‘Existential’ is the word of the year for 2019. Popular use of existential peaked when hippies and psychedelics were cool. But it is in style again.
Dictionaries tell us that existential refers to existence (which doesn’t help much). An existential crisis occurs when we realize our existence is something other than what we believed.
As Ted explained, in Bill and Ted’s Excellent Adventure, “All we are is dust in the wind, dude.”
Existential Crisis
Doctoring has changed and become something that doctors were never trained to deliver.
Sensitive, hard-working students turn into weary doctors, who walk through clinics by willing each leg to move. One more patient. One less name on the day-sheet. One leg forward. Then the other leg. I can do this.
Medical students learn one thing, but we expect them to practice something else after graduation.
Medical training creates a secular, pseudo-religiosity unique to clinical care. Huddled around naked parts, noses pressed low to the point of interest, learners mumble medicalese, sotto voce.
At the professor’s lead, they straighten up in unison. The professor blesses his patient with soft generalizations. The Padawans nod and smile behind him.
Having mumbled and blessed, the gnostics form a confessional line. They shuffle off, white robes swishing, to huddle over the next patient.
The point here is descriptive, not normative. Students train in a way which attempts to preserve an ideal of patient dignity. But the ideal cannot hide the real.
Ignoring Cries for Help
I remember my first patient crying out for help.
“Doctor! Please help me! Help! Doctor!”
She got louder as our clinical teaching team moved past her door.
“Hello there. I’m just a medical student. But can I help you?”
“Oh yes, doctor! Thank you doctor! I can’t find Charlie!”
Her thin, sinewed biceps flexed against padded wrist restraints.
“No problem!” I said. “I can help you find him. Who’s Charlie?”
“He’s my cat. Have you seen him?”
My team almost wet themselves. If our staff man had not been there, they would have howled without mercy.
Ignoring the Wrong Cries
Students learn to ignore demented patients crying out for lost cats. Trainees learn to weave down hospital hallways, around patients with dementia, who each want the doctor to stop and help.
After graduation, doctors learn to ignore lucid patients crying out for help with real concerns. All students experience crowded emergency departments and patients asking for test results and wait times. But it is different. Students leave. The existential crisis comes later.
We turn kind, sensitive students into doctors and then force them to refuse help, as a central part of their career. Doctors know what patients need, but they cannot provide it. So they walk past legitimate needs and try to forget about cancelled surgeries.
If a doctor stopped to address every patient request raised in a crowded hallway, she would never get out. Doctors stop saying, “Sorry, I cannot talk right now.” They learn to walk quickly, head down, avoiding eye contact. But each time they scurry past, something shrivels inside them. It must. One cannot remain fully committed to treating patients with dignity, when all around patients suffer indignity.
False Impressions
If we drench students in reminders about the honour and privilege of being a doctor (or nurse or teacher), we will turn out professionals who believe it. But belief never impacts only the believer. A doctor or nurse, who oozes a humble sense of honour, privilege, and calling, will find it exquisitely more painful when they realize that the rest of the world does not share their belief.
Public conviction that a calling is worthy, noble, and respectable presupposes that most of society agrees. Convictions must rest on some objective truth. If they do not, we call them dreams or delusions.
Long ago, patients abandoned the idea that doctors and nurses were a kind of angelic being. More and more, patients are nice when we provide what they want, but vicious when we do not.
When a doctor realizes that a significant number of her patients do not share her convictions, she starts to doubt.
How can my profession be noble, if I must continually ignore my patients’ cries for help?
Is my profession still honourable, when a colleague is forced to perform a pseudo pelvic exam in a hallway stretcher? (Actually happened.)
So a doctor’s conviction crumbles from without and within. External evidence of patients’ changing impression of doctors, matched with the cognitive dissonance of ignoble behaviour, makes the conviction of nobility impossible to retain. It creates an existential crisis.
Rationalize the Irrational
Some clinicians rationalize their need to ignore patients. They attend to one patient and ignore the rest. They fortify their convictions by doing a fantastic job for one patient at a time. I cannot do anything about all those other patients.
All rationalization is irrational. If a behaviour was truly rational, we would not have to rationalize in the first place.
Napoleon’s surgeons used to triage wounded soldiers to be salvaged or left to die. Around the same time, regular doctors worked more like Fildes’ The Doctor.
Too often today, clinical care feels like battlefield triage. Doctors make utilitarian judgements based on technical expertise, with as much ruthless accuracy as the environment will allow.
And there’s the rub. An ontological change to the practice of medicine—turning it from one thing into another—creates an existential crisis for doctors.
Medical schools choose students most able to become doctors, who could sit with sick children. Then we expect those same doctors to behave like Napoleon’s triage surgeons. If medicine is now battlefield triage, then we need students suited to the work: brilliant, decisive, cold, and calculating.
Society cannot have it both ways. Either we let doctors provide the care they were trained to give, or we train doctors to triage, ration, and deny care.
Doctors cannot devote themselves to caring for everyone, while denying care to patients at the same time. It creates an existential crisis for doctors, and more importantly, patients suffer.
PS. Merry Christmas!
Love the interwoven themes that are becoming more apparent. Underlying the risk to have these experiences as a doctor is a high percentage of doctors or anyone in the caring profession are “wounded healers” of the Jungian archetype. They are unknowingly seeking to heal a wound that cannot be repaired, by the practice of medicine. However they will intensify their efforts to their detriment. The self awareness of why you need to do and what you need to do for yourself will liberate the person within you to have an existence , that is enmeshed in caring for others when actively ignoring your own needs. The existential crisis exists when your existence is now dependent on the vagaries of your professional achievements. That platform distracts from knowing the person who is not the doctor ,and when it needs to be defined or respected the skill set to do so needs to be built. The mirage of being by caring for others is evanescent and is overly tenuous. There is a point where that charade is no longer sustainable and that is the crisis doctors in many cases ultimately face. It is predictable and avoidable only if aware well in advance.
Wow. Szymon, you have stretched me. Thank you!
You took this to a deeper level for sure. I was barely scraping the surface. I agree that the understanding of ourselves, including our unconscious motivations to pursue a caring profession, become inseparable from our experience of it.
I appreciate you making the point that this discussion could (and perhaps should) go far beyond the superficial policy level at which I put it together.
Thanks so much for taking time to read and comment!
Cheers
This is quite a message to be followed by “Merry Christmas..”!
In my 40 plus years as a teacher, I guess, I missed a lot of this “existential” angst in students and residents, as well as many doctors. For sure it was there in some patients, usually in my field with very serious progressive neurological disease. And of course the technology and bureaucracy drained and continued to drain the very core of what we wanted in a personal way for everyone. However, there was always hope, and I was always impressed and sometimes surprised how people could give when it seemed hard to do and came through the other end satisfied and gratified for the experience….maybe I read your post wrongly, but I do wish you a “Happy” holiday….thanks for your comments…..and insights,. Allan the retired neurologist…
Loved your comments, Allan!
Yes, there needs to be hope in the whole caring transaction. And I love how you link it with the hope of a Happy holiday! 🙂
I find it fascinating to hear from you, someone with (I assume) extensive experience as an academic neurologist. I wonder if you were better able to maintain the primacy of the ideal we hope to craft for our students? Or perhaps, like many of my other speciality colleagues, you could focus on the case(s) in front of you without feeling the madding crowd? I remember my short time in Otolaryngology and feeling free to not worry about the hordes in the emergency room. I only needed to find the one patient I was called down to see.
Again, thank you so much for taking time to read, reflect, and post a comment! Excellent.
Cheers
I enjoy your posts a lot Shawn and follow you and others on The Medical Post blogs and signed up for your site. I rarely comment but I thought maybe some “uplifting comment” would be nice on Xmas Eve. Yes long academic career as Head Chief of Neurology then Medicine. Spent many hours in the ‘crucible’ of the ER…I admire anyone now who can work there and also appreciated what they did. Finally, i am a big supporter of GPs as we could not function without them . I guess iiwas one of the lucky ones and loved anything to do with the brain. Lots of times there were frustrations and difficult decisions to make but overall loved it! Take care and keep writing!!!!
Allan
Wow, such an encouraging comment. Thanks so much, Allan!
It is always inspiring to hear from someone who “overall loved it!” You are absolutely correct that, in our desire to improve, we do not get into too dark of a corner. Having said that, we know that docs show disturbingly high rates of burnout, depression, and suicide. So we cannot ignore the darkness either.
Again, I really appreciate hearing from you!
Cheers
Existentialism was also the word in the 50’s and 60’s.
Existentialism can be very difficult for those who follow the convoluted thinking processes of the world’s prominent philosophers that have written profusely on the subject…it turns some into pretzels…or simple if one has been fortunate enough to work out one’s own personal raison d’être….no existential crisis for the like…becoming a physician should not change one’s raison d’être, for the fortunate it should complement it.
Expectation is an interesting topic….where Canadian centrally planned health care is concerned there are going to be disappointments all around.
Well said, Andris.
I agree. Much of the what the existentialist philosophers wrote remains incomprehensible to me, if I try to put it in my own words. I like how you’ve said that it can also be simple, as in the way it’s presented in the post.
Expectation might be worth its own discussion. It seems to relate to appropriateness, limits, trade-offs, and a discussion about why medicare exists in the first place.
Thanks so much for taking time to read and comment!
Great blog post and I appreciate that “I was barely scraping the surface”.
I think that there is a bit more to the existential crisis that physicians face and a lot of it goes back to our training…often training under those that are at their own points along the existential crisis continuum. The amount of self-sacrifice and delayed gratification that goes into becoming is something that only those close to a physician can comprehend. Physicians lose 10-15 years of their lives that they will never get back. For 2-7 years they are often working 60-100 hours per week. They amass huge amounts of debt while others they grew up with/are friends with are getting ahead with their lives/families and building their nest eggs. They are taught what an honour and privilege it is to go through this ordeal and ‘it will all be worth it in the end’.
However…for many…along the way they are dehumanized by the process and lose their identity. They are no longer ‘John Smith’. They are ‘Doctor Smith’. ‘John Smith’ no longer exists. So…’Doctor Smith’ was taught to provide the best care possible in a timely manner in…usually…a well supported academic setting. Indeed, ‘Doctor Smith’ was taught that the realities of practicing medicine would be that he/she would be able to provide the best/highest quality care possible to patients in a timely manner in a system that would support them in providing that care. The reality, as you have stated, is very different. Physicians are expected to cater to the wants and whims and wishes of patients…even if it goes against their knowledge and skills. Meanwhile, patients who need care gain access to wait lists and deteriorate. The physician feels bad…and is often blamed…for delays in timely and effective care in a system that rations necessary care.
Also because…for many…this is a calling (in addition to being an honour and a privilege). That means that we will put up with huge amounts of mistreatment and abuse because ‘we are doing what we are meant to do’. No one else would put up with what we have to but we are expected to ‘wear it’ like a badge of honour and persevere and overcome because it is a ‘calling’. Since it is a ‘calling’ we are made to feel guilty from earning a living from our knowledge base and skill set. The amounts that we get paid for the services that we render are obscenely low and people are always shocked when they learn the truth. But we work so hard for so long and provide so many services that most fixate on what they know and understand…annual gross income. We were never taught that we would actually have to run a business and received no education and training in this. It was something that was poo-pooed and never discussed. And then we had to get out there and buy equipment and supplies and pay rent and salaries out of those obscenely low billings. This is also happening when we are trying to catch up with our lives…we have delayed having families in many cases and have to pay off debts while trying to start to build a nest egg.
In a physician’s training, they are also taught that they will be respected and valued. This is not reality. Nothing prepares the physician for the onslaught of denigration/vilification/devaluation and scorn heaped upon them by the government, the media and the public. This dissonance between what we are taught and the actual reality contributes greatly to the existential crisis. Meanwhile, those with less knowledge and training and those who put in less hours and effort are appreciated more and being paid more to do simpler tasks that are often lacking in evidence.
Anyway…sorry for my disorganized rambling and ranting. Much of what I wrote you already mentioned…I just elaborated on it. Thanks for writing this post. It is illuminating and informative, as usual.
Fantastic comments, Paul! Clear, passionate, AND well-organized.
I especially enjoyed your paragraph on calling. There’s a whole blog waiting to be written there for sure. Everything else you said was excellent too, of course. I won’t even attempt to comment on it all other than to say I really hope readers take the time to read through and digest it.
On another social media platform, someone commented to the effect that the public owns medicare so they should be in charge, full stop. Docs should be quiet and do what they are told. And this was from a relatively polite, sympathetic listener.
Again, huge thank you for taking time to read and share!
The founders of the US Constitution were wise to say that there was a right for the pursuit of happyness, not a “right” to happyness ….if there was such a “ right” to happyness , then others would have to be deprived of their liberties in order to provide “ happyness”to others.
There should be a right for the pursuit of good health and the right for the pursuit of access to good health care….however when there is a “right” to health care then others would have to be deprived of their rights and liberties in order to provide the recipient that ”right”.
The Canadian medical profession is being enslaved ( its representatives pretty well volunteered their membership for enslavement) , its members are being deprived of their human rights ( just look at the Bills coming down the pipeline across the country) in order to provide the supposed right to the rest of the population to free heath care…with a giant well compensated bureaucracy built to ensure that the right to health care is enforced and god help any physician or surgeon who falls short in its provision.
Animal Farm comes to mind where all animals are equal with some more equal than others….the medical profession being the steady dutiful work horse , Boxer , being worked to death ( even as it is accused of consuming too much hay) and then sent to the glue factory when of no further use.
Your distinction between the pursuit of health versus the acquisition of health is vital and not trivial. It has the same feel as the difference between negative rights (the right to be left alone) and positive rights (the right to have something, which usually means someone else must give it).
Excellent. Thanks!
Neuro endocrine linkages to “stress”
Stress can induce release of endorphins – natural pain killers – episodic stressors are accommodated and no stressors or challenges could be unhealthy
We are biologically designed to cope with stressors but may over define them and magnify their impact. Once they are seen as more potent then they use use more resources to respond to them. Reinforcing there is commonality in relating to others about burnout it may make it a relatable topic , which is unhealthy. Seeing stressors as the core of what they are which is a mindset may be a healthier choice. The pathways when amplified to react means cortisol surges react in anticipation of a stressor that may not occur. Anticipation of a challenge rallies resources that inhibits an ability to be more content and the societal collective has moved towards more isolation to reduce risk of “demands” from others which is adding to mental ill health issues.There can be a joy to stress which infers a negative outcome – if redefined as a challenge to engage in and overcome it produces a reward. If a challenge may not be overcome then is it worth wasting effort attempting to fix it? Placing such insurmountable challenges on an island that be isolated from active observation may be a helpful mechanism and keep the bite sized challenges as ones you may relish to take on, without which purpose can be hard to define. Stress and burnout is now expected and can we redefine the normal HPA axis that is designed to handle “challenges” that we are now labelling as stressors and maintained at a chronic level , that we are not designed to do. Without challenges to overcome we will not have purpose or gratification. We need to define for ourselves the reality of the challenges and the gratification we seek , that can be sourced elsewhere also besides medicine. Most challenges we tend to engage with are surmountable and a diagnostic challenge when worked out in medicine can be very gratifying to resolve , and we need to relate to what we can do well and feel good about it! We have skills and can use them well and that applies to how you we can redefine our experiences and interpretations. Watching Dr Sanjay’s HBO documentary called “one nation under Stress” is an eye 👁 opener to what we all face if we cannot redefine our sense of fulfillment. Developing nations can teach us about what we have lost! Let 2020 be the start of being proud of what we can do and support each other in these quests.
Hey, thanks again, Szymon.
I agree that stress is a fact of life, healthy in manageable doses, and that its impact depends, in part, on our response to it. But all of this assumes a rational, predictable level or type of stress. Animals adapt well to rational stress responses. However, irrational stress — shocking rats without rhyme or reason — causes PTSD, starvation, death.
Treatment of physicians driving by political whim/expedient, like we saw with Kathleen Wynne in Ontario, causes irreversible damage. Doctors cannot unlearn the need to keep one eye over their shoulder as insurance they do not get surprised the next time a government attacks. A whole generation of doctors spends their career dividing their focus, even just in a small part, on something other than patient care.
So it is not just about stress. It is about robbing patients of the focus and attention they would have otherwise received from their docs.
Cheers
As you’ve said, there is a disconnect between what we expect going into medicine and the reality of actual practice.
There’s a lot of “this is not what I signed up for” leading to dismay and questioning our choice in careers.
Often, when the reality is recognized, it is too late to make substantial career path changes as we are entrenched in debt, leases, and other obligations. And one wonders why there is depression and suicide in such high numbers.
One despairs when control is lost – when we no longer are at the helm of our own destinies and simply become a cog in the machine.
Centralist regimes like Big Brother, the former USSR and the Ministry of Health produce scores of unmotivated morlocks trudging thru a mindless existence.
The solution is obvious. A wrench needs to be thrown into the centralist machine and soon, otherwise in a generation, all that will be left of medicine will be a 1927 Metropolis like hive of mediocrity.
And there will no longer be an existential crisis, as no one will expect anything extraordinary, or even ordinary..
Well said, Rob.
Missed expectations realised too late matched with the loss of control leads to despair–a mindless existence. I cribbed each of your paragraphs–excellent!
For those who missed the 1927 Metropolis movie reference, I included the link to WiKi. I had forgotten about that one. Thank you.
I love how you looped back to end with expectations again. Well done!
Thanks again
Thanks Shawn…
As always your writings are thought provoking.
Thanks to those of you who have taken the time to deepen the discussion. I find value in your comments.
As physicians we would find ourselves in a completely different position with a much more satisfying experience of medicine, if we had the ability to direct healthcare in Ontario/Canada, in essence to self-determine.
The ability to do so will only be regained through solidarity.
We as a physician community must find it within ourselves to join together, support our physician leads despite our diverse perspectives and fierce sense of independence, and take action as one body.
Otherwise, we are destined to be tossed to and fro at the mercy of the merciless, the ministries, the public (as opposed to individual patients who are lovely and build me up) and the system.
Merry Christmas, Happy New Year and may 2020 be a better vintage for MDs in Ontario
And thank YOU, Joy.
Readers might not realise that you excel at what you suggest: leading physicians to join together and self-determine. I was really impressed to see your email about another big event you’ve planned in D7 (sorry, I haven’t responded to your note yet!). These local organic groups/gatherings/events are exactly that which strengthens, paradoxically, local individuals and weakens the ability of central planners to mandate arbitrary structure.
Authoritarian central planners fear local organizations; governments that love liberty promote local organizations.
Thanks again for reading, posting a comment, and for all that you do!
Cheers
Thanks Shawn.
I,as well,would like to thank those who have deepened this discussion.
I believe it is truly unfortunate that Ontario’s doctors are feeling increasing levels if stress/burnout/alienation …. but not unexpected.
The system has been developed FOR patients at the EXPENSE of doctors,and there is an increasing imbalance such that if a doc is not willing to have a religious zeal to treat,at personal expense,dysatisfaction results.
Doctors need to have CHOICES(just like patients)to provide services on their own terms …. for their own sanity,much like the 1950’s doc who provided care to the poor for free but charged the wealthy double.
I keep returning to the same narrative,but truly feel a parallel private system is our only savior.
BRIAN DAY ROCKS !!!!
I really like this, Ram.
You’ve touched on a core debate in the policy literature: What is medicare for? You and I believe that it is for patients. ‘Experts’ call that the naive clinical view. The experts believe the system exists to provide a national cohesion, a national identity, wealth redistribution, and control of an otherwise free enterprise industry. Patient care just happens to be one of the outcomes the flow from the system’s existence. I am not making this up — just read Bob Evans, Canada’s “foremost health policy analyst”.
We can try all the modern gadgets, gimmicks, and governance techniques to improve quality and service, but nothing will ever be great without the most fundamental element you identified: choice. Monopolies will always disappoint.
Thanks again. Great to hear from you!
Cheers
Shawn,
I would add that all entitlement programs also mitigate the risk of civil unrest. The best way to peacefully suppress a population is to give them things. Or at least promise that you’re going to give them things 😉
Brilliant practical cynicism, MD.
I suspect you are right — a modern version of bread but without circuses (well, without circuses for the most part).
Thanks for this!
Rome used “ bread and circuses/ games” to control its restless population ( Juvenal)…the moderns are perfecting the process by going the route of Aldous Huxley’s Brave New World with the use of an opiatelike Soma to control the population offering it a sense of calm and wellbeing, the legalization of marijuana being the first step with the legalization of so called recreational drugs following not far behind with governments controlling the supply.
Added to generous entitlement programs and constant entertainment offered by TV/ Internet and smart phones that follow their daily activities…the hierarchies will be able to preserve and maintain their dominance indefinitely.