Tuesday, March 05, 2013

Job Satisfaction

I read an article the other day of a survey of practicing doctors. This included questions related to job satisfaction, salary, and if one could do it again, would they pick the same specialty.
I wasn't terribly surprised with much of the answers for endocrinology. Close to half of those surveyed stated they would have picked a different specialty. Many reported a lack of satisfaction with the work.
Though this field deals with all kinds of hormonal disorders, due to the current health climate, most of our day is spent seeing people with diabetes mellitus.
Because diabetes is one of the unique conditions where direct, hands-on self-management by the patient is vital to success, endocrinologists have very little control over outcomes.
It's a concept scary to many patients: You want me to self adjust my insulin doses? Why can't you just tell me how much to use? (Because I see you only every 3 months but in the meantime, if your glucoses are consistently out of your goal range, it needs to be adjusted periodically. And because I am not there when you are eating; so you need to count your mealtime carbs to properly dose the prandial insulin).
I liken it to driving. You can't tell someone over the phone how to drive. You provide them with the teaching. And then when they are on the road, they are required to turn left, or right, or brake or speed up, based on what they see real-time.
And so, to do well when one is on multiple daily insulin, regular glucose self-testing and relatively independent self-adjustments are necessities. It's a tiresome and expensive process, unfortunately. But it works, and until technology evolves, this is the best we have.
Herein lies a tiresome phenomenon I see repeated daily. Patients very frequently walk in with no glucose data, and very frequently missing their insulin shots. Often they just shrug their shoulders, or smile guiltily. Or some who test and have been consistently hyperglycemic for the last 3 months but have not increased their insulin.
It's a pleasant enough visit- I enjoy seeing my patients again, hearing about their family. Professionally though it is frustrating; hemoglobin A1c 9%, 8%, 9.2%, 9% over and over again.
And I imagine many are like me; I don't see patients as dollar signs walking in my door- rather (believe it or not) I do want my patients to do well, to remain healthy despite having diabetes. And so, I know I for one do personally take it as a sign of failure on the healthcare team's part, when things remain uncontrolled.
Despite reminders, numerous visits with the doctor and the diabetes educators.
There are days when I come home beaming because I feel that I made a difference; but there are often days when I come home feeling like I did nothing.
One factor is obviously cost and inconvenience. Another however, which is the real silent killer, is the lack of urgency. When a doctor tells a patient "You have cancer", or "you had a heart attack", people jump. They know it's dangerous and something needs to be done.
When you tell someone their diabetes is badly controlled, many ask: So what? Why do I need insulin if I feel good now, never mind my bloodtest? Uncontrolled diabetes is the leading cause of blindness and kidney failure, and a major contributor to heart disease. The disconnect is that we are talking about the future. It's not a tangible risk.
But the greatest tragedy is once the complications set it and they start to worry about it and try to get things under better control, the damage is done. You can prevent it from worsening, but you can't undo it.
Thus, am I surprised that many endocrinologists find a lack of satisfaction in their careers? No. It reminds me of some good friends, great patient people, who surprised me when they quit practicing medicine to join a pharmaceutical company. Maybe it was the hours. Or maybe they just got tired working with patients.
No, I can't see myself doing that; I love the patient interaction too much and would hate to give that up. Have I been tempted to do something different? Definitely.

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