Three months ago, I was writing the last visit notes on each of my clinic patients, my last, not theirs, in preparation for transition to a leadership role in quality in a different city. Saying goodbyes was emotionally depleting. There was Larry, not his real name, who had a mistrust of healthcare and somehow thankfully grew to like me after I held his hand as he was getting his covid vaccine. There was Jerry (not his real name either; all names in this post have been altered) who wouldn’t agree to a bone marrow biopsy when the hematologist recommended it to him, until I talked to the hematologist myself and went back to Jerry and re-explained to him why he needed the biopsy. There was Mary who didn’t want to see safe sex recommendations (which are embedded into our clinic note templates) printed on her after visit summary because she didn’t want her grandchildren in the house to think that “grandma is fooling around.” She hasn’t been sexually active for many years and not planning to “go there”, and in her opinion, safe sex recommendations are unnecessary and moreover, have the potential to plant seeds of discord in her family life. It didn’t matter that the program that funds her HIV care required her after visit summary to have those recommendations. It was a major feat for me and the two nurses who helped me get to the source of those boiler plate recommendations in the electronic medical record and custom remove them from her after visit summary. This act of kindness won me a huge fan, nonetheless. She didn’t want to lose the relationship we developed over the year, and remained apprehensive in spite of my reassurances that the next doctor is going to be equally great. And then there was Adam, who always carried two condoms in his pockets, just in case the moment came, (“one for you and one for me”) who was highly upset that his test for a sexually transmitted infection was positive. “I was careful, doc”, he insisted, leaving me to explain how the infection might have happened in spite of the precautions he took, and how the situation might have been worse if he hadn’t taken precautions.
When I graduated from infectious diseases fellowship, I became a healthcare epidemiologist overseeing infection prevention programs, which took ~80% of my professional effort, leaving me ~20% for clinical and other activities. This past year was the first year since fellowship, when I saw patients full-time. Updating my clinical knowledge and skills was one thing. Recognizing that I am an older and a different person now, with an updated worldview on everything was something else entirely. I was noticing so many more things (that were wrong and in need of fixing) in my patient’s lives and the world we live in. I was seeing the impact of structural and social determinants of health in their lives with much more clarity. Writing the clinic notes at the end of the day is an exercise in recall and putting together sentences from scribbled notes on my notepad a huge strain on my ability to construct sentences. As error-prone and harmful to personal well-being it is (because it’s your “pajama time”), avoiding it by writing the clinic notes while at work doesn’t work on most days. As I write the notes on my couch, somehow, the emotional detail comes to mind with far more clarity than the medical detail and I wonder if that happens to my peers. Writing these notes with the knowledge that my patients have access to them weighs on me and persistently reminds me to represent their lives in a fair light. What would they want written about them? What would they find offensive? Where do I write about the patient’s life situation and the so-called social determinants of health? At the very beginning of the note where they have the potential to bias a professional colleague also taking care of this patient, or at the end, by which time my colleague reading the note would have already developed an unbiased view of my patient’s medical problems? Then there are my own feelings of learned helplessness in the face of socioeconomic realities of my patients’ lives. A patient I will call Jerome told me that the food store he could walk to and buy food from closed down recently, and the next nearest store is five miles away and he doesn’t have a car. As I write about this while eating my dinner in the comfort of my own home, I struggle to draw boundaries between my responsibility as a doctor, my responsibilities as a member of society, and the collective responsibility of our society towards Jerome. If I was writing the same note fifteen years ago, I might have just called him a noncompliant homeless patient in need of treatment for each one of his multiple medical problems. Somewhere in the course of my life, I had a thought that I could never shake off ever again – what if everyone is already doing their best, and bad things are still happening in their lives? May be my job as a doctor and a leader is to start with their best, and make it a bit better for them, as their best is not sufficient right now to keep them healthy and out of trouble.
Peeling myself away from my patient’s lives doesn’t come easy. They entrusted me with intimate details of their lives and the gravity of that is not lost on me. Choosing a career in quality sometimes feels like a cop out, an escape from the day-to-day realities of the patients’ lives, while at the same time allowing me to think that it’s a wonderful opportunity to solve problems at the system level with potential to make it better for several patients at once. Long time ago, a colleague called me a “hobby doctor” when I explained that I practiced healthcare epidemiology 80% of my time and clinical infectious diseases 20% of my time. I flipped the term over and over in my head many times since then and thought about what does it really mean to be a doctor. Does taking care of patients through systems improvement not constitute doctoring? Somehow, the idea that it doesn’t constitute doctoring doesn’t sit well with me, and I decide to give myself a better name, a “systems doctor”, one who solves patient problems at the systems level. The patients may not know who I am, but they will feel the results of my work if I do my job well as a systems doctor. With that reconciliation, I closed my laptop for the last time before it’s due to be turned in the next day, and went to bed with my old admin’s voice in my head, “we’ll come back tomorrow, and try again.”
PS: Picture copied from here.