Some days I just want out

The longest journey is the journey inwards — Dag Hammarskjöld

I've worked in a small-town rural family practice for more than 26 years. I think it may be time to leave, but I hate making such monumental, life-altering decisions. It's so much easier to drift along in a comfortable and familiar space.

There is, after all, something of home in a place where you have spent so many years, something that makes leaving daunting at best and impossible at worst. It makes me wonder if the most confusing and oppressive prison cell is the one I call home. It confines without bars, its walls are welcome and its barriers lie somewhere inside me. I cannot leave without breaking down some intangible psycho-emotional borders. I cannot leave without abandoning part of myself.

But some days it's so hard to go on. Some days the frustrations seem insurmountable and the mental fatigue withering. Some days I just want out.

As I age, the practice of medicine does not become easier. That wisdom born of experience has eluded me, perhaps rendered stillborn by technology and knowledge that have increased exponentially. The stresses of 26 years seem cumulative. I worry more today than when I first began. Time has taught me the many pitfalls, medical, legal and ethical, that await any wavering judgement. I yearn for the bliss of youthful medical innocence and the certainty of the untried. Perhaps I have seen the fullness of suffering a human body and soul waits to, longs to, embrace, and I am full of doubt. Some days I think we are moths drawn to a flame, so much do we seek pain.

Nothing is simple anymore. The sore throat that used to be dismissed with a “call me in a few days if you're not better” now elicits a comment from the patient — “But Doctor, I can never get through to you and they won't give me an appointment in a few days” — and requires an explanation of the sore-throat “rules,” perhaps a throat swab, and definitely a lecture on antibiotic overuse. Even if I prescribe an antibiotic, I do so with trepidation. Have I checked for allergies and warned about side effects? Is the patient's memory reliable (“I remember you once gave me something that didn't agree with me”), or must I review the chart? And if the patient is a female of child-bearing age, have I asked about oral contraceptive use? Perhaps nothing ever was simple.

The clinic in which I work used to have 4 physicians, a few nurses and some receptionists. We were friends and neighbours. Now we are 9 physicians and upwards of 20 staff. We are colleagues. We talk occasionally in the hallways for a few minutes. We are much too busy, too focused, to have time for each other, let alone ourselves.

Maybe this is the way medicine needs to be practised now, as a job, not a way of life. The science is increasingly difficult and the art is disappearing. The laying on of hands has been replaced by the ordering of tests, the clinical/therapeutic touch by the algorithm. Perhaps medicine has evolved beyond the art. Perhaps it really is a science now. And perhaps this is a necessary and natural evolution. Increasingly I am an anachronism.

Lately I have felt like Job. One calamity follows another. Patients go sour who never should. Rare complications occur. This sounds so feeble when explained to relatives. Or perhaps it is just my perspective now, my burnout that makes me see my world this way. I used to welcome the night. It was calm and dark, warm and inviting. Immersion there provided a quiet time of dreams, rest, imagination and escape. Issues became clearer and answers serendipitously appeared. Now the ghosts come at night. They steal sleep and scream silent accusations:

“What if?”

“Should I have?”

“If only.”

Nightly I am placed on trial and cross-examined. Decisions. Decisions make me tired, and I make far too many every day. Often I don't know if they are right or wrong. I look at a report and tell someone they have not long to live. I look at a different report and tell another all is well. I suffer too much with the one and rejoice too little with the other.

Decisions used to be something I was good at, or at least I thought I was. Is this patient really unable to work for 3 months following an uncomplicated broken clavicle? He says it hurts so much. The x-ray looks okay. Range of motion and strength appear normal. But he does do heavy construction work. And pain is such a subjective thing. How can I know exactly what he is feeling? I can't. Yet at some point I must be the judge. The insurance company demands it and insists that I am in the best position to make a decision. Should he be off work? For how long? Should he get a disability? Permanent or temporary? I don't deserve this kind of power. I don't want it.

We are supposed to be egalitarian. We're supposed to guide people in making their own health decisions. So often this is the last thing they want to do, and for some it is the last thing they are capable of doing. Or is my doctor-as-god complex showing?

Some of my patients, those whom I have known so well over the years, will linger with me. Perhaps those who have grown so dependent I will miss the most.

I began seeing her when she was 20. She is now middle-aged and still comes to see me regularly. She has a personality disorder, and keeping her out of jail or a psychiatric hospital has been a victory of sorts. Every week or so for the past 2 decades, barring holidays, she has come to my office to tell me what's happening in her life. She's graduated from one dysfunctional family to another, only slightly better, one. But now she does have the insight that there are at least a few warm bodies who would ask where she was if she wasn't there. I hardly ever do anything besides listen for 15 or 20 minutes, but she is always so grateful. I shall miss her, or perhaps I shall just miss her needing me.

I shall not miss the incessantly demanding, reason-defying, constantly complaining, list-bringing, what-have-you-done-for-me-lately, form-filling, it's-everybody-else's-fault patients who seem to plague me daily. They are my bane. They make leaving attractive.

And I shall miss some of my colleagues. They have been my lifeline in a profession that is too often solitary and unconcerned with its own. Others won't know that I am gone. I shall miss them anyway. They have been a part of every day for so many years.

Like most of us (I suspect) I grossly overestimate my own importance. In my grandiose moments I wonder how some of my patients will ever survive without my ministering. How deluded I am. On a more rational day I realize that scarcely weeks after I leave my name will be difficult for most to recall.

And so I must go. But where? Perhaps I'm tired of being “just a GP” (or a dinosaur, as one of my colleagues observed). I suspect the era of the rural general practitioner who did a little of everything is over. Perhaps this is also for the greater good, yet I mourn the passing. Is it a sign of age that some part of me yearns for the good old days.

I feel I need to find a niche somewhere. Niche medicine seems to be in vogue. The obesity clinics that charge exorbitantly for common sense, the men's and women's health clinics, the travel clinics, are all possibilities. I have my own personal niche working as a GP at a psychiatric hospital. Several locums there almost have me convinced to leave my practice. The pay is good, the hours are great and the extent of things I need to know about is manageable. The work seems much less stressful. And then there is the overseas work I've wanted to do for so long.

But do I have the courage to make any of these changes? I keep looking for a place from which I could watch the world end. Perhaps this is an illusion and such perfection cannot exist. So I go on with more questions than answers. And I think that perhaps this is the way it is supposed to be at the end of the day: the Zen puzzle, not the rationalist relief.

So all this complaining, this late mid-life whining, is papier mâché, hardly worth the trees. If I change or don't change probably doesn't matter much. That I examine and understand the path is a win, that I show up and do my job a victory, that each day have a meaning, a goal. Whether I've talked myself into doing something different or not seems immaterial. I've come to realize that outward change is an option, not a necessity. The real journey lies elsewhere.