Summary

An emergency physician reflects on his career and contemplates the value of recertifying for the third time, weighing the impact of his work against the societal and personal challenges he faces.

Abstract

The article presents a personal narrative of an emergency physician at a crossroads in his career. He recalls the atmosphere of his first ABEM re-certification exam in 2000 and contrasts it with his current situation in 2020, where he is considering whether to recertify for the third time. Despite the initial allure of Emergency Medicine—variety, immediacy, and the satisfaction of problem-solving—he grapples with the realization that his role may contribute to enabling harmful behaviors and the broader societal issues he encounters daily. He shares his experiences with patients, ranging from the rewarding to the deeply troubling, including cases of abuse, addiction, and societal neglect. The physician questions the ultimate impact of his work, given the recurring nature of these issues and the limited control he has over patient outcomes. He also reflects on the positive aspects of his career, such as teaching and mentoring, but remains conflicted about his future in the field.

Opinions

The author feels that emergency physicians may inadvertently enable harmful behaviors by providing immediate care without addressing underlying issues.
There is a sense of disillusionment with the profession, as the physician confronts the repetitive and often futile nature of treating preventable conditions.
The author expresses frustration with the healthcare system, which often fails to provide adequate support for the homeless and mentally ill, leading to inappropriate use of emergency services.
Despite the challenges, the physician acknowledges the rewarding aspects of his work, particularly the opportunity to teach and mentor the next generation of doctors.
The article conveys a deep ambivalence about the value of recertifying for the third time, with the author questioning whether continuing in his role would contribute to or alleviate the "horribleness" he perceives in his professional life.

A Recertification Exam Forces a Doctor to Question His Future

Assessing My Professional Life — Press On or Move On?

The year 2000. I’m sitting in a semi-fancy hotel ballroom near LAX along with several hundred slightly edgy Emergency Physicians. We’re all awaiting the start of our ABEM written re-certification examination.

This was in the old-school days of live re-cert exams. We had an MD Master of Ceremonies, a famous EM leader. I can still remember his message to the assemblage. “If you’re re-certing for the first time, welcome, relax, good luck and you’ll do fine.” (His subtle recognition, that I was young enough to remember some of what I’d learned in residency, was heartening and slowed my palpitating, somewhat.) He continued…smiling, “If you’re re-certing for the second time, my condolences!” Polite titters and a few groans issued from the crowd.

I partly missed his meaning then; now I understand. Then, before telling us to break the exam seal and pick up our #2 pencils, or whatever it was we did to start, he said “If you’re re-certifying for the 3rd time, you’ve done something horribly wrong in the stock market.” And without having to state it, his one arched eyebrow and sardonic grin drove home “ … and in your life.”

The year 2020. I’m supposed to re-cert for the 3rd time. With the dual soft landings of Medicare and Social Security, and my non-horrible stock market performance, I don’t really have to re-cert to live. But I do find myself wondering, have I done something horrible … with my life?

Emergency Medicine drew me in because it allowed me to do good deeds. More seductions included … variety, immediacy, collegiality, and other treats. The “Sherlock Holmes” aspects of EM appealed to me. I got to figure stuff out, problem solve, do helpful procedures, comfort, and aid others.

Recently though a colleague ventured that we were likely the world’s greatest enablers, perfectly trained and positioned to prop people up just enough so that they could go out and hurt themselves again. Another wickedly opined, “this job makes me hate people.”

I know he doesn’t, and I don’t either, but I understand his shorthand. When I darkly disgorged to a now-dismissed therapist of mine that “I can’t remember saving anyone worth saving” he ping-ponged in return, “Maybe you feel like you’re not worth saving?”

I don’t know. I have “talked” some nervous dislocated shoulders back in, one or two even in the lobby, much to the disjointed’s relief. A few tension pneumothoraces have yielded to my ministrations, making me look heroic, briefly. Diagnosing pneumonia or pyelonephritis or a pulmonary embolism when the presentation is atypical allows for admission to the “thinking doctors” (AKA Internists). They then can keep someone alive long enough for the body to heal itself and a good life to continue.

Mostly though I remember countless knees and backs groaning under weight they were never meant to bear and countless-and-one requests for pain medications. This, when diet advice would have been the best path for the pathology.

Police bring in scads of disruptive homeless folks, leaving them to me. Often flinging “we can book you or you can stay here, your call” before departing. I understand why they do it, but the Emergency Department is not the right place for these unfortunates. Many of the left-behinds punch nurses, pee on the floor, screaming maniacally and demand services I couldn’t, wouldn’t and shouldn’t ever provide. One defecated in triage.

I can still see the room where I met two little girls, ages 3 and 5, bug-eyed, rampaging, tachycardic and skeletal, meth’d out of their minds after years living in a “cook” house. I provided benzodiazepines and food so they wouldn’t destroy the place, but I can’t fix that. Would it have been better if everyone, mom, dad, and their two tortured dependents had perished in an explosion?

How about the foster kid, age 5, beaten daily and starved, with a fresh sub-dural and circular buttock burns? We patched him up; and he left the hospital. His “rescue” parents went to prison, but I think we all know his pitiful life’s likely trajectory.

Wives killed by husbands and vice versa. Kids dead because of drunk-driving parents. Still-smoking COPD-ers on home oxygen, and “f*#k you doc” for hinting at even considering a smoking-cessation program. Cerberus, the 3-headed hound of Hades — diabetes, hypertension, and hyperlipidemia — when a 2-hour video, “Forks Over Knives” offers salvation. How about all the septic nursing home patients, begging to be peacefully released from life but subjected to tubes and lines, tubes and lines, and more tubes and lines, all to no avail?

I could go on and on, but I won’t. I do have a lifetime of horror stories in my head though, many with dismal, unjust, unfair, and painful endings. Many I’ve helped write, urging the narrative forward, seemingly in the wrong direction, if one considers the big picture. Our species is trashing the planet; and everywhere I look, individuals are trashing themselves. Am I driving the garbage truck?

Teaching, watching the light of understanding appear behind younger eyes, has been great. I’ve invested 20+ years in the graduate medical education world, working with students and residents, guiding, mentoring, furthering careers, hopes, aspirations and skills. You could say that that’s the son-of-enabling, possibly epic-scale enabling (since the ripples of my little stone in the pond of medicine fan out and touch so many other lives). But it feels less like it than being pressed directly against dysfunction you know you can’t heal.

So, am I to be a thrice “re-certer” and continue the horribleness, or do I flash forward and attempt 20/20 hindsight from the present, plus 2020 foresight, and call it quits? Or, do I focus on the goodness, recert, continue, and man up, realizing that you do what you can do, and outcomes aren’t always, or maybe even ever, under your control?

Where is that witty MD MC from my 2000 re-cert festivities when I need him?

Postscript

This dark-themed piece — a thin slice of the totality of my thoughts about my professional life — first appeared in the now-defunct Tincture https://tincture.io/year-2000-4fc3b6e18335.

I’m studying now, and plan to re-certify in EM soon.