The Battlefield Mentality Of Medicine

 The Physician Casualties of Medical Tragedies

A Guest Post by Dike Drummond, a family doctor who specializes in physician burnout prevention and treatment at his website, The Happy MD.

The mother of the dead baby sat in her husband's arms and simply asked "why?" over and over through the Vietnamese interpreter. I had no way to answer the question. I didn't know why. There was nothing to point to. No defect in the child or mother or the actions taken in L&D.

All I could do was say "I am so sorry" ... for your baby, for you ... for everyone involved.

It was a nightmare, losing a baby during childbirth in my family practice residency. It was THE thing each of us dreaded the most. What happened afterwards was even more devastating in the long run. What happened was ... nothing.

It had been a normal evening on call. The family practice residents ran our community hospital. I would end up delivering over 250 babies in my two years here. It was just before midnight, three women in labor, I had just changed out of my clothes into green scrubs and the typical long white jacket.

As I walked past the first labor room on the left I heard an obvious deceleration on the external monitor. HR dropped from 140 to less than 60 for almost a full minute with what looked like a late pattern. The mother was a Hmong woman who did not speak English. This was her third child. No previous problems in childbirth.

She was doing just fine. Dad was standing by the bed in the half light of the labor room. Everything was quiet - that’s how I had heard the deceleration. The night shift had just come on. A calm scene really, except for the yellow light of my nerves jangling from the deceleration.

Exam showed her to be 7 cm dilated, head well applied, normal contraction pattern. The decelerations continued. Protocol called me to rupture the membranes and apply a scalp electrode. I opened the amnion hook, had the nurse stabilize the external monitor puck and apply some fundal pressure. The father held the mother’s hand as they spoke quietly to each other in a language I couldn’t understand.

I ruptured the membranes but only a small amount of clear fluid came out. The heart rate dropped immediately to zero as if it had tipped off the edge of a table and fallen to the floor. 140 - 60 - 20 - nothing. Vaginal exam showed no prolapsed cord, no bleeding or any other abnormality. I was the only doctor in the hospital. The OB attending was 15 minutes away. This baby needed to be out right now.

With much shouting to push, my fingers completing the dilation of the cervix and good cooperation from the mom ... we had the baby out within three contractions.

No nuchal cord, no abruption, no blood anywhere ... the child was normal ... except it had been without a heartbeat for almost 5 minutes at this point. Full resuscitation. Epi down the tube. Chest compressions. Nothing. [Heart breaking. Are we getting anywhere? I do not want to call the code and give up.] Suddenly, five minutes of chest compressions and two doses of Epi in ... we have a heartbeat at 160. [Hallelujah] Stop the chest compressions. Let's tape the tube and call the NICU in the big city down south.

As the nurse and I begin to breathe again ... I feel a gentle tap on my shoulder. The father is standing next to me and points at my left hand. I notice that this whole time - as I stabilize the ET tube and the child’s head - the tip of my left pinky has been touching the baby's open eye. I thank the father, change my grip and close the upper lid. I begin to realize this heartbreak of the last 20 minutes is only the beginning.

We got the call three days later. The child showed no signs of brain activity and the ventilator had been turned off. I released the breath I had been holding since that night in this moment of final recognition. The baby was dead. That is NOT supposed to happen to anyone ... ever. Not to the baby, not to the family and not to any Resident.

The director of the residency program and the OB staff held a case review. No "fault" was found. Procedure had been followed. The baby's post mortem was normal. All actions were deemed "appropriate". I was not to blame. That was very little consolation. The baby was dead. My mind ran over and over the events like a gerbil on a wheel.

A little piece of me died that day. Deliveries were never the same joyful wonder they had been before ... they were bullets to be dodged. For years and another 300 deliveries I would occasionally be jolted awake at night by a vision of an amnion hook with a trigger on it.

In the days and weeks afterwards ... it gradually dawned on me that something I had always taken for granted ... was NOT happening. We were a small residency ... only 8 of us running our community hospital. It felt like a family. I had always assumed any tragedy would be met by a rallying around the unfortunate resident.

Here was our collective worst nightmare ... and ... nothing happened. Nothing except the case review and my meeting with the family - both agonizing experiences where I was by myself. I felt tainted, like a failure, an outcast in the wilderness.

I don't blame anyone. I am certain the first reaction among my colleagues was ... "OMG it happened". Followed by, "thank GOD it didn't happen to ME."

It’s the same thought process as a soldier in battle when his best friend goes down as they storm the beach. I don’t know if I would have thought the same things if it had happened to another resident. I don’t know if that fear would have stopped me from reaching out to them. Here’s what I do know...

Most of the physicians I have worked with have their own version of this story; something bad that happened followed by complete isolation. It has hurt us all. Let’s vow to end this compounding of the natural tragedies that occur in our profession. Losing a baby is bad enough. Coming away from the experience feeling that no one really cares and we are all on our own in the end ... is a wound on a wound. This does not have to continue. We do not have to let our own fear stop us from supporting our colleagues in their hour of greatest need.

If you are still reading this article, I want you to know something with crystal clarity. Your Physician Colleague who suffers a bad outcome wants you to come and talk with them. Sit and have coffee, put a hand on their shoulder. Make them a “hot dish” so they don’t have to cook for a couple days. (I am from the upper Midwest ... that’s just what we do) Do it again and again until they say, "enough already".

There are some stories even our significant other and parents can never understand ... only another doctor can fathom the feelings. The next time tragedy strikes in your medical community, reach out to your sisters and brothers. PLEASE don't run from them because of your own discomfort. They are not contagious, nothing is going to rub off on you.

Don't let the natural "battlefield mentality" win out. Notice it and act in spite of it. It will make a huge difference to your friend. I promise.

This is the time when you can step up and pay it forward. Just be there ... when it counts the most. You never know when you will desperately want them to do the same.

-Dike Drummon M.D. The Happy MD

9 Reasons For Physican Burnout, And One Way To Avoid It

"The burnout epidemic amongst our physicians is a predictable result of the medical training and the generally accepted definition of “success” amongst doctors."

-Dr. Dike Drummond MD Founder of TheHappyMD.com

Dr. Dike Drummond is a Mayo trained Family Practice Physician who has experience in medicine, coaching and personal improvement, and business development. His expertise in personal change was developed over 15 years as a family practice doctor and 8 years as a business coach working with physicians and startup entrepreneurs.

When I met Dr. Drummond, we discussed the reasons why so many physicians get burned out. He asked me how most doctors measure success? “Do they have a busy practice?” The answer popped out of my mouth instantly; it was almost a reflex. This is something you hear all the time. “She is doing well, working in a busy practice,” or “his surgery schedule is booked solid; he must be doing great.” This seems to make sense; after all, we are doctors, and doctors are busy. However using this one tool as your main metric of success can become a recipe for disaster. Unfortunately, this is not the only reason physicians get burned out, but the good news is, there is a solution.

Enter Dike Drummond

What follows are 9 facts about the practice of medicine that lead directly to burnout. The good news is you can do something about it.

1) Being a Doctor is Stressful. Period

The "most stressful" professions are those characterized as having a high level of responsibility and little control over the outcome. We are not selling widgets in medicine. This is a tough job that saps our energy every single day.

2) We Work with Physically and Emotionally Sick People All Day Long

Our days are filled with intense encounters. We spend our time treating sick, scared, and hurting people. In addition to the physical ailments, there are many emotional needs that come with any illness. Physicians do not receive proper training on creating boundaries; our energy can be severely tapped by these emotional needs alone.

3) Balance, What Balance?

Medicine has a powerful tendency to become the “career that ate my brain." Pushing all other life priorities to the side is something that we have ingrained into us during medical school and residency. As we get older, with more family responsibilities, the tension between work and our larger life is a major stressor for many. Training on healthy boundaries would help here too and is rarely available.

4) A Leadership Role with no Leadership Skills

You graduate into the position as leader of a healthcare delivery team without receiving any formal leadership skills training. By default we learn a dysfunctional "Top Down" leadership style. (Medicine and the military are the only professions where the leaders "give orders.") This adds additional stress.

5) The Doctor is the Bottleneck

The team can only go as fast as we can, and we are often behind schedule. Pressure mounts to perform at full steam all day long.

6) Who's Paying for This?

The financial incentives are confusing at best. The patient is often not the one paying for our services, and many of them receive their care with no personal investment on their part. You may have to deal with over a dozen health plans with different formularies and referral and authorization procedures ... of which the patient is blissfully unaware.

7) Medical Practice is A Lawsuit Waiting to Happen

The hostile legal environment causes many of us to see each patient as a potential lawsuit. This fear factor adds to the stress of all the points above.

8) Politics and "Reform" Political debate drives uncertainty about what our careers will look and feel like in the future.

All the pundits share the same complete lack of understanding about our day to day experience as providers in the trenches of patient care. There is no track record of common sense. We simply don’t know what to expect.

9) Things Eventually Get Stale

The ten year threshold when your practice suddenly seems to become much more of a "mindless routine" losing its ability to stimulate your creative juices each week is a shock. All of a sudden it seems as if medicine is “no fun any more."

The Solution

Keep your connection to "WHY" we are a doctors; to your Purpose.

The quality of this connection varies day-by-day; however, it is a source of immense power and endurance when the connection is clear. As physicians, we must deliberately work to keep that connection alive and well. When you have invested over a decade of your life in medical training, it's easy to feel stuck when you think your reason for becoming a doctor is gone or not possible. It's imporant to remember you have a great skill, with more opportunities than you probably know. Keep searching out and pursuing the opportunities that ignite your passion, and do not be afraid to ask for help. Sometimes another perspective can open your eyes to opportunities you did not choose to consider. 

When you notice the three cardinal signs of Burnout

     1) Exhaustion

     2) Cynicism (especially in men)

     3) Questioning the quality of your work or whether you make a difference in the world.

     (Sounds like medical school and residency)

It's time for a break, some balance, to take really good care of yourself, spend some time with your family and even ask for support. You’ve earned it.

To learn more from Dike Drummond visit The Happy MD