“I can't share patients with you any longer, Mark!” she said, shutting the door to my office with such force that it punctuated the end of her sentence with a percussive exclamation mark.

Both the doorframe and my self-assurance were rattled by my partner in practice. As a palliative care specialist, she was one of my most levelheaded colleagues. For years I had watched her conduct end-of-life conversations with a perfectly attuned mix of compassion and calm, so to see her genuinely upset was a jarring departure from her normal demeanor.

She continued: “You can't keep giving these people false hope. And I refuse to play the bad cop to your good cop when I'm the only one between the two of us telling them the truth.”

As was often the case in our dyad, we had recently shared a patient teetering on the very precipice of death. I was an optimist to the end, literally; I had hung my own hopes on a last-line chemotherapy while the noose of terminal cancer constricted inexorably. Worse still, I had persuaded the patient and his family that it was worthwhile to attempt a Hail Mary regimen that could only be administered in the inpatient setting. The prayer brought no deliverance. He died in the hospital.

My peer had been both rigorously impartial and profoundly sympathetic. She had correctly surmised that my final gamble was extremely unlikely to succeed, to the point of imprudent prescribing. But I had felt compelled to try, even against daunting odds and the risk of her righteous indignation. Ultimately, the trolley problem of medical ethics had guided me towards action over passivity, swaying my ambivalent conscience to pull the lever of intervention rather than allowing the aggressive disease biology to run its rampant course.

The days that followed brought the patient's final reckoning and my own posthumous recrimination. Our surgical colleagues have protocolized these ex post facto analyses into morbidity and mortality (M&M) conferences they attend in groups. But most medical oncologists must convene a personal M&M through unflinching introspection. When I did so, it did not afford a pleasant view of my interior.

I found a doctor who was stuck between first doing no harm and yet necessarily hurting to heal. The moral distress became as cyclic as the chemo through which, despite the best of intentions, I inflicted indiscriminate toxicity. The Latinate triad was sequenced as follows: violating the categorical imperative of primum non nocere, hawking chemotherapy to a desperate clientele without enough emphasis on caveat emptor, and then memento mori after I could not postpone the inevitable. I was Willy Loman inverted in a white coat; rather than experiencing the death of a salesman, I became the salesman of death.

The intersection between clinical practice and the commerce of the healthcare industry already made me wary of profiteering from suffering but, if I was being brutally honest, I was also swindling my patients out of more peaceful ends. Tightrope-walking the line between what we can do and what we should, I was leaning too heavily towards the former. And then I fell.

As the son of a preacher man, Sundays have always held special significance for me, so much so that I like to believe I would have entered the ministry if I hadn't been called to medicine instead. With my pedigree and my Protestant guilt at breaking a generational chain of clergymen, it was natural that I would look for assuaging parallels between my father's pastoral care and his wayward son's secular profession. But the most authentic Christians bear witness (they don't pretend to be the savior themselves),whereas the inflationary needs of my own ego were approaching blasphemy. Rather than respecting the Sabbath I would spend each Sunday in a wrestling match between self-doubt and self-belief. I would panic that my patients were dying in droves simply because I wasn't good enough at my job, then resurrect my confidence with an over-correcting bravado. These mood swings as I prepared for the coming workweek became a pattern so obvious to my family that they began to call them my “Sunday scaries.”

Many animals conceal fear with bluster, and I was no exception. To the outside observer I may have been projecting an unmerited swagger, but no patient with cancer really wants an oncologist who looks too unsure of their acumen. Of course, nobody really *wants* chemotherapy either, so it is up to their physician to convincingly demonstrate a therapeutic need. Providing such appropriately wise counsel is key to the art of cancer medicine; it mandates not just lifelong learning of best practices but constant re-examination and re-calibration of one's judgment. Otherwise, hope mutates with worrying ease into hype, and over-promising becomes twinned to under-delivering, making one even more likely to see the next case as an opportunity to redeem past failures.

The spiraling, gnawing sense that I was becoming a con artist was one symptom of impending burnout, and I was self-medicating with arrogance. But if the physician who has himself as a patient has a fool for adoctor, then it took the bracing objectivity of a concerned colleague to break my mirrored gazing at a charlatan. Throughout our years of comanagement, she had earned my respect for both the accuracy and the humanity of her prognostications. It was no different when she worriedly showed me my own stark, dark future if I continued to lead my patients into temptation and myself into delusion. For all my provision of “salvage therapy,” I was also in need of rescue.

Even now, as I write these words, I know we have a medical culture that prizes gritty suppression over heart-on-sleeve admission, that refuses to acknowledge doctors' susceptibility to the same cognitive biases and crises of confidence that affect every fellow human they treat. Yet, if we do not tend to physicians' mental health—which sometimes requires the uncomfortable incisiveness of authentic inquiry into a work partner's inner well-being—we are doomed to one of two unfavorable outcomes: the self-immolation of emotional over-investment or the robotic detachment of an automaton going through the motions. The proper stewardship of trauma requires us to again balance under- and over-treatment, but this time we are the recipients of our own ministrations.

In over a decade of formal medical training, I was never taught that self-care isn't selfish. I had to learn as an initially skeptical autodidact that it is, in fact, a vital component of the renewal, a remedy that staves off job dissatisfaction and poor performance. We can be both our own worst critics and our best hopes of grace, which must be dispensed before it can be accepted. Slowly and stubbornly, I began to forgive myself for what I could not have foreseen or forestalled.

A sage friend put it this way: “Mark, the best climber in the world can reach the summit, look down, and see that there was an easier way up. But you can't know that from the altitude of base camp. You just have to commit to a route and go.”

So no, I still cannot always see the correct path from the outset; a carefully plotted ascent can pitch and plummet suddenly into a crevasse. But I am becoming more comfortable with navigating the uncertainties of the present. Recognizing my own pitfalls (overbearing pride on one side, self-lacerating contempt on the other) makes me a better guide for my patients. Their mountains are calling, and I must go.

Source of Support: None. Conflict of Interest: None.

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