Playing doctor

Posted by on Nov 30, 2013 in Cancer Care, Life & Health | 12 comments

Playing doctor

I have outstanding, compassionate and dedicated partners; rarely goes by a day that they fail to teach me by their intelligence and example.  Nonetheless, yesterday, in the middle of 30+ patient office hours, one of them said, “You know there are times when I just can’t stand to listen to another complaint.”   He took a deep breath, straightened his coat, and opened the exam room door and, smiling, greeted the next patient.  It was a moment to “play” doctor.

I find the practice of medicine, even after all these years, to be an emotional continuum between “playing doctor” and actually “being” a doctor.  Many days and moments working with patients, helping them cope with cancer, is satisfying, stimulating and interesting.   Doctor and patient connect and I learn things about myself and about living, which are remarkable, precious and privileged. I cannot imagine any other career.

However, there are times when it gets to be too much.  When one is tired, the paperwork piled to the ceiling, you are missing irreplaceable personal events, then the quality of patient interactions seems to deteriorate to completing disability forms, rescheduling already delayed procedures, rethinking diagnostic ideas, salvaging failed therapies and running late in a chaos of myriad minor delays. Then it is very hard to summon the needed insight, compassion and focus which are vital to being the kind of doctor towards which each of us strives. Then, the best you can do is “play doctor.”  When that happens, not only are you miserable, but you feel guilty because, at some level, you are a fraud.

At the start of a doctor’s career, during those first years as a student, resident and young attending, you have no idea how to connect emotionally to yourself, let along how to bond to patients or do your job.   You play doctor all the time.  You act the part of someone strange and foreign, the perfect physician, and each day you fail.  Overtime, remarkably, miraculously, after much error, uncertainty and pain, you start, just a little, to get it “right.”

You become a better technical physician; i.e. you make the right diagnoses and your treatments actually work some of the time. As important, you begin to touch the souls of your patients and they yours. At first, this happens in rare powerful moments, like a flash going off, but if you are patient that bright light shines more often.  The education of a doctor means playing less and being more.

Then, if a doctor heals through connection, he is soothed and supported by the power of the relationship and the contribution to life, which it can produce.

Nonetheless, you are just human, so those tough moments will occur, when you cannot really “be” a doctor.  Then it feels as if there is distance between you and your patients and the bond stretches, almost to breaking.  On those days, you just “do your job,” be there for the patient and suppress the loss and weariness.  Paradoxically, it is that commitment to the doctor’s role, when you are just “playing,” which marks the great doctors, because even on their weakest day they put the patient first and their own healing later.

12 Comments

  1. Is that not true of all of us? I “played” an engineer in the early years when I’d yet to gain experience. And now, I “play” again when technical difficulties abound, schedule is threatening to slip, or budgets are blowing up . . .

    yet, Ms. Sonso NEEDS me (that nice mechanical engineer) to check the AC in her office because she gets cold at 5 PM everyday. The fact that the sun has moved to the other side of the building and she HAS a thermostat control as close as that telephone she dials me on . . . I do it with as much kindness as I have in the moment.

    • So true. It is interesting to consider that we learn and grow when we “play,” as well as serve.
      jcs

  2. I also think one difference between a technically competent “good” doctor and technically competent “mediocre” one is that the good doctors (just like any other good professional) have learned how to (and actually do so) “play” doctor (or whatever the profession is) when the need arises. (“Good” parents learn to do this too when they reach the point whey they start to realize why some species eat their young and as parents are struggling against the urge to run away from home leaving their kids behind with a freezer full of microwave pizza LOL).

    I also think another part of the picture that contributes to a professional’s ability to continue to be a “good” doctor (or other professional in a profession that can be emotionally taxing) is that you learn how to deal with the beginnings of burnout before it gets out of hand, learn how to recharge when you first need it rather than wait until you are ready to run screaming from your job, learn how to separate yourself enough emotionally from your patients that you still truly care about them but also learn how to do it in a way that doesn’t emotionally destroy you. No one, of course, can do this all the time and so there are then days they need to “play” doctor. There are good reasons why we all sometimes call playing hooky from work “mental health days”.

    I think this is something that needs to be discussed explicitly with medical students and again with interns/residents when the excitement of finally having patients they are responsible for day after day starts to wear thin; when they are over tired and no end appears to be in sight; when bad things happen to patients they have emotionally connected to and they replay that movie in their head over and over as they try to figure out if they could have done anything differently (especially if they really did make a mistake, as all humans can do)… Probably needs to also be something people at all levels of their career need reminded of and need given tools to help them deal with it if they haven’t already figured out how.

    • Doctors/students need to be reminded to take care of themselves, so that they can take care of others. However many “professions”, such as being a mommy, leading a vital enterprise, or practicing medicine demand that when it gets tough, you sacrifice yourself.
      jcs

      • I would agree that this is much harder when you can’t leave your job behind at the end of an “8 hour day” (8 hours Ha!), when realistically no one can really substitute for you or pick up the slack and every day/hour that you miss work threatens a train wreck with significant irreversible impact.

        I would still argue though that there are ways to decrease the emotional impact on the provider without that meaning that the provider stops caring about the client/stops connecting with the client. I burned out of a previous profession three times before something finally turned on in my brain and I found I was able to manage the stresses without (generally) struggling. If I could figure out what changed inside my head or how I got to that point I’d bottle it and run a training program to teach others.

        I found, back when I worked 24/7 for 28 days straight with adjudicated youth (canoeing across the state of Florida with them) who spend much of their time trying to push my buttons or each other’s buttons thus risking 12-14 kids engaging in a brawl, running away, etc., kids who needed close supervision all the time (even at night as they’d run away then too even in places with no place to go), etc. that somehow, eventually, I managed to emotionally disengage from them in a way that allowed me to still care about them in a way that was real but I was no longer (generally) emotionally exhausted by them. Came in handy with the kid I adopted who had (and still has) a boat load of issues. About the only time I struggled at times to keep that balance and mindset was in the middle of dealing with two cancers in one year, while doing chemo alone, having to continue to work full time even chemo weeks and weeks I was sick (my teaching reviews were still extremely high and I was still getting 95+% on audits so I was still functional enough I could “play” good teacher), financial stress, nasty boss…(role overload combined with significant stress I could do nothing about to remove the stressors). Had I not earlier worked with adjudicated youth and learned how to cope I would have been far more of a basket case.

        The literature on burnout talks a lot about things that burn out employees – that is what you are more or less talking about, but it sounds like you manage to pull it together before you reach the point where it is very difficult to bootstrap yourself out of that hole. Things like role overload and role conflict, working too many hours for too many days in a row, having little control over aspects of your job including being subjected to significant stressors you can’t do much about, being in a situation where mistakes have significant negative consequences, dealing with people who are being unpleasant or emotionally demanding on a regular basis (bosses/co-workers or clients/customers), professions where there are high emotional demands… are all things that put people at higher risk.

        Solutions that research document that work run the gamut from changing the environment/job/person to stress reduction activities/strategies that help people deal with a situation they can’t change, ways to recharge daily, ways to deal with stress more effectively… Not a panacea for sure, nothing is going to work 100% of the time or in all situations, and not everything has a solution – instead one needs to up their coping skills which again won’t always solve the problem, but every little bit here or there helps. Some of the coping skills are teachable and all I was really arguing is that those skills that are teachable need taught…along with making sure people realize they need to “play” doctor even days they’d rather bite people’s heads off, hide under the covers in a dark cave, or run away to sea somewhere warm and pleasant.

      • So true. The toddlers, etc, don’t care that mommy has the flu- or they care but are powerless to do anything about it. Much of life is theatrics-Mommy, teacher, doctor, even a ship’s crew-especially the officers and the cooks. This might sound weird, but there is nothing like the drama of a seacook taking the time to set somebody’s toast on fire, and placing it on the eggs and asking if there are anymore complaints, while the toast is still burning. Small ships turn hard, and a seacook can end up with 3rd degree burns from the chest down. After medical care in the sick bay, they immediately return to the galley to cook another meal. Once my son dropped his trousers to show the burns. The other cooks had the flu really bad, so he was alone-and made sandwiches for over a 100 men, which wasn’t on the menu.
        Bless the doctors that put on that Kabuki face, smile and are very competent.

        • Fascinating observation, thanks. jcs

  3. Another thoughtful and thought-provoking essay, Dr. S – thank you for this. When you write: “…there are times when it gets to be too much”, it really struck a chord with me.

    But I’m not a physician – I am a patient. I reached that “too much” point shortly after I first heard the cardiologist’s words “significant heart disease” five years ago, unable to continue working, relentlessly focused on learning to manage every decision of everyday life trying, sometimes successfully, to learn this “new normal” and live some semblance of a former life. I remember one day at home after yet another hospital stay, in a fit of pique, marching around our apartment collecting up every bouquet of flowers and get-well card and unceremoniously trashing the lot of them. I was tired of living in a place that looked like an invalid must live there. I was sick of being sick. I wanted my old life back. Didn’t work.

    I spent much of my 3-decade career working in corporate, government and non-profit Public Relations. Like your physician colleague, PR folks learn to perfect slapping on that happy face, regardless of how we’re actually “feeling” inside. Doesn’t matter if you have a broken leg or a broken heart, we just learn to suck it up, take a big breath, and tapdance out to meet the fray.

    The difference between needing to do that at work and being a patient? Patients don’t get a break from being patients. And sadly, “playing” normal often doesn’t work for us.

    • You said, “The difference between needing to do that at work and being a patient? Patients don’t get a break from being patients. And sadly, “playing” normal often doesn’t work for us.”

      And when playing normal doesn’t work for us (e.g. we just aren’t capable of doing so at that particular point in time) we end up increasing the stress on doctors increasing their need to “play” at being a caring doctor. Not all doctors make that effort to “play” (and some are too burned out to) and instead demand that we “play” at being normal or they fire us as a patient.

      The general expectation is that the doctor is the one who is supposed to make more of an effort because they are the professional being paid to help… and allowances are made (or should be made) for patients who are stressed beyond their ability to cope. What we don’t really have in place are ways for doctors stressed beyond their ability to deal with it to be able to step out long enough to pull it together.

      The biggest problems, in my opinion, arise when a beyond stressed out doctor is caring for a beyond stressed out patient – then neither are likely to “play” well enough at begin a “caring” doctor or a “pleasant, non-needy” patient for things to work well. Some doctors have better coping skills than others, better work ethic than others, are better human beings than others… and so some try harder than others when they need to “play” at being a caring doctor. It is unfortunate that that is a skill that doctors even need though…

      • I think that the medical system is set up for moaners and whiners. I don’t do that, and I’ve had doctors say that they didn’t realize that I was so sick or injured.

        I’m an adrenalin junkie-my brother is too. It hurts so much that we stand up straight if possible, and we try to comport ourselves with dignity, because of the extra adrenaline. My son is the same way.

        We’ve finally had to go up and threaten to sue, or pull our pants down or whatever to show the injury. Once I took my blouse off to show where a horse bit me and pulled my shoulder blade off.
        Then we go right in.

        I don’t know how much pain others are in, but I can tell when the staff points at me and laughs-and the woman next to me has a sprained ankle that’s not swollen and she’s walking all over to the vending machine- then hops in on one foot moaning-that’s when I go up and undress in front of the waiting room.

        Do you know what they say? Why didn’t you tell us that you were really hurt?

    • Thought provoking comment … perhaps that is most intricate and difficult part of the patient – physician relationship; the balance between both persons “playing” and trying to “be.” How we ever find trust in the muddle, is a small miracle. Thanks very much, jcs

  4. Honest and thought provoking. I have an incurable cancer and I am also a health care provider. I have been on both sides. I find myself thinking about the feelings of my providers. Frankly it should be my time to receive support and excellent medical care. What I hope is that my providers will exercise and take care of themselves. It is also OK with me if my oncologist says he is having a bad day. We are all just people but having an open heart takes far less energy. Always know you do very important work.

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