Wednesday, June 7

OH HEY LET'S TALK ABOUT MONEY

In honor of everyone graduating and moving on to the next step, let's talk about money!  And by money I mean debt, because new doctors don't have any money!  All we have is bills to pay!

So I am the one who does the money things in our household.  It really happened by accident.  Matt was deployed shortly after we got married, before we had fully decided our financial plan as a couple, so all daily responsibilities were de facto handed off to me.  By the time he got back a year later, all the accounts and whatnot had my passwords on them and all the bills auto-debited out of my checking account so I could keep track of them (insofar as a medical student can keep track of anything besides the filtration system of a nephron).  Over the years of our marriage it has taken on a comfortable, natural sort of balance where we check in regularly with each other and the bills are somewhat more evenly distributed, but I still do the weekly bookkeeping and the nuts and bolts of our budget.  I like it.  It's like folding towels, which I also like - a nice, sequential task where the corners line up neatly with the bonus of a visibly completed task when I'm finished. 

That calm, simple task (money, not towels) kind of exploded once I graduated residency and everything changed.  Matt graduated law school and started working full time.  I switched from a modest salaried job to a higher-paid-but-extremely-variable hourly job.  We bought a house.  We sold a car and bought another one.  And oh, yeah - all of our student loans came due

I knew in a vague way during training that we had a lot of debt.  I would glance at it out of the corner of my eye from time to time, but everything was in forbearance or deferment, so nothing was due.  Out of sight, out of mind, amirite?  It felt insubstantial to me, like a theoretical concept.  And it's not like there was a way around it.  If we wanted to complete the training we had begun, then massive debt was part of the package.  Here I will also admit that I had a naïve, trusting sense that if my school didn't think we students would be able to pay the money back as physicians, surely they wouldn't be helping to get us all in such debt, right?  So I ignored it and kept working and surviving, and all the while the law of compounding interest ticked quietly away in the background.  I knew our debt was mumble-mumble-hundred-thousand-mumble-and-change, but I literally only checked it every few years when I was forced to.  And I had never even looked at Matt's student loans.  Law school was slightly less per year than medical school and it was a year shorter.  That was the full extent of my knowledge.

There is a reason that if you listen to Dave Ramsey and a caller states they have six figure student loan debt, he asks who the doctor or lawyer is.  It's because we accumulate student loan debt on a scale that most people never conceive of, and that's on top of "normal" things like credit cards and cars and family debt and having a mortgage.

When I took a deep breath and did the arithmetic, we were about $750,000 in debt.

Quite a number, isn't it.

Of course, I didn't add all of that up until about a year ago.  I promptly panicked.  It was only then that Matt and I finally sat down over lunch with a napkin and a pen and hashed out the basics of our repayment plan.  Could we have done it sooner?  Eh, maybe, but we didn't have all the numbers we needed to do the proper math, like my expected monthly income.  I certainly don't think we could have waited any longer than we did without ending up in some trouble, though.

Over the past year, I've learned a few things about money, which was necessary as I abruptly found out I knew nothing whatsoever about money other than basic budgeting.  Change was time consuming and mostly driven by need as we ran into financial thing after financial thing.  My colleague told me a horror story about blindly paying the minimums on her student loans for 10 years only to find out she still owed $150k, so we learned about refinancing and put all our loans on a seven year term with a better lender than the government.  We had cosigned a loan for a friend forever ago who was having trouble (please do not ever ever ever cosign anything for a friend EVER), so we learned about how to finally get some control of that loan to keep it from vomiting all over our credit.  I started listening to Dave Ramsey and reading The White Coat Investor.  We found out how behind we are on retirement stuff, yay.  And we finally got in the habit of throwing buckets and buckets and buckets of money at our debts.  We have paid a few small things off, which felt like a triumph.  The rest won't go away without years of consistent effort.

Here's roughly what our budget looks like now, in terms of percentage of our monthly income:

Tithe - 10%
Student loan payments ~ 40-50%
Retirement savings - 6%
Mortgage/ house stuff ~ 10%
Car payments ~ 6%
Other ~ 20-30%

I put things in the order we generally pay them.  It's not quite a painful way to live since we live in a cheap area of the country and we have never had a lot of money to spend anyway.  But I still worry sometimes, and clearly the two of us cannot afford to do less than work full time at the jobs we currently have for the next 5-7 years.  I especially always feel like that big retirement chunk hurts to lose, even though the reasons for it are sound.  We've settled into the plan and things are stable and workable.  I feel immensely thankful for that, considering how much worse it could be.  But I have to say... it's not really fun to have half your income going to student loan debt and to know that can't change for almost as long as it took to accumulate that debt.

I was talking to a premed student a while ago and she was telling me she got into multiple medical schools, but wasn't sure which one to choose.  One was the local state school.  The other was a private school in California.  We talked for a while about the similarities and differences, and then I offhandedly asked if there was much of a price difference between the two.  She turned sheepish.  Turns out the fancy California school was $30k more per year and she wanted to do family medicine.  I kinda lost it on her.  $30k per year becomes $120k on graduation becomes $150k after residency becomes a $2000 difference in monthly payments for 5-10 years.  Not very socially appropriate of me to lay it out like that, but she had never looked at it that way.  Last I heard she was headed to the state school.

So why bring all of this up?  Because no one ever talks to med students, residents, and doctors about money and it can really hurt us.  We shouldn't go to extremely expensive medical schools really ever, but especially not if we want to go into primary care.  We shouldn't take the max student loans out when it will cost us literally thousands extra a few years down the road.  We should learn about budgeting and investing and taxes and talk about it with each other so hopefully we can stop making dumb mistakes (example: I literally realized today that I have to be careful about how much money goes into my retirement account now because apparently there's a fee if I go over some arbitrary limit the IRS set.  This is called a contribution limit and it's really basic and I had no idea).  If it were just about money it wouldn't matter.  But as I explained to that premed student, money = freedom.  Freedom to have a long parental leave when you have kids.  Freedom to take low-paying work and get to missionary work sooner.  Freedom to support missionaries and sponsor lots of kids through Compassion International.  Freedom to leave medicine if you want.  Freedom to take a freaking vacation.  The list goes on.

So, med students, residents, fellow new docs, educate yourself as early as you can.  Treat debt like the enemy it is.  And talk to each other. 

Saturday, April 22

The Other Side of Passion

The other day I was talking to my dad about the terror I feel growing into my new career.  My shifts are generally split 50/50 between an urgent care clinic and my local emergency room, which is a level III trauma center (read: a normal busy ER with good specialists and equipment, but not with trauma surgeons or subspecialists).  I've been there about six months now, and I've only just started sleeping properly the night before a shift in the emergency department.  At first I would spend the entire twelve hour shift with my stomach tight and sweat running down my chest.  My drive home would be mostly exhale.  I cannot express how hard it is to complete nearly ten years of work and study, to "finish" your training, and then to realize, yet again, that you really know nothing.  It's a pit of the stomach feeling.  Sometimes there's shame.  Why don't I know more about that disease?  How do I not have that dosage memorized yet?  My patients need better.  My patients deserve better.

Sometimes I wonder why I put myself through it all.  I honestly don't have a concrete answer.  The only thing I have is what I told my dad at the end of that conversation.  "I don't know how it'll turn out," I said, walking contemplative laps around my living room, "but I have to satisfy this ambition in me."

So I listen to lectures in the car, and I review my procedures, and I learn from my colleagues, and I sweat and have sleepless nights.  There is an ambition in me, and until I have answered it and satisfied it, it will drive me. 

Saturday, February 25

Saying No

Teach more? Full-time academics? More emergency medicine work? Free clinic work? This week I said no to all of it.

When I was a teenager I perpetually went through boom and bust cycles of activity, where I would overextend myself for weeks or months at a time and then abruptly become an unreliable hermit for a while once my energy bottomed out. I always felt guilty about that. Other people seemed able to sustain one pace without suddenly giving out here and there. So once I got a bit older I became a committed believer in the power of 'no' to change your life. I started saying no to things all the time. I'm not going to do that. I won't be attending that thing. I will not be able to help you with that. No. No. No. And my life got a lot better.

Then residency happened. Residency is essentially one giant YES. You have one option to say no, and that is at the very beginning. If you say yes to residency, you have inherently said yes to everything in residency.* I'm not proud of how I handled that overall, but I am grateful that God brought me through it. I think.

I'm in an interesting stage right now where I have too many wonderful opportunities. Talk about job security - I could honestly work as much as I wanted and have as many jobs as I wanted, all of them good positions. This is new territory and it brings up old bad habits. For me, it's a real struggle to look at all of the ways that I could be helping people and growing and contributing and collaborating - and to have to say no to so many of them. I have to remind myself that I already have two jobs where I work more than full time and am climbing more than one challenging learning curve. It's enough. Often it's more than enough and I wish I could dial back even more than I already have. But there's so much more that can be done. There's so much more to do.

While I don't have a solution, it's a good problem to have. Can I say for certain that I'm glad that I didn't quit residency? No, I can't. But maybe one day.

*Don't get me wrong, there's always something optional enough that you can get away with saying no. I said no to everything I could. It just wasn't enough.

Saturday, December 10

Complex Redemption

There are some patients I saw during my time in residency that truly changed me as a person.  I've written about a few, but there are many more.  Here is what I have to say about one of them.  Names and other personal details are of course altered for privacy.

I took a deep breath, forced the best smile I could, and turned the doorknob.  Inside, Rosa sat in her wheelchair like usual; a few months ago we had celebrated her regaining her ability to walk with a cane after her stroke, but she quickly went back to the wheelchair as it was easier for her.  Today was our monthly meeting to discuss her chronic conditions.  In medicine we call this secondary prevention.  Primary prevention is focused on keeping someone from having a serious event like a heart attack or stroke, while secondary prevention tries to minimize the person's risk of another event occurring.  We are trying to keep history from repeating itself.  Rosa and I had been working together for nearly a year at this point, although perhaps "working together" is a misnomer; our appointments generally consisted of her giving one word answers to my questions, me setting some homework that she would promise to work on over the next 2-4 weeks, and then a short period of silence where I tried to discern something about her true mindset or intentions.  No matter my approach, I had never gotten any closer to her.  And she had never done a single thing she told me she would do.  She never checked her blood sugars.  She never drank less soda.  She never took her medications.  She wouldn't take walks or eat vegetables.  And she would never tell me why.  She just showed up, timely and polite and unknowable, for every visit.

As I entered, Rosa's aunt and caretaker glared at me silently from the corner - both aunt and glare cornerstones of our appointments.

"Hi!  How are you today?"  I asked Rosa.

She promptly burst into tears.  Her caretaker made no move from her seat across the room.

The deluge lasted at least five minutes.  I sat in silence with my arm around her, flabbergasted.  Where has this come from?  She had never given any sign of sadness before.  I handed her a stream of tissues, mute in shock and witness.

When it was over, she sniffled one final time, sat up straight, and said, "I'm fine."

I almost laughed.  "Rosa, what do you mean you're fine?  You basically cried on my shoulder for the past few minutes."

"I'm fine."

I pressed her but got little in response.  She wouldn't tell me why she felt so sad.  I asked if she wanted to try counselling and she said no.  I asked if she was feeling depressed and she did say yes, so we agreed to start an antidepressant that day.  A month later she came back for her check-in.  She hadn't taken the antidepressant.  When I asked her why, she shrugged and said she felt better, and wouldn't elaborate.  And so we fell back into our routine.

One day after maybe two years of this pattern, I walked into the room not with my previous forced enthusiasm but with the sort of calm, professional blankness that comes with knowing you are about to have another pleasant but fruitless encounter.  In hindsight I can see that the lack of change had been wearing me down gradually, but at the time it felt like an abrupt change.  After our usual exchange of Hi-Rosa-how-are-you-I'm-fine, I simply said:


"What do we need to talk about today?"

"I don't know."

"Well, would you like to talk about your diabetes today?"

"Not really."

I paused.  "Okay, then.  What would you like to discuss?"

"I don't know."

Always previously, I had pushed past her recalcitrance, prodding her to some sort of lopsided discussion about her medical conditions, behaviours, habits, and so on.  After all, why else would she come and see me?  I had been determined to help her in some small way.  But that day, hearing her respond so casually - not really, I don't know - I was suddenly furious.  So much effort.  So much time spent with her.  So many clinics where I let myself run late to attempt to talk to her.  And for what?  So that after years of this, she could casually flush our agenda down the toilet as though none of it mattered.  And just like that I was done.  If she wanted to waste this time, I was going to let her.

"Okay... well do you need refills of any of your medicines?"

"I don't think so."

"Anything you need from me today?"

"No, not really."

"...Well, okay then."

The visit was over about a minute later.  I never saw her again.

I still struggle with the choice I made that day, born as it was from the cliff's edge of patience.  Perhaps I did the right thing externally, but internally I gave up on her, and that alone makes my judgment questionable.  Should I have kept pushing, had more compassion and perseverance?  Was I serving some vague therapeutic purpose?  Did I set us both free from a pointless rut we had been stuck in?  Or did I just cut off a source of easy emotional investment that she wanted but didn't want to work for?

The truth is probably buried somewhere in the middle of all of those possibilities.  I don't claim to see it clearly.  After she stopped coming to see me, I prayed for her and prayed for her, and then I got angry at her again and shouted at God about how ridiculous the whole situation was.  And ultimately I trusted Him to redeem it all for good.  And this is the nature of medicine and ministry, right?  Many times it goes nowhere that we can see.  Often in this field there is what psychologists call a complex separation from our patients, one without closure or denouement, and thus also without any kind of satisfaction on the part of the provider.  It is stressful but unavoidable.  Most of my career I will attempt to take care of someone the best way I know how, and I will never know in this lifetime how it really turned out.  And in the midst of that uncertainty, in those stories that seem to stop at failure, I can choose to let my viewpoint be similarly limited or I can look further out and further ahead.  I can shout at God and be done with it, or I can choose to trust that He is the author of redemption.  He makes all things new and good in His perfect timing.

I'm still coming to terms with that.

Wednesday, November 9

Another step back, or, This is what it looks like to recover from severe burnout

I am in that featureless, dimly lit middle stage on the journey out of burnout.  They say with attention to the issue, it gets better and that with time I can be fully invested in my work.  Right now it varies day to day.  Some days I drag myself out of bed late, reluctant to meet people and be happy.  Some days I rise from bed fresh and invigorated; I cherish these days as harbingers of change.


I laugh with coworkers.  I bring coffee, help decorate our new clinic.  I like the patients I see.  I am lavish with my emotional coin since urgent care requires so little of it overall.  No one asks me to be their everything here, so there is no emotional abyss of investment to guard against, so I can be generous with myself.  I encourage, educate, rebuke, reassure.  I remind myself not to get too possessive or protective of these people; these are not my patients.  They are just patients.  I get to do immensely satisfying things like sew lacerations and fish things out of ears and burr metal flakes out of a man's eye.  I puzzle over rashes.  I argue about antibiotics.  I work twelve to fourteen hours a day, then drive home and smile easily at my husband.

At work, I get a card someone left at the front desk.  A card?  For me?  Yes, says my receptionist.  I don't tell her the truth: I don't want a card. 

It has my name on the front.  I open it and read it aloud to my nurse.  It is from a patient I saw a week ago who was in emotional crisis.  I remember that we talked for a while and after I determined that she was not in imminent danger, I started her on some medications.  I told her she needed a therapist.  I remember that I tried to show her kindness but not too much.  

The language of the card is effusive.  My compassion and flexibility floored her, she writes.  My prayers gave her strength.  She tells me I saved her.  She asks if she can see me again at the urgent care clinic.

I read the letter feeling as though someone has started to press down on my neck.  My nurse cries and says she has goosebumps, which is a helpful signal to me to pause for a moment.  I just want to run, but a reaction is required here.  I mumble something about how touched I am, but really I'm uncomfortably reminded of how much of my shows of compassion are a farce, external signposts that freely promise warm, green destinations but lead instead to cool grey expanses of indifference.  I push away the dread and remind myself that navigating a continued doctor-patient relationship with this woman is not my job anymore.

How nice of her, I say.  But no, she can't come and see me again.  I put down the card and pick up the next chart in the rack.

Saturday, September 10

Doctors get sick too and this is a good thing

Every time I get sick, it changes my practice just slightly.  It doesn't change my medical management, but I can tell that I react to people differently.  Here's an account I wrote ages ago, then forgot about, that illustrates this well.

So I have this lump in my breast.  No, no, don't freak out; it meets all the criteria for likely being benign:

1. young patient with no medical problems
2. no family history of breast cancer, or really cancer of any kind
3. lump is well-defined
4. freely movable (i.e. doesn't seem attached to the chest wall)
5. tender (super tender.)
6. started suddenly
7. no funny-seeming lymph nodes
8. no other symptoms

All of that put together likely equals a cyst that is infected or blocking a duct or something like that.  At worst, it may be a benign tumor, but even that seems like a stretch.  All other possibilities are way out there in The Land Of Rare Things.  Despite all that, though, I still needed to see a doctor myself.  I thought this thing should probably get checked out, and also it was hurting and I wanted it to not hurt anymore. 

I'll be honest; it was a good reminder of the patient experience. 

It was hard to be perfectly on time.  Getting a breast exam was kind of awkward despite how professional and nice my doctor is.  I completely forgot something I wanted to tell him and he had to come back in.  When he said he thought this was "kind of weird" and that he wanted to get a mammogram "just to be safe," I felt a little chill; we'd just finished talking about low risk I am for cancer, but still!  I worried a bit about the cost of all this stuff.  I went for some labwork and that needle really hurt, although I was a big girl and didn't swat at the nurse.  I'm grateful that I'm on vacation this week so I can go and have these tests without using sick days, but at the same time I really don't want to go and have this tender lump squished about by a mammogram machine. 

In the end, I got an ultrasound rather than a mammogram, and they put me on antibiotics for a week, which seemed to take care of it.  I still had to see a breast specialist and get several breast exams to make sure the lump was gone, though; at my last visit, he told me I wouldn't need any more extra surveillance.  It was just a small infection after all.


I like to think I take good care of my patients in that I not only give good medical treatment, but also do my best to respond to my patients with sensitivity.  But the fact is that it's very easy to gloss over the reality of someone else's experience, especially when each individual is just one in a long line of people you have to see that day.  When you are a totally healthy person, you simply forget that medical care is awkward and time-consuming and at times nerve-wracking for patients.  Sickness, mild or severe, reminds us of all these things.

To put it simply, having my share of normal human suffering allows me to connect with people better, which is the most fulfilling part of my job.  So I'm glad that I've had back pain and bronchitis and breast infections.  I'm glad that I've been that patient that was so miserable from a cold that I went to my doctor, hoping against hope that it might be bacterial so I could get an antibiotic to feel better (it was viral.  I was grumpy and ill for two weeks).  Having known the poison of depression lets me pray for those who are depressed with empathy and compassion.  Knowing the agony of migraines makes it easy to really care when someone comes in and tells me that his headaches are ruining his life.  Experience with grief allows me to offer better comfort to those who are grieving.  I know what I'm saying when I tell someone that His grace is sufficient in their weakness.  His grace is sufficient in my weakness, too.

Tuesday, August 23

The Other Side of Disillusionment

It took a couple of weeks after I graduated residency this summer to finally bring it up.

"You know what?"

My husband looked over at me. "What?"

I looked at him for a moment, and then finally said the thing that had been brewing all day, slowly forming in my mind as a firm conclusion.

"I hated residency."

He half-smiled. "Yeah, we knew that."

"No. I really hated residency.  Really, really, really hated it."

His smile dropped away.  "I know."

-----

Yeah, I finished residency.  I think I'm expected to say something like, "Man, there were a lot of ups and downs!  It's an intense period of your life and it's really hard.  But it's over now, and I'm soooooo excited to do medicine my way!"  But you know what?  I hated residency so much it's hard to just get over it.  It feels trite to say that, because in medicine it's kind of like saying that water is wet or MIs are deadly.  But I learned from watching my fellow residents that "hating residency" can mean many things; some of us just loathe the suck, while others are truly damaged by the process.  No one comes out the same as they went in - we all finish somewhat better as physicians but somewhat worse as human beings - but some of us come out in pieces.  I hated residency so much that I couldn't even admit it to myself properly during the process because to admit how deep my disillusionment went would be to rob myself of the stoicism necessary to endure through until the end.  No wonder empathy takes a record dive among residents.  If that was my introduction to real medicine then I wish I could afford to have no part in it.

But why hate residency? you say.  It's hard training and hard work, but it's necessary for you to become a doctor.  You learned a lot.  And it was a job and you got paid.   And I don't mean to ignore the good parts of the past few years.  I made some good friends who I think will be with me for life.  I met a few people who I consider role models.  I had some funny mishaps.  I found out just how well and how long I survive on minimal sleep (the answer is: a long time, but not that well).  But plumbing the depths of exhaustion while learning what this profession is and is not made me question the very premises that led me to medicine in the first place. 

1. Medicine is not what I wanted it to be because it is a business, you guys.  It's one thing to know that from the outside in a vague sort of way.  It's another thing when you have to send a nice old man with dementia to the homeless shelter because no one wants to pay for his hospital stay and his family won't take him back.  Or when you realise there's a gaping hole in the safety net for those with mental illness that can only be filled by paying cash to a dubiously trained caretaker.  Or when pediatricians or obstetricians or family docs or specialists won't take Medicaid patients because it "doesn't pay enough".  Or when you see patients who are begging you for solutions and you have nothing for them despite living in a first-world country because they don't have any money.  There were so many times that I cried at the lack of options for someone, all because of money.  More money means better medical care in so many ways, in ways that you have probably never thought of.  In ways that make me feel ashamed.

2. A doctor's job is not what I wanted it to be, because it's mostly paperwork, or at least it feels that way.  This is especially true in primary care.  About once a week during residency, my medical assistant would thunk down a thick folder next to my computer.  It was full of forms for me to review and fill out or sign.  FMLA, disability queries, home health updates, refill requests, Rx prior authorisations...  Half the time I had no idea how to even complete the paperwork so I would just do my best and hope it was good enough.  You want to know why your doctor's office has started charging for forms to get filled out?  Because I would spend literally hours every week on charting and forms and calling around to places for various things.  Forms do not get magically filled out by form fairies.  Forms get filled out by doctors staying an hour or two late every few days to clear the backlog.  I didn't even have what would be considered a full panel of patients for a primary care physician since I was only in clinic about 1/3 of the time.  I cannot even imagine how much paperwork a full time family doc has to do.

3. My patients are not who I wanted them to be.  I think I am a fixer.  I need problems that I can actually solve.  But in medicine you meet so many people with things you can't fix, or problems that are not yours to solve.  I keep a list in my head - not intentionally - of all the people I met who I just could not help.  It's longer than you might expect.  I remember a guy who was an alcoholic; he would binge drink and then come in with a horrible flare of pancreatitis, vomiting uncontrollably and in severe pain.  And yet he would leave after being treated and then come back a short while later, drunk and sick again.  We offered him so many resources for quitting, and he would lie to us, and refuse... it was like we weren't even there.  I saw many people like that - people locked in a struggle with their demons, grappling with them as their medical team essentially stood by and watched.  There were many others who were just too sick for any medical treatment to offer much.  I don't know what I'm meant to do with those people, either in person or as the haunting memories in my head. 

4. My colleagues are not who I wanted them to be.  Residency doesn't bring out the best in anyone, and we are all flawed to begin with.  There were a lot of times when if we hadn't needed each other I think we all might have been at each others' throats, while at the same time there was a lot of irritating pretense that we were all doing okay.  There were some minor and major betrayals from attendings, one of which almost cost me a timely graduation.

5. I am not who I wanted to be.  Remember when I said residency doesn't bring out the best in you?  I don't deal with authority very well, nor do I work particularly well as part of a team unless I am the leader.  I am easily demotivated when under stress.  I am absolutely certain that I was a grumpy, harsh, lousy person to deal with about half the time (and any time administration wanted me to do something).  I am prone to emotionally overinvesting and then I have no way to fill that empty well back up.  And I am full of selfish pride.  I spent a lot of time in residency not thinking about how best to serve others but instead focused on how best to survive intact.  The irony of that is that I didn't survive intact, not really.  I finished residency feeling depleted, angry, and afraid of the future.  Would I have fared better or even worse if I hadn't been so focused on myself?  Who can say?  It's hard to imagine how it could have been worse, though.  I spent months at a time just getting by.

Residencies are required to do exit counselling as part of staying accredited by the ACGME, the organisation responsible for policing postgraduate training for physicians.  My "exit interview" consisted of a 90 minute group SWOT session for my graduating class, a stupid and contrived format that they had clearly settled on as a way to keep people from talking a lot and thus complaining.  It meant I didn't get to say any of what I wanted to say.  What I wanted to say was, I gave you the last gasp of my idealism and true youth and you gave me back the ashes of dreams and a smaller version of myself.  What I wanted to say was, no one told me it would be like this.  If they had told me, maybe I would have chosen work that doesn't take so much more than it gives.  What I wanted to say was, I have finally learned to hate medicine.  You've convinced me to run away.

-----
Of course I don't have the luxury of running away.  My husband and I are in the kind of debt that you would not believe thanks to my training; let's just say our monthly student loan payments are six times our mortgage payments.  I obviously have to work.  For now, I've chosen the next best thing to nothing: urgent care.  It feels like I'm letting people down by doing this instead of choosing Work That Will Help People.  But at this moment in my life, fresh out of training and counting the cost, I'm not sure what that work is.  So I'll treat colds for a while, and we'll see.  Maybe residency has just been an extended low point and I'll recharge.  Maybe my questions about the practice of medicine have no answer.  Maybe I'll learn to be okay with that.  Maybe I won't. 

Sunday, October 4

Helping People Die, or, R3: Internal Medicine


His name was Ray, he was a lovely old man, and he had metastatic cancer.  When he got his diagnosis several weeks ago, initially the plan was to fight it; CyberKnife had shown some decent results with his type of cancer and his family really wanted him to beat it.  The only condition was that he had to gain some strength back before he could begin treatment.  Instead, however, he got weaker.  He quickly lost his appetite and his immune system.  When his family brought him in to the hospital, he was suffering from a bad infection that had set in insidiously but deeply.

The first day I came on his case, I talked with his family as Ray slept.  I told them that for most of our lives, living longer and living better are the same thing, but sometimes we reach a point where those two options fork away from each other.  I told them that we had reached that crossroads with Ray.  The next day we stopped the antibiotics and the blood pressure meds, the fluids and the suppositories, and placed him on comfort measures.  I asked if I could pray for them.  It was a very peaceful prayer overall, intercession for a family that has accepted what is coming and has started mourning, which God can use as its own kind of healing.

I walked out of the room scrubbing tears off my face and ran into their nurse, who looked at me with concern.  "Oh, praying with the dying never gets easier," I said as lightly as I could.  She nodded, mouth twisting with understanding.  "You would think with time," she said, laying a hand on my arm, "but it never does."

I actually love the oncology floor because the nurses and techs acknowledge things like that a bit more readily.  And it doesn't seem to be getting easier, at least not for me.  This time I think I actually mourned in aggregate, seeing as I prayed several faces of past patients that I assisted in the dying process.  The sense of grief lingered with me the whole day, making it hard to move on to other patients who needed me to be present.

I cried all the way home.

I don't know why internal medicine does this to me.  I find it exhausting.  It certainly is honourable work, helping families navigate the medical system and helping terminal patients die well... but I personally can't sustain it.  Whatever distance other practitioners have that lets them disengage easily, whatever perspective they have that helps them feel that death is not a failure, I just don't have it.  I think this is an area where God wants me to grow, but I'll admit that I don't understand how.  There's a balance there that I have always struggled with.

Ray died about a day after being placed on comfort measures.  He was surrounded by his family, and there was laughter as well as tears.  I can tell his was a life very well lived, and I'm glad he's free from pain and finally home with his Father.  One of my duties in these situations is to declare time of death.  After I had done what I needed to in the room, we prayed again, and as I was about to leave, Ray's daughter stopped me. "Thank you so much," she said, "for helping us to have this time and let him go.  He gave us so much.  We were grateful as his family we could give him this last gift - to pass naturally and in peace."

Honourable work indeed.

Sunday, September 13

Well, That Took a Long Time, or, The Price

Things are getting better.  They are certainly better than they were a year ago.

I contemplated apologizing for not writing for so long, but whatever.  I'm allowed.  I had very little to say this past year anyway.  I finished intern year without any major (external) problems and moved on to being a senior resident.  In my program, rank has some privileges; your workload drops from 80+ hours a week to more like 60, and (most importantly for me!) you don't have to get up nearly as early most of the time because you do more outpatient, or clinic, rotations.  I do not miss 4am!

All of that luxurious ease (ha), however, made it possible to sink into a state of quiet apathy.  It was easy to do, and apathy has a lot to recommend it for someone who's coming back from hysterical sobbing in the middle of the resident lounge.  You don't enjoy much, but you also don't have to walk around bleeding emotions on everyone, which is not my favourite.  I learned a lot of medicine.  I did not learn much about myself or grow much in my understanding of Christ.  The ice started cracking this summer, though, and I have been a bit sad to see it go.  I'm not saying that's a good way to feel; I'm just being honest.  It was very effective self-protection.  I think the last couple of years (and in a wider way, the last six years or so, with my husband's deployment and all) taught me a lot about how to be afraid and how easy it is to get compacted into a smaller person by the worries and risks of this world.  I think I needed to learn this first so that I could be prepared for the next lesson - how to love people anyway. 

Jesus tells us to count the cost of following Him - "Whoever does not bear his own cross and come after Me cannot be My discipleFor which of you, wanting to build a tower, doesn’t first sit down and calculate the cost to see if he has enough to complete it? Otherwise, after he has laid the foundation and cannot finish it, all the onlookers will begin to make fun of himsaying, ‘This man started to build and wasn’t able to finish’...  In the same way, therefore, every one of you who does not say good-bye to all his possessions cannot be My disciple."  We can understand from the larger context of Luke 14 that Jesus is not only speaking of the willingness to give up material possessions.  He is also referring to the willingness to abandon ourselves to serving the goodness of His will.  There is a vulnerability required in showing people love.  And there is inherent danger in showing love to people who you don't know; in fact, there is a guaranteed emotional price that you will have to pay, because not all of those people will choose to love you or the One who sent you.  You will at times be betrayed and abandoned by the strangers you have chosen to love.

I paid that price a couple of times as I was learning to serve people at the beginning of residency and I didn't like it one bit.  God knew I would react that way and He very kindly gave me time and the comfort of His Spirit to pull back somewhat and heal up.  For a while it seemed as though I'd gone through something horrible that it would've been better to avoid.  I'm remembering, though, that my call as a Christian - and by that I mean the regular everyday Christian job description - makes no mention of safety of any kind.  It says God will go with us, that He loves us, that His ways are good and His plans for us individually and collectively are also good, but safety and comfort are not guaranteed.  Despite that I say God is worth it.  His kindness, the peace of His Holy Spirit, the care He takes with my life - these things remind me that the price is not too high.  I am still, after almost ten years, only beginning to learn how to walk with God, but I have learned that His presence is immensely valuable to me.  More valuable than safety.  More valuable than any price I could pay.  And I believe that even more good will come from this painful lesson. 

He has stuff for me to do.

Wednesday, March 26

A Little More On Burnout

Thank you to everyone who reached out.  The response I got was surprising both in its volume and its sincerity, but my surprise is really just a reflection of my lack of objectivity at the moment.  In reality, I know a lot of cool people.  I have done some reaching out myself of late, and I'm working on finding good outlets and learning to do my part to lift this darkness.

Speaking of.  Been doing a lot of digging over the last few weeks regarding depression and physician burnout, and surprise! there's not a lot out there.  But it seems to be something people are talking about more in other fields.  I found one person's observations particularly useful.  His name is Carey Nieuwhof; he's a pastor so his insight is based in the field of Christian ministry, but what he says holds universal value.  Below are some posts of his; the things he says align with what I've read elsewhere and add his really honest tale of wrestling with these same symptoms and coming out on the other side.  I'm putting these links here partly for my own reference and partly because, as I said before, I'm not that special so I doubt I'm the only person wrestling with this.

Pre-burnout warning signs

You're probably burned out if...

Damn it, you're already out of gas.  Now what?

If I can ask for prayer, please pray that I would be able to complete my work properly.  It's very hard to find the motivation to stay on top of the more tedious parts of my job.

Sunday, March 23

R1 Winter, or, The Wall

When people are miserable, they get cagey about their emotions.  It's a protection thing.  I understand that.  But it means I can't verify with certainty what I suspect: that I am not the only one who is struggling right now.  I know all the cheery, hopeful, "Hey, we're doctors!" posts have disappeared entirely from my Facebook feed (at least from my class; the crop below me just matched so of course they're thrilled), so I am fairly certain I'm not the only one having a hard time.

On that note, let's talk about hitting the intern wall.

I'm an intern, which is generally equivalent nowadays to being a first-year resident.  (Intern status used to be a year below being a resident, but for a bunch of boring reasons they've mostly merged the two at this point.  In short, it makes residency shorter and more secure.)  First year is the foundation for your clinical training, so it's the time when you have the least control over your life and when you work the hardest.  The learning curve is necessarily steep, although since you were already ascending a steep learning curve in medical school, you think you're probably prepared for what residency holds.  You're wrong about that.  Residency is a new beast entirely.  The mix of being at the bottom of the totem pole again, having new and weighty responsibilities, working significantly longer hours, and suddenly being bad at everything you do is exhausting.  It's all-the-way exhausting, actually, as in it wears you out until you're wrung dry.  That point is what doctors call hitting the wall; when you have nothing left and yet you have to keep pulling the same hours and seeing the same awfulness and making the same hard calls.  It's burnout, plain and simple; for an excellent article on this, read this JAMA publication; the Wikipedia article is also pretty good.

I hit the wall right at the end of December, during my first pediatrics rotation.  One day I was chugging along, doing more or less okay; the next day I started to feel kinda hopeless for no reason.  My patient load started to seem overwhelming and defeating.  January I was on labor and delivery, something I neither love nor hate, but for various reasons our team was effectively a rudderless ship which was horrible for all concerned.  Feeling abandoned by the residents who you depend on to help double-check your work is pretty scary, and all those negative emotions take an enormous amount of energy to maintain.  By the time I started internal medicine in February my tank was close to empty, and that was before I had a truly, truly stressful month, including a high patient load and a sick family member requiring me to take a week off work.  You can't be a person, do life stuff, and do residency stuff at the same time.  You just can't.  You will suffer and one of those other things will suffer, because the truth is that residency takes up everything you have to give.  The evening before I left on my emergency trip, I was so tired and so worried and so overwhelmed that I couldn't even pack a suitcase; my husband had to do it for me as I sat on the bed and sobbed helplessly because it was too hard to figure out what I needed.  Things have not gotten much better from there.

It's been a bad season, you guys.

Both my Maslach Burnout Inventory and my PHQ-9 scores are pretty terrible. The PHQ-9 is a quick screen for depression; the MBI is specifically for burnout. Basically I hit the intern wall so hard, and my ears are still ringing from it.  I've got precious little fight left in me.  I'm not really capable of providing the level of personal care I was giving six months ago because I'm not capable of caring that deeply right now.  I want to, I just... can't.  It's hard enough to convince myself to go back into work every day.  It's hard enough to not snap at people all the time.  It's hard enough to make sure I only cry about it in the dark, quietly, where I won't upset anyone else.   And on a side note, I'm kind of angry that this is essentially expected.  Why is something this terrible expected?  And why don't we know how to fix it?  And why haven't we overhauled the system so there's less attrition and fewer patient care issues from burnout?  Why do we as a profession just let this happen to everyone?!

Anyway.

I'm very grateful to have a good, steady job that lets me reliably have a roof over my head and food to eat.  I'm grateful that I have reliable employment.  But that's all.  It's not a calling right now.  It's just work, and it's a lot of work.

Today at church, though, we sang this, and despite my hopelessness and exhaustion, this resonated deeply:

I will remain confident of this:
I will see the goodness of the Lord.

It's paraphrased from Psalm 27.  And it reminds me that when you belong to the Lord, there is always cause for hope.  I really needed to hear that.

Thursday, December 12

R1 December, Or: Embracing The Suck

Hey all.

I am sorry I have not written in a long time.

I have, actually; you just haven't seen most of it.  I have several posts sitting in my virtual drafts pile in various stages of completion; I just have barely had the willpower to finish all of my real work, let alone come and write something I am happy with.

I wanted to take a smidge of time and say this, though: it's getting better.  This is for two reasons.  One is that I am getting better at my job.  A great deal of my daily angst comes from the fact that I have to learn on people who really deserve a fully trained doctor treating them, because everyone deserves that.  I feel like I'm cheating people somehow and I hate that I'm not good at my job yet.  But after almost six months of working at this every day (literally every single day, in one form or another), I can tell I'm improving.  There's no substitute for immersion when it comes to rapid and sustained learning, and residency is nothing if not immersion in medicine.  There are days I come home feeling like my brain is an overstuffed pillow because I go through so much new stuff - everything from how to fill out an obscure bit of paperwork correctly to reading up on a complex disease interaction I wasn't aware of.

Reason two is that I have adjusted.  By "adjusted" I pretty much just mean toughened up.  At first there was a lot of shock and resentment at how much work this is, not just in terms of hours but also in terms of how mentally and emotionally exhausting it is.  Responsibility = stress!  It was also really physically hard to make my body get up at 4am and work for hours and hours.  And I'll just come out and say it: I missed emergency medicine with a quiet but deep bitterness that made everything just that much harder to get through.  Today, though, I realised I was starting to legitimately embrace the suck.  I work all the time, I have crappy (read: no) work-life boundaries, I don't get to see family for the holidays this year, and I feel constantly like I'm coming down with some bug.  And all of that is okay.  It's residency.  It sucks.  Somehow that's not an inherently bad thing anymore.  And I'm not angry about having to let go of emergency medicine anymore, which is a huge weight off my back.

I don't know where things will go from here.  But I will say that change has been happening while I wasn't even paying attention, and it's good.  This is me trusting the process God put me into.