I Was Lost in an Abyss of Electronic Clicks

It is the end of August 2019. I wheel a cart piled high with the contents of my office out through the clinic's sliding glass doors. Interspersed between the textbooks and files and boxes are multiple bouquets of flowers, creating an oddly festive jumble.

I reflect on my last patient of the day. Maybe the last patient I will ever see in this clinic. But that is uncertain at this point. Everything is uncertain. And what may come is unfathomable, a storm not yet on the horizon.

During my last patient's appointment, I reviewed their imaging with them, pleased to show their dramatic response to chemotherapy. I was especially delighted that the patient was not only responding well but tolerating the treatment without difficulty. It was a good way to spend a final visit. I interpreted the patient's tears as coming from a place of joy, from the good news of their response.

But the patient had something else to say.

"Is it this?" the patient asked, spreading their arms wide.

This? I didn't understand and asked for clarification.

They hesitated.

"It's okay," I told them. "This is a safe space. You can tell me anything."

The patient gestured around the room and then to their body. "This. All this. Having to tell people when it's not good news. When the cancer's back."

I closed my eyes. My patient was so far from the truth. But how could I explain? I never imagined that I would one day join the growing majority of U.S. physicians suffering from burnout.

But the chasm had grown too large, dividing me from my patients, and in the end it was impossible to cross.

Should I explain the growing mountain of tasks required during non-clinic hours? Or the endless phone calls and paperwork to appeal insurance companies' denial of services? What about the inane electronic health record (EHR) tasks for "meaningful use?" And the endless flood of EHR messages, any of which could contain critical patient care information buried amid time-wasting drivel?

Or perhaps I could explain how, adding insult to (moral) injury, nonphysician strangers who'd never laid eyes on my patients could deny their treatments if they couldn't find the right box to check, creating hours of ridiculous, unnecessary, and spirit-crushing work.

I yearned to explain that I was leaving not because of the burden of patient care as an oncologist, but because I could no longer live with the actuality that in my daily work, the patients had been relegated to an afterthought.

Rather than being able to focus on my patients, my life had become the EHR. Each morning I reached for my laptop, charting from the first waking moment, with a distracted wave to my family, who had long learned to manage without me. Returning home each night well past dinner, the first thing I reached for was not my children, but again the laptop, to log back into the EHR. Because if I devoted every waking hour to the EHR, only then could I keep up.

I had come to secretly resent any family activity that required my presence because all I could think about were the hours of charting not getting done.

Soon after, I was forced to acknowledge the depths of my demoralization when an awful truth hit me — I had come to dread my time with patients, the heart and soul of my practice, as interfering with my EHR tasks.

And with that, the systematic eradication of my core values as a physician was complete. At first, I resisted this knowledge. The thought of leaving was inconceivable.

But my soul was already impossibly astray. If grace still existed, it had long been consumed by an abyss of electronic clicks. Empathy was not efficient and, thus, no longer welcome. It was a moral disconnect that I could no longer reconcile.

In struggling to provide my patients with the safe and sacred spaces they deserved — in a system that promoted the opposite — I had burned myself out. I had become angry, and the bitterness was spilling into my interactions. I came to the painful realization that I was doing no one any good by staying. I would have to leave to have a chance of finding my way back again.

When I informed my patients that I would be leaving the practice for an undetermined time, most — like this last patient — assumed that I needed time away from the specialty of oncology. I could not find the words to correct their assumptions. How could I reveal to ill and vulnerable patients the extent of the brokenness of the system?

I wished I could explain. The patients had it all wrong — it wasn't their illnesses. As an oncologist, it had been my privilege — the culmination of my profession — to guide them through their cancer treatment journeys. But it came with an apprenticeship of suffering. As medical students, interns, and residents, we freely offered up our souls, understanding that sacrifice was necessary for metamorphosis.

Sustained by a deep-seated altruism, we yearned to become healers to our fellow human beings. We entered the world of medicine as energetic, optimistic, young professionals eager to learn the science and practice the art of medicine. We were instead transformed into empty shells clicking at keyboards to meet productivity goals. Joy and curiosity were replaced by dread and apathy.

We always knew there would be challenges and sacrifices. But we didn't know our ability to use our hard-won knowledge and skillsets would be kicked out from under us at every turn — by the insurance companies, by those who wanted to run the business of medicine like an industrial-age conveyer belt, and by a workplace culture that shamed us if we admitted we were suffering by being forced to practice assembly-line medicine.

The cold patter of the rain splashes on the cart and brings me back to the present moment. I'm still standing outside facing the empty parking lot of my clinic — except I have to remind myself that it's no longer my clinic.

I blink in bewilderment at the bright blooms on the cart in front of me. Tucked between the textbooks and the boxes and the flowers is another gift. A small canvas painting from a patient, an artist. It depicts an older woman surfing the ocean waves.

The artist had explained that the woman, at eighty years old, still surfs every day. The painting captured the joy and serenity of this person. The surfer is perfectly balanced amid the waves. Silver hair, pear-shaped body in a wetsuit, one gets the sense that she has freed herself of constraints and is doing the thing she was born to do. She doesn't fight the current, she rides the waves where they take her. With grace. The painting speaks to me of joy. Of a safe and sacred space.

It has taken me almost twenty years, but I tell myself it is not too late to value what is directly in front of me. I may have never been taught to protect my own safe and sacred space, but my patients need me to. My patients have shown me how. The system may not have any empathy — but it can no longer have all of mine.

There is no more excuse to delay. I step into the rain, pushing the cart toward my car, my thoughts returning once more to my last patient asking, Is it this?

When I could find my voice again in the exam room, I could only answer, gently, with these words: "It's not this. It's not you."

I reach my car and unload the cart's contents into the trunk, hurrying to get them out of the rain. It doesn't take long. When I'm finished, the evidence of my years of practice is reduced to only a half-full car trunk. It seems so little, for so much.

This is an excerpt from a longer essay, "Walking Back From Burnout," as published in Prevention of Burnout in Medicine: Multimedia Primer and Lifebook, used with permission of the publisher. Part 2 will be published in June.

Jennifer L. Lycette, MD, is a rural community hematologist-oncologist, mom of three, and recovering perfectionist who's writing her way back from physician burnout, one word at a time. Her essays have been published in The Intima, The New England Journal of Medicine, JAMA, JAMA Oncology, Journal of Clinical Oncology, The ASCO Post, and more. Connect with her on Twitter @JL_Lycette or her website.

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