COVID Burnout

I still have a lot of patients who are unvaccinated. At the beginning of 2021, I was very sympathetic. this was the first mRNA vaccine in mass production. We knew so little about COVID, and even less about a vaccine for it. It was only natural to have some concerns. But the risks (morbidity or mortality from infection, or infecting others) was a big enough motivator that getting the vaccine seemed like a straightforward choice. 

Now a year since I have been fully vaccinated, my sympathy is gone. The entirety of what we are experiencing with COVID at this point is because of the unwillingness of people to get vaccinated. I watch people suffer, have horrible complications, and die from COVID because of no other reason than obstinance. 

And it's not the death and suffering that bothers me the most, nor is it the strain of health care systems buckling under the weight of COVID cases. What bothers me the most is watching my friends and colleagues who have lost their passion for health care. We all went into medicine because caring for others means something to us. It might not have been the primary motivator, but you cannot survive in medicine if you do not value caring for others. 

And so I watched those who were materially motivated fall away from medicine. And then I watched those valuing their own health above others fall away. And now I am watching people who love caring for others drop out of health care, because they have entirely lost their passion. 

You can't call it burnout at this point. Burnout is a slow cooker. COVID is an incinerator. 

And I want you all to realize that we are approaching a moment where you will call EMS and no one will come. You will go to your doctor's office and no one will be there. You will go to the ER and no one will help you. And this is the only result of the path we are taking.

I was talking about this with a colleague, and he suggested we should get the nurses some gifts. I was polite enough not to slap him.

I'm not a yeller

I had a patient who avoided seeing me for several months because his diabetes was worse and he was worried about what I would say. "I knew I was going to get yelled at."

So I asked a real straightforward question: "What makes you think I'll yell at you? It's your life. I don't have to live it." I have all kinds of advice and recommendations, but at the end of the day, I only experience maybe an hour of their existence over a year's time. 

I get this a lot from COVID un-vaccinated patients. They think I'm going to berate them. Not really. I am interested in giving them knowledge, and context, and compassion. People make their own decisions, but I want that decision to be well informed. When people tell me, "Well, I hear a lot of things..." then I want to talk about it. I am a doctor. It's literally my job to give you health information individualized and personalized to you.

One of my patients still isn't vaccinated, and he knows everything about why he should, but he is just totally terrified of needles. And he knows he needs to get vaccinated but just can't get over the hurtle. Let's work on this together.

Rituals

It's so cliche that you already know how it happens. The doctor walks up to the family member and says, "We need to talk. Please come with me." The person is ushered into a room and asked to sit. If they don't sit, then they are encouraged to sit.

"I have some bad news." Colloquially known as a warning shot, this is the clue to the person that this is bad. There will be no 'good news, bad news' game here. It's only bad. Next comes a formula repeated in every hospital in the country. A recitation of facts about what happened, and at the end, telling the family member that their loved one has died. The doctor says, "We did everything we could, but we couldn't save him, and he died." There are accusations, and shock, and tears. Tissues are provided. Hugs sometimes or a hand on a shoulder.

While it seems like a cliche, it serves a purpose. When people experience a situation they know, then it helps to provide structure to the process. It's no different than a Catholic mass. There are no surprises. You know exactly what is going to happen, what people will say, and when it will end. So when faced with terrible circumstances, it's reassuring to know that there is a structure to it, and a role to play. The doctor knows what they're supposed to do, and the family knows as well. So while reciting the words and gonig through the ritual, a person has for a brief moment the chance to truly grieve, cloaked in the words and actions already predetermined.

If you're looking for advice on breaking bad news, then there are lots of formulas. I think that SPIKES is as good as any. I do have a few tips.

1. Make sure you say that you did everything you could. In fact, use that exact phrase. "We did everything we could."
2. Make sure you say that the patient died in no uncertain terms. Not "passed", not "lost". Something like, "We couldn't save him, and PATIENT died."

You would not believe, despite saying those exact words, how many people will question you on those two points. And that's natural. Don't be defensive. The human creature can only process so much trauma at one time. People want to make sure that everything was done. People want to make sure that their loved one is indeed dead. It's not blame. It's shock.

Pencils and crayons, part 2

The word "acumen" means a quickness of perception and discernment. In medicine, someone with clinical acumen is sharp and fast to an accurate diagnosis with minimal effort or information. A doctor will walk into the room, take a quick smell and a glance, and pronounce to the patient, "You have a bleeding peptic ulcer." The patient and all the house staff are astonished at the quickness and the veracity of the diagnosis, and sure enough, the endoscopy proves him right.

The reality is that the doctor could smell the distinct odor of melena, and observed upon walking into the room that the patient was eating a plate of hot wings his wife had brought in, and had a beer belly. It was a pretty safe bet that he had an ulcer.

Acumen comes from the Latin word for a sharp point. And so, just like sharpening a pencil, clinical acumen needs to be sharpened too, but it's hard to keep sharp, easy to dull, and sharpening itself takes work. Because the way most of us physicians keep our acumen sharp is honed on the bodies of the dead and dying left in our wake.

I won't miss pancreatic cancer again because Mrs R is dead now, and maybe I could've done something to stop it if I'd only found it sooner. I won't use steroids to treat acute arthritis if I haven't ruled out a septic joint, because I've seen what happens to an infected joint that gets steroids.

Keeping a pencil sharp takes some effort, not much but some. Keeping a crayon sharp is an exercise in futility. At the end of the day, it's not just the sharpening that takes work, but we have to strive to be something worth keeping sharp.

Pencils and crayons

Getting compliments from patients can be funny. I like to get compliments, don't we all, but in my heart, I know that most of the time, these praises are unearned. I didn't do anything marvelous or spectacular. I did the doctor equivalent of a teeth cleaning, and for that, the patient is singing my praises to everyone they know. It's not earned. I'd rather get praise that I earned.

Lot of patients don't have good relationships with their doctors, for whatever reason. Sometimes, it's the patient having unrealistic expectations or demands. Sometimes it's the doctor not communicating well or not providing good care. Sometimes, it's just personalities not harmonizing. There are lots of reasons that a patient and a physician don't end up on the same page.

For this patient, I did nothing. I was assuming care for the person after their previous physician left the area. We talked about his medical issues and medications, about the clinic policies and my own personal policies, and then I did my exam. He was so shocked at how thorough my physical exam was (it was actually pretty cursory and mediocre), how detailed my history-taking was, and how well I explained what was happening next. He thanked me, and proceeded to sing my praises to my staff and then to his wife in the waiting room. But the reality was that the care I delivered was perfectly mediocre. It was dinner at Applebee's.

My MA was surprised. "What did you do in there?"

My reply: "When all you’ve ever known is crayons, then a pencil is gonna seem pretty awesome."