It’s been almost two years since I left clinical medicine. In the midst of our country’s health care attrition crisis, stories of early retirement, burnout, and career transitions aren’t hard to find. While each of those accounts brings a deeper understanding of the problem, as well as potential strategies to remedy it, this is not a story about why I left medicine. Instead, it is an observation of how medicine warped my own reality without me knowing it was happening.
I spent two decades as a frontline physician in emergency and urgent care medicine. With my chosen trade came numerous benefits that inarguably improved my life – financial security, smart and witty colleagues who became great friends, and, for a time, professional fulfillment. I’m grateful for those gifts, as they’ve helped me arrive healthy at this moment. But only now, after two years away, do I realize that an aspect of my former career harmed me. Those twenty years on the ER and UC frontlines severely damaged my sense of time. I’ll try to explain what I mean and how I think it happened.
I did my EM training in a busy, urban level 1 trauma center. The approachability of attending physicians, combined with high acuity, volume, and patient diversity, drew top-tier medical school graduates from across the country. My residency experience was incredible. I gained the expertise and confidence to enable a nearly seamless transition to a career in non-academic emergency medicine.
For twenty years of my work life, I navigated a vast sea of humanity with the singular, short-sighted goal of arriving at the next case. When I left a patient room (or hallway stretcher), I sought out the next patient. Many times, I was directed by staff and colleagues to the one who needed the quickest attention and interventions. Just as often, I scanned the new arrivals on the tracking board and prioritized patients based on the perceived danger of their presenting problems, age, and vital signs. In the ER, the work is never really completed; it’s just that a different platoon of staff and clinicians arrives to take over. Over my two decades in medicine, mid-shift reprieves became less and less frequent; they eventually became non-existent. Nowhere does nature abhor a vacuum more than in an urban ED. Every time a space is vacated, it is instantly filled. About five years into my post-residency career, I remember hustling to see the next patient during an insane evening shift when I chanced upon a seizing, vomiting, and cyanotic patient on a hallway stretcher. The rest of the staff was in other rooms. “Pull someone out!” I shouted. This is ER code speak to evict a mostly stable patient from their ER bay to make room for the immediate resuscitation of another patient. In the ensuing months and years, overburdened and understaffed became the normal, accepted day-to-day work environment.
Volumes have been written on “the tragedy of the commons” that has befallen emergency medicine, and dozens of helpful suggestions, strategies, and modifications have been proposed. Some have been enacted. This piece is not intended to add to that conversation; it is written as a reflection, from the perspective of a former insider, on one of the ways the work environment described above injured my psyche and personality.
Early in my clinical career, I really liked repairing lacerations, particularly facial lacerations. I also enjoyed making connections with troubled and “difficult” patients. To perform tasks like that, I needed to spend some extra time with those patients. This is not to mean that those cases required an inordinate amount of time – only that 3 to 5 minutes was insufficient to do the job well. But I quickly discovered that any satisfaction I received from the 20 to 30 minutes preparing and repairing a complex facial laceration would soon be replaced by the urgency of 5 to 6 new arrivals. Often, more than one of those new arrivals needed immediate evaluation and intervention. Subconsciously, I knew that in the absence of a mass casualty event in the universe we occupy, that amount of illness and injury couldn’t possibly occur at a single location in 20 to 30 minutes. So, my subconscious brain began to perceive 5 minutes spent with a patient as a half hour. 20 minutes in a single patient’s room meant that someone in shock wasn’t getting the interventions they needed. They meant that a 75-year-old with a leaking abdominal aortic aneurysm was languishing with one foot already in the grave; those 20 minutes meant that a dialysis patient with hyperkalemia was approaching cardiovascular collapse. In this new reality, I stopped enjoying repairing complex lacerations; I didn’t spend as much time working to connect with the difficult patients. Years in the ER had given me the worst imaginable version of FOMO.
This twisted perception of time carried into my life away from work. Checkout lines, traffic, and phone conversations became anxiety-riddled misery. Picking up my kids after a sleepover or playdate became a quest to unceremoniously peel them away from their friends as quickly as possible. On departure day after a trip or long weekend, I prodded my family to move along to leave as early as we could. I knew that I was impatient, but brushed it off as “just my personality.” Until I left clinical medicine, I never considered that maybe I wasn’t programmed to be impatient; I never thought that there was much more to it than my DNA and other internal factors.
For a dozen reasons, I left medicine and began teaching middle-school science two years ago. My current work environment is 90 percent positive energy – it’s challenging and unpredictable, but filled with autonomy, supportive colleagues, and fun personalities. I am happy to drive to work again and feel like I’m exactly where I belong professionally. Over the last couple of months, I’ve noticed that my personality has changed. Perhaps “reverted” is a more accurate word. I believe the most significant change is that I’ve recovered a healthy, normal perception of time. When I feel like the lab full of 8th graders has been dissecting chicken wings for 45 minutes of an hour-long class, I look at the clock, and it agrees with my perception. When I have 20 minutes to spend eating lunch before heading to lunch duty, those 20 minutes feel exactly like 20 minutes should feel. When I meet with a student who needs to make up a lab or spend some enrichment time, I don’t feel internal pressure to hurry and move to the next task. In less than two years, I’m different than who I was. I’d like to think that recovering time has made me a better version of myself.
None of this is to suggest that modern physicians and clinical health care workers can’t live emotionally healthy lives – I personally know dozens who are pulling it off. Maybe if I had been more introspective, learned to employ mindfulness strategies, adopted yoga, or sought professional advice, I could have maintained a healthy sense of time during my career in clinical medicine. I won’t ever know if that’s the case; I’m an imperfect person who is mostly just making it up as he goes along. I guess my hope for this essay is that it compels the frontline clinicians who need it to pause, pull back, and get an aerial view of themselves. Has your job changed you? How? Are some of those changes negative? How and with whom do you start a conversation about those changes?
Keith Pochick is an emergency physician.