Smalltown Practice: Even a Bathroom Stall Is No Escape

Relationships with patients can be the most satisfying part of our practice but can also serve as our greatest source of stress. These are lessons I learned from 24 years in private practice in a town located just a few miles from the family farm where I grew up. My patient population consisted of family members, friends, and acquaintances. Many of those relationships were forged long before I started medical school.

I recently met a young physician who had reached the same crossroad where I once stood; she questioned if she should continue in a smalltown practice where every public encounter can easily turn into an office visit. I was happy to offer insight and a sympathetic ear.

"I can't even go to my children's school functions without some measure of dread," she began. "There is no privacy here."

I pointed toward a bench just inside the door of the gym, and we sat down while her young daughters happily picked up a ball and started to play. "Sometimes it just helps to laugh," I said with a smile, making certain no one was within earshot.

You Can't Make This Up

I told her that I had just come from the funeral home, where I gave condolences to my patient's family. A lady I'd never met kept telling me her symptoms as I stood in line at the casket. The poor widow had to wait for me to get untangled. Then, I ducked into the bathroom on my way out the door. A minute or two later I realized just how much privacy I'd lost when I heard the person in the next stall say, "Walton-Shirley, is that you?"

I didn't know what else to do but say yes. "Well, I hate to ask you this," she said, but of course she asked anyway. "My blood pressure's been up and I'm on amlodipine. I was going to call the office Monday to see if I could go up to 5.0 mg. Do you think that would be okay?"

I recognized her voice, so I told her I'd make a note in her record when I got back to the office, and that increasing her dose should be fine. She thanked me and left. Then I heard a woman call from another stall, "Hey, whatcha doin'?" "Oh, nothing," I replied, thinking, you've got to be kidding me. Then the voice asked, "Can you pick us up some milk on your way home, honey?", at which point I realized the woman was talking to someone else on her cell.

Relaying the story to my younger peer, I laughed again at the scenario.

She laughed out loud and glanced toward the basketball court where her kids were throwing a ball back and forth, oblivious to her angst. "But how did you have a life outside the office in a place where you can't even buy gas without being engaged?" she asked.

I explained that familiarity spells accessibility and that as women, we will always be viewed as approachable. We females have a hard time saying no, so we must guard against being used up while not wanting to appear uncaring. My male partner, Jim, didn't deal with half of the requests for favors I got. Often, I'd hear, "I hope you don't mind. I didn't want to bother Jim with this," as if he was off-limits for any after-hours conversations.

She nodded in agreement, obviously identifying.

And it wasn't just strangers. Once my dad called, knowing I was in labor. He wanted me to speak to his coworker, whose mother-in-law was having a stroke somewhere on the East Coast. I had to tell the guy that he had only 8 minutes to ask his questions before my next contraction. Undeterred, he told me the entire scenario and asked if he should travel to see his mother-in-law. Remembering this story, I felt about as annoyed as I did when it happened 27 years ago.

Prevention Strategies

The best thing to do is to practice a bit of prevention, I advised the young doctor.

"What do you mean?" she asked.

To preserve family time, I shopped at Walmart at midnight among the meth heads looking for Sudafed (before it was taken off the shelves). It was dangerous, yes, but I got through the aisles without interruption. My husband and I used to go to the movies a lot because it was dark and no one could see us. We used to leave church a little early, before I could be asked to discuss the implication of test results.

I advised her to go early or very late to restaurants and sit in a booth in the back. "Also, try not to give out your cell number," I warned. "If you do, you're on call 24/7. If you have to, insist that patients text."

"The vast majority of patients absolutely mean no harm," I reassured her, recalling advice I'd been given by a friend and orthopedist who was put upon about as much as I was. They have no idea how often we hear, "We are so sorry to bother you." They don't understand that every "quick" medical question turns into a 10-minute conversation because we want to give good advice and cover all the possibilities, and that these "quick" encounters easily dissolve the only hour of time we have with our children or husband.

The young doctor was silent for a few moments, then acknowledged that she had been too accessible after hours for patients and less present for her daughters.

I reminded her to take time for herself and her family. Try for a date night every week. Eat right. Exercise. Get outside. Feed your soul with things you enjoy. If you are a spiritual person, pray for discernment and joy. If you don't have a housekeeper, hire one. Take a 3-day weekend whenever you can and as much vacation time as you can afford, but most of all, remember that no patient has any idea how much of you has been consumed that day by others, so be patient.

The Really Tough Stuff

Then, I decided to tell the young doctor about the really tough stuff because being brutally honest was only fair. "Treating those you love or someone with whom you have a deep connection is risky," I admitted. When my partner was busy in the cath lab, I treated his patient, my uncle, for an inferior myocardial infarction. He died of an intracranial bleed and it almost broke me. He was my mother's only sibling. I would have never blamed my partner if he had written the order for the tissue plasminogen activator. Only my mother telling me I'd done my best with no hint of resentment helped me to cope.

Another patient and neighbor died shortly after I'd assessed him as low risk for back surgery. I thought I'd killed him. I ducked behind shrubs, hoping no one saw me because I was sure they blamed me. It was paranoia at its finest. When I finally got the courage to call the emergency department to ask what happened, I found out that he died of an acute leukemic crisis and refused transfusion. It had nothing to do with his surgery because he never had the surgery. I wish I'd called sooner. "Remember to get the facts before you torture yourself over a bad outcome," I insisted.

I warned her that no matter how good you are, you have to accept that for some, you are only as good as the last game you pitched. "There is a lady in my hometown who to this day barely speaks to me because she thinks I killed her sister. The sister died a few weeks after I cathed her—the cath was clean, and she had a normal ECG and a normal echo. I have no idea what killed her, but I still get the blame and it's been 15 years."

When I glanced up, my new friend looked horrified. Now it was time to give her the good stuff.

Regrets, I've Had a Few…

I told her that despite all of that, I wouldn't trade my hometown practice experience for anything. I loved my patients, partner, and colleagues more than I hated my schedule. Though I sometimes regret the time my dedication took away from my family, my daughters say they knew no other life and that I was a great mother. When I'm awash with guilt, my oldest, a psychologist, assures me that she's seen firsthand what bad parents look like, and her dad and I in no way resemble those she has encountered.

When you are in the trenches, your reality is skewed toward the negative. My husband was always great about giving me an occasional "It's a Wonderful Life" moment. "You have no idea the gratitude I see and hear about you from others," he would tell me. And I know he's right. When I see a young child holding their grandmother's hand, a grandmother that I balloon-pumped in cardiogenic shock years before that grandchild was born, I smile because I am proud of my work.

I recently spoke to the widow of a man I treated for flash pulmonary edema several years ago. He refused intubation yet wanted to see his child born. I bagged him and cradled him in my arms for over an hour, taking turns with the respiratory therapist until his Lasix, nitroglycerin, and morphine kicked in. He lived to throw a football to his son. I recalled a conversation with a teacher which was remarkable because she was completely aphasic when I first met her, mid-stroke. With no neurologist on our staff, I thrombolysed her. She now gardens and walks. I have thousands of those stories. Was all the stress and worry worth it? I'll answer that with a resounding yes.

I confessed that since I didn't have ready access to any female cardiologist mentors, it took me a decade to learn how to balance and, on some days, I still failed.

The young physician stood and motioned to her kids that it was time to go. She thanked me as she headed toward the door. "You didn't have to take the time on a Saturday morning to do this but I really appreciate it."

It was important that I took the time for this conversation because I was her, not all that long ago.

Melissa Walton-Shirley, MD is a native Kentuckian who retired from full-time invasive cardiology. She enjoys locums work in Montana and is a champion of physician rights and patient safety. In addition to opinion writing, she enjoys spending time with her husband, daughters, and parents and sidelines as a backing vocalist for local rock bands.

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