I was finishing up a new patient clinic when I heard a difficult to hear sentence last week.
It had been a long morning of meeting three new cancer patients. The first patient was the only one who still had a chance of cure. She was young, in her mid-fifties. She had recovered from a rather large surgery to remove an enormous colorectal cancer and a spot of cancer which had spread to her liver. She had an equal chance of cure versus recurrence if we proceeded with six months of appropriate chemotherapy. The second and third patients I saw would eventually succumb to their colon cancers. I offered both palliative treatments knowing they’d likely only have a few more summers to enjoy.
Parallel to my clinic, there are two or three other medical oncologists seeing new gastrointestinal oncology patients. The benefit of having similar clinics running at a time in the same area is that we often discuss cases allowing for consensus treatment recommendations. We are never truly working alone.
As usual, there were many hard conversations occurring. I could tell a colleague was having a difficult bad-news-giving day. She happened to have a resident working with her that morning.
As my colleague and the resident came out of their last consultation, the resident was clearly pressed for time. They were apologizing for their need to rush out of clinic. They had to oversee set-up for a half day of learning lectures across the street at the university. Part of these duties seemed to include ensuring lunch was picked up and laid out for the other residents as they arrived. Judging by the time on the clock, they were not going to make the deadline.
That’s when they said the sentence: Who am I going to disappoint today?
In a vulnerable display of honesty, they explained they were getting accustomed to asking themself this question. As if beaten down by an invisible force they had no chance of defeating, they were rather hopeless as they said it. It was a rhetorical question uttered by a resident going through the same training I went through almost two decades ago. Had nothing improved in twenty years?
Who am I going to disappoint today? The question made me wince. It gave the centre of my gut an ache I hadn’t had in a while. That question took me back to medical school and residency and the first many years of medical oncology practice when everything I did didn’t seem to be good enough.
My colleague and I locked eyes seconds after the resident said this. We shared a knowing grunt. She is a handful of years younger than me, in age and in number of years in practice. The two of us have had many conversations about the pressures of our jobs and how easy it is to always seem to be missing the mark.
In medicine we are taught to triage. We must deal with the life-threatening issues first: airway, breathing, circulation. Only if those key systems are supported and safe should we move on to address other problems. Triaging is so essential; it gets drilled into our very being. Without even knowing it, we incorporate triaging into how we manage throughout the course of our training and then, our careers. But, if we aren’t careful, triaging can make the person underneath the white coat disappear.
Should I sleep? Yes, but I really have to study for that exam because I need to know all this stuff that hasn’t sunk into my brain yet. Sleep: triaged until tomorrow.
Should I eat? Of course, but I must see those two patients I was asked to see in the emergency room first or I will fall even farther behind in the list of things I have to get done on the ward. Eating: triaged to the bottom of the list. Maybe I can grab some soda crackers from the patient kitchen on my way past.
My bladder is going to explode if I don’t pee soon. Ugh, I just have to click a few hundred more times in my Connectcare portal to order those blood tests and a heart tracing for the patient with chest pain I was called about fifteen minutes ago. Peeing: triaged to an hour from now, maybe longer … depends if I sneeze.
When was the last time I showered?
My supervising staff wants to meet at 5:00pm to go over our patient list. I have to teach the medical students at 5:01pm. My study group is scheduled to meet at 5:02pm to run through practice scenarios for an upcoming exam. I’ll be on time for all these tasks. Of course, I will. I can’t not be on time. Until I’m not. Then I disappoint. Of course, I disappoint.
There is always more to do, more to learn. Do this. Do that. Come here. Go there. Don’t forget my research projects because how the hell will I get into the specialty I want if I don’t have fifteen publications in well-respected peer-reviewed journals by the end of my second year of residency?!
These feelings, the yucky ones, that tell us we aren’t enough and that we are bound to disappoint at least one other person every day (because we often do, by the way) are a systemic problem in medicine. They are rooted in unrealistic expectations, an I-did-it-so-you-should-have-to-too attitude from “teachers”, many of which aren’t trained to be educators, and an overburdened, underfunded healthcare system that would collapse without the services medical students and residents provide.
I wonder if medicine can improve attempts at humanizing the medical school and residency processes. Can we build a more supportive training system? Can teach wellness and mental health fitness? Can we model boundary-making skills? Can we hire professionally trained life coaches for our trainees to help them reach their full potentials?
The answer to these questions is yes. We CAN do all these things. But will we?
I wonder what would happen if medicine triaged the global health for our caregivers to the top of the problem list. What would happen if we all took care of our physical, psychological, and emotional health. My hunch is if we knew how to better take care of ourselves, we could better take care of you.
It’s time to change.
Author Notes:
I am still a work in progress but I’m not shy to share with colleagues, residents, and medical students that most of the time, the worry I will disappointment others has all but burned out of me. That flame flickers now and then, when the winds of fatigue and frustration at situations gone wrong flare, but I try to smother it quickly.
The worry I will disappoint has not gone by the way of apathy. It was learned out of me through years of professional experience and a whole lot of work I have done on my mental health fitness with the help of others. I pursued this fitness on my own. I had to. I would have burned myself to the ground years ago if I hadn’t.
I have mostly accepted there might be people along my path each day who don’t appreciate my efforts or who disagree with my recommendations. I will disappoint people. That’s okay. I’ve learned how to activate my forcefield, the one that allows me to say no to asks and tasks that are meaningless to me. It’s so healthy to be able to say no. Boundaries are good. I didn’t know what a boundary was for many years. Medicine doesn’t teach healthy boundaries. It should.
I am curious to know, reader, have you ever been concerned about who you will disappoint today? Do you think that other person was really disappointed or was the disappointment a subjective perceived reality which you concocted in a story were telling yourself?
