The Paradox
“Go take a break.” “Let me quickly pick up these two patients.” “Go grab some food and come back.” “I’m fine, I’ll just…” “Sanjay, get the hell out and don’t come back for fifteen minutes.”
It was my sixth overnight in a row. After having struggled for over 15 minutes with trying to place an ultrasound guided IV in a sickle cell patient, my senior resident felt my exasperation. She had also probably seen me almost engage in a yelling match with a middle-aged man who was demanding a plain film for chronic muscular lower back pain and witnessed my frustration when dealing with several patients requesting medication refills for their metformin and insulin.
As second years in a four-year training program, my co-residents and I are now expected to master triage, volume, and efficiency – we are the workhorse of the program; the night shifts are endless and running an entire side of the ED in a county hospital is often an uphill battle. Every shift begins with a colleague asking, “So what number night is this?” – though they needn’t ask; the bags under my eyes are typically more indicative.
Anyone who practices clinical medicine understands that faster is rarely better – as trainees, we are incessantly taught that thoroughness is a priority. And it is. Emergency medicine, though, presents a unique challenge. The fact of that matter is, there is always someone sicker in the waiting room. And there are probably a handful of patients that don’t necessarily need to be in the department.
Part of our jobs is throughput. Who is sick now? Who can wait? We do a disservice to both our patients and our colleagues when we don’t keep the department moving. After one particularly difficult overnight shift, my attending noted, “Our jobs are difficult but our goals are simple: Don’t let them die. Don’t let them cry. Figure out why. Let them fly.” Save your patients, treat their symptoms, figure out the problem, and send them.
I chose to pursue emergency medicine because I wanted to be the ultimate advocate for my patients. And I still do. I take enormous pride is seeing anyone who walks through those ED doors. But in my new role, I’m finding it challenging to balance being smarter, faster and more efficient vs. maintaining my patience, empathy, and sense of humanity. At face value, it seems paradoxical: to be quick and thorough, efficient yet patient.
When I really think about it, the most unforgiving part of this year is tackling every patient with a sense of acuity, compassion, and empathy – regardless of whether it’s my first or twentieth patient, or my first or sixth straight overnight. A certain degree of desensitization is inevitable – we constantly see people during some of the worst times of their life and it is easy to forget the scope of our practice. Every clinical encounter has the potential to forever alter a patient’s course – even if it is as humdrum as chronic back pain or as severe as life threatening respiratory distress.
The emotional tolls of this job are not my patient’s fault – they are my own to deal with. This field requires a great deal of emotional intelligence and there are times when it is more valuable than any modicum of clinical acumen.
While efficiency is a vital aspect of our job, it mustn’t come at the expense of our humanity as physicians. There is a saying by Voltaire: “The art of medicine consists in amusing the patient while nature cures the disease.” Tend to your patients, tend to yourself. The best physicians do both.
Emergency medicine is tough for all reasons you mentioned. Unfortunately, it continues to haunt EM physicians at any stage of their practice. There are more frustrating things, such as patient-satisfaction surveys and how they tie to your salary, administrative control on improving efficiency (which results in less time spent with each patient), big expectations of patients coming into the ED based on WebMD’s suggestions, and the difficulty on admitting patients because all hospitals are full. Humanity and compassion became rare quality to maintain while sarcasm and burnout are increasingly common in EM physicians. It helps to recognize your own burnout symptoms, have strategies to deal with them, and periodically check on your compassion level compared to medical school. Just my 2 cents.