No textbook or journal can train us for the hard parts of medicine. Books teach the endless range of pathologies that besiege the human body, the ever-increasing array of drugs and interactions, and the complexity of critical care, but those are easy compared with the curve balls and judgment calls for which nothing can prepare us. I've been grappling with one of these conundrums, and the more I ponder, the more I realize how difficult it is to determine the right answer, if there is a right answer at all.
My problem: when to speak out and when to let it go. “Pick your battles” is a lovely platitude that belies the cognitive dissonance of choosing to tolerate something you don't believe in for the sake of peace and the mental discomfort of fighting for one thing you believe in at risk to another.
The bromides go right out the window when the stakes are high. What if you were fired from your clinical practice for op-ed articles you wrote on your own time outside of work? How would you choose between fighting the injustice, which might jeopardize your future employment and the ability to support your children, or not fighting it, which might make you forever regret not standing up for yourself?
This has been my personal struggle. Ironically, I was fired on National Doctors' Day more than a year ago for what I wrote in this column. I didn't take legal action or write about it. I didn't publicize it; I just quietly went away.
It weighs on me every day.
Fight or Flight
We EPs have a lot of fight in us. Anyone who can successfully run an ED has more than enough chutzpah to stand up for herself. Inquisitiveness, skepticism, and the desire to find a better solution are all hallmarks of a great physician. We are trained to be lifelong questioners and to fight for our patients. Yet, we often stand by silently when it comes to ourselves. What motivates a decision to fight v. a decision to stand down?
We decide to fight when we feel strongly and care deeply. Sometimes an injustice offends our sense of fairness, and we cannot stand by quietly. We let our voices be heard when we are passionate about something despite the risk of speaking out. “We can't let them terminate EPs for writing articles,” the late Kevin Rodgers, MD, told me while he was the president of the American Academy of Emergency Medicine. He encouraged me to fight, offering the full backing of AAEM, including financial and legal support. “This should be a precedent case. We can fight this. Let me know what you want to do.”
I would have been fighting for what's right because it's not fair to fire me for writing to try to effect positive change. I would have been fighting for all EPs because, trust me, if they can do it to me, they can do it to you. I would have been setting an example for my children by not just going away. I want to raise kids who stand up and make a difference when someone clearly needs to take a stand.
On the other hand, fighting would have been a great personal risk. “Would you rather be right, or would you rather be happy?” my wise father asked. Often choosing restraint is as indicative of our priorities as choosing to fight. We decide to stand down because fighting jeopardizes the things we care about.
It's easy to say “you should sue” when you have nothing to lose. Colleagues who said this to me are themselves reluctant even to send an email that might be seen as out of line. It's much easier to be passionate about right and wrong when someone else is the martyr. Dr. Rodgers told me what the legal battle was like for Wanda Espinoza-Cruz, DO. She was fired for speaking out despite an unblemished personnel record.
Her transgression? She spoke to the hospital CEO about patient safety and low staffing after a stroke patient sat in her waiting room for so long that he was outside the intervention window by the time he was seen. (Tampa Bay Times, Feb. 20, 2015; http://bit.ly/2n4ULU1.) She has been tied up in litigation for years, and the lawsuit has made it difficult for her to find work.
Sacrifice, Scars, and Silence
I thought about devoting my time, money, and emotional energy to a legal battle and how that would affect what I hold dear. I feared that a lawsuit's effects on my mental health would impede my ability to be the happy, attentive mom that my kids deserve. I was afraid that being known as a doctor who sued her employer would severely limit my future employment options.
I was not willing to sacrifice the years of training and work it took to earn the privilege of taking care of patients. Ironically, fighting for the principles I want to teach my sons could jeopardize my ability to support them. Fighting on behalf of all EPs could paradoxically imperil my own ability to practice emergency medicine. To me the risk was too high, so I didn't fight.
I've moved on to better things, and I am happy in my new job. The battles we don't fight leave scars just as deep as those we do. When we stand down, the internal strife and mental turmoil behind our silence can be tremendous. It pains us to watch silently what is happening to our beloved profession. The balancing act of doing what's right for the patient and meeting CMS metrics weigh heavily on us.
Physicians are overachievers who want to do well in their jobs, but if we raise a concern about the validity of a measure because new research supports care differently, we are seen as “difficult.” So we go to work and put on a happy face to hide our discouragement. Under our smiles, we often feel powerless and demoralized as the medical system seems to be imploding around us. But instead of stirring up conflict, we yield.
Too often physicians yield to everyone else until we have given up a piece of ourselves. It's no wonder so many physicians struggle with depression, usually in silence. I've been there. Now I try to make choices that look out for my own mental health because physician mental health is still not a priority in today's health care culture. Too often it seems there's no right answer. Do we speak out for our mental health to avoid the pain of not feeling heard and not feeling like our voices matter, or do we stay silent for our mental health to avoid conflict and aim for happiness? When it comes to being right or being happy, I'd rather be happy.
But can we be happy if we don't fight for what's right? Is it right to let things go for the sake of happiness? Do we overlook things that we feel are wrong so that we can support our kids? How do we lay our head on our pillows at night knowing we rolled over and said nothing about things we feel are wrong? That's the psychologic distress beneath many physicians' smiles and a contributing factor, I believe, to many physicians' suicides. How do we fight for physician wellness when it means sacrificing our own?
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