Survival of the Fittest

An observation that I and many of my emergency medicine colleagues have made about vacations: we need them. We need them for wellness, to recharge, to recover. Great saves, terrible tragedies, we witness it all and it can wear on you. Unfortunately, when vacation plans are made, it is not uncommon to find oneself working even more shifts before the break to offset our absence on the schedule, making the time away absolutely critical by the time it rolls around.

And so after ten shifts in thirteen days, I find myself exhausted, unprepared, nervous, on a hot, humid bus that is supposed to be taking us to the dock but instead slows unexpectedly. A land iguana, a golden brown ancient dinosaur, creeps off of the road into the side brush. Piling off the bus, we are directed toward a concrete platform adorned with huge lounging marine iguanas. I gather my belongings and catch myself from stumbling, nearly stepping on an iguana’s whiplike tail that seems to have appeared right next to me. It spits salt water at me in retaliation but does not move. Sally lightfoots scuttle along the jagged shore, red as the lava the rocks once were. When I ask which boat is ours, I am interrupted by shouts of “Blue footed boobie!” causing me to forget the question I just asked. This is the first hour in the Galapagos.

Land iguana

Land iguana

In the days to come, the glee and sensory overload continue with sea lions, sea turtles, giant tortoises, and a collage of birds. Frigate birds above the top deck of the boat, reverse shadows hovering overhead; red footed, blue footed, and Nazca boobies with all of their baby boobies a beak’s length away (“we love boobies!” becomes our ongoing joke); the race to spot the well camouflaged short-eared Galapagos owl as it hunts the swarms of petrols endlessly rolling and unfolding over their spawning ground.

Of all the Galapagos birds, the most unassuming and the least flashy is the finch, yet it is the star in the modern story of the islands. The Galapagos finches of fame and lore are the object of decades of study by modern evolutionists. They fall into categories of seed, insect, bud, or fruit eaters that very specifically dwell in different locales: ground, cacti, or trees. Within the subspecies, variations of tenths of millimeters in beak length may decide which finches survive the harsh dry season and which do not. Evolution occurs before your very eyes, day by day, hour by hour, minute by minute. A fragile ecosystem with die-hard inhabitants.

A Galapagos Finch

A Galapagos Finch

It is impossible, as it turns out, to not think of evolution daily as we tour the islands. Even approaching each island by panga, a quick survey of the visible desert vegetation from shore reveals whether cacti-feeding reptiles are present. Cacti shrubs indicate no ground reptiles (nothing to drive those succulents off the ground); cacti trees indicate ground reptiles (if the cacti wish to survive). And every time we leave our panga to board the boat we call “home,” we offer our shoes and lower legs to a garden hose spraying seawater, washing off traces of the island we were just on. Knowing that the accidental transfer of one stray seed could potentially throw off the delicate balance of the next island, the consequences of action and reaction lie heavily on us. Leave no footprint.

When I find myself on the verge of sea turtle sighting fatigue, vacation is over; just long enough to have developed a vacation routine and sea legs, to have forgotten the emergency department that I find myself working in less than twenty-four hours after returning to the U.S.

A Galapagos Green Sea Turtle

A Galapagos Green Sea Turtle

The restorative time away quickly becomes a distant memory, overtaken by the immediate pressing needs of my patients and the environment in which I practice. Not even halfway through my shift, my vacation is virtually scrubbed away with tears, threats, tragedy, lies, and desperation. An unexpected death of one patient, another trying to convince me that he is safe to go home while simultaneously boasting that he has just obtained his “blue card” (license to obtain weapons in Rhode Island), another admitted for sepsis, her infection worsening, having filled her doctor’s prescriptions selectively (opiates trumped antibiotics), not to mention multiple complaints about wait times and lack of hot food or accommodations such as blankets and fluffy pillows — I leave the hospital with my heart heavy. The only reminder of the vacation I was on the day before is the rocking sensation when I lie down for bed that night.

The emergency department is not unlike the Galapagos’ harsh dry season environment: scarce resources, fear of the unknown, life hanging in the balance. It is in this context that I find myself newly thinking about evolution and my own survival. I am in the dawn of my emergency medicine career, less than five years out from residency. At a time when I am finding my stride, I’m hearing from more experienced colleagues about “burn out” and “exit strategies” and beginning to worry about the evolution of the role of the compassionate physician. Morale is low amongst many physicians, taxed for time, torn between the business of medicine and the patient’s bedside. It’s a struggle not to be affected by this plague. How can I ensure that I am fit enough to survive the compliance pressures of the medical industry, the inherent strain of the emergency department environment, and the tough patient encounters with my altruistic compassion intact?

Marine iguanas

Marine iguanas

On that first day back from vacation, I walk into a room and ask one simple question, “Why have you come to the emergency department today?” In response, I am called a “bitch” and “stupid” by the patient and her husband. It is only through a conversation with the police officer who brought them that I can discern what their potential emergency might be. I discover that they were equally offensive to a bank teller who then called the police. The officer, unable to differentiate between public intoxication, an underlying psychiatric issue, or just bad behavior, brought both of them to the emergency department, society’s so-called “safety net.” He leaves them in my care, believing that I can expertly tease out the etiology and ignores that they are continuing their abuse and directing it at me as I attempt to do so. As opposed to the bank teller, I am expected to rise above the insults and threats, turn the other cheek and genuinely care for their underlying health needs. I would like to say that this situation is an uncommon occurrence, but sadly it is all too common. There is inherent conflict in this concept, that I should care for a person while he or she is attacking me. And yet, despite this clash of concepts, I do it all the time. But I worry that my steadfast professionalism in the face of such conflict is causing cracks in my foundation of compassion.

Like the long beaked cactus finch that feeds on the blooms of the cactus tree, a resource available even in the dry spells, will this harsh emergency department environment select for certain traits in my species? Must the species of compassionate doctors evolve the thick skin of cynicism to survive? I hope not, yet that is the fear that is driving me to search for outlets for such encounters in these harsh environs, creating my own respite care plan so that I am steadfast in always choosing empathy over cynicism, preventing my degeneration into an untrusting and uninvested doctor. Thankfully, unlike true evolution, I do not have to wait for the test of time to witness my survival. I can and must remove myself from the trenches on occasion, reflect on my situational responses and performance, and then identify what resources I need to navigate forward in this field. Our work as physicians is difficult for sure, but these difficulties can be offset if we remember to allow ourselves the chance to consider the motivation, the rewards that bring us back day after day.

Relaxing on a park bench

Relaxing on a park bench

Experience is gradually revealing that the ability to appreciate and value the rewards of this profession are dependant on my own wellness. Expert at taking care of others, I have been a slow learner at how to take care of myself. The phrase “physician heal thyself” is often cavalierly tossed around amongst me and my colleagues, but when seriously considered in the literal sense, that a physician must come from a place of well-being in order to best deliver healing care, it is quite profound. Logical for sure, it is also in direct opposition to what our training and practice sometimes seems to demand. Survival depends on wellness and wellness, I’m learning, is an individual journey that traditionally hasn’t been taught.

But I am trying, and this alone feels like a victory. Self-reflection as a practice takes time and careful consideration, the antithesis of the emergency department environment in which I clinically operate. I know my own survival depends on it. That and remembering that after some shifts, the best I can do is to hose off my shoes and try to start anew the next day.


Nadine Himelfarb (@DinaHfarbMD) is an Assistant Professor of Emergency Medicine (Clinical) at the Alpert Medical School of Brown University. A former classicist, her interests in medicine are medical education, medical history, and narrative in medical humanities.

5 responses to “Survival of the Fittest”

  1. Amy says:

    Lovely, Dina. Thank you.

  2. Liz says:

    Beautifully written. Thank you! Critical longevity tools for the physician are certainly vacations, and colleagues like yourself that are honest, compassionate, and put to words what many feel, but can’t express so poignantly. There is comfort in realizing you are not alone in these sentiments!

  3. Alexis says:

    Just lovely. Thanks.

  4. Deb says:

    Great piece, Dina! Beautifully written and really rings true for physicians and their family “wellness teams.”

  5. Alyson says:

    Wonderful! Many sentiments hit home….