Dr John Mandrola


February 15, 2013

All jobs have nadirs.

The challenge for most doctors is that we hang so much of our self-esteem on the doctoring peg. That's always a risky proposition. It requires a very strong peg. In good times, the peg holds strong; the load is light. When nadirs occur, as they always do, the peg can crack and bend. Self-esteem can fall onto the floor.

You have probably read that doctors have a high burnout rate. Many experienced and extremely capable physicians are retiring early. (This is real.) Many young doctors can see this danger, and they strive for shift work or part-time employment. At its worst, the nadirs of doctoring can result in some specialties having a higher-than-predicted incidence of suicide. (Sadly, my medical community recently experienced this tragedy.) In my simple mind, these sorts of things stem from self-esteem pegs cracking under the weight of all that we hang on them.

Our jobs matter so much. How well our patients do matters. So does patient satisfaction. What are colleagues think of us matters—a lot. A new facet of modern doctoring is how our employer treats us. Remember the famous data that show workers with low control have higher incidences of heart disease? Unlike the previous era, where doctors made self-determining decisions every day, in an employed model, these decisions are made for us. We must follow orders from nonphysicians. That's not always easy. We aren't used to being pawns in corporate machines. More weight on the peg.

The toxicity of distrust can get you down. The constant threat of not following the ever-increasing rules of billing causes low-grade inflammation. (Honest people don't like the insinuation of dishonesty.) Because we care deeply about our patients, intrusions to the patient-doctor relationship (like EMR) create serious tension. And I would be remiss not to mention the issue of lawsuits. Either the threat of one or the presence of one really strains the peg.

So when these inevitable nadirs hit, it's easy to get in a low place—"right quick," as we say here in the Southern US.

The good news is that medicine offers many antidotes, peg-strengtheners if you will: The basics of patient care, for instance. Doctors help people. What's a successful catheter ablation to you? Normal. What is it for the patient? Life altering. If you choose to, you can notice these facts.

Then if you slow down, as I have tried lately, it's possible to notice the intangibles. Sit on the side of the bed of an older person and let her go on for a minute. You might hear about something that happened in 1965, when you were a baby. Ask a veteran about their service and you might hear firsthand something you read about in history class. (I really like older people. Call them faves.)

Or you can marvel at why a bothersome period of atrial fibrillation miraculously converted back to regular rhythm after three months. You didn't do anything to make it happen; it just happened. When the patient's pastor asked whether prayer helped, you can pause for a moment and wonder about all that. You can say, with honesty and perhaps a tincture of hope, that maybe it did. (Because you can't really understand the heart's rhythm.)

You can watch the people you work with in the EP lab. You can marvel at their dedication and skill. How in the world do they know how to hook up all those wires and run that massive computer mapping system—of which both electrophysiologist and patient depend on? These are people that form the well-functioning team that make the magic of EP procedures. These are good people, your people. I don't know about you, but being on a team helps me.

Speaking of team, you can surely stop and pause to appreciate the nurse who works directly with cardiologists—a specialist for sure. You know them: in the hospital at 0430, getting the list ready, talking to the night-shift nurses, dampening the fires, and connecting important players of the healthcare team. They are tireless, immensely self-confident, and, in their ability to do long-term work with cardiologists, medicine's most Aspergeresque; they are special people indeed. They are your people. If you are lucky (like me), your nurse might offer a hug or knuckles on occasion.

So despite the lower reimbursements, the toxicity of distrust, the loss of control with employment models, the burden of lawsuits, and all that, doctors have at their disposal a dizzying array of peg-strengtheners.

All we have to do is detach a little and open our eyes.

It's there. And it's beautiful. Still.



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