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» Sometimes it just ain’t in ya…

Sometimes it just ain’t in ya…

There are days when it just isn’t in you.  I know everyone has these days, but somehow as a doctor you just aren’t supposed to.  There is an expectation that if you’re any good you will rise above all BS, never let it suck you in, and never let it bring you down.  Even if you lose your temper it is supposed to be a noble loss of temper. You can only be on edge because you’re waging war on disease and battling to save patients, giving it you’re all, exerting Herculean effort, and never sleeping.  Complaining is not becoming to a professional, regardless of how much sleep is missed, how many meals are skipped, and how annoying some patients can become.

When attending to drug addicts you’re supposed to acknowledge the shame and loss of human potential while advising them knowingly.  You mostly know that they aren’t going to change.  That seems to be the one constant.  You should refuse to assist their indulgence out of principal while acknowledging how hard life must be for them.  Say, without actually saying, that you understand.  You understand that it’s not their fault life is a complete waste for them.  All the while holding on to your buoyant credentials and rising above it all.

I suppose the expectations lay persons have of health professionals make it more difficult to accept days when the elusive ‘it’ is not in us.  The days when one simply goes through the motions and depends upon habits and rituals to make it through.  Explanations are repeated over the years, practically verbatim, until they are almost meaningless.  It actually allows semi-down time when one can run on auto-pilot and become a robotic actor in a white coat repeating various scripts.  For patients who have these ’scripted’ discussions for the first time there is more meaning than most can imagine.  The meaning does not become lost on clinicians either, it is only the wow factor that seems to lose luster and become mundane.

This is one of many experiences that make it difficult to ‘have it in you’ everyday and keep interactions with patients fresh.  “Having your appendix removed is actually a very simple procedure, and it is in fact necessary.  Without it you will certainly become much more sick, and perhaps die”.  I used to imagine what it would be like to hear these words as though my own appendix was sitting in there inflamed and ready to destroy me from the inside out.  After a while I simply began to wait for the look of shock in a patient’s face as I repeated this dialog and he or she actually grasped the fact that surgery was to be performed right away and that the gnawing pain he or she hesitated to seek attention for was actually serious.  I’m pretty sure that I say it the same way each time, but people seem to have such different reactions that become triggered at varying moments.  Sometimes I ask out of curiosity what they are reacting to.  It’s almost always someone they know who died after surgery, how much it’s going to cost, or how much work they will need to miss.  Sometimes the big concern is who’s going to take care of their pets or children.  Pet’s seem to be harder to find care takers for in my experience.  I now have scripted responses  for each of these concerns, and various other questions as well (”Can i donate blood in case he needs it?”, “How big will the scar be?”, “Can it grow back?”, and “When can we start having sex again?”).

I go through my script, answer the now predictable questions, and raise my eyebrows at just the right moment to convey that yes I’m serious, and absolutely as concerned and moved as they are about their worm-sized intestinal appendage suddenly turning on them, and also the fact that kitty-cat is going to be so stressed and worried.  Of course I also add reassurance that everything will be ok (”barring any unforeseen circumstances” I also say, somewhat under my breath).  Even though it is a life-threatening condition, thank goodness it is completely curable.

Somehow, even on my worst days I can still pull off these easy straight forward cases, giving myself an A+ in all categories (efficiency, accuracy, compassion, problem solving, etc.) without much effort.  The cases that really challenge me on bad days are the manipulative narcotic seekers and morbidly obese patients with joints pains.  Neither can be fixed right away, both are self-induced, and these people turn to you with expectations that are simply unreasonable.  On my best days I try to deal with them as I would appreciate a doctor approaching me if I was in that situation.  I tackle their obvious major life issue head on, but with as much respect as I can possible muster.  On a good day it’s easy.  On days when these people seem to come in back-to-back-to-back, and have the nerve to become impatient while truly sick and dying people are attended to first, it is much more difficult to keep the professional mask firmly in place.  Still I try to maintain the thought that it could be any one of us in these shoes, even me.

If I am feeling really good that day I will ask them, “Is this the life you want for yourself?”  I will remind them that it would be much easier and faster for me to write an order for morphine, or dilaudid, or vicodin, or percocet, or anything else they may want than it is to actually spend time talking about how they might start making healthy changes in their lives.  I don’t BS them, I don’t say it’s easy, I try not to come from a position of superiority.  I just call a spade a spade and then let them decide if today perhaps 1mg of dilaudid instead of 2 or 4 might be a reasonable first step.  Perhaps throwing away every hostess product in the cabinet and starting to buy their snacks at TJ’s or the farmer’s market might be a reasonable first step.  I tell them about free activities I like to do on my days off, and what I ate for dinner the night before.  These are the moments that remind me that health care providers can do great things any day we choose to, when we have it in us.  I try to have as many of those days as possible.  It makes me feel connected.  It makes me feel like I’m actually giving everybody something, even if it is the same advice they could get from Oprah any weekday from the comfort of their own living room.  The fact is many of these patients need Oprah more than they need a doctor, and when I recognize that I try to become my own version of Oprah for that visit.

On days when I just don’t have it in me, I still take good care of patients (from a medical standard) and I just move on and try not to worry about my less than extraordinary performance that day.  I assume that I’ll just need some sleep, some time to regroup, and maybe a visit to the spa so I can come back next time ready to do great things.

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