Becoming Cynical, Part 3

The problem of physician burnout, which in a previous post I defined as a
“loss of enthusiasm for work, feelings of cynicism, and a low sense of accomplishment,” increasingly plagues the American medical profession. In an article in the Archives of Internal Medicine in 2012, researchers
found that U.S. physicians suffer more burnout than other American workers. This year, a Medscape Physician Lifestyle Report found that 46 percent of all
physicians who responded had burnout, “a substantial increase since the Medscape 2013 Lifestyle Report, in which burnout was reported in slightly under 40 percent of respondents.”

The consequences are deleterious: burnout negatively affects
patient care and is associated with higher rates of suicidal ideation. In two earlier posts (here and here) I offered a couple of reasons why physicians become
cynical. In this post, I expand on my previous entry
suggesting this phenomenon is partially due to the “patient population one deals with.”

Let me start with a story.

One night, the general medical team admitted a patient with severe hyperglycemia, or high blood sugar, who had a
history of IV drug abuse, alcoholism, diabetes, and hepatitis C, a viral disease that can destroy the
liver. The patient drank so much hard liquor that he got dehydrated, neglected to take his insulin and
went into a hyperosmolar hyperglycemic state. Patients with diabetes develop this
condition when they have an infection, preceding illness, or dehydration. In diabetics, physiological stresses like these reduce insulin, a hormone which
normally regulates blood sugar levels, causing unmitigated hyperglycemia. The blood becomes hyperosmolar due to the excess sugar and draws more fluid into the intravascular space
leading to dehydration of cells within the body and increased excretion of water in the urine — which in turn worsens the pre-existing dehydration. As urine is
excreted there is also a loss of electrolytes like sodium and potassium. Severe hypotension (low blood pressure) ensues and
patients can die. Treatment involves IV fluids, insulin to correct the hyperglycemia and continuous monitoring.

After recovering overnight, our patient declared that he would start a new life and give up drinking — he was ready to make a change. As his symptoms
improved and his labs normalized the medical team worked toward this goal. We arranged for follow-up appointments with a primary care physician, an
infectious disease physician, and a psychiatrist. The pharmacist managed to get him insulin through a hospital-assistance program. And the social worker
arranged for him to go directly to an intensive alcoholic recovery program gratis. In order to get there, he was offered transportation from the hospital. The
hospital ate the cost for treating him because he was uninsured. It is both wonderful and incredible that all these resources, given freely, go towards
helping a patient get back on his feet.

However, on the day of his discharge, the patient left the hospital but did not take the ride or his insulin. He drank two bottles of vodka and came back
that evening in a drunken stupor and a hyperosmolar hyperglycemic state. He cursed at his nurses and the female resident who admitted him. Because he also
threatened them, the hospital staff put him in restraints in his bed so he wouldn’t violently swing at those giving him medications. The medical team
repeated the previous day’s actions — but two days later, the patient did the exact same thing. And for the third time, the medical team readmitted him.


This sequence of events elicits all kinds of thoughts and visceral reactions pulling us in two different directions. Surely, this patient has an illness
(alcoholism) and so we need to be understanding even if we hold him responsible for his actions. And yet, the hospital gave him multiple golden
opportunities to attempt to turn his life around and he declined to do so. At what point does the hospital turn him away and refuse to pay for his medical
care? Would it be ethical to do so? The money can be better spent on destitute patients who will take their medications but can’t pay for them. Given the
limited resources of any system, shouldn’t we at least entertain the idea?

Unfortunately, doctors face this conundrum on a weekly basis. Some diabetics refuse to take insulin; other patients refuse to give up an unhealthy diet;
some don’t take their blood pressure medications. Statistics back this up: in one particular review article in the Journal of the American Pharmacists Association in 2000, 43 percent of
the general population and 55 percent of the elderly population were found to be nonadherent to their medications. Approximately 125,000 deaths per year have been
attributed to nonadherence to treatment for cardiovascular disease. Finally, the direct and indirect costs of nonadherence to medications are estimated to
be $100 billion per year in the United States.

Physicians want patients to get better, and this is more than just a matter of prescribing medicine. They spend time talking to patients about their illnesses and treatments. They call consults from specialists who then take time to figure out a plan for a particular aspect of the patient’s ailment.
Social workers arrange for affordable medical services, transportation, and institutional and governmental help. Physical therapists and occupational
therapists see patients who need to regain strength. All this requires logistical tasks that aren’t always intellectually stimulating or exciting and may
not even be compensated for at all.

Of course it is true that the doctor can fail the patient, but it is also true that the patient can fail the doctor. In the Medscape survey I referenced above, physicians cited “too many difficult patients” as one of the reasons for their burnout. This reaction is completely understandable. After seeing patients make poor choices again and again, a general malaise can set in. At some point, physicians ask themselves, “why should we care?” Doctors may start to go through the motions of writing notes, coming up with a plan, and making
arrangements for these patients but with an emptiness of spirit. We may become embittered, both toward the patient and toward some of the annoying tasks involved in the work. A sense of futility and even detachment can follow.

Let’s not forget that the practice of medicine is a very human enterprise. Indeed, as healthcare professionals, we ought to
recognize the problem of nonadherence even after putting aside the issue of limited resources. However, it is useless to just complain about uselessness — to throw our hands in the air and ask “Why even bother?” In every field there is work that does not bear fruit; entrepreneurs, for example, fail 80 percent of the time when starting a new
business. Why expect a profession that relies on the Sisyphean task of changing a human being’s behavior and habits will be exempt from this fact?
Patient failure, just like physician failure, is an integral part of our fallible medical system.

A Day in the Life, Part 2

This post continues my description in the last one of a day in the life of a medical student on rotation, where I’ve left off at lunchtime of an inpatient service day.

During the afternoon, the work of executing plans continues. If the team discharges a patient, that patient needs a follow-up appointment in clinic to make
sure there are no complications from the hospital visit. We call up the outpatient clinics and schedule patients for their next appointments. In other
cases, we need a patient’s hospital records from his or her previous visit to another hospital. Because electronic health records are usually closed within
a hospital system, we have to request that other hospitals fax us medical information. This is a rate-limiting factor in getting complete access to lab and
imaging results, which are integral to patient care. For instance, if a patient comes in with a severe headache and another hospital performed a CT scan of
his head, access to that scan may be essential to ruling out a diagnosis of something serious, like a brain tumor or infection. And if we can’t get
the images from the other hospital we may have to do one at our hospital. This is, undoubtedly, one of the major weaknesses of a non-universal electronic
health record system.

The medical team may also discharge a patient to a skilled nursing facility (SNF) or an old-age home, in which case the facility needs documentation
regarding what further care is needed. Some patients do not have anywhere to go after the hospital; some abuse alcohol or drugs and must go to a rehab
program; some can’t pay for the oxygen they need at home or medications for HIV; others started taking a blood thinner called warfarin and need to schedule appointments at a lab to get blood levels of this medication checked. To
deal with all this, the residents, attending, pharmacists, nurses, and social workers all coordinate with each other and with governmental and private
organizations to get the patient where he or she needs to be and what he or she needs in order to stay healthy. The healthcare team takes on this Sisyphean
task with varied success. Given the number of factors involved in this transition, one of which is whether the patient takes his or her medication, the
result is not always ideal. I’ll write more about this later.

Additionally, the residents and attending physician sometimes admit new patients to the hospital during the afternoons from smaller hospitals in the
community. Community hospitals are not always capable of caring for patients with a rare tumor or disease, while academic medical centers, which are
attached to medical schools, have more physicians who specialize in and research rare disorders. For example, a patient having seizures that cannot be controlled with first or second-line medications is sent
over to an academic institution where neurologists experienced in handling refractory seizures can care for the patient.

The medical team may also admit a patient from the Emergency Department (ED) for a full diagnostic workup and treatment of an acute or chronic disease. For instance, a patient
with worsening Chronic Obstructive Pulmonary Disease (COPD) needs temporary
high-potency medications for a few days before going back home. Some patients with an exacerbation of this disease need constant monitoring so they don’t
experience respiratory failure. Clearly, then, the afternoons can get busy, especially if the residents have to finish their notes.

At 6 p.m., the night intern arrives and receives checkout from the day team: The day intern runs through a list with the night intern, describing the new
admissions to the hospital service, the events over the course of the day for each patient, and which lab and imaging results the night intern needs to

Image via Shutterstock

Outpatient and the ED

The time that we spend in a doctor’s office — on our outpatient weeks — is a lot less hectic. Whether we are in family medicine, pediatrics, or obstetrics/gynecology clinic, we arrive at 8 a.m., which
gives us time to exercise in the morning or stay up a bit later at night. The residents arrive at the same time. We look at the clinic schedule for the
day on the electronic health system and begin to read old notes in the electronic health record to get ourselves up to date with the latest medical information
on each patient.

When patients arrive, the medical student goes in first to interview a patient and do a focused physical exam, after which the student reports his findings and his plan to the resident, just like we do in the ED. The attending and the
resident then see the patient and come up with a tailored plan for how to proceed. We have an hour for lunch at noon and then come back from 1 p.m. to 5 p.m. (This is similar to our ED
shifts, since they are both eight hours — except of course our ED shifts are sometimes late at night or overnight, and there are no scheduled meal breaks during an ED shift.)

After our days finish, we are expected to do research on a disease process we saw during the day. If a patient comes in with pneumonia, we read up on the
common causes of pneumonia and the various treatments available for it. We also study for our shelf exam, which is a national multiple-choice test that we must pass
after each third-year rotation. At the end of pediatrics, for instance, the shelf exam tests us on pediatric illnesses and treatments. These tests are difficult
and so we frequently study from various third-party review resources —

, UWorld, PreTest, Case Files, and others. A whole industry is built around these shelf exams, which
eventually culminate in a nine-hour, eight-section national licensing exam called STEP 2 CK. This comprehensive exam
tests basic clinical knowledge at the end of third year. So on a day-to-day basis we not only worry about learning how to deal with patients and their
illnesses but we also study for our exams, which is a requirement that ensures we know the important information involved in our daily practice.