Over the years I have had some strange dreams. In one recurrent dream I am back in high school playing football. It is not like the old days when I was an All Star. Despite the fact that I feel that I am at least as good as the other guys, even though I am in my seventies, the coach is paying me no attention and I am wandering up and down the sidelines just hoping to get onto the field. It’s all very frustrating and potentially embarrassing if I am found out to be a fraud.
I also have dreams about going back to college. There are several variations but they all have the same core message that I am not what I once was. I am now struggling to make C’s and sensing that my chances of getting into medical school, even the state medical school, are “slip slidin’ away.” I will leave the analysis of my “do over” nightmares to you and others, but recently I had a totally new “do over” dream that I have never had before.
Perhaps the dream was the result of a guilty conscious. Let me explain. In last week’s posting I introduced the medical writer Eve Shapiro. She is interviewing clinicians and medical managers for a book she is writing that will explore both the joy and the frustrations in practice. I asked you to contact her at eveshapiro912@gmail.com to schedule an interview about your own joys and frustration in practice.
My own conversation with her was scheduled for after my posting. The letter was my prep. As I talked with her, I realized that I had not been as open with my concerns in the letter as truth would require and that I had been evasive on some real sore points. Eve is not a physician, but her questions clearly demonstrate that she understands the value of good social and family histories. In a metaphorical way she is also digging for a “past medical history” and is not quickly jumping to a “chief complaint. ” She cares about conducting the interview and considering the answers in the context of understanding the whole individual.
I gave her a pretty positive description of my family of origin, and my path toward a life in medicine. I avoided giving much detail about anything other than the “joy in practice” that I have experienced. I celebrated the serendipity of arriving at the right place at the right time through no effort of my own. Because of my lack of candor I am not sure that I helped Eve very much in her desire to understand why so many clinicians complain of symptoms that can only be ascribed to “burnout.” I did acknowledge the difficulties reported by others, but I implied that the safe havens of Harvard Community Health Plan and its legacy organizations had sheltered me from the trials that others endured. My review was “Pollyanna” and not realistically balanced. In truth I had known more frustration than I admitted.
I could fool myself in the light of day, but my subconscious mind “outed me” in my dreams. In the first part of my frightening new dream I am back on the wards of the “old Peter Bent” Brigham Hospital. The image from an old post card from the thirties that is the header for this post shows the Peter Bent Brigham opening on to Brigham Circle. It looked much the same in 1971 when I began my internship. The large marble monolithic presence of building “A,” now called Gordon Hall, which sits at the top of the “quadrangle” of buildings that make up the med school campus where we spent much of our “preclinical” years, can be seen looking “over the shoulder” of the Brigham.
Early in the dream, the problem is that I am the “admitting” intern for the male ward service. I am called once again by the senior resident in the emergency room to tell me that I am getting another “hit.” I can’t tell him that I still have not finished working up or writing orders for the last two patients that came up. Everything is falling apart around me. I can’t even find a pen or progress note paper for the chart. Nurses keep interrupting me to ask me questions. When I try to dial the operator to answer the pages that keep coming to my beeper, I can’t get my fingers to dial the phone without making a mistake that forces me to start all over, again and again. Then things get progressively worse. Nothing is working and I have no time to think or get things under control.
In truth the dream was an enhanced “remembrance.” I was in the last group of Brigham interns to endure 10 months of every other night call. We had two “recovery rotations” that were “light call” and every third night in the hospital. Things have changed for interns now, but I fear that much of what I endured has morphed into something different that has its own new horrors and excellent reasons for sweat producing anxiety, a pounding heart, and the ability to fall asleep at intersections while waiting for the light to turn from red to green.
At my age your dreams get several installments since there are multiple obligatory trips to the bathroom to negotiate without falling during any given night. My ibuprofen is strategically placed near the bathroom sink since things get sore when you wrestle with demons in your dreams. I dream in installments. It is a relief to wake up and say, “Well that was just a dream!” But as soon as I have returned to bed, a new episode in the same story begins. It’s just like binge watching on Netflix.
Once back in bed, the time of my dream shifted forward a few years from 1971 toward the late seventies. The scene moves from Brigham Circle to Kenmore Square, about a mile away. In the new installment, or second episode, I am experiencing much of the same sense of being in an environment that is out of control. My schedule is full, over full, yet I feel inadequate because I see Joe Dorsey’s schedule and he has about thirty patients booked for the afternoon session compared to the seventeen that I have. I ask myself, “How does he do it?” When I arrived from a morning in the hospital there was a stack of “call slips” waiting for attention. People want to come in or they want to talk about a lab result and hope that I will call soon. One of those calls could be from someone who needs to be seen right now.
Sitting next to the call slips is a ream of that old computer paper that made great banners. It’s not a banner. There are dozens of printed lab results for me to review. In time I will scribble a reassuring note that there is no need to worry about the results, but call me with any questions.
A colleague calls to ask if he can send down a patient for me to see. Alternatively, I could come up to his office and take a quick look at the EKG and listen to his heart so that we might avoid sending another patient to the ER. I tell him that I will pop up in a couple of minutes. Oh, and there are a hundred or so EKGs that must be read before I go home.
My medical assistant seems distressed. Both of my exam rooms are occupied by patients who are getting a little “antsy” waiting for me. I am way behind. Gone is any hope to see the last few innings of my son’s little league game. I had promised him that I would do my best to get there. Was it all a dream or just a more honest memory?
As Eve interviewed me I remembered much more than I had originally admitted. What I also remembered was that I was part of a group that felt responsible for finding a better way to “manage the practice.” In retrospect we were trying to manage our frustrations. We were facing huge problems that few people fully understood, and that no one could “fix” for us. We felt there were both personal and collective necessities to be involved in the search for solutions.
It is right for patients to expect better access and the focused attention of the doctor, PA, or NP when they do finally get to the office. It occurred to me years ago that the last patient that I saw long after 5:30 PM had every right to expect the same level of attention from me as the one that I had seen at 8:30 AM. It is perfectly acceptable and understandable for patients to complain about the rising cost of their care, especially if they do not see a commensurate rise in value. It is also a reality that each of us has emotional, intellectual, and physical limits that can be overwhelmed.
I do believe that part of responsible professional behavior is to recognize one’s limitations and ask for help when the limits of responsible performance are approaching. It is not productive to just complain about the incessant demands coupled with the non compliance of our patients. It is also not healthy to sense that everything “depends” on me as I sensed in my dream, and often sensed in the light of day.
I will still contend that there are practice solutions that we can find if we are open to innovation and change. The way forward requires flexibility and a willingness to discard what has been “usual practice” but is no longer productive. What we discard must be replaced by changes in care delivery that can provide a better experience for the patient and less frustration and physical and emotional destruction for providers.
Since the election in 2016 significant momentum has been lost in the process of improvement. We have gone from experimentation with ideas about how to improve care, to defending some fraction of the gains we have made toward universal access. Our longterm goal should be to eliminate the chaos and stress that frustrates so many clinicians and patients. More time is needed for the development of personal knowledge of the patient and the application of critical thinking to improving quality and solving clinical problems. Instead of making progress we are forced into a retreat that has as its objective the preservation of some fraction of what we had already accomplished.
It will take focus and commitment to a common set of ideals and many new innovative ideas to awaken from this bad dream and improve the deteriorating lot experienced by many clinicians, and restore the full measure of joy that was always the payoff for the realistic and survivable levels of stress that have always been associated with practice.
Never has there been a better time to think about a fuller vision of what the Triple Aim or “Quadruple Aim” would be like. After we have addressed the reality of where we are versus where we want to be, we can analyze the barriers to progress, and articulate a hypothesis that might lead us toward our objectives. There will be discovery along the way, just as there has been in the past. There will be a sense of possibility once we start again toward making healthcare universally available.
We will move closer to our objective if we just keep applying what we learn from our failures as course corrections moving forward. That’s how I survived my fears, frustrations, and disappointments, and now at the end of road can find some joy in the fact that even though I never got to where I wanted to go, I do look back with some satisfaction that is greater than the regrets. “Do overs” are not possible, but there can be great joy in less than perfect efforts.
