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.