flourish in your career. Career longevity can be a real possibility while still being a doctor. Helping yourself might just be the tool you can use to better treat and care for your patients and really make a difference in your life and the lives of the ones you care about.