Don’t blame others for the burned-out road you are on: It is your own “Ass-Phalt.”

OK.

I know that sounds harsh. We, physicians and other clinicians suffer under the demands of irrelevant EMR guidelines, insensitive hospital administrators, and tyrannical medical–big pharma dictates. However, all these are “external” forces. They are not our “phault.” But what about the “internal” forces, forces that may be, in some way, our “phault” (or at least under our control)? What about those forces intrinsic to our DNA?

“Burnout,” so goes the conventional wisdom, leads to “moral injury.” And “moral injury,” we are told, occurs because our actions (or our feelings) don’t match our values.

Let’s take this one step further.

Burnout, moral injury, and the mismatch between our values and our actions are, I believe, founded on two “internal” self-generated myths, myths intrinsic to our DNA. These myths are myths that we impose on ourselves, but they are also myths that we may have control over.

Let me explain:

Myth #1: “I should do things right!”

I am a neurologist, retired now, but when I was in practice for over 40 years, I confronted the following type of situation over and over. Let’s say, for example, the family of a Parkinson’s patient calls my office. Dad is going downhill. They want him to be seen by me, pronto. But I can’t do it. It is just not possible. It is Friday afternoon, and I already have several work-ins. So, I give my medical assistant some advice for the family, hoping it will keep them satisfied. But if I lived up to my values, which I have posted on my homepage and which declare: “I will treat all my patients like family,” then on that day (and many days like it), I did not live up to my values. I did not treat my patient like family. If I did, I would have seen the patient in person. Another day, another patient, and again, “I did not do it right.” Another day when the moral injury knife thrower hit a bullseye.

Folks like me had been taught to “do things right” all our lives. We produced. We achieved. If we got a “B” in middle school, it was a family crisis. We aced our PSAT, SAT, MDCAP, and match days. Many of us came from immigrant parents. We were the great hope of our families.

We memorized the Krebs cycle, for gosh sakes!

We do it right! Except when we can’t. (Which are many of our working days.) And those are the days, little by little, we suffer moral injury. The days when our actions don’t match our values. For over 40 years, I have borne witness to that.

Myth #2: “I should do it with compassion.”

Remember that person with Parkinson’s?

When I got the message, guess what?

I did not feel compassion.

I felt anger.

I felt anger at the patient.

I felt anger at the family.

How dare they call me at 4:30 on a Friday afternoon to demand I see their dad!

I felt angry at my medical organization for putting me in the position of not being able to see this patient in person.

And I felt angry at myself … for being angry at all this stuff.

And to tell the truth, I was getting a little annoyed with God for creating all these folks with defective basal ganglia!

And therein lies the second myth of moral injury,

I should have treated my patient and his family with compassion.

I did not.

I should have at least felt compassion.

I did not.

Thus, my actions (or feelings) did not match my values.

And, again, the moral injury knife thrower hit another bullseye.

Thus, two self-generated myths:

“I should do it right.”

“I should do it with compassion.”

These myths (and not only the EMR, the hospital administration, or the medical-Big Pharma industrial complex) can lead us down the road of burnout and moral injury. These are the self-imposed, self-generated, DNA-intrinsic burdens that may be our “Own Ass-Phault.”

And yet, there is hope. There is perhaps something we can do to overcome the consequences of these two myths. I am not suggesting we change who we are at our core. I am not suggesting we become less conscientious. I am not suggesting we become less compassionate. But perhaps, there is a way we can “repave and repair and cruise happily on our own ‘Ass-Phault.'”

Let me share an example from my own experience of over forty years practicing neurology.

Joanne is a 38-year-old housewife and mother of twin girls aged ten sent to me for a consultation. Joanne’s own mother died suddenly of a brain aneurysm when Joanne was 13. She was referred to me because although a brain MRI showed no aneurysm, it did show a minor abnormality. I examined Joanne and reviewed the MRI. Everything was perfectly fine. The MRI showed an incidental, harmless finding, a “nothingoma.” As I reassured her and as I was making my exit, Joanne grasped my hand between hers. “Oh, doctor,” she tearfully exclaimed, “thank you so much. I was so worried. I am so grateful to you. God bless you, doctor.”

To be honest, I was embarrassed by this effusive praise. All I did was review a routine MRI.

“Joanne,” I said, “No problem. It was nothing.” But later that night, I got to thinking about this. Then, I realized:

To Joanne, this was not nothing.

To Joanne, this was something.

To Joanne, this was a big something.

And this should have been, to me, something.

This should have been to me, a big something.

I should have cherished that moment as much as she did.

I saw a bumper sticker a while ago. It read:

“It’s amazing how you can affect someone’s life so deeply and never appreciate it.”

I will confess. For much of my medical career, in this situation, I would have been in the category of “never appreciate it.” But I now understand, for Joanne, that encounter was a life-affirming blessing. And I now understand that, for me, that encounter was not just a routine “waste of my precious time” consultation but was just as much such a blessing.

And to all my physician colleagues, let me ask this question:

How many of us are in the category of “never appreciate it?”

How many of us ignore the powerful blessings of our everyday “nothingomas?”

And yet, if we could approach each patient with self-appreciation for the impact we might have on their life (even for a “nothingoma”), if we could approach each patient encounter as a “gift-giving” blessing, then perhaps we could feel that our actions (and feelings) will match our values. Perhaps we could find our daily professional life filled with more joy and meaning. And perhaps we could then “repave and repair and cruise happily on our own ‘Ass-Phault.'”

Scott Abramson practiced neurology with Kaiser Permanente Northern California for over 40 years, from 1979 to 2020. Throughout those years, Dr. Abramson was passionately involved in physician communication and physician wellness endeavors. Some of his insights and stories from his experiences in these endeavors can be found in video format on his YouTube website channel: Doctor Wisdom.