Several months after the first wave of the COVID-19 pandemic I had just gotten to work on my on-call holiday and weekend shift, which, for those of you not in healthcare, translates into a single physician taking care of all of the patients on the rehab unit. The goal is to try and put out the fires and just see those patients that are having acute issues, discharge any who are ready to go home, and admit any new patients from the acute hospital who are ready to start their rehabilitation. I was sitting at the nursing station and had just logged into the computer to print out the long list of patients, with a plan to check in with the charge nurse to find out whom I needed to make a priority to see first.
Immediately there were four nurses next to me, vying for my attention, like my cats eagerly waiting to be fed in the morning.
The first nurse was telling me that one patient who was ready for discharge had decided he wanted his prescriptions to go to a different pharmacy, so could I please resend them (a process you’d think in the day and age of the electronic medical record would be quick, but actually requires you to click on every single medication and re-order). I prayed he had a short list of medications.
The second nurse was telling me that a patient was refusing to go to therapy, so could I please go talk to her? Nope, I could not. Have the therapist try again this afternoon, or just put in a “patient refused” therapy order.
The third nurse told me that a patient that discharged the day prior called to say one of his medications was not covered by his insurance because it needed a pre-authorization request, and he wanted to know what to do. This was on a Saturday, when insurance companies, who would authorize the request, were closed. I prayed it wasn’t an important medication like a seizure medication or an antibiotic for a serious infection.
And the last nurse was telling me about a patient complaining of abdominal pain. I knew this patient because she was my own and the day prior, I had gotten an abdominal x-ray that showed she was very constipated. I had ordered my usual bowel “clean out” cocktail, four doses of Miralax followed by an enema, but the patient had refused the bowel medications. I said irritably to the nurse, “Yeah, I know, she’s full of sh*t. Get her to take the bowel medications.”
I then printed out the list of patients, double checked who my colleagues needed me to see (in order to satisfy Medicare’s criteria for a certain number of visits per week by a physician), asked the charge nurse who was having acute medical issues that I needed to attend to (other than my patient full of poop), checked in with the admission nurse regarding which patients were going to be admitted that afternoon and also which new patient consults I needed to review to determine if they were appropriate inpatient rehabilitation candidates. I had just gotten to work and I already wanted to go home.
As I rounded on patients I tried to be as brief as possible, making sure that patients were at least medically stable. Many issues I had to punt until Monday morning (When is my follow up appointment with my cardiologist? Am I getting home health or outpatient therapy when I leave? What day am I discharging next week?). These questions were best answered when the case managers and the patient’s primary attending physicians would be back to resume care.
I found myself having difficulty paying attention, especially when patients started complaining about things that I had no control over (uncomfortable bed, cold room at night, bored with green beans on their meal tray, sharing a room with another patient). It’s not that these are not valid complaints, or that we shouldn’t make our patients as comfortable in the hospital as possible, but (I wanted to respond yet held my tongue) it’s a hospital, not a hotel!
In the background there is also the pressure of having good “patient satisfaction scores,” those surveys that are mailed out to patients so they can rate the quality of the care provided to them by their physicians and other staff members. I’m sure you’ve gotten some in the mail, (and please fill them out!), as it is well-known that when patients have a bad experience, they will tell many more people than when they are pleased. So, I try to do my best in managing and passing on complaints, not because of the patient satisfaction scores, but because I really do care.
But what do I do when I am having a rough day with too many “fires” to put out, like on this particular day? How do I effectively manage my time when there is so much to do, but not enough hours in the day? How do I stay focused and provide competent care when I am feeling irritable and overwhelmed? How do I continue to have compassion with my patients and remain approachable to the nurses and others I work with? I don’t remember reading a chapter in any book during medical school or residency that gives me any answers to these questions. While the topic of physician burnout was discussed during my training, I do not recall learning specific strategies in how to manage the many demands of the profession.
When I got home that night after eleven hours of work, I felt such a deep sense of fatigue, resentment, and inefficacy. After venting about my day to my wonderfully supportive husband, I suddenly had the insight that what I was experiencing was physician burnout, something I had not yet experienced so acutely on the job. Physician burnout is a topic that has slowly gained recognition over the years as a real problem that needs to be addressed, not only for the well-being of patients, but also for the well-being of physicians. The syndrome can be described as a combination of feeling exhausted (check), feeling cynical and/or detached from your patients (check), experiencing reduced productivity (heading in that direction, for sure) as well as difficulty with coping (check).
Adding to the “normal” daily stress of being a physician has been the incredible pressure of taking care of COVID-19 survivors --like putting gasoline on a fire that was already growing out of control. I had to quickly figure out how to take better care of myself so that I could take better care of my patients and last at least another ten to fifteen years until retirement. I did not want to add to the growing wave of physicians who are deciding to retire early,1 adding to the projected shortage of 100,000 physicians by the year 2030.2 I did not want to become one of the many charred and hollow trees on the mountain hillside.
1. https://centerforhealthjournalism.org/2014/03/10/whether-it%E2%80%99s-retire-or-flee-doctors-are-leaving-health-care