By Kai Mebust
“I was sick, and you took care of me” – St. Matthew 25:36
Why did you go to med school, or nursing school, or PA school?
I went to escape my first real job. It was at the Washington Consulting Group in D. C., where I helped develop forecasting models for federal agencies involved in energy and aviation issues. The work appealed to my scientific training and to my inclination towards quantitative analysis. As the smartest young person in the firm, I advanced quickly, with frequent pay raises, escalating responsibilities, and, before long, a window office of my own. I had a future at WCG. I found the work fairly easy, and though I got paid for eight hours every day, I estimate that I engaged in productive activities for no more than one and a half of those eight hours. Good pay for little work, as a healthy young man in a world capital. What could be better?
Well, as it turns out, lots of things. I’m a social person, yet 95% of my job at WCG involved sitting behind a computer screen. I’d always assumed I would do something “important,” yet I found myself working on forecasting models that never had a chance of correctly predicting the future about dreary topics like the price of electricity in the residential sector 15 years from now. I’d never been driven to become rich, yet as part of a profit-making enterprise I was expected to use money as the organizing principle for every activity, employee evaluation; every decision I made.
As the years went by, I became less committed to my job. I began arriving late, leaving early, and taking two-hour lunches. I became an expert in Tetris. Sometimes, I’d close my office door and take naps on the floor. In what I now realize was a symptom of depression, I spent hours every day in elaborate fantasies of how to commit suicide and make it look like an accident.
What at first glance may have seemed like a good job really was anything but that. The foundation of my job did not support my own interests and values. Luckily, I had the good sense to get out before the obligations to a wife, kids, and a mortgage trapped me there. I’m glad I switched careers, and though I work harder and longer and have much more difficult challenges every day, I have been fundamentally happier in medicine that I ever was as a consultant.
I’ve been reflecting on those times recently, as I hear so many of my colleagues express frustration and dissatisfaction with their work. Though our primary encounter with these sentiments is through our work at Basset [the local hospital], we all know that similar conversations are happening around the country. Our profession is in an emotional slump, with more and more physicians considering leaving patient care for something else entirely.
It seems crazy. As in my first job, somebody looking in from the outside would likely conclude that doctors ought to be very happy. Even the most modest physician salaries are much higher than the $45,000 median household income in Otsego County. We get respect at work, where it’s “Yes, Dr. Mebust, No, Dr. Mebust” (compared to at home where it’s “Kai have you dumped out the compost yet?”). Our standing as medical professionals often leads to invitations to play leading roles in civic organizations, political groups, and churches.
So where is the dissatisfaction coming from? As with my job at WCG, there is a mismatch between who we want to be at work and who we feel compelled to be by the pressures of institutionalized medicine.
In Bob Lancey’s talk at the Bassett Alumni Reunion last weekend, he revisited his med school application essay, in which he wrote of his desire to provide care in a community setting as a primary care physician. Of course things turned out differently for him – he became a cardiothoracic surgeon. But the underlying desire to help other people in their times of great need was still there. He challenged us all to “be the person you said you were going to be in your med school essay.”
I think we all start out the same way – with a strong dose of idealism and the intention to master our craft as a means toward our ultimate goal of helping our fellow man. We want a profession of the personal.
Yet it turns out our world overwhelmingly emphasizes an endless string of impersonal technical details. In medical school it’s learning “the sartorius muscle’s insertions,” the Krebs cycle, and endless side effects of unpronounceable drugs. In residency and fellowship we learn how to do a lap cholecystectomy, a cervical spine injecton, or R-CHOP chemo. When we finally begin our practice, we find ourselves beholden to a bewildering array of quantitative standards – CMS Core Measures of how often we order echos in heart failure, HCAPS surveys of how well our patients feel their pain is controlled, rates of surgical wound infections, average levels of hemoglobin A1Cs. Our Grand Rounds, conferences, and board recertification exams focus on the technical aspects of our fields – the pathophysiology of celiac disease, the differential diagnosis of chest pain, and the latest drugs for diabetes. Our colleagues who take care of the financial and administrative aspects of our practices focus on the size of our patient backlog, how many RVUs we generate, and whether we sign our notes on time.
The daily work of being a physician begins to seem like an unwinnable game against the clock. See the day’s first patient. How quickly can I ask the questions and do the minimal exam to establish a diagnosis, recall the therapy options, then choose the one most appropriate to the patient’s specific set of comorbidities? Order the tests, write the scripts, finish the progress note, then move on to the next patient before I get too far behind. Lunches and evenings are for patient phone calls and dealing with complaints. From time to time, we go to a departmental meeting, only to find that despite our best efforts, financial pressures remain. Core Measures and HCAPS scores are still below goal. We are told to see more patients and get better at ordering echocardiograms for heart failure. The hospital and clinic start to seem like a factory: the patients are cars coming down an ever faster conveyor belt, and we are the line workers trying to keep up, judged solely by how fast we screw on the lug nuts and how many of them we drop on the floor by mistake.
Where is the human contact we wrote about in that application essay?
Well, it’s still there, and always has been. One of the challenges of our job is to recognize when we do make that contact, and take advantage when it happens. This means refocusing the way we look at our patients, making our contact with them the center of each encounter rather than the tests, procedures, drugs, and performance standards.
These technical tools of medicine by the way, all come from God. Thankfully, ultimate responsibility for cure is not ours.
In Genesis – after the creation of all good things – came the Fall, when man brought sin, pain, sickness and death into the world. The Bible’s story since then is the account of God’s plan to restore his world to communion with him. We who work in medicine are to use our God-given skills and God-given tools to play a specific role in that plan.
In Ecclesiasticus today, we read of the physician that “the Lord created him.” Lest we take too great a stock in ourselves, we are told that “healing comes from the Most High” (i.e. not from man alone), and that “from God health is upon the face of the earth.” Our tools are not of our own making, as we read that “the Lord created medicines…and by them he heals and takes away pain.” When we are successful in healing, we are playing our role in God’s plan to heal and restore his world. God’s gifts to physicians – our intellect, our health, our society’s investment in our education, our material comfort, our social standing – are all given so we can channel them and use the medicines he gives us to comfort his people.
In the late nineteenth century, Dr. Edward Livingston Trudeau established the first of the famous Adirondack sanitoria for people with tuberculosis in Saranac Lake, New York. The theory at the time was that cold, clear mountain air could somehow cure “consumption.” Dr. Trudeau was a serious scientist, not some quack turning a buck by bringing the latest European fad to gullible New Worlders. He was a graduate of the Columbia College of Physicians and Surgeons.
In addition to his medical practice, he established the Saranac Laboratory for the Study of Tuberculosis, which exists today as the Trudeau Institute where 25 PhD-level scientists pursue active bench research in several areas of infectious disease. And he was the first president of the organization that became the American Lung Association, whose founding mission was to pursue active research into prevention and cure of TB.
Yet for all his academic focus, he is remembered for his humanity. You see, for Dr. Trudeau, TB was not simply some interesting yet abstract contagion. He chose to become a doctor after nursing his older brother in a losing battle against the disease. He later contracted TB himself, and lost one of his children to it. Pain and suffering from tuberculosis was very real to him, as was the toll in inflicted on a patient’s loved ones. In his lifetime he strove mightily to find a cure for TB, but he recognized that was the lesser of his professional obligations. He described his duties as a physician as:
“To cure sometimes, to relieve often, to comfort always”
As we read in today’s Gospel, this is the very standard Christ gives us. Matthew’s account the Last Judgment very clearly sets out what might be considered some “standards of care”, or “core measures” for how a Christian is to live his or her life. These are not vague ambiguous statements open to interpretation. Matthew uses active, precise language, challenging us to feed the hungry, clothe the naked, welcome strangers, and visit prisoners.
The key passage for today is “when I was sick, you cared for me.” It is a great relief to know we will not be on judged whether or not we eradicated disease. Again, healing comes from God. Christ’s challenge is not to cure, but simply “to care for me”. The NIV says to “take care of me.” The King James translation has it as “you visited me”. God did not judge Dr. Trudeau on whether he found the cure for tuberculosis, and luckily you and I will not be judged on whether we discover a cure for AIDS.
Our primary job is simply to provide the compassion and caring.
And in that charge to show compassion are the seeds of our own rejuvenation. As Matthew states very clearly, Christ is present in all our patients, even the least of them. He is there when we spend the extra minutes listening to a sad and lonely widow tell stories about her long-departed husband. He is there when we take it upon ourselves go get a feverish young man a cup of water, and when we hold the hand of a scared cancer patient in physical and emotional pain as she realizes that she’s dying. God wants us in these situations simply to be there, to support his children in their time of need… to care.
Yes, we can also leave the room and order Zoloft for the depression, or saline for the thirst, or morphine for the pain. But in a very real way, prescribing these medications is not really giving of ourselves. The medicines come directly from God. We act as the instruments by which he gives these gifts to his broken people. The compassion – the caring – that is the thing we that we give of ourselves to our patients.
I’ll be the first to admit that in these situations, I don’t usually think in such concrete terms, that “this patient is Christ.” But I do know that when I take the time to get to know something of my patients as people, I feel better.
It is rejuvenating to me to learn that though the old man with pneumonia who bravely survived landings in North Africa, Sicily, and Normandy, is now scared that he won’t be able to live at home any more. Yes, learning those extra details allow me to address his needs more completely: say, by involving social work or connecting him with home health nurses.
But it’s more than that. It’s the deep feeling of satisfaction I get by making a real and deep human connection – somehow and in some way I get something out of the encounter too. Just as God returns back to us manifold our offerings of time, talent, and treasure, I find he returns to me a measure of inner peace and professional satisfaction when I simply hold a patient’s hand, listen to their story, and really see them as a child of God. I think that is what Christ means when he says that “when you do it to the least of these, you do it to me.”
Surveys say that physicians are unhappy not because of their compensation, professional support, or autonomy – though these are certainly causes of concern for many. Rather, they are most frustrated that external demands have reduced the amount of time they have to spend with patients. This speaks to our innate understanding of the restorative power in the patient-physician relationship for both parties. I have no special solutions for the structural problems that face our profession. I can only suggest that we each make the most of the time we do have when we are the presence of out patients.
At Grand Rounds on Friday, our speaker talked about physician resilience. He suggested a number of strategies for dealing with stress and preventing burnout. Among them was the conscious act of stopping for two seconds when reaching for the door to go into the next patient’s room. In that moment, he advised us to clear our mind of the last patient’s problem and ready ourselves for the new issues of the next patient.
I’m going to try and do this from now on. But in those two seconds, I will remind myself that behind the door is not just the next patient. It is an opportunity to see in that person Christ himself, an opportunity to care for him as Christ commands, and thus an opportunity for me to receive His blessings as I play my own small part in God’s plan to heal his broken world.
Dr. Kai Mebust is chief of the Department of Medicine at Bassett Medical Center, Cooperstown, New York, and a vestryman of Christ Church, Cooperstown.