Boundaries And The Three As
By
Leonard Zwelling
When we old docs get together, we talk about the younger physicians the way the old docs talked about us when we were in training.
“They don’t work hard enough,” is the most frequent complaint.
It was thus interesting to read in this article from The New York Times on May 19 that a particular short sequence in an episode from the second season of The Pitt has generated a great deal of controversy. You can see the sequence embedded in the story on the Times’ website attached above.
A young medical student with a photographic memory and a very cool demeanor walks out of the emergency room after her twelve-hour shift noting the high degree of burnout among ER physicians and that she did not wish to fall victim to the adverse effects of long, tough work hours. She had done her time and now she was going home.
“Maybe all you lunatics ought to learn how to set some boundaries,” she says on the way out the door to the resident who had just returned from rehab after being caught stealing drugs from patients in season 1.
This boundary setting contrasts starkly with the three As—the character traits desired by patients of their doctor. Availability, Affability and Ability.
I was trained to deliver the three As. Today’s young doctors are demanding a fourth, adaptability, and that demands a system geared for “work-life balance,” a term my senior rabbi David Lyon agrees with me about. We don’t understand it.
For my generation of doctors (and rabbis, I guess), work came first, last, and always. If you were feeling stressed during your job, you were to tough it out. Today’s young professionals are demanding more from their work environments. Many professionals are working from home. Those who still show up some place for work are demanding strict boundaries between their non-work life and the job.
Here’s what we old docs fear about this.
In training, you can never predict when the next learning experience will present itself. A procedure you’ve never done, but need to learn, may be needed at 3 in the morning. If you are in bed and the hospitalist is doing the procedure, you learn nothing.
Many disease states evolve over time. An insulin-dependent diabetic may present in diabetic ketoacidosis to the ER at midnight. Again, if you are home and the endocrinology fellow on call manages the patient, what have you learned? Nothing.
Finally, what emerges from late nights on call, trying to keep up with an alcoholic GI bleeder, tapping a hot, gouty joint, or managing a patient with right-sided bacterial endocarditis who is an intravenous drug abuser is confidence. This is where the Ability is born. I walked into my internship in late June of 1973 knowing nothing and not being a competent physician. I finished my residency in June of 1975 and I was afraid of nothing that might face me from a heart attack to a bleeding leukemic with no platelets.
Duke house officer motto: seen it, done it. But have the young docs done it? Have they even seen it?
I understand the effects of burnout. I suffered them myself and it got me into therapy. But, the confidence my training had given me also got me out of many difficult situations—clinical and otherwise.
I hear the people who think work-life balance has a place in medical training. I am just not one of those people. I’m the guy who thinks that they don’t work hard enough and, yet, they will be my doctors. However, I happen to be very lucky and have a panel of doctors (internist, cardiologist, gastroenterologist, urologist, dermatologist, invasive anesthesiologist, orthopedic surgeon, acupuncturist) who trained the way I did. I find each of them available and affable, but most importantly able. I hope their doctors have trained like they have as well.
Being a doctor, it never occurred to me to set boundaries when I would not be a doctor because I was off. From medical school until now, I am on call for whatever I can do to help.
Silly me. I thought that was my profession and professionals are always there if needed. Always.
