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How often do you think of doing something else?


FloatingGhost

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I am a staff in a community hospital in the GTA. I practice in an internal medicine subspecialty. 

Generally, most of my days at work feel OK. I feel good on occasion and bad on occasion. I do get burnt out every now and then (once every 3-6 months or so) and it generally passes. When I think about what triggers a bad day or burn out, it usually is elderly patients with poor prognoses - many with recurrent admissions every 1-2 months or more frequently, many bed bound, and almost all frail. Sometimes I wonder if I make a difference for some patients, and in probably at least 40-60% of cases it is hard for me to think past the fact that I only really get someone well enough for a temporary discharge before they have to come back in again because there is too much going on with their body.

All in all, medicine does have fulfilling moments, but they are rarer than I had hoped when I was in medical school and the patient population I describe above is much more common. My proudest moments are when I am able to cure, but that really is an opportunity that is less and less frequent with an aging population that has chronic disease. I wanted to ask how frequently people think of doing something else (for me, I think about it at least once a week). TBH, if I had more money and a clearer avenue to do something else, I probably would. If I knew this is how I would feel when I was going in to medical school and I had opportunity to do something else, I probably would have chosen something else.

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Maybe try outpatient and a different population of patients? More non-urgent ambulatory work?

In all honesty everyone likes to think what they do is important and will make a big positive impact on someone/society, but most of CTU/internal medicine is patching up a leaky boat anyways (from my limited experience). Of course it's not just IM, probably every specialty have these moments. Sometimes I too wonder if other clinicians read the reports I write and how much of what I say matters to them and the patient lol. 

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  • 2 weeks later...

I felt very similarly in the cases you described in my short time on IM off-service in residency. There is a discordance between what we want (to help the patient) and what the reality is (using a bucket to take water out of a leaky boat). In some cases there may even be a moral dissonance, where we feel our actions with further interventions/management are actually doing harm.

It's very difficult for physicians to find another career entirely in Canada. But maybe try a major change in your practice and move towards handling outpatient clinics instead of inpatient work. Another option is doing a bit of further training and doing something else entirely like palliative care. Honestly sometimes I felt I made the biggest difference when I helped the patient/family shift their focus away from length of life, to quality of life.

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I definitely agree that the medical school focus on pathophysiology, mechanisms, learning, etc does not necessarily prepare one for the reality of managing elderly patient with multiple advanced, complex conditions.  In my limited IM/CTU experience as a resident, I found the relatively high in-patient mortality rate for elderly patients especially, needed time to process.  There was something discordant about seeing a given patient daily, actively treating/investigating, believing in a more positive prognosis, and then, maybe not long afterwards, losing the patient.  My impression was that more outpatient focused IM subspecialties had better outcomes or at least more stable courses.I found the book "Being Mortal: Medicine and What Matters in the End" (A Gawande) to provide an excellent perspective on understanding health care and elderly patients especially.

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On 1/11/2022 at 11:03 PM, FloatingGhost said:

I am a staff in a community hospital in the GTA. I practice in an internal medicine subspecialty. 

Generally, most of my days at work feel OK. I feel good on occasion and bad on occasion. I do get burnt out every now and then (once every 3-6 months or so) and it generally passes. When I think about what triggers a bad day or burn out, it usually is elderly patients with poor prognoses - many with recurrent admissions every 1-2 months or more frequently, many bed bound, and almost all frail. Sometimes I wonder if I make a difference for some patients, and in probably at least 40-60% of cases it is hard for me to think past the fact that I only really get someone well enough for a temporary discharge before they have to come back in again because there is too much going on with their body.

All in all, medicine does have fulfilling moments, but they are rarer than I had hoped when I was in medical school and the patient population I describe above is much more common. My proudest moments are when I am able to cure, but that really is an opportunity that is less and less frequent with an aging population that has chronic disease. I wanted to ask how frequently people think of doing something else (for me, I think about it at least once a week). TBH, if I had more money and a clearer avenue to do something else, I probably would. If I knew this is how I would feel when I was going in to medical school and I had opportunity to do something else, I probably would have chosen something else.

See what parts of your field could be tailored to an outpatient consultative practice?  Work with FM docs to work-up and manage patients early on in their trajectory to try and slow and prevent the sig. decline? Could be a bit more rewarding - though i do not know how much proecedures play into your renumeration currently (i.e. resp, nephro dialysis etc). Could be worth it to find a better balance for longevity.

Alternatively, i assume you have the ability to practice as an outpatient GIM - could work part-time in a consultative fashion for primary care docs, and work half-time in hospital doing coverage work for your current role.

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I think more about how I could put together enough money to take a long period of time off (minimum 6 months).  I think about that daily, but it's not really financially possible.  Being a doctor sucks right now, but I can't think of anything else that would be more viable or much better.

I often think these days that if I had it to do again I might have gone into social work and just done psychotherapy in private practice, just entirely dodged the mess that is the health care system and the massive baggage that comes with psychiatry (being dumped on from every angle constantly).  But of course that has its own challenges.

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For what it's worth, I've become mostly numb to disease and death. I think about the absurdity of life a lot. The ground beneath you disappears when you genuinely internalize how ephemeral all of this is. It's also liberating because trivial worries and cares can no longer shake you. For me, I focus on family, because what I feel when I am with them is the purest truth I know. If I may, I suggest that wondering what you could have done instead is a distractor for a deeper crisis; what, more fundamentally, do you want from the little time we have?

I'm on IM right now, and I see myself in my elderly patients; I know that in a blink, I'll be laying in that bed too, being asked uncomfortably forward questions from an exhausted med student who is disinterested in IM and just wants to finish the day as soon as possible. One day, I will also be reduced to a few clicks and lines on the EMR, and the addressing of my crumbling agency will similarly be sidestepped by a consult to PT/OT. For now, I can still hold onto the conviction that the role of a physician is not to cure, but to guide. I imagine patients passing to the other side, whatever that is, with us as the stoic checkpoints along that path.

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Thank you so much for the discussion. I really appreciate it. Before medicine, I seldom thought about sickness and death. I think the constant bombardment of sickness and death in some medicine subspecialties and GIM is intrinsically unhealthy. I will try to continue to learn to adapt or switch out if I can. I assumed I would adapt as I was going through med school, residency and fellowship, but as a staff, it is actually harder than I remember how it felt when I was training. 

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