Finding Joy In Practice

My wife volunteers a half day a week at a thrift shop that is run by our local VNA. The aging crowd in our community donates great items for sale either before or after their demise. Some know that their children don’t value what they once thought were the earmarks of their social status, and they are cleaning house in preparation of their final move. In some situations the generation that has valued these items passed hoping that their treasures would be equally valued by their progeny, and the “inheritors” are just cleaning up the clutter that they inherited. Those items that were once the defining possessions of a sophisticated home; now, nobody under the age of seventy wants them.  

 

No matter how the items arrive, the inventory is great, and there are many bargains. Silverware, really nice china, and Waterford crystal are available for a song. Last year the shop sold more than $2 million in recycled treasures which certainly financed a lot of home care since they have virtually no overhead because most of the workers volunteer their time. Some items have practical value. Dropping by regularly just to see what has come in is a profitable habit. Last year, I picked up an almost new utility trailer for about $500. What a deal!

 

I stopped by the “Renaissance Shop” recently while my wife was working just to see what new items might be available. I like to buy old Parker and Esterbrook fountain pens, but those are rare finds. The visit did not yield a pen, but to my delight I saw a lovely figurine that was a depiction of Norman Rockwell’s famous picture, “The Doctor and the Doll.” The price was right, just $5.00! If you clicked on the link you know that I got a $45.00 item for $5.00! I think I would have paid ten times as much because of the meaning in the image.  The AMA Journal of Ethics also sees value in the image:

 

On March 9, 1929, The Saturday Evening Post cover was a Norman Rockwell vignette called “Doctor and Doll.” It was one of hundreds of covers the artist painted on commission for that popular magazine. As was customary, the Post cover tells a story. A little girl, perhaps 7 or 8 years old, has brought her doll to the doctor’s office. The doctor, a grandfatherly man with twinkling kindly eyes, is gravely listening to the doll’s “heart” with his stethoscope. The trio float on a spatial island that, by deleting the room surrounding, concentrates the meaning of the image on the actors. Every object and article of dress works to reveal the status and character of the actors of this little drama. …His face is ruddy, perhaps weathered… and its contours suggest a habitual cheerful benevolence, even humor. The sense of his humanity is accentuated by the shock of unruly gray hair that is in contrast with his sartorial fastidiousness.

 

The little girl who stands facing him proffering her “baby” for examination is well-nourished and warmly dressed…She stands formally, even rigidly before the physician. The anxious little mother knows the rituals of office examination because she has removed the doll’s dress, tucking it under her arm…

 

The story the image tells is of perfect trust. The “good mother” brings her “baby” to the doctor as she herself has been brought. She knows and trusts the customary medical rituals because she knows and trusts the doctor. He accepts the trust and enters into the child’s creative play, listening gravely to the heart that isn’t there…

 

Do, then, the tender feelings “Doctor and Doll” instill define the default image of the doctor/patient relationship? Does this innocent interaction, so leisurely, so full of imagination and empathy and—perhaps—the tender condescension adults bestow on children—visualize for us an escape from the scientific, social, and ethical dilemmas and issues of our day?

 

In the past to say that one was a lover of the work of Norman Rockwell placed you in jeopardy of being considered unsophisticated. I have always loved his work. Perhaps I love Rockwell’s paintings because his illustrations were frequently on the cover of Boys Life and The Saturday Evening Post, two of the three magazines that were delivered to our house in the fifties. The third was the Reader’s Digest.

 

I am delighted with my purchase. It reminds me of my protected childhood. Most importantly it reminds me of the joy that I experienced in the practice of medicine.

 

Before I read David Brooks’ recent book The Second Mountain: The Quest For A Moral Life , I had never been exposed to an analysis of “joy.” Brooks goes to great lengths to be sure that we understand “joy” the way he thinks about joy.

 

…I want to pause over that last point—the one about joy being real. Our public conversation is muddled about the definition of a good life. Often, we say a good life is a happy life. We live, as it says in our founding document, in pursuit of happiness. In all forms of happiness we feel good, elated, uplifted. But the word “happiness” can mean a lot of different things. So it’s important to make a distinction between happiness and joy. What’s the difference? Happiness involves a victory for the self, an expansion of self. Happiness comes as we move toward our goals, when things go our way….Joy tends to involve some transcendence of self. It’s when the skin barrier between you and some other person or entity fades away and you feel fused together…Joy often involves self-forgetting…We can help create happiness, but we are seized by joy. We are pleased by happiness, but we are transformed by joy. When we experience joy we often feel we have glimpsed into a deeper and truer layer of reality. A narcissist can be happy, but a narcissist can never be joyful, because the surrender of self is the precise thing a narcissist can’t do. A narcissist can’t even conceive of joy…while happiness tends to be fickle and fleeting, joy can be fundamental and enduring.

 

When I read articles or hear people talk about restoring joy to practice I get confused. Joy is always possible in practice and is not a function of how smoothly the office is running. Joy as  Brooks’ defines it is always possible when we are trying to meet the needs of patients and not so focused on our problems:

 

Joy tends to involve some transcendence of self. It’s when the skin barrier between you and some other person or entity fades away and you feel fused together…Joy often involves self-forgetting.

 

Most of the articles I read about burnout are lists of inconveniences and barriers to practice that induce frustration, fatigue, and despair. Those issues are far from “self forgetting.” The job feels impossible. The primary focus becomes how to make the job doable. Is it the impossibly complex requirements of inputting data into the EMR that induces burnout? Is it the time compression of less than fifteen minutes in which to see the patient, review the issues of the appointment, assess current management and plan next steps, plus have a meaningful social and therapeutic interaction with the patient that is the core of the frustration that leads to burnout? Are patients more demanding and less trustful now that they can get so much information off the Internet? Perhaps it is provider frustration with the necessity to make more and more calls to payers to present the need for procedures and assure payment that burns out so many providers.

 

Whatever the cause of burnout, what I hear most frequently are concerns about the impact on the provider. At times there is the lament that there is not enough time to spend with the patient, but even then the perspective often feels like the lack of time primarily impacts how we practice, so again it frequently sounds like a clinician first, patient second concern.

 

The question I find myself asking is whether there would be real joy in practice if all of the barriers described as root cause problems in the hundreds of articles on burnout were completely resolved. There is no question that clinicians would be “happier” if they were better supported, had fewer barriers to practice like clunky inputting requirements in the EMR, and more generous payers with lower thresholds for approval, but would that create joy? It’s a tough question, but I have spoken to clinicians who work in resource poor environments who seem to find great joy in what they do. I am not suggesting that we should give up efforts to improve practice, or that our concerns about the deadly consequences of burnout for both clinicians and patients are misplaced. I am suggesting that we give deeper consideration to the true origin of joy in practice, if joy is what we are missing. 

 

Brooks goes so far as to suggest that joy often arises from difficult circumstances. There is no question that it is thrilling to solve a difficult clinical problem. I felt great joy when a patient that I had not seen in over a year forced himself on to my schedule just to show that he had lost over a hundred pounds and now had a normal blood sugar and well controlled blood pressure on minimal meds. Just seeing his success brought great joy even before he told me that a comment that I had made to him had motivated him to take charge of his health. I got great satisfaction when a patient who had class IV cardiac symptoms reported that since he had learned to weigh himself on a daily basis and adjust his diuretics, he was enabled to do many things that he had not been able to do for the past year. But, those joys are even small compared to the joy I experience as I think back over relationships with patients that lasted for one, two, or even three decades. I was a part of their lives, and they were an important part of mine.

 

I also find great joy in reflecting on my relationships with colleagues, and with the managers and support staff that maintained the environment where I practiced. Some of them knew “my” patients better than I did, and cared about them as deeply as I did. Our collaboration benefited  patients as we sustained one another. Those partnerships occurred in the midst of the same issues that cause burnout, and yet they were a great source of joy. 

 

There has been much written about the significance of isolation and disrupted communities as causes of the epidemic of depression, despair, and substance abuse that is an increasing public health concern. Johann Hari’s book, Lost Connections: Why You’re Depressed and How to Find Hope is a great review of our willingness to discount isolation from considerations of the origin of depression, and the deliterious impact of the overuse of medications to address a problem that has social origins. We all have heard humorous but depressing  descriptions of “group practice” like “doctors sharing a parking lot.” Equally depressing are comparisons of medical practice to “parallel play” of very young children. What is the origin of these behaviors? Why do some clinicans turn away from the support of colleagues, and seem not to find a way to establish deep connections with the people who come to them for care? 

 

In retrospect, one of the formative experiences of my early days in practice that served me well over the next several decades was participation in a “Balint Group.” I wrote about that experience back in February, and at the same time I mentioned Rockwell’s “The Doctor and the Doll.” I described my Balint Group exposure as an “inoculation” against burnout. That piece was largely about professionalism as a necessity in achieving the Triple Aim. The is no way to survive in practice and to find joy in the work without focusing on the principles of professionalism and the theraputic contract that implies that we will put the patient first, and find our joy in their success. I would add that exploring what we can do together for patients can “create” joy. I would like to think that a focus on how to experience more joy, rather than making lists of what kills joy, may be a more certain pathway for the return of “joy” to practice.