Archives of The Cheerful Oncologist, Volume 2

As part of our continuing series on the mysteries of the medical profession we bring you the following tale of a sad situation when a doctor’s heart is no longer in his work. For those interested, parts I, II, and III of the “Hidden Lives” series can be found stuffed somewhere in a drawer in the archives of this website, which is just another way to state that the blogmeister is too lazy to link to them.

[Editor’s note: the following observations were made by a patient living in an average city somewhere in America.]

“I went to my doctor today and after leaving his office had the most amazing revelation.”

“What - you discovered that you had left your trousers hanging on the back of the exam door?”

“Har, har. No, not that, silly. It’s just that I realized that he doesn’t enjoy his work anymore. I think he’s on his way to becoming a victim of doctor burn-out.”

“I suppose you had to wait forever to be seen.”

“No, he came in right after the nurse closed the door. He was as punctual as always.”

“So did he pay any attention to you or just shuffle his papers?”

“No, he asked me about my pain meds and such. He even noticed that I have lost weight and wanted to know how my appetite was - and my swallowing.”

“What about the scans you had last week. Did he know the results?”

“He did. He reviewed the reports with me and told me what things I should be on the lookout for over the next few weeks. He always is thinking ahead of what might go wrong. He says I need to ‘Be Prepared’ just like the Boy Scouts.”

“What’s wrong with that? He sounds like a good guy to me. Why do you think he’s burned out?”

“I was in and out of that room within five minutes, I swear. It seemed like he was in a hurry to move on to the next patient or whatever was next. That’s not like him.”

“Maybe he was just behind schedule, or had a bad night. Doctors are only human, you know.”

“Maybe, but I got the impression that he just didn’t care about my case. It seemed like he was just going through the motions. I felt bad all the way driving home.”

“Why don’t you ask him about this the next time you see him?”

“Well, this isn’t the first time I’ve noticed this change, and frankly I’ve decided to switch doctors. My sister wants me to go to the Medical Center to see an expert there, and I’ve already made an appointment for next week.”

With the reader’s kind permission The Cheerful Oncologist would like to weigh in on the above vignette. Without further ado then, here is his astonishingly insightful and sagacious commentary:

I sympathize with both the patient and the doctor in this story. The doctor mentioned above does seem caring, but the fact is he lost a patient today because of his detatched mien and hurried pace. The practice of modern medicine is more intense now than ever, and the pressure placed on physicians is enormous what with obeying Kafka-like rules and regulations, trying to please the high and higher expectations from patients, and second-guessing treatment decisions under the threat of malpractice lawsuits. The potential for physicians to burn-out and lose their desire to pursue excellence, let alone mediocrity, in their daily work is as great as ever. Since no one wants to have a lost soul for a doctor, it behooves us here at T.C.O. to provide a little helpful advice to patients who just might be wondering whether or not their local practitioner still has enough fuel inside to keep the fire burning bright, to ward off the deadly chill of apathy or anger.

Rather than list the signs of doctor burn-out (after all, this is supposed to be a cheery rest stop for voyagers of the blogosphere), let us instead identify the clues that one’s physician is definitely not embittered, worn-out or fed up. These characteristics are as follows:

1. The doctor uses your actual name when addressing you, not some idiotic condescending title like “Sweetie,” or “Buddy.” What, has he mistaken you for his pet dachshund? An even worse scenario is when the doctor never calls you by name, as if you’re completing a transaction in front of a fast food counter.

2. The doctor makes eye contact with his audience, whether it be one person or a dozen, and maintains it throughout the visit.

3. Whenever feasible, especially when the news is not good, the doctor sits down before beginning a discussion.

4. The doctor asks questions about his patients’ lives - their children, their vacations, any good books they might have read lately. He is genuinely interested in his patients, no two of which are alike. For World War II buffs like myself, this is a great way to learn a little bit of history from one who was actually there, if not personally court-martialed by General Patton for not wearing a proper uniform.

5. Lastly, the most important clue of all in my opinion is that the doctor smiles, chuckles, makes you laugh, uses humor to break the ice, to form a bond, to provide encouragement or diffuse anger, to charm the crowd. When they say that laughter is the best medicine they aren’t just referring to patients. The doctor who truly loves his job cannot help but see how he has the unique opportunity to bring a grin to someone who just might be in desperate need of one today.

As we now return you to your normal lives, please remember these words of wisdom - “Fight burn-out now - tell your doctor a joke today!”

Our tour through this strange and mysterious building known as The Museum of Medical Secrets has now reached the third room. Those who were not listening to the docent during his commentary on Room One and Room Two may perform an about-face and recap by clicking on the respective hyperlinks. The rest of you may walk on. Please raise your hand if you have a question or need to visit the lavoratory.

Despite the entreaties of some of their more anxious patients, most doctors are not available 365 days a year. If I may be so bold as to comment - this is a good thing. No sane person one would jump at the chance to be cared for by someone so overworked they looked like an extra from the cast of Night of the Living Dead. Doctors therefore typically rotate weekend duty with their partners or with friendly peers. In this standard arrangement the covering physician performs hospital rounds for his missing colleagues and then on Monday morning updates them about the events of the last two days.

This certainly sounds like a straightforward, if not a particularly uninspiring way to spend a weekend, but Oh, Oh, Oh! The trauma actually felt vigorously giving vast attention here! If the gentle readers could only experience the intrigue and mayhem coiled within those fateful 72 hours, they would gladly cancel their season pass to the Grand Guignol. Actually, weekend rounds are like going on a military patrol. One has to trudge hour after hour through dangerous territory, always under the risk of being attacked - in the doctor’s case by a difficult patient or problem.

Smart weekend warriors, therefore, approach call like a battle-hardened soldier saddling up for duty - with a mixture of preparation and trepidation. After sixteen years of taking call, I ought to know. The following assessment is completely hypothetical, of course. Here’s how I break the scenario down:

Wake Up Sleepyhead! Every Saturday morning on call I awaken to hear a debate between a little angel sitting on my right shoulder and some mustache-twirling creep in a red union suit perched on my left. It’s always the same argument - do I cut slumber short and dash off to my rounds, thereby guaranteeing I’ll be so exhausted by afternoon that the dog, finding me unconscious on the couch, will try to bury me - or do I sleep in? What’s the catch, you ask? The later I arrive at the hospital (fully rested, of course) the more family members there are hovering around the bed. If I start my work before the first rays of dawn caress my grimy windshield I’ll be more likely to finish up before the visitors arrive with their myriad of questions.

Dress Code? What Dress Code? Yes, I know that some physicians get a kick out of dressing up in fancy suits and pressed white shirts. Even I try to put a necktie on during the week, but come the weekend - forget it. Even that pompous flunky Hermann Goering got to romp around the Black Forest occasionally without having to don the clown outfit. Oh, I’ve paid the price for my “casual coordinates” look - once I got fired by a patient for showing up on Sunday sans socks. I now always wear socks, even at the risk of getting kicked out of the Preppy Doctor’s Club. As for keeping a smooth face - can you believe that some of my colleagues actually don’t even shave prior to hitting the highway for weekend rounds? May I be struck down by lightning if I’ve ever shown up at a nurses’ station stippled with stubble!

Yoo Hoo! Here I Am - Anyone Have a Crisis for Me? Doctors tend to be superstitious creatures, hence the well-known slang term black cloud, used to chastise physicians who tend to be an irresistable target for every possible medical crisis or lunatic patient available for quick and easy take-out. In order to minimize the risk of getting slammed with a horrific case I love to accomplish a perfect game, set and match of what I call “ghost rounds.” This is where the doctor walks onto the floor, sees his patients, writes his notes and orders in the chart and exits without any nurses ever noticing him. Hey, they can’t hurt you if they can’t see you, right? I’ve heard stories about interns who went months on service without anyone figuring out what their speciality was, but this could be apocryphal.

“You Look Marvelous!” “How ya’ doin’?” “I’m jes’ goin’ ’round checkin’ on folks.” Let’s face it - it’s hard to be committed to a complete and thorough evaluation of patients when the Saturday sun is streaming through the window, begging for a chance to baste a pasty-faced doctor with ultraviolet radiation. Just like Count Dracula being asked to sink his fangs into a victim of aplastic anemia, when I round on strangers I think - where’s my motivation? No matter how fabulous a job I do on the weekend, come Monday my partners will resume all responsibility for care, and all my hours of sacrifice will fade from memory faster than the laurels in my rose garden withering under the brutal August sun. So I tend to assume a folksy manner, dispensing words of encouragement without actually getting tangled up in the messy details of a patient’s prolonged and/or onerous hospital stay. Some experts call this crisis blindness. I call it slaloming, baby.

So Long, Farewell, Auf Wiedersehn, Goodbye! Whether I spend five minutes or five hours tending to my weekend patients, there comes a time when I must enter my spaceship and return to Earth, to the land where my wife and family await me, to the place where my little doggie languishes, her tail wagging with anticipation. Thank God I am not someone who has to work 24 hours a day, like a philosopher. Being a physician is an unbelievably rewarding profession, as long as one is willing to put up with working weekends. Now that I think about it, it’s not so bad being on call. It does get one out of doing household chores, or yard work, or helping with homework - at least until I pull back into the garage.

tergiversate: to use evasions or ambiguities; equivocate.

Anyone who thinks doctors do not work under pressure obviously has never been sick. How soon we forget the last time we sat in an exam room or in the Emergency Ward and, just like on a soap opera, nervously waited for the physician to come in and tell us that “everything was going to be all right.” What rippling confidence he had as he put his arms around our shoulders! How relieved we felt with the first glimpse of his immaculate smile and his crisply ironed lab coat as he pronounced the phrase we so desperately needed to hear! How calm and collected he was all throughout this crisis! What a sweet surprise it was to be invited to his flat that night for an elegant dinner prepared by his lovable housekeeper!

Yes, what a wonderful conclusion it was - unfortunately it had nothing to do with us because this blissful scene was from an old T.V. show we watched last night. In reality doctors don’t have scripts to follow, or directors to prod them to a better performance, not to mention a pre-written happy ending followed by a word from our sponsor. On the other hand, in real life physicians are continuously doing an improvisational act in front of a very attentive if not critical audience, and with no intermission. Seriously, when was the last time you interrupted your doctor in order to get a snack? See what I mean? Patients, especially the very ill, tend to hang on every word emerging from the doctor’s mouth.

Not that there’s a problem with that. It’s just that when communicating information to patients and their families physicians are often expected to understand the illness fully (omniscience), to have implemented the correct solution to the problem (omnipotence) and to be able to determine in advance what the outcome will be (precognition).

Gee, the last time I checked there was only one individual with all three of those powers and it wasn’t that dude with the red cape and the big “S” on his chest, let alone a humble doctor. Asking physicians to summon more powers than they were endowed with leads to this dilemma - should they play along with this role of a lifetime, or admit that they are less than perfect, thereby exposing themselves to the scorn of the anxious assembled all around them?

Let’s consider the options. We could choose to react to pointed or hostile questions that we haven’t a clue what the answer is like a gang of bandits cornered in a warehouse, firing back in anger. This manuever has about as much a chance of winning over the crowd as shouting “Heil Hitler!” during the playing of the national anthem before the start of a WWE match. Getting all defensive about the fact that despite treatment grandpa isn’t recovering from his brain metastases doesn’t strike me as a judicious let alone constructive use of one’s skills and energy. Then there’s always the “I don’t know” angle, whereby we assume a pose of mystical, Gandhi-like quiescence and look off toward some distant peak as we confess the limitations of humanity. This certainly might get one off the hook but does not exactly inspire confidence in our leadership of the crisis.

Therefore, when faced with a touchy situation or a clinical mystery that has us stumped, we bearers of the caduceus sometimes resort to circumlocution, to perphrasis, to taking evasive action like a submarine diving beneath the thermocline to escape a Russian torpedo. As a Method actor might say during rehearsals, “What’s my motive for this behavior?” Here’s what the director might say:

“You’re trying to avoid a confrontation. Doctors in general do not like to get into fights with their clients.”

“You’re desperately trying to focus on the good news; for example just think of all the money she’ll save on groceries by losing her appetite.”

“You’re afraid of being labeled an insensitive louse by the patient’s heavily tattooed family.”

“You’ve convinced yourself that your patient will improve despite any setbacks such as the fact that she just died.”

I know it has been said before, but let me repeat it for all: doctors have to learn to become good actors if they ever want their practice to flourish. The truth, aside from being something in the movies that folks are accused of not being able to handle, hurts when it is composed of unfortunate news. Sometimes doctors have to provide counseling in such a manner as to not create a wailing morass of distraught relatives who become a whirling dervish of misinformation and despair. You may call it tergiversation, but we pros call it diplomacy. Think of it as that old joke about the fellow who said, “Don’t just come out and tell me our cat died! For Pete’s sake break it to me easy - say that the cat is on the roof, and then the next day say it won’t come down, and the next day say it slipped and fell onto the rocks! By the way, where’s Grandma?”

“She’s up on the roof.”

The author wishes to announce the first of an occasional series dedicated to revealing the secret culture of the intrepid men and women who have chosen medicine as their life’s calling, not to mention a way to pay for the kids’ orthodontia. We kick off this series with a heretofore undescribed look at one of the most sacred of all medical rituals, a ceremony practiced by doctors young and old, from every corner of the country, in every speciality where the well-being of the entire patient is of interest (which rules out dermatology, psychiatry and of course that branch of medicine where a live patient is not necessary for one to whistle while one works). We refer to what is colloquially known as passing the baton, or blowing out of here, also known as signing out. It is during this act that the crucial details of a patient’s case are outlined to the doctor assuming care for the next tour of duty. At first glance this would appear to be one of the most lethargic discussions ever chronicled, capable of dropping anyone who dares to listen in faster than a well-placed dart from a tranquilizer gun.

That, dear reader, is where we are wrong, for a signout session is full of high drama and intrigue. It’s just that the casual listener is unable to decipher the abstruse jargon and sarcastic innuendo that goes on during the verbal jousting between the departing doctor and his traditionally unhappy replacement. Picture this scene taking place in some pizza-box laden corner of a nurses’ lounge. On our left we see a giddy sleep-deprived resident who can hardly wait to read the last name written on his grimy piece of paper so he can then jump into a battered 1988 Camry and make a beeline for the upper bunk. Over on our right we find a beleaguered soul staring blankly into space as he writes. This person, obviously the on-call doctor, is easy to identify by his unwrinkled shirt and his poorly disguised look of agony, often seen in paratroopers who forget to attach their chute to the static line. What controversy could possibly exist in such a mundane activity?

After twenty years of being victimized by these charlatans I can answer this question easily, namely that doctors tend to view the signing out procedure like a lioness stalking a wounded kudu, and one can very well guess which is the predator and which is the entree in this little tete-a-tete. Let us therefore parse the signing out procedure for what it really is: a sales transaction where the seller (going off-duty) is eagerly trying to gain the upper hand by using every trick in the book on the buyer (coming on-duty). For any young doctors out there reading this, I provide this compilation of schemes to be aware of:

1. The Early Sign Out. On the day of the transfer would it be asking too much if you would at least wait until the sun has crested the skyline before hovering over the on-call physician with your sign-out list? During my residency we used to vamoose so early our patients started reading their own x-rays just to keep up to date. Upon hearing of our little chicanery the Chief quickly put an end to it in his typically graceful way.

2. The “Cast of Thousands.” C’mon now, do I have to see every single blue-haired granny admitted for some R & R from her loony husband? How long is this list anyway? Aren’t there some patients who can be followed by “telephone rounds,” which means if they don’t telephone you, you don’t know they exist?

3. Late Arrivals. There is nothing more depressing than to get a call from your colleague that starts as follows: “I just spoke with the E.R. at Pigeon Forge and they’re transferring this guy to you - he should arrive in about five hours.” Egad - there goes my plans for dinner and a movie.

4. Scut Work? No, Not That! Beware of the peer who casually asks you to check on the results of biopsies, cultures or other results that could bog down your entire weekend. Please, please tie up all loose ends of patient care before jetting off to Crapsville, leaving us poor on-call slobs up to our tongue depressors in work.

5. The Psych Alert. As a courtesy to the covering physician we (discreetly) ask that you notify us of any and all patients and family members who are off their rocker, or uttering voodoo curses, or seething with anger, or simply in a coma. Think of all those World War II movies where buddies look out for each other when on patrol. Do we deserve any less?

6. The Maiden Voyage of the Titanic. This is otherwise known as the impending disaster, where a patient isn’t doing so well, but gosh, it’s time to go home, so the departing physician reassures his covering partner with the gentlest breezes of euphemisms that this patient is tucked in for the night. One can imagine what happens in Act II as the on-call physician, just minutes ago burrowed under the sheets and drooling on his pillow, is now racing down the hallway toward that same Mrs. Jones, billed as “a mild case of bronchitis” at quitting time but now sitting bolt upright in bed, her eyes coming out of her head like the Bride of Frankenstein as she gasps for oxygen.

I could go on, just as I’m sure others can add to this list, but for now that is enough. When it comes to accepting the sign-out list from a colleague, my advice is the same as with any transaction where the phrase “slimy weasel” may surface in the aftermath: Caveat Emptor!