Every now and then I see an obituary or read an article in a journal that can send me back in time more than forty years in my professional life and up to seventy years in the totality of life. There is a big “scrapbook” in my brain where I log a lot of “screen time.” Another trigger that sends me on a trip down memory lane is to see a younger person making a “rookie” mistake. When that occurs my inner thoughts might go in several different directions depending on my mood at the moment. One harsh response might be, “These coddled younger people have got a lot to learn!” A less caustic thought is reminiscent of George Bernard Shaw’s moan, “It’s a pity that youth is wasted on the young.” Then there is the introspective, “I wonder if I ever looked that naive or lost?” Probably the most charitable response is to mutter to myself, “I hope this will not be as painful for them as it was for me when I made that error.”
Whether your guru is Erik Erikson or Gail Sheehy, the story for folks in retirement is pretty similar. In retirement the challenge is to be honest with one’s self and accept the race as run, or nearly done, and be okay with your effort when you stepped off the track. Retirement is a challenge like going off to college. You know that you are going, and although you know you are not the first to pass through the portal, you can’t be sure what your personal experience will be like.
While visiting my granddaughter and her family in Miami where everyone is busy with school or their profession and we are mostly spectators, my wife and I stumbled onto a series on HBO that we had not watched, perhaps because the title was off putting, “True Detective.” It is one of those over the top crime shows that reminds me of my mother’s admonition to be careful what I watched or read because one becomes what one thinks about.
The mystery that was presented was very brutal, but it captured our attention and we continued to watch it for several nights running in small doses that mitigated some of the brutality. In the seventh of eight segments, the two troubled protagonists played by Woody Harrelson and Matthew McConaughey get back together several years after a bloody split that left both of their lives in shambles.
They begin to have a conversation about what their younger selves might have been had they not gotten distracted by their police work. It is clear that both feel that they had missed opportunities or had played the wrong card at some earlier time. McConaughey’s character said that it was too late to become a painter, and Harrelson’s character had an even longer list of missed turns and waves not ridden. McConaughey resolves the moment by stating that given the opportunities that remained for both of them in life, solving the difficult case that had obsessed and distorted their lives for twenty five years was the only opportunity for fulfillment left for him and also for Harrelson. Harrelson’s character seemed skeptical, but also began to see the challenge as his only option and grudgingly agreed to set aside the old grievances and join the quest.
The scene spoke to me. I understand the concept of few remaining options. Some roads “not taken” to desirable destinations are no longer available to “rerouting,” and that must be accepted. The two characters set old grudges aside as best they can and return to the trail of clues that they abandoned more than a decade before now enabled with insight and focus no longer distorted by personal rivalry. Is it true that as the end of the journey approaches there is more clarity and understanding about what is really important? When there are only a few remaining exits available off the turnpike to the unknown, the challenge is to use one’s experience to choose wisely among the available options, hoping to be rewarded by some joy not yet experienced.
Whenever I begin to think about the future, especially in the context of my time constrained options, I inevitably begin with recalling the past. The past is full of anxieties, most of which were successfully endured. More importantly, the past is a crowded place for me. I am luckier than many because my past is mostly populated by positive experiences with family, friends, patients, colleagues, mentors, teachers, and acquaintances of note who gave me encouragement or helped me when I was lost, afraid, confused, or just uninformed. I can also remember all the errors and pain that were the usual outcome of doing it “my way.”
It is understandable that when I am on the memory train I frequently ride back to my practice days. Counting my years in training I was in the office, the hospital, or both for over four decades. When I think about those years I usually am triggered to visit a specific site and the patients I saw there, but most often the first thing I do reflexly is to call up the images of my colleagues in that particular office or hospital environment. I am not diminishing the remembered joys and challenges of the patients that I saw. Some of those relationships with patients lasted for four decades and whether there was one encounter or several hundred, those professional interactions were the reason that I think that I can lay claim to a successful completion of Erikson’s eighth and final stage of life, “Ego Integrity vs. Despair.”
“Burnout” has been one of the most actively discussed issues in healthcare over the past five years, and I see no end to the discussion in the near future. Some studies are suggesting that over fifty percent of doctors and nurses as well as many other healthcare professionals have experienced some degree of burnout. Burnout is a threat to patient safety and has a devastating impact on the professional. At its worst burnout progresses to debilitating depression and an alarming number of suicides. I certainly experienced symptoms of anxiety and depression related to work from time to time, but I never went over the edge. The Mayo Clinic, Stanford and other academic medical centers are delving deep into the organizational, professional and personal issues that are significant risk factors for burnout. Based on the research of the last few years many organizations are focused on interventions that may make a difference. I know that at the board meetings I attend “burnout” is a frequently discussed concern, and we are trying to put together programs and make operational changes that might mitigate the stresses that seem to increase the frequency of burnout. We are also trying hard to identify those individuals who may already be suffering. With greater uncertainty we are beginning to conceptualize the changes and “remedies” that might provide some amelioration and relief.
As I try to remember myself as a young clinician, what I see in memory is a young doctor who looked and sounded well prepared for any challenge. What I remember feeling was great uncertainty and anxiety about how to be someone’s physician. I was afraid of errors that might cause harm despite the fact that I was the product of an outstanding academic program. Unfortunately that program focused on teaching us how to manage patients in a tertiary teaching hospital environment where we spent hours debating and pontificating about disease and the latest appropriate literature and where the doctors often held themselves up as more important than any other player in the delivery of care. At the Brigham there were always experts to call upon. It was poor preparation for life in a world where you were independently practicing at a fast pace.
When I began to “moonlight” in emergency rooms during my residency and fellowship years, the first thing I noticed was that I was alone. In 1972 in a suburban hospital with no house staff it was often true that I was the only doctor in the building. I was busy seeing patients who were coming to the EW where I was pretty comfortable, but I was also called frequently to see patients anywhere from the surgical ICU to the pediatric service. I could call the private doctor to discuss a case, but I quickly learned that my calls after 10 PM would not be well received. What I soon realized was that the nurses were my greatest asset. They were concerned for the wellbeing of the patient, and they were concerned for my well being. I soon learned my best strategy was to articulate my respect for their expertise, and elicit their help resolving the problem. They usually had “seen it before,” and more often than not they were delighted to have an opportunity to talk with me about what the best course of action might be.
When I began to work at HCHP I had the good fortune to be adopted by two of the “founding mothers” of the practice. One, Barbara Taylor, had been a visiting nurse for years and was “grandmothered” as a nurse practitioner before there were NP training programs. Barbara and I “shared” a practice for over twelve years until she was taken from the office with a stroke that was the first symptom of an aggressive cancer. The other “founding mother” of HCHP was Stella Goldsmith, who was a very experienced ICU nurse. Stella managed our urgent care department where she suffered no fools. Stella and Barbara were focused on quality, safety, and the patient experience before there was much literature to suggest that medicine lacked the quality one would would expect, was not as safe as one might hope, and was primarily organized to serve the needs of the doctor and not the patient. It would be sixteen years before the IHI would emerge, and twenty four years before “To Err Is Human” would be published. Stella and Barbara already knew what it would take others more than twenty years to be able to articulate.
I credit Stella and Barbara, as much as any other professionals, with establishing the culture that would nourish me as an effective professional, teach me how to be a team member, and ultimately save me from “burnout.” There were many other Stellas and Barbaras in my career, too many to name in a post that I am trying to keep under two thousand words, but all of these colleagues do join me in my pleasant memories of practice.
A friend recently told me that success was defined by a combination of individual freedom and community that fostered action. I think that he was trying to describe something that I fear is often missing in practice these days. We get focused on our individual concerns and become isolated from the community of our colleagues, and the result is a tension that is not very beneficial for the individual or for the work group. I was impressed several months ago by the truth demonstrated by examples in Jonathan Hari’s Lost Connections: Uncovering the Real Causes of Depression – and the Unexpected Solutions. What I remember when I look back on my years of practice are the connections. The connections with patients and the many supportive connections with colleagues of many professional types.
What could be better than being an individual, working in an environment of reciprocating professional relationships in a community of practice, in pursuit of a motivating purpose like the Triple Aim? I was blessed with that experience. It made success in Erikson’s last stage a lock for me. I don’t need to have a conversation like the one that Harrelson and McConaughey had about the roads not taken because I was very fortunate to have worked with nurses, doctors, and other healthcare professionals who nurtured me in an organization that was driven by purpose and built on supporting relationships.
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