When people find out what I do for a living, the first response is most often something along the lines of “That must be so hard.” (That’s when they find out I’m a pediatric emergency physician; when they hear I’m also an administrator, it’s more of a sneer.) My reply is typically that most kids are pretty healthy, and most of what I see is fortunately not that serious or ends well. Which is true. But the fact is, sometimes it is hard. All of us in medicine have ways of coping with those difficult times, with patients who suffer and whom we can’t help as much as we’d hope to, with the child that dies. But, as discussed in a recent New York Times article, too often that coping mechanism is to distance ourselves. This detachment – which can cross over into callousness or cynicism, as documented famously in Samuel Shem’s novel The House of God – is contrary to the various oaths we take when entering the medical profession, in which we pledge to be compassionate and empathetic to the sufferings of those we care for. It can play out in several ways. Some physicians focus on the intellectual aspects and science of medicine. For others, emotional detachment along with time and economic pressures can lead to burnout.
For all of us, underemphasizing the humanism and altruism, combined with the increasing emphasis on medicine as a business, can lead us to feel like we are in an occupation, rather than a profession – a calling. We can forget what it is about medicine that gives it real meaning. Work hour restrictions, preauthorizations, shared savings and pay-for-performance: these are some of the reasons why many long-practicing physicians say medicine has changed for the worse, and they wouldn’t recommend it to their children.
Perhaps we need to be reminded of the old-fashioned commitment to the well-being of a patient, to being a healer, as a counterweight to economic and administrative pressures to be efficient. Lest we get too nostalgic, however, let me put in a plug for the administrators. As noble as the sentiments expressed in the Oaths of Hippocrates and Maimonides are, the singular focus on the individual patient can blind to the equally real needs of others, and more importantly, the fact that those needs must be balanced. There is only so much health care to go around. While we like to think that when we are sick, we want everything done and money is no object, that sentiment is typically expressed when we are not paying for it. The decrease in health care utilization that accompanied the economic downturn of 2008 and beyond shows that money is, in fact, an object, at least for many people. And with a few extraordinary exceptions, not many of us providers are willing to work without pay (and quite decent pay at that). In a world of limited resources, we need to balance our commitment to healing the person in front of us with the commitment to the health of society as a whole.
Those who provide the care and those who manage it need to understand each other better. We need to recognize the filters through which we see the world, accepting that a diversity of views is the best way to see the big picture. I believe as a provider, I may need to err on the side of connecting with and advocating for my individual patient. The administrator may need to be more vigilant about the efficient use of resources. But we must appreciate that we are all working toward a common purpose – serving our patients and their families – and a common vision of having the healthiest kids in the country here in our own community. Each of us can find meaning in what we do, and have an impact in our own way.