THE MINDFUL LIFE
March 30, 2023: Doctor’s Day. As much as I love finding every opportunity to celebrate, I did what I usually do on any given day: work, teach, then try to disconnect and recharge. But I don’t think of myself as fitting the mold of doctor worthy of being celebrated if we consider that doctor to be one who sees countless patients, works tirelessly (without whining or hating EMRs), and who is compliant about everything, always with a smile.
While in Minnesota over a decade ago, as life demands increased for me proportionately to our expanding family, I started wondering if I had ADD. After a lifetime of impeccable punctuality inherited from my father, I started showing up late to commitments and became more frequently distracted to the point that I had forgotten to renew my medical license. I was mortified to realize that for a few weeks I had practiced medicine with an expired license, that I had been — from a bureaucratic standpoint, at least — what I never thought could happen to me: delinquent. Fortunately, other than some late fees there weren’t any real consequences.
For quite a few years now, I have been receiving emails from the EMR police threatening to suspend my privileges every time some of my notes, or residents’ notes to co-sign, are overdue. And by overdue, that means barely more than seven days after the visit. I often start my notes during the visit, but I must jump into another session or feel too mentally saturated to finish them right after. Depending on my mood and the time I intend to waste on any given day, I will open, read or immediately delete those emails. I now find myself deeply entrenched in a paralyzing shame spiral of procrastination.
Depending on my mood and the time I intend to waste on any given day, I will open, read or immediately delete those emails. I now find myself deeply entrenched in a paralyzing shame spiral of procrastination.
I also get notices that evaluations are late. As an educator, I am not proud when I get behind turning in feedback for trainees. Yet, despite my willpower (because I often have so little left), I have witnessed a crescendo-like trajectory of my delinquency.
This recently culminated in a threatening message about mandatory trainings at my institution, including some that need to be retaken yearly (and for which, by now, I know the quiz responses by heart, so what is the point?). A component of my income was contingent upon me completing those. So, I launched into a four-hour refresh on workplace violence and harassment, finishing just in time despite a frustrating system crash that wouldn’t let me finish the videos.
At first glance, delinquency and my name constitute an oxymoron. I have always been a good, quiet, studious and disciplined learner in school and in life. The oldest of three children, through my entire youth I was this hyper-responsible, parentified, rule-following girl no one had to ever worry about. I was the “reasonable and wise” one. If I ever dared to try to raise doubt or argue with my parents, the shaming reprimand quite typically experienced by Xers came: “We don’t talk back at our parents!”
My two spirited younger siblings were the ones who tended to defy authority and get in trouble, especially my sister, an exuberant, rebellious tomboy who was the first female hockey player in town. I admired her ability to denounce certain injustices like sexism, especially when she displayed a huge poster on her bedroom door of a male wearing wet, white, very minimalist swimwear as a counter-response to objectification of women.
It turns out, as I believe is the case in so many families, that we were polarized into "the quiet, disciplined, intellectual one" (Caroline) and the “playful, athletic, active one” (Isabelle).
Nothing is ever so black or white, of course. We both shared various characteristics with the other, but were not encouraged to express them until later in life. After years of career choice wandering, my sister became more goal-oriented, went through a rigorous training and became a thriving Mountie. The other side of me started to transpire through my writing: for three years, my column in the student paper of our physical therapy program where my comments about aberrations, injustices and controversies earned me the nickname “Miss Foglia” after Pierre Foglia, a renown and respected Canadian columnist famous for opinion pieces emphasizing flaws in society. Then, over the years, I joined five marches and protests, which is still too few compared to my inner fire, and I continued to write. I have been gradually shedding and healing from “good girl syndrome.”
I am sure there are other yet-to-be-created categories of my delinquency. I am prone to resisting the various aberrations and redundancies in our health care system, including upgrades of all kinds, whether it is filling out in a timely fashion a “status form” on a website for monitoring patients on clozapine (because monthly visits and monitoring of white blood cell count are apparently not enough) or creating an online account for prior authorizations. You see, I am not a cookie-cutter type of person. I cannot execute tasks without understanding their relevance, and I don’t hesitate to point out how tedious and ridiculous certain processes are.
Many years ago, when I was the medical director of a county clinic, after we were told how to document our findings, I stated that on my deathbed I wouldn’t care whether or not I had not included the vitals in a separate tab. They were already included in my notes, and I didn’t see the point of wasting time by duplicating a data entry. Behind-the-scenes with colleagues, I would go as far as to qualify the discussions around endless paperwork and other menial tasks as “intellectual masturbation” or even “fly sodomy” (a direct translation of a quote from Stéphanie, my best friend in med school, another delinquent, “partner in crime” and now a family doctor I have the utmost admiration for). And now that I am confronted with even more hardship in my personal life, I regret not having been more of a dissenter.
Don’t get me wrong, I love being a doctor and practicing medicine. But nowadays, medicine has little to do with healing. It is about numbers, metrics, productivity. I want nothing to do with that. You can be productive from an organization standpoint because seeing a lot of patients brings revenue, but it doesn’t mean you are making a significant impact on a patient level by improving health outcomes. In fact, seeing a lot of patients is ultimately not a good sign because that means we don't live well, we make poor health choices, and as a result, sickness is rampant. Our ultimate goal should be for doctors to be out of business — because we’ve solved the world’s ailments — or, at least, out of burnout.
I am a psychiatrist because I seek to help people reduce, if not prevent, their suffering. So, I dream of the day, if it ever comes (although it is unlikely in my lifetime) when there won’t be a need for psychiatrists anymore. That will mean people will have found effective ways to heal themselves and each other, living within communities more connected with nature and nurturing humanistic values and spirituality. That will mean the mission of my profession will have been accomplished.
My colleague shared a Wall Street Journal review of If I Betray These Words in which the reviewer couldn’t say it better:
"Indeed, our modern medical system now paradoxically combines the worst excesses of socialism (bureaucracy) and capitalism (greed). This contradictory yet sinewy co-existence is ultimately responsible for physician burnout. And it can only exist in a cultural environment confused about medicine’s purpose.
“If a physician labors only to see and please as many patients as possible, then patients, hospital staff and hospital CEOs will treat physicians as service personnel, profit-generators and 'providers.' If we think of doctors as algorithm-checking assembly workers, then providers belong in a bureaucracy befitting such a role. However, medicine aims to heal the individual patient, an endeavor that requires negotiation, discussion, time and care within a hospital or clinic room. Our laws and our culture ought to drive medicine toward that goal, not distract from it. If we recognize the health of the patient as medicine’s purpose we necessarily treat the doctor-patient relationship as an end that every aspect of the system serves. Only this will attenuate bureaucracy, greed and moral injury."
I got so excited about this article (finally, someone sees the TRUTH!), I unhesitatingly proposed to a colleague that we send this to key people in our organization. He said, “Caro, you have the soul of a revolutionary!” Sure enough, my snappy tongue and irreverent attitude has, episodically, gotten me into some trouble. I admit being a Kali sometimes, destroying illusions about life by bringing harsh realities out in the open.
I started to embrace and accept my outspokenness even more once I realized that my youngest son, who is probably the one who looks the most like me, revealed a rebellious streak underneath his existential questionings and astonishing compassion. (He must have gotten this somewhere!). In fact, my three sons have been vocal about injustices in their own way, and I admire them for that. I am thankful for their sensitive soul that has been so inspiring in my own self-development.
I owe it to my patients and, especially, to my children to be fully me. I embrace my tragic, non-pristine and blissful life. I am messy when I feel creative or down. I can be unpredictably grumpy, I hate certain mastication noises, I complain about bureaucracy, and I can't stand magician shows because I cannot accept not knowing how they trick us. I need to know how all of life works!
I have come to not necessarily see all my emotions as indicators of truth but, as Pema Chödrön wrote, shifts of energy meant to wake us up. Based on the intensity of my emotions, I must have had a severe case of sleepwalking my whole life. I am an emotional paradox: I feel momentarily ecstatic in the midst of deep sorrow, which can be disorienting and draining for those around me. I have let people see who I am. A few reacted viciously to my "witchiness" and became backstabbers, and others applauded my real me. I keep going and discovering disconcerting flaws, holes and endless dilemmas in me, but at the same time I shed what is no longer or has never been me. And for that version of me, I guess, like most, I yearn to be seen. As is. Seen and taken as is.
I became an agnostic of the dogma of the medical profession. Every day, I feel lighter. No more of this "be a good, quiet, smiling girl" paradigm. I am expanding so that my self-acceptance can touch others to make them want to expand, too. That is the type of doctor I want to be free to be. That is the healer I deeply am.
Be fierce. Fight for what you hold dear. Say no. Ask why, to those who try to control you, about everything and anything. And ask “Why not?” to yourself. Show more than you tell.
At various times, challenges in health care will solicit the outlaw archetype in all of us. Maybe all I want is for the type of healer I am to be a mug shot star. Being wanted. As a stepping stone to being fully valued for what I am and have to offer.
Well-behaved physicians likely don’t make history. While I don’t plan on making history, I have no intention to be well-behaved. Ever again.
Be fierce. Fight for what you hold dear. Say no. Ask why, to those who try to control you, about everything and anything. And ask “Why not?” to yourself.
