Don't blame others for the burned road you're on: it's your own “Ass-Phalt.”
ALL RIGHT.
I know that sounds harsh. We physicians and other clinicians suffer under the demands of irrelevant EMR guidelines, insensitive hospital administrators, and the tyrannical dictates of medicine and big pharma. However, these are all “external” forces. They are not our “phault”. But what about the “internal” forces, forces that can be, in some way, our “phault” (or at least under our control)? What about these forces intrinsic to our DNA?
“Burnout,” according to conventional wisdom, leads to “moral injury.” And “moral injury,” we are told, occurs because our actions (or our feelings) do not correspond to our values.
Let's go even further.
Burnout, moral injury and the mismatch between our values and our actions are, I believe, based on two self-generated “internal” myths, myths intrinsic to our DNA. These myths are myths that we impose on ourselves, but they are also myths over which we can have control.
Let me explain:
Myth #1: “I should do things right!” »
I am a neurologist, now retired, but when I practiced medicine for over 40 years, I encountered the following type of situation many times. Let's say, for example, the family of a Parkinson's patient calls my office. Dad is going downhill. They want me to see it, pronto. But I can't do it. It's simply not possible. It's Friday afternoon and I already have several jobs. So, I give my medical assistant some advice for the family, hoping that they will be satisfied. But if I have lived up to my values which I have posted on my home page and which declare: “I will treat all my patients like family”, then on that day (and many other days like this one), I did not live up to my values. I didn't treat my patient like family. If I had, I would have seen the patient in person. Another day, another patient, and again: “I didn’t do it right.” Another day when the moral injury knife thrower hit the nail on the head.
People like me had been learning to “do it right” all their lives. We produced. We have succeeded. If you got a “B” in college, it was a family crisis. We passed our PSAT, SAT, MDCAP and match days. Many of us come from immigrant parents. We were the great hope of our families.
We have the Krebs cycle memorized, for goodness sake!
We do it well! Except when we can't. (Which represents a large part of our working days.) And it is on these days, little by little, that we suffer moral damage. The days when our actions don't match our values. For over 40 years, I have witnessed this.
Myth #2: “I should do it with compassion.” »
Remember that person with Parkinson's disease?
When I received the message, guess what?
I didn't feel any compassion.
I felt angry.
I felt angry with the patient.
I felt anger towards the family.
How dare they call me at 4:30 p.m. on a Friday afternoon demanding that I see their father!
I was angry at my medical organization for making it impossible for me to see this patient in person.
And I felt angry with myself…for being angry about all of this.
And to tell the truth, I was a little angry with God for having created all these people with defective basal ganglia!
And this is where the second myth of moral harm lies,
I should have treated my patient and his family with compassion.
I do not have.
I should have at least felt compassion.
I do not have.
So, my actions (or feelings) did not match my values.
And, once again, the knife thrower for moral injury has hit another target.
Thus, two self-generated myths:
“I should do it right.”
“I should do it with compassion.”
These myths (and not just those of the EMR, hospital administration, or the Big Pharma medical-industrial complex) can lead us down a path to burnout and moral injury. These are the self-imposed, self-generated, DNA-intrinsic burdens that can be our “own Ass-Phault.”
And yet, there is hope. Perhaps we can do something to overcome the consequences of these two myths. I am not suggesting that we change who we fundamentally are. I am not suggesting that we become less conscientious. I am not suggesting that we become less compassionate. But maybe there is a way to “repair, repair and quietly sail our own “Ass-Phault”.
Let me share an example from my own experience of over forty years of practicing neurology.
Joanne is a 38-year-old housewife and mother of ten-year-old twins who were referred to me for consultation. Joanne's own mother died suddenly of a brain aneurysm when Joanne was 13 years old. She was referred to me because although a brain MRI showed no aneurysm, it did reveal a minor abnormality. I examined Joanne and looked at the MRI. Everything was perfectly fine. The MRI showed a harmless, incidental finding, a “nothing.” As I reassured her and walked out, Joanne grabbed my hand between hers. “Oh, doctor,” she exclaimed through tears, “thank you so much. I was so worried. I am so grateful to you. God bless you, doctor.
To be honest, I was embarrassed by this effusive praise. All I did was review a routine MRI.
“Joanne,” I said, “No problem. It was nothing.” But later that night, I started thinking about it. Then I realized:
For Joanne, it was no small thing.
For Joanne, it was something.
For Joanne, it was something big.
And that should have been, for me, something.
It should have been something big for me.
I should have cherished this moment as much as she did.
I saw a bumper sticker a while ago. It read:
“It’s amazing how you can influence someone’s life so profoundly and never appreciate it.”
I'll admit it. For much of my medical career, in this situation, I would have been in the “I'll never like it” category. But I understand now that, for Joanne, this meeting was a blessing that allowed her to live. And I understand now that, for me, this meeting was not just a routine “waste of my precious time” consultation, but was just as much a blessing.
And to all my fellow doctors, let me ask this question:
How many of us fall into the “never appreciate it” category?
How many of us are unaware of the powerful blessings of our daily “Nothingomas”?
And yet, if we could approach each patient with some self-appreciation for the impact we could have on their life (even for a “nothing”), if we could approach each patient encounter as a blessing “gift” , then maybe we could feel that our actions (and feelings) will match our values. Perhaps we might find our daily work lives filled with more joy and meaning. And maybe then we could “repair, repair and happily sail our own “Ass-Phault”.
Scott Abramson practiced neurology at Kaiser Permanente Northern California for over 40 years, from 1979 to 2020. Throughout those years, Dr. Abramson was passionately involved in physician communications and wellness efforts. Some of his ideas and stories from his experiences in these efforts can be found in video format on his YouTube channel: Doctor Wisdom.