It's the year 2000, and I'm sitting in a semi-fancy hotel ballroom near LAX with several hundred other slightly-edgy emergency physicians. We're all awaiting the start of our ABEM written recertification examination. This was in the old school days of live exams. We had an MD master of ceremonies who was a famous EM leader. I can still remember his message to the assemblage: “If you're recerting for the first time, welcome, relax, good luck, and you'll do fine.” (His recognition that I was young enough to remember some of what I'd learned in residency was heartening and slowed my palpitations somewhat. Plus, I had studied.)
He continued, smiling, “If you're recerting for the second time, my condolences!” Polite titters and a few groans issued from the crowd. I partly missed his meaning then; now I understand. Before telling us to break the exam seal and pick up our no. 2 pencils, he said, “If you're recertifying for the third time, you've done something horribly wrong in the stock market.” And without having to state it, his one arched eyebrow and sardonic grin drove home the jarring message, “and in your life.”
It's the year 2020, and I'm supposed to re-cert for the third time. With the dual soft landings of Medicare in a few months and Social Security 14 months after that, as well as my not-horrible stock market performance, I don't really have to recert to live. But I find myself wondering, “Have I done something horrible with my life?”
Emergency medicine drew me in because it allowed me to do good deeds. More seductions included variety, immediacy, collegiality, and other treats. I liked the Sherlock Holmes aspect of EM. I got to figure stuff out, problem-solve, do helpful procedures, help people. But a colleague of mine recently ventured that we were likely the world's greatest enablers, perfectly trained and positioned to prop people up just enough so they could go out and hurt themselves again. Another colleague wickedly opined, “This job makes me hate people.” I know he doesn't, and I don't either, but I understand his shorthand. When I darkly disgorged to a now-dismissed therapist of mine that “I can't remember saving anyone worth saving,” he said, “Maybe you feel like you're not worth saving?”
I don't know. I have “talked” some nervous dislocated shoulders back in, one or two even in the lobby, much to the disjointed's relief. A few tension pneumos have yielded to my ministrations, making me look heroic and helpful for a nanosecond. I guess getting it right and diagnosing pneumonia or pyelo when the presentation isn't classic allow one's admission to the thinking-doctors club and a chance to keep someone alive long enough for his body to heal itself and a good life to continue.
Mostly though, I remember countless knees and backs groaning under weight they were never meant to bear and the countless requests for pain meds when diet advice would have been better for the pathology. The police bring in scads of disruptive homeless folks, leaving them to me and often flinging “We can book you or you can stay here, your call” before departing. Many of those left-behinds punch nurses, pee on the floor, scream bloody murder, and demand services I couldn't, wouldn't, and shouldn't ever provide. One defecated in triage.
Once I met two little girls, ages 3 and 5, bug-eyed, rampaging, tachy and skeletal, methed out of their minds after years of living in a cook house. I gave benzos and food so they wouldn't destroy the room, but I couldn't fix that. How about the foster kid, age 5, beaten daily and starved, sporting a fresh subdural and circular buttock burns? We patched him up, and he left the hospital. His “rescue” parents went to prison, but what about his life?
Wives killed by husbands, and vice versa. Kids dead because of drunk-driving parents. Still-smoking COPD patients on home oxygen, and don't even think of hinting at a smoking cessation program. Cerberus, the three-headed hound of Hades—diabetes, hypertension, and hyperlipidemia—when a two-hour video, “Forks Over Knives,” offers salvation. How about all the septic nursing home patients begging to be released peacefully from life but subjected to tubes and lines, tubes and lines, and more tubes and lines, all to no avail?
I could go on and on. I have a lifetime of horror stories in my head, many with dismal, unjust, unfair, and painful endings. Many I've helped write, urging the narrative forward, seemingly in the wrong direction, if one considers the big picture. Our species is trashing the planet, and everywhere I look, individuals are trashing themselves. Am I driving the garbage truck?
Teaching, watching the light of understanding appear in younger eyes, has been great. I've invested 20-plus years in the GME world working with students and residents, guiding, mentoring, furthering careers, hopes, aspirations, and skills. You could say that that's the son-of-enabling, possibly epic-scale enabling because the ripples of my little stone in the pond of medicine fan out and touch so many other lives, but it feels less like that than being pressed directly against dysfunction you know you can't heal.
Am I to be a thrice recerter and continue the horribleness, or do I project forward and attempt 20/20 hindsight from the present, plus 20/20 foresight, and call it quits? Instead do I focus on the goodness, recert, continue, and man up, realizing that you do what you can do, and outcomes aren't always, or maybe even ever, under your control?
Where is that witty MD MC from my 2000 recert festivities when I need him?
Dr. Burgis an academic emergency physician in California. Follow him on Twitter @BurgMichael.