Notes on a Physician's Life

Crosscutting in reading the business pages highlights the depth of our malaise

Just off vacation, dealing with paying the bills, balancing the checkbook and projecting rest of year expenses, I took a coffee break with the business pages of last Saturday’s New York Times. Unemployment issues loomed large with two headlines reading:

“Despite slower job losses, August unemployment rate reached 9.7%”
and
“Teenage unemployment rate reaches 25.5 percent, the highest level recorded”

Standard scary stuff for our times and doubly disconcerting to see another article (in the deliciously titled segment ‘Wealth Matters’) of a neighborhood kerfuffle in the elite town of Westport, Connecticut where a senior vice president at ING Investment Management has spent $170,000 building a wall on his property, $50,000 on modifications to the wall and $150,000 on legal expenses in response to complaints led by a neighbor who’s a lawyer with UBS investment bank.

What a comfort to know that two high paid workers in the industry that contributed greatly to an economic collapse and severe hardship for so many ordinary citizens should have sufficient wealth to spray money around like confetti.

Crosscutting in reading the business pages at present highlights the depth of our malaise, the chasm between the have-nots and the have-mores and, at least for me, the doubts we’ll ever resolve this financial fiasco when we have one section of society behaving like European nobility of a century or more ago while another segment, despite their delusion that they have freedom, are when you get right down to brass tacks pretty close to serfs.

Freedom, in real life, is always ultimately illusory.

ND feels constrained by the culture of the prestigious healthcare institution where he works. After 20 plus years there, including all of his graduate medical education, he’s not sure he’d fit somewhere else.

Professional and institutional cultures are part of every career landscape. Goodness of fit is crucial and lifetime guarantees are not provided.

Culture is always something of a mask - it smooths out our rough edges and idiosyncrasies creating some semblance of uniformity, not a bad thing if you’re in the patient’s seat.

Masks can harden though to something like a bad botox job, displacing, subsuming, diminishing the person within.

Sloughing of the mask is possible but wherever you go, whatever you do, you’ll have to contend with the reality that all forms of freedom are ultimately illusory. You will be bound to some code or culture, a more comfortable one - perhaps - hopefully, but you’ll be bound just the same.

What a diary has over blogging or twittering.

Blogging is burgeoning I’m told, tweeting is thriving – it’s a world where private thoughtful deliberation has gone the way of the Dodo and the prize goes to those who satisfy third millennium common era mans’ craving for instantaneity.

Blogging may serve some as a replacement for diary keeping but there’s much to be said for keeping early phase musing on major issues to one’s self and a ruled page rather than broadcasting into the cloud for an audience of one, none or some.

Diary writing gets a bad rap from men especially. It’s dismissed as the refuge of teenage girls and the socially maladroit, the musings of those beginning to date and those who can’t snag a date while real men figure themselves out on bar stools or in golf club locker rooms.

True, most diary writing, irrespective of age or gender of the scribe, is a midden heap of solipsistic cavils to agony aunts and their equivalents in other exigencies of life. But that’s not to dismiss the beauty of the approach for those willing to lay it all out to the privacy of their own notebook. An opportunity to dig into deeper strata of ourselves should not be dismissed out of hand. Susan Sontag (‘On Keeping a Journal 1957) used her diary to “not just express myself more openly than I could to any person; I create myself. Joan Didion in her noteworthy 1966 essay, ‘On Keeping a Notebook’ noted that “I have already lost touch with a couple of people I used to be”.

Doubts are best dealt with alone in the early going. Charting them with pen and paper encourages some level of categorization, some notations around cause and effect, some preliminary sketches towards potential solutions. Diaries, used well, facilitate more disciplined thinking, otherwise they are discarded after the same tired thoughts get committed to paper three times in succession.

You can lay out a problem and toggle your own role in it to the beginning or middle or end. You can filter in other aspects of early life, family life, personal or professional circumstances with any degree or variety or detail you care. You can plot out solutions conceiving of their impact on one, many or all of the separate component elements of your life that you must consider. You can allow for the various and versatile selves that exist within you rather that the ONE that most of the time most people, up to and including your own family members and close friends, consider you to be.

If and when you reach the point of going ‘public’ with your doubts or disillusionment, the chances of presenting yourself as coherent and thoughtful will be exponentially higher. Your likelihood of persuading family and friends, present colleagues and future employers that you will accomplish a significant life change successfully will similarly soar.

No amount of working this out in your head as you commute to work, barstool philosophizing or struggling through the early phases with a career consultant will match the returns from committing your own thoughts to paper at you own desk in the privacy of your own home and at essentially no cost.

Worthwhile vision emerges from an appreciation of our horizontal connections with the world around us.

It’s becoming ever harder to reconcile a world where millions of people are out of work and the monster profits achieved by top banks like Goldman Sachs. By now you could line up all the finance experts on the planet to say it’s okay and I’d have to say no way. Silo living helped to get us entangled in the mare’s nest we’re in – how can these disparities suggest we’re making any strides to untrammel ourselves?

I keep running up against the wall of people and organizations with vision that to my mind is sightless. Why are the seers, though lacking ocular proof, the ones with the insight, while the seeing so often offer us insightless visions?

Vision, worthwhile vision anyway, emerges from an appreciation of our horizontal connections with the world around us not from silos that may give us a view of the constellations but little of the nearby here and now desolation.

The Victorian essayist, Thomas Carlyle, described an impoverished widow, refused help by those who denied her sisterhood, who infected them with typhus and killed them in turn. It’s a chilling reminder that ‘no man is an island’ is not some hackneyed overwrought cliché, rather the world as it really is.

Whether it’s Goldman Sachs or healthcare providers and institutions that fail to get solidly behind wholesale healthcare reform, the end product will be the same – there’s no merit in a society where millions suffer disadvantage while a few thrive.

Below is a ‘cut and paste’ from the relevant section of Chapter 2 of Carlyle’s Past and Present (1843):
A poor Irish widow, her husband having died in one of the lanes of
 Edinburgh, went forth with her three children, bare of all resource, to solicit help from the charitable establishments of
 that city. At this charitable establishment and then at that she was refused; referred from one to the other, helped by none;–
till she had exhausted them all; till her strength and heart failed her: she sank down in typhus-fever; died, and infected her lane with fever, so that ’seventeen other persons’ died of
 fever there in consequence. The humane physician asks thereupon,
as with a heart too full for speaking, would it not have been economy to help this poor widow? She took typhus-fever, and killed seventeen of you! Very curious. The forlorn Irish widow applies to her fellow-creatures, as if saying, “Behold I am sinking, bare of help: ye must help me! I am your sister, bone of your bone; one God made us: ye must help me!” They answer,
 “No; impossible: thou art no sister of ours.” But she proves her sisterhood; her typhus-fever kills them: they actually were her brothers, though denying it! Had man ever to go lower for a proof?

All so easy when you’re on the inside.

Explaining tennis scoring to my not-into-sports wife as we watched the Wimbledon finals recently reinforced how much inside-baseball lingo there is to everyday life. We’re always at sea or on land in some aspect of our lives. 15-30-40: how silly can you get? Advantage-deuce-advantage (no, now it’s the other player’s advantage) etc – that’s how silly.

Business sections of newspapers have a penchant for photographs of traders in the pits of stock or mercantile exchanges. I’ve one on my desk as I write this – about 15 men and one woman on the trading floor of the NY mercantile exchange on July 9th last. Most have short dark-colored coats with badges of 4 numbers above 4 letters clipped to their left lapel. There’s a vaguely blue-collared look to the scene which I’m betting is deceiving – they’ve probably all got MBAs from Wharton or Harvard and are taking home mid six-figured incomes or more.

Certainly, all are intent on their work – on the phone, entering data on handhelds or slips. At least three have US flags over their left upper arm – they probably refuse to buy oil for more than $50/bl. The whole scene radiates tensity – one of the flag wearers has the tips of two fingers in his mouth. Hey, fella; is that my money you have at work there?

You ask yourself – at least I do – do they know what they are doing? Given the roiling financial markets of the past year why wouldn’t one?

The outsiders view of these insiders must parallel what lay people feel when crossing the portals of a hospital or clinic. Who are all these men and women clad in scrubs or white coats? Does the uniform reassure or rattle. Even if you can make out MD on a coat or badge is that resident, fellow or staff physician? Even if you know it’s a staff doctor does that really allow you feel sure they are experienced, competent and conscientious?

For years I had an office at the University of Michigan close to the nexus of the adult hospital and the principal outpatient facility. At certain times of the day (early morning and lunchtime most of all) it was a frenzied hubbub of activity. I knew many of these people and those I didn’t I could, in the main, characterize their role in the whole apparatus. But even that didn’t quiet the wonder in me about how this whole apparatus worked together. It seemed ripe for a Rube Goldberg drawing.

Yet, it worked, and not just in the main, it worked quite well, thank you, a testament to who or what, I’m not quite sure. Perhaps, most of all, to the intrinsic good nature of mankind.

For the outsider though, it’s not intrinsically reassuring. Signage, however much improved over times past, still needs work at most healthcare centers. But it’s the orally produced signs where the most work is required – the language of the healthcare cognoscente in his or her individual work with a patient is where the difficulty is most likely to emerge. Recollection of how easily any of us can feel at sea when out of our own cultural and professional milieu might help us be more thoughtful and patient when we’re the knowing one and they’re the at sea patient.

My role in everything, good bad or indifferent, that happened to me.

Now that public enemy #1, Bernie Madoff, is tucked away behind bars for the next two lifetimes, the need to lay on the blame is back in full spate. Blame BM, blame his still TBD confreres, blame the SEC, blame anyone, blame everyone, just don’t blame me.

Sadly, regrettably, unfortunately, you, me, we are all to blame. For if we’ve not had to spend every cent of our paycheck on life’s basic necessities or lived off social support over the past decade or longer, we’ve been, consciously or no, participants in one great bacchanal of greed. We’ve loved the ones who promised outsize returns. We’ve asked few tough questions. When we did we were easily fobbed off with trite answers. With the goodies rolling in this time it really was going to be different. Bernie Madoff and his ilk were meeting our needs. We thanked them, lined up to hand over our loot and chose to be fools.

The business section of the July 1 2009 NYT had an article about a Belgian bank, KBC, now (surprise, surprise) a recipient of huge cash support from the Belgian government, whose investment bankers had been only looking at deals with 22% or greater returns. Madeup, mad, or made off returns; whatever japey moniker you pick their unreality seems unmistakable now. But it was equally unreal then. For then, whenever these deals were being assessed, whenever BM was promising outsize returns in perpetuity, we should have known this had to be bogus. We allowed that gremlin greed to close our eyes, plug our ears and dull our grey matter. Like me, you may never have been snared by Madoff, but I’ve yet to meet anyone remotely honest who hasn’t been singed by housing, acquisition or investment decisions made as a rider on the great gravy train of the past decade or two.

The challenge we have in turning the examining light on ourselves compounds, perpetuates and confounds these messes. But short of doing this we’ll never break beyond cycles of fault-finding, of laying blame on others, and engaging in the hypocrisy of whingeing over lack of oversight in this instance while simultaneously decrying it in other areas, when some malfunction in the supply demand curve for self-control comes closest to root cause.

This tendency to always cut ourselves some personal responsibility slack had leached into every arena in our culture. With the usual mixed bag of success and stumbles in personal and professional arenas, I’m as quick as the next guy to claim credit for the high points and blame some other for those less momentous. But irrespective of circumstances I’ve never been blameless, and, the more readily I’ve accepted my role the more rapidly I’ve been able to move on.

Madoff’s victims bear significant responsibility, however painful this is to acknowledge. Beyond the man, Madoff is a symbol of a cultural malaise we’ve all subscribed to and for which we all bear responsibility.

We wanted the great returns at full throttle and the right to 100% blame when the train derailed. Madoff has been meeting both needs as man and symbol. Ultimately, that’s a track that will keep on hurting us.

“Perfectionism undermines and destroys its own basic purpose.”

A sturdy, resilient streak of perfectionism runs through my nature. I’ve turned it too good effect in many arenas of my life but it’s undermined me to equal degree. It works well for some patients and colleagues but an equal number find it excessive if not oppressive. My wife, blessed with abundant serenity and a sure sense of self, screens it out, placidly staying on her path, while reminding me to “slow down and take it easy”. I try. I fail. I try again. I fail again.

I’m thinking of having the quote above, from George Kennan, the historian and political scientist, emblazoned above my office desk, a reminder of the opportunity costs of perfectionism in an imperfect world.

I’ve lots of company among members of the medical profession.

Sam, an accomplished internist, would seem to have it all. Trained in medicine and his subspecialty at a prestigious medical center, talented at procedures that net him and his practice partners a steady stream of patients and revenue, blessed with a delightful wife and three healthy children, yet….
Sam, beneath the surface calm and success, is not at ease. Ten percent of his mind is always off in another world where words like meaningless, futility and restless abound. Ten percent of the time he’s absorbed totally with such glass half empty emotions.

He can’t seem to make up his mind whether to enjoy or endure.
What has he achieved or is yet to accomplish?
Which matters more - that which is easy or that which is difficult?

He sees the absurdity but can’t stop himself. A young adult life of constant striving has corrupted his neural networks to strive to improve while procrastinating on enjoyment. He finds himself hard to live with. his wife and children feel this too. Most of his colleagues and support staff sense this tension, admire him for his abilities but also find him tough to tolerate.

Sam could be a poster child for the perpetually perfectionist physician. An attribute whose kinetics are non-linear, where toxicity is all too common, where a variation on the adage that saints are hell to live with all too accurate. Saul Bellow put it eloquently: ” Some people embrace their gifts with gratitude. Others have no use for them and can only think about overcoming their weaknesses. Only their defects interest and challenge them.”

A not insignificant amount of the career dissatisfaction expressed by many physicians has a Sam-like quality to it. Most importantly, no career changes, no amount of career advising can accomplish much without an awareness of this quality in those affected coupled with an unbounding determination to change it.

One must, pun intended, be a perfectionist in decoupling our need to be a perfectionist. Thereafter, all things are possible.

The costs of overly dutiful doctoring

Duty was a great word in my family. There was doing your Easter duties, cleansing your soul for Christ’s resurrection. There was the more generic ‘being dutiful’ - to parents, grandparents or teachers but they were all poor human surrogates for God. The word triggered a near reflex in me of dropping my head and shoulders and closing my eyelids as I’d murmur “yes Mummy” or yes to some dog-collared reverend - all good training for doctoring I suppose.

A surgeon at a local medical center emailed me a while back to express frustration with his professional success. He said: “I have a bunch of hobbies .. and no time to do them, but I’m hopelessly addicted to the satisfaction of helping people..”

“Hopelessly addicted” is quite a confession. Life as an ace clinician is an intoxicating reward that carries a substantial opportunity cost. And, if unlike my colleague you don’t recognize this, your family knows better.
You are not home enough.
When at home, you’re not really there.
In the shower or the car, you think about your family and other interests and remind yourself that now is the time to give them attention. The next morning, back in the hospital, absorbing the ambrosia of success, you slide back to square one.

The demands of contemporary medical practice on the successful physician’s physical, emotional and temporal resources outstrip supply. As a rule, family and outside interests are likely to be subordinated to professional endeavors.

Many physicians feel caught in the cross hairs of this dilemma:
If I am available to my patients, students and residents, colleagues and support staff, the way I should be, where is the time for my family and friends?
If I neglect my family and friends, will my sensibilities change my patients and those whom I mentor be disadvantaged?
If I dedicate myself to remaining current in my field, do I by default neglect the humanities or other non professional enthusiasms that keep me interesting and feeling well-rounded?
If I neglect the humanities or other avocations, will my sensibilities change and my patients and those whom I mentor be disadvantaged?

And so on.

Feeling over-extended is close to endemic in the medical profession today. Our high threshold for tolerating personal distress and delayed gratification that got us into and through medical school and residency training comes to our rescue. An overly developed sense of duty and responsibility - what I’m terming deontological doctoring is a trap for at least some of us. But at what cost?

Why do so many initiatives within a family or a work family falter?

Whether carefully considered or impulsive, beginnings are relatively easy. Words like engagement, excitement, enthusiasm and energy abound, until, almost inevitably, an end arrives. Pain, sadness, grief, frustration, or at the very least disappointment then emerge and often linger sometimes lengthily. Business or pleasure, professional or personal, it’s as if an inviolate rule book was being followed.

Why do so many marriages and personal relationships fail? Why is the failure rate of business at the 80% mark? Why do so many initiatives within a family or a work family falter?

Choose well, build a business plan, lay the groundwork, do the background research, we’re told.
Many do, and still fail. They fail, we fail, I fail, because neither they, nor we, nor I manage the middle adequately.

Who is more likely to have a lasting relationship? A couple perfectly suited to each other who assume that’s sufficient and meander along through life doing their own thing, or a couple sharing less in common who regularly reshape their relationship. A medical practice that sees an opportunity, develops a business model and ploughs straight ahead, or one that is constantly refining their mission and practice model.

While the questions can seem as pedantic as the answers are obvious, there is a disconnect between what we know and how we act. When these same truths are pointed out to an individual or group, their disappointment is often palpable. We sought the wisdom of Solomon, and this is your answer?
Yet, if such truth was incorporated into our work and life, there would be no need to solicit advice or seek consolation in the first place.

In a nation renowned for offering second, third or more chances, the opportunity to end and move on amounts to a right. But when are we going to face up to the costs of an unending cycle of peaks and troughs? Has the financial meltdown of the last year finally hammered home the destructiveness of such cultural forces?

I’ve heard wonderful visions expressed, I’ve espoused grand missions myself. But more business plans, mission and vision statements, and marketing plans end up gathering dust on bookshelves, rendered obsolete in a week or a month by factors unanticipated at the time of their production. I’ve witnessed and participated in personal relationships, chock full of optimism and excitement at onset, yet all too quickly slipping like quicksilver through my fingers.

A modern-day philosopher, Woody Allen, pointed out that 80% of success in life was showing up. This writer, says that 80% of any relationship is spent in the middle. The critical middle. It’s the middle that determines the nature and quality of the end.

Not everything can last. But should we not be talking about 20% rather than 80% failure rates? We can only get to that lower failure rate by concentrating our efforts at home and at work on the critical middle stage. That is achieved by methodical management, consistency, attention to detail, and frequent minor adjustments. It is not high drama, of appeal to the media, or even ego-boosting. It requires us to shelve our almost reflex dismissal of “middle-management”. It is middle-management that makes our personal relationships and work enterprises thrive. It is what turns the world.

Robert Frost may have taken the “road less traveled”, but I’m guessing he stood at the diverging point in the woods for a while and pondered.

Early in life we all became expert in carefully orchestrating our last few puffs on a dandelion so the final seed floats away on an up note. She loves me; that microcosm of life imbued firstly with hope, but secondly with our need for clarity. Maybes, doubts or ambiguities lead us to fret. We’d sooner a poor outcome to a period of uncertainty.

Our language is replete with phrases like:
“I want to know where I stand.”
“I can deal with anything, just so long as I know.”
“Don’t leave him/her/it hanging”.

Pejoratives abound when certainty is in short supply, especially in our dealings with others:
“He’s full of self-doubt.”
“She lacks self-confidence.”
“He’s so indecisive.”
“She can’t make up her mind.”

In the medical profession we may disparage colleagues who fail to show what we view as the right stuff.
The colleague who orders more tests and consultations than we would - “clinically indecisive”.
The colleague who admits more from the ER than we say we would - “a sieve”.
The pathologist or radiologist who wants more studies - “that chap can never make up his mind about anything”.

However much we try to iron out the creases that are the uncertainties, doubts, what ifs and maybes, they are integral to the fabric of our lives and our relationships. Robert Frost may have taken the “road less traveled”, but I’m guessing he stood at the diverging point in the woods for a while and pondered.

And, so must you, to pass through to a different phase of your career. Instantaneous epiphanies are as rare as the dodo. Doubts are the stuff of an enquiring mind. Tolerance of ambiguity is a measure of personal maturity. An understanding that the answer emerges from an at times difficult journey and search is the mark of personal responsibility. Unspoken by Robert Frost, perhaps, but just the same, implied.