Reflections on Primary Care

Just because I haven't written about burnout in a while doesn't mean I don't still care about it.

Over the past year or so, I've become an avid, sympathetic reader of a blog called Reflections of a Millennial Doctor.  The author, M, vividly details her struggle with burnout and giving up on primary care.  She fought so hard this past year, wrestling with whether or not to stay in her current practice or throw in the towel and try her hand at something else.  She recently admitted that she will be leaving her practice soon for a job as a hospitalist.  I can relate - not to the hospitalist part! I hate hospital medicine.  But her tale of getting bled dry by her clinic job resonated with me deeply.  Honestly, I don't know how her primary care dreams survived her training.  Mine didn't.

I remember being a medical student and writing an essay about the importance of trajectory change for my family medicine residency application.
The goal of primary care, I wrote, was prevention through education and support of healthy habits.  The reasoning is this: if you can get a person to make small healthful changes now, those will yield more and more benefits as the person gets older.  You can change the trajectory of their health long term.  It seemed elegant, noble, necessary.  I pictured myself as a healer walking with my patients through their highs and lows, providing gentle guidance as they lived their best lives.

It all sounds like so much romanticised horseshit now.

Okay, I'm being unfair.  Not horseshit, precisely.  But close.  You see, while the theory still sounds reasonable, I never saw any evidence of patients beginning trajectory change while I was in residency.  We would set goals together, and they would fail to start taking their medication or checking their blood sugar.  I would hand-write instructions.  They would never make that fabled appointment with a therapist.  I would encourage, give hugs, follow up by phone.  The visits were often very positive.  But they never started going on those ten minute walks.  They never started working on sleep hygiene.  They never cut down on their smoking, or alcohol, or Dr. Pepper, or street drugs.  They never added in that daily vegetable.  They came to me for help, but never seemed to do anything I asked them to do.

Except come back.  They were always willing to come back and see me, sometimes for months on end.  I spent about a year wondering why people were so happy to come and recycle through the same spiel of mine over and over again while doing exactly zero of the things they said they would do.  Eventually I realised it was at least partly because of me personally.  They liked me.  They liked talking to me, spilling their problems to a sympathetic ear.  They liked that I believed in them, not because it actually galvanised them to change, but because I was nice and that felt good.  Realising that I had become an emotional ATM - that I was no source for solutions but instead just a new component of their problems - signalled the beginning of the premature end of my primary care career.

Those patients broke something in me, not like a bone that heals and grows strong again, but like a glass vase that, once shattered, loses both its present and future potential for function.  All you can do is clean up the mess.  You try not to get cut on the pieces as you go.  Eventually you replace it with something uglier but more durable; I am not capable of investing to the degree I once was.

Just like M, I pulled the chute.  Unlike her, I had no optimism left after residency, so I yanked that ripcord way earlier.  I actually applaud her for giving primary care a try for a while to see if it was different after training.  I have to say, though, it really doesn't surprise me that she found it to be more of the same. And it doesn't surprise me that she has been driven out by the impossible demands of her job. I can't sustain a job where the patients I'm taking care of have no buy-in with what I'm telling them to do, and it sounds like she can't either.

God has blessed me enormously by allowing me to get back in the ED, where I discovered that I can still love medicine.  I love my job so much now that even in the face of my burgeoning disability, I am determined to fight through to stay in this field as long as I safely can.  I truly hope she finds the same.