• Rosalind Kaplan, MD

How Much Will You Sacrifice for Medicine?

Updated: Feb 17

I've been really distracted from my original mission, which was to write about physician wellness. I think the reasons for distraction have been pretty obvious: the world has been turned topsy-turvy by the pandemic. The country has been turned on its head by the lunacy of the Trump administration. Systemic racism has, rightfully, been front page news. The simmering pot of problems in the US boiled over around the election, and it's going to take a long time and a lot of work to clean up the mess. Lots of people, me included, have not been able to focus on their own work. Who can blame us?

The thing is, though, that physician wellness is an important topic in the midst of the morass. Now that the pandemic is raging in such a truly out-of-control way, I'm thinking again about the sacrifices we make as doctors--the years of training, the pressure, the sleep deprivation, the expense, the abuse, and yes, the risks to our health inherent in a medical life. And I am thinking of the purpose and connection and joy of a medical life, as well as the economic benefits. I feel a need to return to my intention, to write about the balance of positive and negative energy generated by practicing medicine, and to think about how we might tap into a net positive balance.

I wrote a lot in the past about sacrificing my own health to medicine. I look back on my early career, which was marked by contracting Hepatitis C at the age of 30. My only risk factor was my occupation; I had never had a transfusion or used IV drugs. But I had sustained a few needle stick injuries as a medical student and resident, and my liver function tests became abnormal just months after I finished residency (since we only became capable of diagnosing hep C in 1991 and I finished residency in 1990, there is no way for me to pin down the source of my infection in any more concrete way). Occupational hazard, right? It then took 8 years of experimental drugs and study protocols, 8 years of worrying and of intermittently being a guinea pig. I had two liver biopsies, one complicated by a capsular bleed, and years of flu-like side effects from interferon. I was lucky in that I was young and overall strong; I was able to work and raise my kids despite this adversity. It sucked, but I ultimately came out of it okay. I ultimately felt grateful for the medical professionals who cared for me, and for the advances of science that made my treatment possible. The experience did not make me hate medicine, or want to leave it. Ultimately being a patient made me a better doctor. I'm also grateful that anyone dealing with Hep C now can get more effective and less toxic treatment. It's all a win in the end.

I wish I could say that my illness was the only sacrifice I've made. But you know it's not.

At intervals, my mental health has suffered from practicing medicine. There have been times that the pressure and worry of caring for sick and dying patients has weighed heavily on me, but that's normal. What is abnormal is the many, many times that I've felt despair because of unmanageable administrative tasks (data entry, prior authorizations, precertifications, etc) and the inability to unplug and recharge because of inadequate support from institutions, ancillary staff, and colleagues. That lack of support made self-care (sleep, nutrition, time off) pretty impossible at many junctures. Ultimately, I burned out because the energy output was greater that the energy input.

I am lucky in that my burnout was late in my career, and I could afford to walk away temporarily and to regroup. Now I can afford to work part time in a setting that is, usually, less toxic for me. Working in Urgent Care can be very taxing while I'm there. Especially since I'm often supervising 20 or more Physician Assistants by phone at the same time as I'm seeing patients. The 12+ hour shifts are very long and often hectic. They can be physically challenging, with lots of tasks requiring dexterity, flexibility and strength, and mentally challenging, requiring me to think on my feet and make quick decisions based on minimal information. I often miss meals when I'm working. But I'm only doing a couple shifts a week, so I have lots of recovery time in between. I usually feel like there's enough staff support at work. I don't take any night call, so I can sleep every night. And I don't deal with an inbox when I'm not physically present. This works for me currently.

Here's my big problem. Right now, I'm not working. For the past couple weeks I've been on leave because of the pandemic. I am very lucky that I was granted this leave by a health system that understood my position as an older doctor who has already dealt with a significant occupationally-induced health problem. And again, I am lucky in that I have financial stability. My husband and I are not supporting kids or paying college tuitions anymore, and he is working at his usual academic physician job. So I can take this time. I sincerely wish I didn't have to, though. I miss work, and feel isolated staying home. I like patient care, and I miss the stimulation of work, and the feeling of usefulness it gives me. But the huge influx of patients with Covid symptoms requiring care and testing within a building with limited ventilation, and the necessary reuse of PPE to prevent a critical shortage, feels way too risky. I am just not willing to take that risk right now, at this point in my life. So I'm sidelined. I feel bad deserting my colleagues, but there is currently adequate staffing to cover my absence. And I have to do what is right for me, and for may family, at this moment in time. I'm ready to get vaccinated as soon as a vaccine is available. I want to get back to work.

There is no answer to this conundrum. As physicians, some of us are going to be at risk of illness in the service of taking care of our patients. The question each of us has to answer for ourselves is whether it is worth it in any given situation. We have to advocate for our patients, but also for ourselves. Ideally, we can also advocate for other caregivers.

So that's where it is with health. I am sure that many, many physicians are worried about their own physical health in the pandemic. Especially those working in hospital covid units, ICUs and Emergency Rooms, but also those of us who interface with a symptomatic outpatient population. And I know that many physicians are dealing with the burnout from patient care, administrative burdens, and lack of support. We need to keep pushing on employers and insurance companies to decrease the administrative scutwork and provide support for us and our patients.

Next post, I'll talk a little more about the other sacrifices we make: time, constant evaluations, financial burdens and abuse by patients and others.

Stay safe and sane.

© 2017 Rosalind Kaplan