Reflections on Primary Care

Just because I haven't written about burnout in a while doesn't mean I don't still care about it.

Over the past year or so, I've become an avid, sympathetic reader of a blog called Reflections of a Millennial Doctor.  The author, M, vividly details her struggle with burnout and giving up on primary care.  She fought so hard this past year, wrestling with whether or not to stay in her current practice or throw in the towel and try her hand at something else.  She recently admitted that she will be leaving her practice soon for a job as a hospitalist.  I can relate - not to the hospitalist part! I hate hospital medicine.  But her tale of getting bled dry by her clinic job resonated with me deeply.  Honestly, I don't know how her primary care dreams survived her training.  Mine didn't.

I remember being a medical student and writing an essay about the importance of trajectory change for my family medicine residency application.

Sometimes they live

A patient walked out on me the other day.

It doesn't happen every day, but it happens often enough.  I usually never find out why.  Sometimes it's to go pick up children or meet another time-sensitive obligation.  Sometimes it's to go smoke a cigarette or get a dose of drugs.  I think sometimes they get scared and feel as though running from the department can help them escape their diagnosis.  Whatever the reason, I learned early on that I have to be able to let those people go.  The other side of the patient autonomy coin is this: they're responsible for getting the care they need and it's not my job to force or coerce them.

Except when it is.

Sometimes they die

Honestly?  I hate traumas.

I can't stop thinking about one I got a while back.  Auto vs. motorcycle.  A nice young man had been driving at dusk - not texting or anything as far as we know - and turned left in front of a motorcyclist who wasn't wearing any gear.  He never even saw the motorcycle coming.  The driver in the car was fine.  The guy riding the motorcycle - another young guy, I never quite learned his age - became our patient.  I was the backup doctor in the room but it still felt like he belonged to me.

Traumas don't go the way you would envision from watching a show.

Suffering

It's 6am and I've been up for three hours, the consequence of coming off a long weekend of night shifts.  I read for a while, but as often happens to me, eventually I was driven to write.  And so here I am.

My hands are healing, I think, and my feet.  In retrospect I've been through this cycle a dozen times before and just didn't recognise it.  It matches what my neurologist told me about my disease.  It's a cyclic dance, led by demyelination, followed by damage to the axon, the long delicate wire of the nerve cell, as it loses its insulating myelin sheath.  I lose some function.  Then comes whatever healing the body can muster and some degree of functional improvement - all set against the relentless drumbeat of the disease state itself.  So I get worse, and then I get better, sort of.  What matters to me now is that I've crossed back over the invisible line that lets me use my right hand.  I can write again, so I can do my own paperwork at work.  I can hold a glass in my dominant hand without thinking about it.  I can put my car in gear without reaching across my body.  I can type a bit.  I'm definitely not back to normal.  I still wear a wrist brace (like this one) on the right about half the time since it's very fatiguing for me to control my wrist and fingers simultaneously.  I prefer to use a big silly-looking pen that's easier for me to grip.  I've switched my mouse to my left hand and don't plan to switch back.  And at this point I still can't really do repetitive tasks that require fine motor skills - scissors, suturing, chopping vegetables.  But it's so much better than it was.

Obviously it's going to get worse again eventually.

I've been thinking lately about suffering, and about God's purposes in allowing His children to suffer.  I have found myself crying out to Him this summer in confusion and pain.  Why, God?  Why this?  Why now?  Why my right hand, the hand I rely on?  Why should I suffer like this?  It's a hard question, and a nuanced one.  It's different from painfully pouring oneself out to serve others,  different from the direct and expected consequences of sin, different again from persecution for my faith.  This just... sucks.  It sucks every day.  And nothing I or anyone else did caused this.  I think the temptation is to see suffering as meaningless, just a random consequence of living in a broken, messed-up world, but Christians don't have that philosophical out.  We trust and believe that we have a personal God, one who cares for us and is invested in us.  So why the suffering?

Yesterday I sobbed through a talk given by Joni Eareckson Tada, a lady who is a staunch believer in Jesus, an author, speaker, and artist, and a quadriplegic since the age of 17.  I highly recommend that you listen to the talk, although if you're not dealing with personal hardship/ disability it may not resonate with you.  She confronts the endless gauntlet of her daily life (you'd better believe that being a sharp mind trapped in a useless body involves suffering) with a matter-of-fact courage that frightens me.  She does not spare anyone the harshness of truth.  I'll give you an example.  For anyone, but especially a quadriplegic, to say, There are better things than walking.  There are better things than the use of your hands, is deeply shocking, right?  But with reflection I've realised that of course that is true, especially for a Christian.  Jesus is better than anything.

The goodness of God is the truth that sustains a person through even the deepest darkness.  I thank her for reminding me of that.  Joni Eareckson Tada exemplifies for me the concept of suffering well, something she touches on in that talk.  It's hard for me to get my arms all the way around the idea, but I think it's a mixture of day-to-day grit and unswerving, joyful faith in a good God.  I don't know how to do it yet like she does (I'll grant that she's had fifty years to learn how to suffer well and I've had, like, two months).  But I think most people never learn how.  It's just not guaranteed.  And I think it's a lofty goal but a worthy one, this idea of suffering well as a Christian.  I have this disease.  There is no getting rid of it.  But to suffer well... if that is my race to run in this life, God grant that I might achieve that.

Spoons

A few weeks ago, my hand cramped solid around a woman's leg while I was trying to put a splint on her, and then went limp for the rest of the shift.  Let's talk about spoons.

News

I thought about being artistically coy in how I would introduce this post, but I can't bring myself to do it.  I got some bad news about a month ago and it has changed my life.

I was recently diagnosed with Charcot-Marie-Tooth disease.  In medical terms, it is a genetic neuromuscular disorder, caused (in my case) by a duplication of one tiny area of chromosome 17.  It leads to abnormal nerve structure and thus abnormal nerve signal transmission.  Over time, the nerves degrade and die off (this is called neuropathy), taking the muscles with them.  It starts in the feet and works its way up the legs, and at some point begins in the hands and works its way up the arms.  The rate and degree of progression is different for every affected person.

CMT is a progressive disease, and the form I have generally comes on slowly.  So it was with me, although I didn't know it.  I've been "clumsy" all my life, with weak ankles that are prone to rolling, and weak reflexes.  I've always gotten muscle cramps a lot.  My feet are always cold.  None of that held me back, per se, but there were a series of nuisances to be managed.  No stiletto heels.  Watch how you walk so you don't sprain an ankle again.  Do any workout besides running.  But otherwise, it was fine.  Then during residency, I started getting intermittent weakness in my feet and toes.  The cramps got worse.  I started having falls and trouble keeping my balance, especially when I'd been awake for long shifts or wasn't sleeping well.  People commented a few times on how my gait looked different, "like it's hard for you to walk."  They were right.  It felt very hard to walk.  I assumed I needed to sleep more and be more diligent about working out, chalked the falls up to residency fatigue, and kept pushing.

I know, I know.  I'm crazy.  No one in their mid twenties should be falling and having trouble walking.  I know.  But I... just didn't think about it.  I was trying to hold it together and finish training, and there was work to be done.  So I went to work.

Fast forward a few more years.  This spring I started tripping over my toes, and I realized I couldn't move them.  My right hand began cramping around my pen every time I picked it up.  I realized I couldn't feel the bottoms of my feet.  Then my knees started to constantly feel like they were giving out, and I finally got scared enough to pursue a possible diagnosis.  If you think a doctor can't have denial, think again; despite all of that I honestly thought they were going to tell me it was stress.  Instead, two neurologists and $3000 worth of tests later, I was given a diagnosis that explained every troublesome thing I've ever had with this body - and made it clear it is going to get worse.  And it has gotten worse; it's gotten a lot worse just in the past couple of months.  Apparently that happens sometimes.

I will be honest here and admit that I feel inexpressibly sad about it all.  I don't know what this will mean for my personal life or my career.  It's scary and taxing to try to navigate the sudden drop in my physical ability (a topic to discuss more in a later post).  I feel newly, terrifyingly dependent on Jesus, while at the same time I feel so confused that He would allow a time bomb like this to be seeded in my DNA.  I trust Him.  But I don't understand.

I expect the tone of this blog will change significantly from here on out but I don't yet know how.  I guess I'll just take it post by post and day by day.  But I knew that I couldn't blithely write about the happenings of my life and career while withholding this diagnosis.

On Terror

"EMS to ED."

My charge nurse hit the button on the transponder.

"This is ED, go ahead EMS."

"ED, this is EMS en route to your facility, emergency status - "

All the staff within hearing distance stopped what we were doing to listen further.

Change

So I'm changing things up for myself.

When I finished residency, you may remember that I was pretty much done with medicine but still needed to earn a living in order to pay off our debts.  I chose urgent care because I needed something that was simple in terms of the mechanics of the job and emotionally undemanding in terms of the patient care required.  I think urgent care is pretty much the pinnacle of that.  See patient, make 1-2 decisions regarding care, discharge patient, write short note.  Move on.  No call, no critically ill patients (most of the time), minimal paperwork, few moving parts.  The hiring process went very smoothly.  But for some reason that I barely understood given that I felt like I was aiming to get out of medicine altogether, I threw in an ask in my interview: I wanted to do a little work in my local ED if they were amenable to that.  It turned out they were.

Tired.

It was so hard to get my sorry self to work yesterday. I had the flu a couple of weeks ago - I don't recommend it - and the cough and fatigue have lingered. I entered this stretch of shifts feeling sluggish and still a little short of breath. My coworkers cracked good-natured jokes the whole weekend about how I needed to check in as a patient. Considering I've spent most of the last two weeks first feverish and vomiting, then alternately passed out and hacking up a lung, it felt more accurate than amusing. I'm pretty tired.

Residents: you are enough.

I remember the day I decided to quit residency.

It was January in my intern year and I was on one of my internal medicine rotations, which always were my least favourite.  I felt like my life consisted only of long hours and a surfeit of other people's suffering.  That morning, after four hours of rounding alone on my patients, I was about fifteen minutes late for morning group rounds, and mid-month evaluations were being held.  During my evaluation, I was told by my chief resident that I did not do a good enough job of being on time.  She was clear that my job was not to be right, it was to be punctual.  She was there to help with the rest, she said.  Then at rounds I got some questions wrong and was told by an attending I needed to review some topics and make sure I knew my patients better.  We also concluded two of my patients were terminal.

Cut to twelve or thirteen hours later when I was finishing up my evening call.  I was in the middle of checking out the patient list to the nighttime senior - a fast-paced, highly regimented process in my program since our patient lists tended to be long and medically complex - when the other chief resident breezed into the room.  He had seen some of my notes on my patients, he told me.  They were lacking in depth.  I needed to take more time and make sure I was being appropriately thorough.  He breezed back out of the room and, after a pause, I completed my checkout.

A short time later, sitting in my car in the parking garage, I went to turn my car on and couldn't even initiate the movement.  Instead I sat there in the cold as the sum of the day became clear.  A profound heaviness took up residence in my chest.  Had I accomplished anything that day?  I got criticized for taking too long and not taking long enough.  Likewise, I didn't know enough but wasn't meant to know more.  And I couldn't help many of my patients anyway, since many of them were dying.

What the hell was I doing this to myself for?  I had no answer.  Yeah, I'm done, I thought, and turned the key in the ignition.

-----

Obviously I'm writing this as a licensed, board-certified physician who works full time in clinical medicine, so we know how the story ended.  But I will never forget that moment, sitting there in the chill darkness, quietly listening to my last big dream break apart.  I cannot describe the pain of that to you, especially because I know that I am a creature that was made for hard work.  Why did this happen?  Because I couldn't hack it?  Not tough enough, or in the modern burnout parlance, not resilient enough?  I pondered that for a while and almost accepted it as true.  But now that I've had a little time to gain perspective, I reject that.

I'm a low maintenance, mentally tough woman with deep emotional resources and the personal grit necessary to grind out hard work over months and years.  My childhood dreams always involved work and adventure, not the more domestic goals many of my friends had.  I'm a career woman at heart and I'm comfortable knowing God made me that way.  But residency broke me (twice, actually, but that's a different story).

There are a lot of articles out there discussing how horribly residents get treated, whether it be through overwork (you try staying awake and doing hard mental and sometimes physical work for 24-48 hours continuously), emotional fatigue without time to process, or genuine personal abuse.  There's also a lot out there about burnout in medicine, although not as much on treating burnout in residents.  I obsessively read what little there was my second year of residency, looking and looking for solutions, but they're few and far between for those still in training.  The truth about treating burnout is one that is directly addressed in discussions of burnout in attendings: it doesn't usually get better unless/ until your circumstances change.  The articles discussing burnout in residents try to dance around this fact, which is disingenuous of them.  There are mitigating measures you can take, of course, but those are a wound dressing on the infection, not an antibiotic.

In the end, I didn't quit.  I started some crappy counselling where she mostly told me I needed to sleep more, sometimes with tears in her eyes.  I started gardening a bit and I took up knitting, so that no matter how many people I saw who I couldn't help, I would have something tangibly positive to pursue.  I cried every evening about going into work the next day.  I started Zoloft.  I was on that for six months.  I knitted more.  I made all my loved ones ugly scarves.  My herbs died, but at least I got outside in the sun a bit.  Mostly, I moved on to second year, which in my program isn't quite so horrible, and I was able to upgrade from misery to numbness and a simmering anger that lasted until graduation.  Since getting out of training I've been tentatively exploring happiness again, and it is fresh, beautiful territory.  I'm grateful but I'm not used to it yet.

I'm doing fine now, but it's the end of another long, dark winter, and I'm sure there are residents suffering and questioning themselves and their commitment.  If you're one of those residents, I feel deeply for you.  I can't tell you whether to stay in or leave the field.  But I can tell you that it's probably not your fault that you're having a hard time.  Medicine is difficult at the best of times; it's the nature of the beast.  And the current setup for training is draining, demoralizing, and at times outright abusive.  It's normal to struggle with a burden like the one you are handed during residency.  You're not imagining it.  Other people don't have to go through this.  You're not being overly sensitive.

So get some of your own crappy counselling if you can.  Maybe you need some Zoloft.  I highly recommend something positive and physical and low-maintenance like growing some plants or knitting.  Read The Resilient Practitioner, which hopefully will help you as much as it helped me.  Email me if you can't afford it and I will buy it for you.  And please believe me when I say that it can get better.