A Dozen Years of Writing About Doctoring

On April 28, 2008 I hit the “Publish” button for the first time on “A Country Doctor Writes”. That post, “Cholesterol Guidelines and the Bachelor With Platform Shoes” is featured in the sidebar (or below, reading on a smartphone).

In the twelve years since then I have hit the Publish button 654 more times. Thinking back over all those words and the years that have passed, I especially value my clinical vignettes and glimpses into other people’s way of dealing with their illnesses and circumstances. I also notice how much I have written about what it means to be a physician and how I have evolved in my profession over the last 40 years (41 this summer).

As medicine has changed, I have also seen physicians change. I have seen distractions from our old focus of patients and their diseases multiply, and I have seen more and more burnout and disillusionment around me.

I have worked on my own feelings and attitudes because of the distractions in my own life. I love medicine and I have felt that this was my purpose in life since I was a very young child. When I don’t take time to reconnect with this sense of purpose I can feel my mental focus dragging my emotions away from the profound joy and satisfaction doctoring usually brings me.

For my twelve year anniversary, I decided to gather a sampling of pieces that illustrate the many aspects of doctoring I keep thinking about: The Fixer, The Hippocratic Apostle and The Guide through Life and Death.

Rather than reposting the pieces in their entirety, I decided to include a good size quote and a link to the original post, hoping this will give the essence of my observations without having to read too many words, for those with other things to spend their time on.

(Each title is a link to the original post)

Doctor Fix-It (2008)

Today I visited Ginny Leach. She lives by herself in an old trailer not far from our house. She is an ageless more or less shut-in woman.

A mild chaos erupted the moment I walked through Ginny’s front door. She was on the phone with her sister; I think they must call each other at least three times a day. Her only other contact seems to be the nuns from a nearby order; they help her out with chores and hand-me-downs. As I walked through the door, Ginny gestured to me, stretched the phone cord, and somehow her Slimline telephone fell to the floor and went dead on her. Ginny worried that her sister would assume something bad had happened.

Before I knew it, I was on my knees on the floor, examining the jack and the telephone…

The Apostolic Nature of Our Profession (2009)

I twice had a priest for a patient and I have been the personal physician of a handful of protestant ministers of various denominations. In each of these doctor-patient relationships I have found myself entering a ministerial role vis-à-vis my pastoral patient.

I have had reason to temper the hypochondriachal tendencies of one man of the cloth, and I have cautioned another that taking care of one’s body is a form of stewardship, and as such, just as important as taking care of one’s spiritual health. I have urged a minister to quit smoking and a priest to temper his sweet tooth.

Each time I have done one of those things I have been reminded of the apostolic nature of both our professions. People come to each of us, clergy or physician, with hearts and minds that are at least to some degree more open to hear what we have to say because of the office we hold, the cloaks we wear, that make our words somehow carry more weight than those of friends, relatives or family members.

Thank You, Father (2009)

I checked his heart and lungs without finding anything unusual, and then Mrs. McCann proceeded to expertly change his dressings, so I could inspect his diabetic ulcers.

“They’re coming along great”, I said, and added, “You are doing a superb job”.

“I do my best”, she answered, beaming.

I wrote some new prescriptions and we agreed on the timing of my next house call. She followed me to the door.

“Thank you, Father”, she said, and then quickly corrected herself.

“I mean, thank you, Doctor. Father Harris was here yesterday to see him.”

It struck me that Father Harris and I had come on similar errands, giving our blessing to the care and commitment we see in that house, neither one of us delivering much more than reassurance that the McCanns are doing their part and whatever happens next is in God’s hands.

The Counterintuitive Concept of Burnout Skills (2011)

“Burnout skills are the actions at which you excel, that people identify as your strong points but which drain you of motivation. They are unable to energise you and therefore deplete you without refueling you.” (Clair Burge)

The other night I suddenly realized I have always had the wrong perspective on how burnout occurs. It doesn’t happen to us, we bring it on ourselves.

One of our [reading] choices the other night was provocatively titled “Not Every Skill Is Profitable”. The subtitle was even more provocative: “In fact, some will just burn you out.” The writer referred to a South African blogger and businesswoman, Claire Burge, whose words in one instant changed my understanding of burnout:

“Burnout skills are the actions at which you excel, that people identify as your strong points but which drain you of motivation. They are unable to energise you and therefore deplete you without refueling you.”

I realize now that my strength as a tenacious problem-solver can be a burnout skill if I choose to take on problems that are ultimately unsolvable or go beyond my scope or authority as an employed primary care physician. When I can’t fix such problems, I feel frustrated and drained. My strengths as a diagnostician, communicator and motivator are my energizing skills. I need to use and cultivate them more in order not to risk burnout in my career.

A Samurai Physician’s Teachings (2013)

The images of a samurai – a self-disciplined warrior, somehow both noble master and devoted servant – juxtaposed with the idea of “physician” were a novel constellation to me. I can’t say I was able to predict exactly what the book contained, but I had an idea, and found the book in many ways inspiring.

Ekiken’s own words, in 1714, really describe Disease Prevention the way we now see it:

“The first principle of the Way of Nurturing Life is avoiding overexposure to things that can damage your body. These can be divided into two categories: inner desires and negative external influences.

Inner desires encompass the desires for food, drink, sex, sleep, and excessive talking as well as the desires of the seven emotions – joy, anger, anxiety, yearning, sorrow, fear and astonishment. (I see in this a reference to archetypal or somatic medicine.)

The negative external influences comprise the four dispositions of Nature: wind, cold, heat and humidity.

If you restrain the inner desires, they will diminish.

If you are aware of the negative external influences and their effects, you can keep them at bay.

Following both of these rules of thumb, you will avoid damaging your health, be free from disease, and be able to maintain and even increase your natural life span.”

On the topic of Restraint, the Yellow Emperor text states:

In the remote past, those who understood the Way followed the patterns of yin and yang, harmonized these with nurturing practices, put limits on their eating and drinking, and did not recklessly overexert themselves. Thus, body and spirit interacted well, they lived out their naturally given years, and only left this world after a hundred years or more.

During the Ming dynasty, a prominent physician wrote:

“Premature death due to the hundred diseases is mostly connected to eating and drinking.” 

That quote still carries relevance today.

Something Extra (2016)

The pressures of time, the complexity of our patients’ needs and today’s documentation requirements can easily make a medical provider feel less than generous these days. We must counteract that in order to carry on as healers.

All day long, I am conscious of the time as I work my way through my long list of fifteen minute encounters. But I am also conscious of the fact that the more pressure I feel, the less empathic I can become, and the less effective I am in building and maintaining the relationships that lie at the root of my ability to care for my patients.

It is only because of those relationships that I am in any way able to tell a fellow human being what to do; it is that relationship that allows me to reassure someone in just a few words with only my demeanor and the tone in my voice.

I can only cover so many issues and help solve so many problems in fifteen minutes, and I have long been aware that some of those minutes need to be time spent nurturing the relationship that allows me to be my patient’s doctor, not just any doctor.

Be the Guide, Not the Hero (2018)

The dominating narratives present a flawed, insecure hero, who faces challenges while also reaching a higher level of insight, and he or she is supported by a guide who is older or wiser (Obi-Wan Kenobi or Yoda) but in no way competing with the fledging hero. These characters have been there, done that, and have nothing to prove. They are portrayed in ways that indicate they are supremely competent and yet almost self effacing. It is not their turn to shine.

That is a useful way for doctors to think of themselves. We must support our patients in their own pursuit of health and happiness. They must find out or choose for themselves. We can not make them do things that they don’t see or feel by themselves. And we have no right to expect that they will always follow our advice.

Our quality metrics can make us feel as if we are the main characters, or heroes in the story analogy, in our interactions with our patients. The results of our efforts can make us feel as if we are experiencing success or failure. This in turn can create job stress and burnout.

By adopting and staying in the role of Guide, physicians can preserve their stamina and enthusiasm for each and every patient encounter. We offer guidance, but every hero is free to choose whether or not to accept our words of wisdom.

Curiosity, Antidote to Burnout (2019)

I read an article on the BBC website that made me think again of my patient’s observation and how it fired up my curiosity. Titled “The secrets of the ‘high-potential’ personality”, it described curiosity as an antidote to burnout and one of several predictors of professional success that the authors claim to be better predictors than the Myers-Briggs Personality Types.

“Compared to our other mental traits, curiosity has been somewhat neglected by psychologists. Yet recent research shows that an inherent interest in new ideas brings many advantages to the workplace: it may mean that you are more creative and flexible in the procedures you use, help you to learn more easily, increases your overall job satisfaction and protects you from burnout.”

At the beginning of my day, my mind had been wandering back to New Year’s Eves away from the office, trudging through the snow in the Swedish countryside or dancing at Chateau Frontenac in Quebec.

As my workday ended, I wished my Suboxone group Happy New Year and thought about the literature search I wanted to do on my day off.

May I never lose my curiosity…

The Stages of a Man’s Life (2019)

Jungian psychologist Robert A. Johnson explains the difference between mood and feeling. Feeling is the ability to value and mood is being overtaken or possessed by a man’s inner feminine.

I am still working on reining in my tendency for moodiness on some levels, and I am working on letting go of my Americanized idea of “the pursuit of happiness”.

Johnson, as many other thinkers says that happiness is, linguistically and philosophically, living in the present, with “what happens”.

He references Alexis de Tocqueville:

“One cannot pursue happiness; if he does he obscures it. If he will proceed with the human task of life, the relocation of the center of gravity of the personality to something greater outside itself, happiness will be the outcome.”

Here I am, unpacking boxes, mending fences, cleaning stalls, reorganizing closets and cupboards; life is happening in a humble red farmhouse with peeling paint and a sagging front porch. It feels a lot like moving out to camp every summer when I was a young boy, before I started to think I had to be a knight and a dragon slayer…

To quote James Taylor, not for the first time:

“The secret of life is enjoying the passage of time. Any fool can do it. There ain’t nothing to it.”

1 Response to “A Dozen Years of Writing About Doctoring”

  1. 1 Amanda (@changeiswelcome) April 27, 2020 at 3:44 am

    Happy 12th Anniversary ! Long time reader, just commenting to let you know that I enjoy your writing very much. Thank you! Hears to 12 more!

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Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.


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