the serenity prayer.

I was recently reminded about the existence of the serenity prayer. I have not thought about that prayer for many years. I was so happy to run across it again because I have completely lost that truth in my life. It used to resonate so deeply for me. I remember hearing it for the first time in 1st or 2nd grade, sitting in a pew at Holy Rosary church one Friday morning, and writing it down on my hand so I could remember to tell my mom how wonderful it was!

It is such a valuable knowledge to understand in medicine.. It is also something that I really struggle with having lost in medicine. I think the one thing, in particular, of all the things that has made me really unhappy since I embarked on this journey of "medicine" is the loss of the truth of that simple prayer...

Grant me the serenity to accept the things I cannot change.. the courage to change the things I can.. and the wisdom to know the difference.

It's so lacking in my life. My mind in medicine has become a vicious tangle of cynicism, hopelessness, and confusion.

I attended a lecture this week by a family doctor presenting his experience in the realm of practicing family medicine "since residency." He separates the concepts of the reality of the world from the pain of residency, as all physicians do. Residency being a harsh "right of passage," "survival of the fittest," "perseverance through pain," "i have gone more hours than you have without sleeping," "i have lost all ability to feel happiness," and similar crap. The real world being.... something else, to be determined. Something really humane. Unjust, but still beautiful in it's own way. The whole interplay of people dancing to an offbeat song.. Some people are smart, some strong, some weak, some passionate, some desperate. All of us somehow co-dependent but existing in our own private scope of reality. We all dance together, and one day inevitably periodically all join one another through medicine...

So this doctor made one of his points via a PowerPoint slide.. He had a circle depicting his idea of the interaction between a patient and a physician with various factors jumping into the circle.. you know, you've probably heard one of these talks that are given by people who spend more time designing models and less time actually interacting with human beings... things enter this circle, for example like "patient's expectations, doctor's time constraints, etc.." Then in the midst of this elaborate, construed circle - he pressed his *next* button, and a heart jumped out from the middle with the words "Respect and Trust."

His point being, obviously, that in order for the "circle of patient/doctor relations" - or whatever you want to call it - to have a life, it must have at it's heart a foundation of Respect and Trust. Physician to Patient, and Vice Versa.

Respect and Trust. For others, and for oneself. What a beautiful and idealistic model..

Interestingly, I am sure that this is what Residency has torn away from me. This is me Laying Blame.

I find some messages really difficult to digest. Interestingly, most of them are from my residency advisor. I realize these nagging messages remain in my consciousness because there is probably some truth to them that I do not want to admit to... Why am I "getting exactly what I am supposed to from residency"? What is that exactly? Is it the sorrow of realizing and knowing that nothing that I do really matters at all in the end? Is it the pain that comes from recognizing that I have been serially manipulated, repeatedly injured with malicious stabbing at the tiniest, softest area of unarmored skin still remaining as I build up more and more armor and scar tissue to protect myself from bleeding to death while a shower of arrows of unrealistic expectations comes flying at me from every direction I turn? Is it the acceptance of the simple fact that gross and harsh injustices will continue to occur over and over in this life, especially in medicine? Is it about recognizing that, shockingly, I am still somehow able to rally the last ounce of strength I have to do the right thing during those rare moments when it is absolutely clear to me what that is? Or is it the knowledge that I have strength to attempt to try again when I fail to do the right thing because I am too weak or too tired or simply don't know?

I realize, as I vomit this stream of consciousness into words, these "things that Residency has taught me".. that perhaps I am talking about the message of the serenity prayer.

I remember the serenity prayer being such a simple, straightforward, and beautiful prayer when I was younger. I remember it being something that was so clearly true. Now, as I look at the words of it, I feel sort of exhausted and spent. I recognize the truth of it, but I am doubtful that I have the energy to act upon it. Maybe that is the dividing "knife edge" between Residency and The Real World. Maybe what Residency is teaching us is how to figure out what it will be worth spending our time and energy on once, if ever, we have time and energy again.

And it's true, I have learned that lesson. "Things that will be worth spending my time in energy on" are more clear to me now than ever before. That is something I know I have learned.

Now back to this message of Respect and Trust as a foundation of patient/doctor relations... Respect and Trust for others, and for oneself. A beautiful and idealistic model..

And what a complete load of crap.

If there is another truth I have definitively, no doubt, for sure learned in medicine, it is that there is much more often than not very little "respect and trust" floating in the space between physicians and patients... Much more often, there is a deep chasm stuffed with of lack of understanding about diseases and life circumstances, distrust in motivation, suspicion about each other's compensation, goals, options, objectives, and there are endless cycles of enabling and manipulation.. Spend one week in residency. I promise this will become absolutely clear.

Nevertheless, the lecture was interesting. I was engrossed in this lecture for a variety of reasons.. Primarily because of my sheer desperation to grasp for some meaning or worth in what I have chosen to do with my life. What I have spent the last six exhausting years of my life learning about. The idea of a family doc imparting his "post-residency wisdom" was intriguing to me. His models were compelling, and I am a sucker for well-designed models that make absolute sense until you try to impose them onto reality, like a square peg into a circular hole..

By the end of the lecture, the concept of "Respect and Trust" sustaining the life of physician/patient relations nagged me enough to the point that I raised my hand and asked him these two questions...

"Do you have any recommendations for protecting your core of "respect and trust" against the natural cynicism that develops from being repeatedly manipulated, criticized, and abused by the people you are trying to help?"

and..

"Do you have any recommendation for regaining a personal sense of "respect and trust" for yourself after you have lost it when you make a devastating mistake that was the direct result of trying to take on too many things by yourself as a family doctor?"

I felt, at the time, that his answers were so disappointing and empty... he had no answer for me..

He said, to the first question, that he learned his strategy for dealing with manipulation, criticism, and abuse when he was working for a penitentiary clinic. Whenever this happened, repeatedly, he would turn to the officer security guard at the door and ask for the patient to be escorted out, welcoming him to return when willing to engage in a mutual discussion..

I thought, he is describing Cowardice and Abandonment.

But maybe he has decided to Accept Things he Cannot Change.

To the second question, he answered that everyone makes mistakes. But he feels that the overall balance of his work has trended toward the positive...

I thought, he is Making Excuses for his mistakes, which are our own fault for trying to take on too much.

But maybe he simply has the Courage to Change the things he can.

The fact that he is still alive after many years of practice indicates that he must have learned some wisdom to know the difference between those two. Because if you bash your head against a brick wall enough times trying to change things that will not change.. you will kill yourself. If you lose all sense of self worth and progress in the quicksand of stagnation, fatigue, and self-deprecation, you will kill yourself.

He concluded his lecture by making us write down something on a business card... (yes, it was one of those lectures..). He wanted us to write down something that reminds us about why we are still doing this work.

I quickly scribbled down "hope for change" as my mind distractedly wandered off to the chaotic day I was about to face, starting with rounds..

As I was walking back to the hospital, one of our exceptional and extremely idealistic interns confided in me that she could not think of anything to write on her card...

September, month #3...

I gave her mine and she looked at it.. we were silent for a second, then we both laughed.. It was the type of laugh that is sad and mocking.. you hear it from people sometimes who have lost something essential to them and feel it deeply.. like when a child first goes through puberty.. a person goes through a divorce.. an idealist loses their belief system..

Maybe she's "getting exactly what she is supposed to out of residency."

Maybe I should give her a copy of the Serenity Prayer.

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God grant me the serenity
to accept the things I cannot change;
courage to change the things I can;
and wisdom to know the difference.