Never underestimate the self-flagellation of the physician [PODCAST]

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This episode is sponsored by Athelas, the number one provider of remote patient monitoring.

“Patients die. This is a tragic truism in the world of medicine. Usually, the patients who die are elderly. Patients die from diabetes and kidney disease, or from alcohol abuse and liver failure, or from heavy smoking and lung disease. Or patients die from cancer.

As a physician, I take these deaths in stride. I try to provide comfort care as they lay dying. Patients often pass into a dreamlike state, at the end. They are not fully conscious. I provide morphine for any pain, which may or may not hasten their entry into the final, dreamlike state.”

Janet Tamaren is a family physician and author of Yankee Doctor in the Bible Belt: A Memoir. She can be reached at her self-titled site, Dr. Janet Tamaren, and on Twitter @jtamaren.

She shares her story and discusses her KevinMD article, “Patients should never underestimate the self-flagellation of the physician.”

Reflect and earn 1.0 AMA PRA Category 1 CME for this episode.

This episode is sponsored by Athelas, the number one provider of remote patient monitoring.

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today, we welcome back on the show Janet Tamaren. She is a family physician and author of the book Yankee Doctor in the Bible Belt: A Memoir, and she wrote the KevinMD article “Patients should never underestimate the self-flagellation of the physician.” Janet, welcome back on the show.

Janet Tamaren: Thank you.

Kevin Pho: So we’ll get into the article in a little bit, but for those who didn’t get a chance to listen to our first episode together, can you just briefly share your story and journey to where you are today?

Janet Tamaren: I’ve worked as a family doctor in Kentucky for 20 years, but getting there was a bit circuitous. I’d gone to medical school in Kentucky, and I was older when I went. I was 38, so I had a different attitude than many of the youngsters; I was almost old enough to be their mother. While going through medical school, my initial ambition was to become a geneticist, to do a fellowship in genetics. That was my first interest. That didn’t happen. I happened to have a couple of pregnancies during medical school, so my ambitions got truncated, and I ended up going into family medicine and working in rural health clinics outside of Lexington, Kentucky.

I discovered it wasn’t what I expected. I know what I expected; I was sort of open-minded, but I ended up enjoying it a great deal. I left that practice about seven years ago to come back to Denver, where I have family. When I first came back here, I kind of missed my patients. Well, I did miss my patients. I missed the stories they had told me, and their stories stayed in my mind. I started writing them down, and that ended up being a memoir. I didn’t know it was going to be enough words to fill a book, but it was. Then I had that published, and I’ve been kind of promoting it, doing Zoom talks, writing a blog, and so on.

Besides that, I worked in Denver in primary care for a few more years and retired two years ago when COVID came to town. I was fully of an age where I was terrified I was going to die, because they told us, they said, if you’re over the age of 70, they kind of made it sound like you were toast. Anyway, so I did retire, and I’ve continued to be retired and stay busy with other things.

Kevin Pho: So you talk about the importance of patient stories, and this KevinMD article is about one of those stories. It’s titled “Patients should never underestimate the self-flagellation of the physician.” Now, for those who didn’t get a chance to read your article, can you just walk my audience through it and share the story of why you decided to write it?

Janet Tamaren: Well, as I was sitting down, and this was some years ago, thinking back over my life as a doctor, one of the most devastating experiences was when I had a patient die and I didn’t know if I had done something wrong. I still don’t know if I’d done something wrong. But as a doctor, you’re told that you’re really good, you’re really smart, you should be perfect. There’s this huge expectation laid on us that we’ll do things perfectly, and then you don’t know if you made a mistake. That is especially harsh for someone who was raised as a perfectionist, which I think applies to most of us; most doctors have that expectation.

I found it so devastating that I actually sought out a friend who’s a psychiatrist and told him how badly I was taking this, and he said, “What, you think you’re such a good doctor that none of your patients are going to die?” For some reason, it hurt when he said that. I thought he was supposed to say, “I understand your pain. We can work through it.” But that’s not what he said. He said this is what doctors deal with. This is the reality of being a doctor: You do the best you can, and people are going to die, and you’re going to self-flagellate, and then you have to work through it. It took me a couple of days to process. That’s what I think he meant.

In so doing, I realized that he himself, as a psychiatrist, was seeing suicidal patients all the time, depressed patients, and he had lost patients. So I sort of interpreted that to mean that I was part of the brotherhood now, that I had been initiated: You do the best you can, and you will lose a patient. He was pretty much telling me that. He was saying, “Welcome to the brotherhood.”

So that’s why I wrote this article, “Patients should never underestimate the self-flagellation of the physician,” because that’s always a fear that we have, that Doctor Death is in the room and we’re not paying attention to him. Something terrible is going to happen, and we’re not sharp enough to see it. That was the inspiration for writing that. In writing this book, I was pretty much trying to share the intellectual experiences I’d gone through during my career as a doctor, and that was definitely a memorable one.

Kevin Pho: Now, in the events leading up to that patient death, did you have any type of training? Did anything prepare you to accept when one of your patients died?

Janet Tamaren: Well, I had trained in the tertiary care hospital in Lexington, so I had a whole coterie of specialists surrounding me, and that pretty much buffered me. There was someone else you could turn to. There was always someone else you could blame, if it came to that. But working in rural health, I didn’t have all that buffering going on. So really, it wasn’t that much. No, there wasn’t any preparation for that. There was always an expectation that you would not make a mistake.

Kevin Pho: And immediately after that patient death, you mentioned that you weren’t ready for it, or there were all these emotions and feelings that you experienced for the first time. Take us through that in a little bit more detail. What exactly were you asking yourself? What kind of emotions and feelings were you going through at that time?

Janet Tamaren: It felt like a knife through my heart. It felt like just a hollowness inside, a grief. I had actually experienced that when my mother died, and I’d felt that same grief. It was a different flavor, but it was hard. With the grief, my family rallied around me. They saw I was devastated. My daughter flew in from Denver to offer support, and that was helpful. And the family who lost, it was a child. The family lost the child. They continued to see me, and they were not blaming me, and that was helpful.

Just over time, I could regain an equilibrium and be that much more aware, though, that you had to secure your patients against any intrusions of Doctor Death. You had to put up more totems and more buffers and be even more vigilant. You had to protect your mental spheres so that you were not distracted. You had a distraction; I think it’s the death of the doctor. You have to be sure and keep your mind open.

Kevin Pho: Now, as you progressed through your career, I’m sure you’ve had other experiences with patient deaths. You mentioned some of the things that you did to protect yourself from some of the emotions after those deaths. So what kind of things did you do to better accept it whenever a patient unexpectedly passes away?

Janet Tamaren: Well, at some point I realized that by the time you see the patient in the hospital, they’re sick. So whatever brought them in, it’s already a larger situation. It isn’t just you at work here. Something has already happened which is not good, and you may be able to reverse that, or you may not. So it’s just realizing there’s something outside your scope of control, but trying to control what you could.

Kevin Pho: So when you talked to that psychiatrist immediately after that first patient death, he asked you, “Do you think you are such an excellent doctor that no patients of yours will die?” As you reflect on that advice, how has that advice aged over the years as you come to the conclusion of your medical career?

Janet Tamaren: You realize you can be an excellent doctor, you can do the best you can, but there are variables outside your control. It’s the risk of being a doctor. You’re in the epicenter of risk. You see patients who are very sick. You do not control all the variables, and you have to be prepared for the possibility that they’re not going to make it. The ones that were the hardest to take were the young people. It was an easier transition if somebody was already in hospice, for example; that was easier. But a young person who shouldn’t have died, that was where this calculus came into play.

Kevin Pho: We’re talking to Janet Tamaren. She’s a family physician and author of the book Yankee Doctor in the Bible Belt: A Memoir. She wrote the KevinMD article “Patients should never underestimate the self-flagellation of the physician.” Janet, as we enter the third year of this pandemic, a lot of us in health care are seeing unexpected patient deaths across all ages, and we have a lot of young physicians and medical students who listen to this podcast. So what kind of advice do you have for them, many of whom may not have experienced death?

Janet Tamaren: You have to be gentle with yourself. You are doing the best you can. You are not perfect. Nobody is perfect. All you can do is the best you can, and realize that you are in a field where the risks are sky-high. The likelihood of death is always lurking there, whether it’s 1 in 50, whatever; it’s there. It’s like a battle zone, and you do the best you can, and that’s all you can do, and be gentle with yourself.

This is one of the major downsides of doctoring: It’s going to be hard. It’s going to be hard if you’re in this war zone. There’s no easy way to do it differently. There’s no easy fix but to do what you can. And we all have to do this: Maintain your own health, your own mental health, your own social sphere, your connection with family. You have to reserve time for that, or you’re worthless. Although that’s not what they teach you in medical school. They teach you 36 hours on and 12 hours off, and you’re ready to go. That’s not really how life works.

Kevin Pho: And my final question: What are some of your take-home messages that you want to leave with the KevinMD audience?

Janet Tamaren: In general, in going through the stories my patients told me, there’s a lot of good. I just described the bad in doctoring, that you’re in a war zone sometimes, but there’s a lot of good in there too. I’ve been reading your articles, the articles on your website, and there’s a lot of despair and pessimism. As for what’s good about being a doctor, I just want to throw out there that there was a lot to enjoy when you weren’t in the war zone, and even in the war zone. Even in the war zone, if you were navigating somebody in the ER who was seizing nonstop, and you had to implement Ativan immediately and get the chopper out there because you were in the depths of the rural, you know, 40 miles away from a major hospital, that was very exciting. So there’s excitement in many of these episodes, many of these high-adrenaline situations. That was exciting. That part of doctoring I found very exciting, and that’s a positive if you like the adrenaline.

The more common situation I found myself in was just talking to people, enjoying their stories, enjoying their lives, getting to know people, getting to spend time with colleagues, having intelligent conversations with colleagues, and the challenge of figuring out what was wrong with somebody, if it was a challenge. If it wasn’t a challenge, if it was otitis media in a small child, which presented very little challenge, it was still fun talking to the kid and goofing around with them. So there are a lot of pleasures in the world of doctoring, depending on which physical space you’re in. The quietude of a family medicine office, looking at earaches, that’s one level of interaction, and in the ER, dealing with trauma, that’s a different one. But there are a lot of challenges, and there’s a lot of pleasure in it, and in getting to know people.

And also, the one thing that I walked away with, and that I’m still aware of: My patients taught me so much, so much. They taught me a lot about medicine. I know we call it the practice of medicine; we’re supposed to pretend we know what we’re doing, but I learned a lot as I was going. They taught me a lot. They probably didn’t want to. Often it was something difficult that they had, something unpleasant, but it was always educational for me. They taught me how to deal with difficulty, how to deal with illness, how to deal with impending death, how to watch a loved one die, and how to go on after that. Those are important skills. They taught me what bipolar disorder looks like in a loved one. They taught me what dementia looks like in a loved one. They taught me what aging looks like. So in many ways, they prepared me for whatever is coming down the pike in my own life and gave me the ability to have a long view on various deep topics.

Oh, they also told me what death looked like. That was also very helpful. There were a lot of patients in the hospital who were under the care of hospice, and in some ways that was reassuring. Often, as they were dying, they would be talking to people who weren’t there. I had a gentleman who was in his 70s and dying of lung disease. They all died of lung disease; this was a smoking area. I came to visit him, and he was talking to his mother, who wasn’t there. You know, she had died years before. He was the uncle of my, everyone knew everyone, he was the uncle of my office manager. She asked me how he was doing. I said he was talking to his mother, and she said his mother died when he was born. He never met his mother. But it was kind of comforting that as people die, or as they go through this final transition, they’re seeing people, they’re talking to people, loved people, and that somehow was comforting. So they taught me things.

Kevin Pho: Janet, thank you so much for coming back on the show and sharing your stories, time, and insight.

Janet Tamaren: OK. Thank you for having me.

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