Occupational Challenges

Last week I wrote about what I enjoy most as a physician.  This week, I'll share some of the challenges that I face.  Let me just say upfront that the good outweigh the bad.  I hope it will forever be the case.  My daughter once asked me what the hardest part of my job was.  She had an occupational survey to do for a school assignment.  My mind went immediately to the part of the physical exam which is most distasteful to both me and my male patients.  Upon further reflection, though, I decided that delivering bad news was probably the hardest.  As I said last week, the end process can be very satisfying, but that initial conversation when I need to tell someone that they have cancer, or another serious illness, is very difficult.  It is gut wrenching.  About the only thing that comes close is when I was in a movie theater many years ago watching the "Lion King" with my daughter.  Simba's father falls to his death in the canyon stampede.  With tears in her eyes, she looks into my face and asks, "Is he going to be all right, Daddy?"  You want to respond that all is going to be fine.  It is important to give hope when there is hope and to be positive so that the patient remains positive.  However, it is also important to be truthful so that they understand what to expect and how to plan.  Some are not ready to hear the bad news and it may have to be explained several times.  Patience is the key.

Sometimes I wish I could be perfect.  There are many stresses that come with our job as physicians.  We have the stress of trying to stay on time, of writing complete notes, of being too busy, of not being busy enough.  We have phone calls and tasks and emails, faxes and letters all pulling us in a hundred different directions.  Now we have the stress of the electronic health record.  We have to make sure we have clicked every box and entered every requirement or we are told that medicare will void out the entire visit.  It is stressful to respond to a patient who is requesting a medication that we feel would do them more harm than good.  By nature we want to please.  Some patients can become very upset if they are not given an antibiotic for their cold or pain pills for their headaches.  Above all else, my greatest stress, though, is the stress of missing a diagnosis or of making the wrong treatment decision.  There have been times when I have made a subtle diagnosis that has likely saved a patient's life.  One in particular was that of picking up prostate cancer in a 38 year old man.  I did an exam and it felt abnormal so I sent him for a biopsy.  He now lives 2000 miles a way but just last year, while visiting St. Louis, he came to say hello and thank me once again.  He is doing fine.  Instead of feeling good about this, it frightens me.  When I saw him, I thought he was over forty.  I did the exam by mistake.  It was pure luck that allowed for his early diagnosis.  Another example is that of an older woman with a fatty mass in her thigh.  I have felt many of these, "lipomas" in patients and sent them on their way, telling them it was nothing to worry about. In her case, it felt just a bit different than the others.  It was a little more firm and more fixed to the leg.  I can still recall the back and forth of my thoughts considering course of action to take.  I was so close to letting it go that her words of gratitude terrify me.  I know how close it was.  She had an aggressive tumor that is usually fatal.  Another month or two may have made the difference between life and death.  It terrifies me that there will be someone else who I may decide to go the other way.  I know I cannot always be right, but I want to be.  I want to do the best for my patients.  That is my greatest stress.

This may be more truth than what you want to hear from a physician but I felt like it would be good to share.    Let me know what your concerns are as you come to the doctor's office.  What worries you the most?  What are your expectations?