Twenty-two years ago, at the age of 34, I received news that changed the course of my life and that of my family.
As I always did in preparation for a surgical procedure, I went to the bathroom. Thirty minutes into the case I excused myself to repeat the same. The procedure was short and, 30 minutes later, I made another visit. I noted that each time my urine was clear, or almost so, and of a large volume.
In recovery I acquired a glucose meter and tested myself. The number was 410. In disbelief, I repeated the test and 412 was displayed. Having completed my single procedure for the day, I returned to my office and sought the advice and consolation of one of my older colleagues. He listened and was incredibly supportive. The myriads of implications for my life and that of my family swarmed through my head.
I explained what I had found to Dr. Rod Smith, a dear colleague and respected older neurosurgeon with whom I had spent many nights operating. His cautionary comments still echo through my head: “Eric,” he said, “this is a marathon and not a sprint.”
At the time, I failed to grasp the full implication of those words. It would have been understandable that my 80-year-old father might have type 2 DM. I was not overweight and ran several miles at least three days a week. My diet was not great but I did not eat frequently, although when I did it was often a hurried meal filled with carbs as bagels tend to be. I was a light sleeper and the periods of sleep were brief. My practice was stressful but tolerable, and I found it very interesting. I enjoyed my patients… well, most of the time.
For the last year, I had known that something was wrong with me but hadn’t identified any specific signs until that test. I had never seen a physician regarding this feeling as I had nothing specific to report and I was surrounded by physicians, anyway. They were my colleagues. I was protected and if I had a problem I would know, right?
Many physicians see themselves as the guardians of health care — not their own, but that of their patients. They believe that the time they would take to see their dentist, ophthalmologist, primary care, psychologist/psychiatrist, radiology technician, physical therapist, chemical dependency physician or counselor is precious time taken from direct and valuable patient care. Physicians will make a choice to care for themselves based on keeping their patients’ access to them. Bearing a child is often delayed or forgone.
I was surrounded by physicians, they were my colleagues. I was protected and if I had a problem I would know, right?
There is a certain arrogance and dismissiveness to think that each of us personally are as good as our primary care physician with whom we might consult. We do not acknowledge the proven connection between dental care and overall health. We do not connect the beginning of the disease process with the outcomes. We are aware of these issues and connections but attribute those risks to others called “patients.” We consider ourselves vaccinated by our attendance to medical school and therefore immune. We would know, of course, if something was serious with us and then we would seek help.
Or, just maybe, we are afraid to discover that there is a medical issue.
Many physicians fail in self-care the way I did and do not complete the marathon as it should be, at a manageable pace that retains a burst of energy that can be summoned as the finish line nears. But what we don’t realize is that the lack of self-care and the stress of practicing is burning that energy before it can be used.
Dr. Smith was correct to remind me that this was not a sprint. A career in medicine if it is to be productive and sustainable must be accompanied by a balanced life.
In the run up to and during our career, those of us who are fortunate to have a family or supportive friends do not entertain this career alone. We share it with a spouse, significant other or others close to us who also deserve our time, attention and commitment. That is healthy for them and for us, and it provides balance and security in life. Our significant other and children, if we have them, deserve to be acknowledged, loved and appreciated. Our patients and our work are made better as a result of that happiness and balance in our personal lives.
The airline industry has been a source of inspiration to the medical industry in the past in the form of time-outs in the operating room. This process that has reduced errors and near-misses has, by standardizing the behavior and care of the surgical patient, improved team interaction, overall patient care and outcomes.
In an analogous manner, the airline industry may have additional lessons to teach us in through its required routine mandatory medical exams. Pilots must have medical examinations every nine months, and it is time to require the same for physicians. It will be good for the physician, for the employer by increasing longevity and lowering costs, and most of all it will be good for the patients of that physician.
Onboarding is costly and time consuming. Institutional memory is invaluable and irreplaceable. Employers should want this. Though the intent is there, many physicians do not partake in the regular physical activity they recommend to their patients. The Department of Health and Human Services has published recommendations of 150 minutes of moderate intensity exercise per week composed of 30 minutes of exercise five days per week and muscle strengthening exercise twice each week. Physicians can and should complete this marathon of a career with a burst of energy across the finish line.
Although the expression “the joy of medicine” is often taken to mean enjoying and being satisfied with one's choice of career, it also means being involved in activities beyond medicine which provide satisfaction — such as meditation, arts, travel, socializing and other activities that lead to a sense of calm or fulfillment. It also means taking care of oneself and getting a regular dose of exercise that is to the ability of, and preferably just beyond, the physician. Consider walking at a brisk pace, yoga, Tai Chi or swimming. Personally, I find the gym boring but for some it works. Whatever it is that enhances your self-care, give it the time and attention you deserve.
The job of medicine is stressful and often, unfortunately, performed alone. Efforts to share the experience with colleagues can reduce the burden and enhance the care of the patient. No one of us has all the answers. If this sounds like an argument for the physician’s lounge, it is. Much useful work and stress reduction is achieved over a meal or a snack. There are many methods of stress reduction and those should be made available to the health care provider.
As physicians, we know our genes define us and can determine our disease susceptibility — and in many cases, disease outcomes. Routine evaluation of a physician’s genetic profile may be viewed as invasive, but there is an argument for taking that step and offering the insight into their profile. Employers can then provide assistance where a difference can be made, such as in diabetes and the control of glucose or in heart disease and the aggressive lowering of cholesterol and blood pressure. This improves the physician’s health while helping employers avoid the higher costs that will ultimately come from undiscovered conditions. It is unconscionable to not act on the information that can be available to us today and in the future.
What do we do when our illness becomes more obvious to those around us than to ourselves? If we are unimpeded by our medical condition and can provide good health care, a lot depends upon our personal attitude and those around us. As we age, various ailments such as heart disease, cancer, difficulty standing, visual impairment and others will afflict us. How does delaying care at the onset of and signs of these conditions help patients? The answer, of course, is that it doesn’t. The desire to continue working is understandable, as physicians it’s what we commit to. But neglecting self-care or ignoring our limitations is not excusable.
A letter I received from my physician-in-chief prior to my retirement put it well. “Your ability to give your best over the course of your career with TPMG depends on your personal health and wellness,” it said, adding that exercise, screenings, immunizations and attention to dietary habits were highly recommended. “At the end of the day, it is the responsibility of each physician to care for themselves as they do for their patients.”
Aging is normal and, no matter how hard we fight it, can compromise our abilities. Yet we are still in the age of often asking an experienced physician who is physically restricted by age to complete a task better suited to a younger physician. Some of this is even encouraged in the work environment.
I am fortunate that I caught my condition relatively early, that there have been numerous advances in the management of diabetes over the last three decades, and that it led me to re-examine my priorities and lifestyle. My condition is now very well managed and life is as close to normal as possible.
Primum non nocere. Hippocrates provided us a path many centuries ago with these three words. Those of us who practice medicine took a Hippocratic oath to “do no harm.” This includes avoiding self-harm, which requires indulging in self-care and in so doing enables us to provide better care to our patients, families and those who depend upon us. By doing these things we will model the best example for our patients to emulate.
Email Eric Williams, MD
