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.
Saturday, September 10
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.
"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 disciple. For 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 him, saying, ‘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.
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 disciple. For 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 him, saying, ‘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.
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.
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.
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.
Wednesday, August 21
WHAT THE *&$^@ *@&#!% IS GOING ON (*$*#@*$&#&$, or, R1 July: Internal Medicine
Fairly recently someone asked about where exactly I am in my training. "So what is a resident? Are you a doctor now?" he asked, "or not a doctor?" The answer is yes. I am technically a physician now, and yet in so many ways I am still more student than professional. This is true in both the philosophical sense - I still have a lot to learn, I need a lot of supervision so I don't make mistakes, etc. - and in the concrete sense - I can't sign prescriptions for narcotics yet, I need to have formal supervision, etc. So I am a doctor because I graduated medical school, and just like a doctor I see patients by myself in the clinic and the hospital. But I am in the postgraduate training phase, and that means during this time there are limits on what I am allowed to do, especially what I am allowed to do unsupervised. I've reached journeyman status, I suppose. For people training to be family physicians (meaning me), this period lasts three years. If I choose to pursue more specialised training after that in OMT, psych, ER, OB, whatever, it would add another 1-2 years of postgrad training.
So I'm a resident now. July was my first month. And it was... I can't even tell you how it was. I wrote some (terrible) haikus my first week that, looking back, I still think are fairly representative:
patient is acidotic
with high bicarb and high CO2?!
acid-base, you bring despair
a drug seeker yells
you doctors never help me
rage his only wealth
small cell carcinoma
how do I tell them he's dying?
I am just an intern
I can tell you this much
one day I will love being in charge
not today. but one day.
the alarm says five
OH MY GOSH THAT'S WHEN WORK STARTS
THERE IS NO POETRY FOR LATENESS
CRAP
The last month was really an extended exercise in fear, uncertainty, and depression. And somehow it was also an exploration of sacrifice and worship. I can't say last month was fun, or that I liked it to any degree. And it's hard even for me to say it was good because there was so much bad stuff in it. But somehow... it was right. It was right that I be there, working all the time, feeling insecure, starting to learn what medicine even means. It was right that I have to struggle with how to show compassion to drug addicts and angry families and the slowly dying (and the acutely dying), again and again and again. I sound crazy, don't I.
I have to be honest, though. After all the years of college and medical school where I refused to give up on my dream, three weeks into this thing I woke up and was like, "This is medicine?! I want out. So long, and thanks for all the fish.*" It was a sobering moment. In school I would get fed up with people who said that, but now I'm wondering if everyone has that moment (or several of those moments) on this journey.
I ended the month by taking care of a manipulative alcoholic and persuading a patient, in progressive stages, that 1. his organ failure was terminal, and 2. getting on more transplant lists in other states probably wouldn't help, because 3. he was no longer a surgical candidate. I also had my first experience with trying for several days to get some kind of help for a patient, only to have every possible avenue of help closed to me. We prayed together over the unavoidably terminal diagnosis, and then that person essentially went home to die. Alone.
Walking all day through other peoples' misery is really exhausting. And it's worse when you are crippled by near complete ignorance of everything from the computer entry system to the specifics of the treatment plan you want to implement (I told you I'm still part student). Calls from nurses, for example, are generally terrifying. How much insulin should you give? Can you give that person pain medicine? How should I know?! Oh, because I'm the doctor. Well. When you put it like that. A nurse called me one day to tell me one of my patients had a critically low platelet count of 16,000 (you want it over 150,000). I thanked her and put the phone down. Then I put my head in my hands and said aloud, "I literally have no idea what I'm meant to do about that." A very kind attending who was sitting nearby put her hand on my shoulder and said, "I remember being there. You'll figure it out."
I didn't, though, because after much research it turned out that issue was unfixable. I sent that patient home to die, too.
:/
I don't think I have formed a very good perspective on all of this yet. But I haven't quit. And God has given me a breather in the form of working in the ER this month. He knew what I'd need after my first month on the floors. Next time, Lord willing, will be better.
*If you don't already know that this line is from The Hitchhiker's Guide to the Galaxy, you need cooler friends and you should probably read more.
So I'm a resident now. July was my first month. And it was... I can't even tell you how it was. I wrote some (terrible) haikus my first week that, looking back, I still think are fairly representative:
patient is acidotic
with high bicarb and high CO2?!
acid-base, you bring despair
a drug seeker yells
you doctors never help me
rage his only wealth
small cell carcinoma
how do I tell them he's dying?
I am just an intern
I can tell you this much
one day I will love being in charge
not today. but one day.
the alarm says five
OH MY GOSH THAT'S WHEN WORK STARTS
THERE IS NO POETRY FOR LATENESS
CRAP
The last month was really an extended exercise in fear, uncertainty, and depression. And somehow it was also an exploration of sacrifice and worship. I can't say last month was fun, or that I liked it to any degree. And it's hard even for me to say it was good because there was so much bad stuff in it. But somehow... it was right. It was right that I be there, working all the time, feeling insecure, starting to learn what medicine even means. It was right that I have to struggle with how to show compassion to drug addicts and angry families and the slowly dying (and the acutely dying), again and again and again. I sound crazy, don't I.
I have to be honest, though. After all the years of college and medical school where I refused to give up on my dream, three weeks into this thing I woke up and was like, "This is medicine?! I want out. So long, and thanks for all the fish.*" It was a sobering moment. In school I would get fed up with people who said that, but now I'm wondering if everyone has that moment (or several of those moments) on this journey.
I ended the month by taking care of a manipulative alcoholic and persuading a patient, in progressive stages, that 1. his organ failure was terminal, and 2. getting on more transplant lists in other states probably wouldn't help, because 3. he was no longer a surgical candidate. I also had my first experience with trying for several days to get some kind of help for a patient, only to have every possible avenue of help closed to me. We prayed together over the unavoidably terminal diagnosis, and then that person essentially went home to die. Alone.
Walking all day through other peoples' misery is really exhausting. And it's worse when you are crippled by near complete ignorance of everything from the computer entry system to the specifics of the treatment plan you want to implement (I told you I'm still part student). Calls from nurses, for example, are generally terrifying. How much insulin should you give? Can you give that person pain medicine? How should I know?! Oh, because I'm the doctor. Well. When you put it like that. A nurse called me one day to tell me one of my patients had a critically low platelet count of 16,000 (you want it over 150,000). I thanked her and put the phone down. Then I put my head in my hands and said aloud, "I literally have no idea what I'm meant to do about that." A very kind attending who was sitting nearby put her hand on my shoulder and said, "I remember being there. You'll figure it out."
I didn't, though, because after much research it turned out that issue was unfixable. I sent that patient home to die, too.
:/
I don't think I have formed a very good perspective on all of this yet. But I haven't quit. And God has given me a breather in the form of working in the ER this month. He knew what I'd need after my first month on the floors. Next time, Lord willing, will be better.
*If you don't already know that this line is from The Hitchhiker's Guide to the Galaxy, you need cooler friends and you should probably read more.
Saturday, July 20
Why everything in a hospital seems to suck
I get a lot of complaints from patients in the hospital that things take too long or that they don't get to see me enough. I feel for them and I agree. It's not going to change, though, so I thought a bit of an explanation might help.
So you are a patient in a hospital, and I am your doctor. You like me at first. When you get in the hospital, I spend like an hour with you and meticulously go through every inch of your complaint. I am sympathetic (unless you curse at me or hit me) and I smile a lot, and you feel reassured that this hospital stay will be useful, albeit stressful because you are sick.
The next morning, I burst in on you at an hour that is proof of our fallen world. You are still rubbing sleep from your eyes when I turn on the dazzling light behind your bed and start throwing questions at you. Five minutes later you have been stethoscoped briefly and I am gone, and you feel bemused, slightly irritated, and potentially slighted. You don't see me again for the rest of the day which seems unfair. Aren't you sick? Shouldn't you be seen by a doctor?
This pattern continues for your four-day hospital stay, with the exception of one day where I come in during the afternoon as well so we can discuss some important test results. During that talk I have magically transformed back into the doctor you met on the first day, sympathetic and ready to listen, free with my time - until a high-pitched beeping interrupts your tearful admission about how afraid you were that you had cancer. I apologise and breeze out of the room, leaving you uncomfortable and wishing you hadn't said anything. I don't come back for half an hour (what could have taken so long??) and the mood is clearly broken as I stick to medical topics, listen to your lungs again, then leave.
The next day, you can leave! Finally! You are overjoyed when I tell you this under the piercingly bright lights at 5:30am. You are, however, considerably less overjoyed when seven hours later you are still sitting in the hospital. I'd warned you to give it some time, but come on! You ask the nurse to call me, and the response is basically nothing. Wait. The doctor hasn't forgotten about you. Yeah, clearly. You can't leave until 3pm, and though my card is sitting in your folder of discharge paperwork so you can see me in the clinic, you aren't sure if you will. I certainly wasn't on top of things in the hospital; why would that be different in clinic?
Let's switch our point of view here.
I am a first year resident physician, and I am terrified. I go to admit you, my patient, and get you all tucked in for the night. In engrish we would say: strong success!
The next morning I start work at 5am after finishing at 8pm the night before. I have three hours to see six patients, by which I mean examine/ talk to the patient, write a note on each person's progress, examine labwork and other doctors' notes, and decide what to do for the day to help make the patient better. I really hope all of my patients are fairly quiet so the exam part can go quickly, because it takes so long for me to really think my way through their plan of care. Apparently I'm the doctor now and I need to do these things. I hate being awake so early, let alone inflicting that on others, but this is my only opportunity to do this, so I turn lights on and speak clearly so that hopefully some of what I say sinks in. It doesn't feel like it, but this is my visit for the day, and I hate that my patients are always sleepy and out of it and not in a place to discuss anything important when I see them, but I don't have a choice. My time is not my own.
Work for me goes like this. I work an average of 14 hours a day. I probably take about 40 minutes a day for myself, what with lunch and various bathroom breaks. Actually, I take that back; I normally work while eating lunch. So I take about 20 minutes a day for myself. 5am - 8am, I see patients and write paperwork. 8 - 9 is academics. 9-11, my fellow interns and I present our patients to the senior residents and the attending (= fully licenced supervising physician) and have our plans tweaked. The rest of the day is unscheduled. This means it is time for discharging patients, admitting new patients, following lab results, talking to specialists about our patients, and doing procedures. If I have time, I like to go back to my patients and talk with them a bit more, as this is excellent time for counselling, information-gathering, and ministry.
The thing that makes all of that a total mess is that all of it happens simultaneously. Several days later when I am trying to discharge you, I cannot work on your paperwork until lunchtime because morning presentations run late, so I start your paperwork (and paperwork for two other people who are also being discharged) as I eat lunch. Except before I can do that, I need to get some specialists on board for other patients who are currently way sicker than you. That takes some doing and multiple phone calls, but once it's done, it's paperwork time. You know all that paperwork you receive when you leave the hospital? Yeah, I put all of that together. I evaluate all of your prescriptions and your discharge instructions, make sure you have the right contact numbers for clinics, etc. You know not to expect to leave until around lunchtime because I told you that morning. As I am working on your discharge, however, a very sick person arrives in the emergency department and needs to be admitted. Remember that hour I spent with you working through your medical issues? I have to go to the ER now to do that for someone else, leaving your paperwork undone for the moment. I am paged five times during that admit which adds easily 30 minutes to the process because some of the questions I am asked I have to run by my senior. One of those pages is actually from your nurse, and I have nothing to offer you except I'm sorry. I'm admitting a patient and I can't get away. Please be patient. It takes about 90 minutes - 2 hours for me to work through admitting a patient because I am slow at this right now and scared I'll miss something important.
Finally it is midafternoon and I am trying to go through your paperwork. It takes some research to make sure I am making the right decisions, but ultimately I'm satisfied and send you on your way. I poke my head in to let you know and you are clearly angry. You have been waiting for ten hours to go home, you say. What is wrong with this place, you say. I apologise again.
Then I walk down the hall and discuss a lady's suicide attempt with her, finding out that she was a victim of child rape and prostitution and she's never recovered from that despite trying to be strong. Then I go down two floors to explain to a man that there's nothing we can do and he needs to start making end-of-life arrangements. My pager goes off during this discussion. There is another patient in the ER who needs to be admitted.
~~~
I am tired enough that my brain is taking my hand-eye coordination away, so I think I will go to bed now. I really hope this post is coherent.
So you are a patient in a hospital, and I am your doctor. You like me at first. When you get in the hospital, I spend like an hour with you and meticulously go through every inch of your complaint. I am sympathetic (unless you curse at me or hit me) and I smile a lot, and you feel reassured that this hospital stay will be useful, albeit stressful because you are sick.
The next morning, I burst in on you at an hour that is proof of our fallen world. You are still rubbing sleep from your eyes when I turn on the dazzling light behind your bed and start throwing questions at you. Five minutes later you have been stethoscoped briefly and I am gone, and you feel bemused, slightly irritated, and potentially slighted. You don't see me again for the rest of the day which seems unfair. Aren't you sick? Shouldn't you be seen by a doctor?
This pattern continues for your four-day hospital stay, with the exception of one day where I come in during the afternoon as well so we can discuss some important test results. During that talk I have magically transformed back into the doctor you met on the first day, sympathetic and ready to listen, free with my time - until a high-pitched beeping interrupts your tearful admission about how afraid you were that you had cancer. I apologise and breeze out of the room, leaving you uncomfortable and wishing you hadn't said anything. I don't come back for half an hour (what could have taken so long??) and the mood is clearly broken as I stick to medical topics, listen to your lungs again, then leave.
The next day, you can leave! Finally! You are overjoyed when I tell you this under the piercingly bright lights at 5:30am. You are, however, considerably less overjoyed when seven hours later you are still sitting in the hospital. I'd warned you to give it some time, but come on! You ask the nurse to call me, and the response is basically nothing. Wait. The doctor hasn't forgotten about you. Yeah, clearly. You can't leave until 3pm, and though my card is sitting in your folder of discharge paperwork so you can see me in the clinic, you aren't sure if you will. I certainly wasn't on top of things in the hospital; why would that be different in clinic?
Let's switch our point of view here.
I am a first year resident physician, and I am terrified. I go to admit you, my patient, and get you all tucked in for the night. In engrish we would say: strong success!
The next morning I start work at 5am after finishing at 8pm the night before. I have three hours to see six patients, by which I mean examine/ talk to the patient, write a note on each person's progress, examine labwork and other doctors' notes, and decide what to do for the day to help make the patient better. I really hope all of my patients are fairly quiet so the exam part can go quickly, because it takes so long for me to really think my way through their plan of care. Apparently I'm the doctor now and I need to do these things. I hate being awake so early, let alone inflicting that on others, but this is my only opportunity to do this, so I turn lights on and speak clearly so that hopefully some of what I say sinks in. It doesn't feel like it, but this is my visit for the day, and I hate that my patients are always sleepy and out of it and not in a place to discuss anything important when I see them, but I don't have a choice. My time is not my own.
Work for me goes like this. I work an average of 14 hours a day. I probably take about 40 minutes a day for myself, what with lunch and various bathroom breaks. Actually, I take that back; I normally work while eating lunch. So I take about 20 minutes a day for myself. 5am - 8am, I see patients and write paperwork. 8 - 9 is academics. 9-11, my fellow interns and I present our patients to the senior residents and the attending (= fully licenced supervising physician) and have our plans tweaked. The rest of the day is unscheduled. This means it is time for discharging patients, admitting new patients, following lab results, talking to specialists about our patients, and doing procedures. If I have time, I like to go back to my patients and talk with them a bit more, as this is excellent time for counselling, information-gathering, and ministry.
The thing that makes all of that a total mess is that all of it happens simultaneously. Several days later when I am trying to discharge you, I cannot work on your paperwork until lunchtime because morning presentations run late, so I start your paperwork (and paperwork for two other people who are also being discharged) as I eat lunch. Except before I can do that, I need to get some specialists on board for other patients who are currently way sicker than you. That takes some doing and multiple phone calls, but once it's done, it's paperwork time. You know all that paperwork you receive when you leave the hospital? Yeah, I put all of that together. I evaluate all of your prescriptions and your discharge instructions, make sure you have the right contact numbers for clinics, etc. You know not to expect to leave until around lunchtime because I told you that morning. As I am working on your discharge, however, a very sick person arrives in the emergency department and needs to be admitted. Remember that hour I spent with you working through your medical issues? I have to go to the ER now to do that for someone else, leaving your paperwork undone for the moment. I am paged five times during that admit which adds easily 30 minutes to the process because some of the questions I am asked I have to run by my senior. One of those pages is actually from your nurse, and I have nothing to offer you except I'm sorry. I'm admitting a patient and I can't get away. Please be patient. It takes about 90 minutes - 2 hours for me to work through admitting a patient because I am slow at this right now and scared I'll miss something important.
Finally it is midafternoon and I am trying to go through your paperwork. It takes some research to make sure I am making the right decisions, but ultimately I'm satisfied and send you on your way. I poke my head in to let you know and you are clearly angry. You have been waiting for ten hours to go home, you say. What is wrong with this place, you say. I apologise again.
Then I walk down the hall and discuss a lady's suicide attempt with her, finding out that she was a victim of child rape and prostitution and she's never recovered from that despite trying to be strong. Then I go down two floors to explain to a man that there's nothing we can do and he needs to start making end-of-life arrangements. My pager goes off during this discussion. There is another patient in the ER who needs to be admitted.
~~~
I am tired enough that my brain is taking my hand-eye coordination away, so I think I will go to bed now. I really hope this post is coherent.
Saturday, June 15
Blog name and address change
Hey, in honor of all of the new ridiculous stories I'm going to have as a resident, I'm changing my blog name and address. This matters because this blog will no longer exist under the old address/ name. So:
old name - Almost a D.O.ctor; doctoralmost.blogspot.com
new name (!) - Practically a D.O.ctor, doctorpractice.blogspot.com
A friend suggested the clever name change to accompany the change in status. I will really be practicing being a doctor now, in the sense that I will have to try to work out patient care on my own and in large part my attendings will exist as a safety net. This is quite different from how you work as a medical student, where you have really no autonomy and there is always someone looking over your shoulder.
I will change the site name in about one week. It doesn't look like there's a forwarding service that I can set up, so don't forget!
old name - Almost a D.O.ctor; doctoralmost.blogspot.com
new name (!) - Practically a D.O.ctor, doctorpractice.blogspot.com
A friend suggested the clever name change to accompany the change in status. I will really be practicing being a doctor now, in the sense that I will have to try to work out patient care on my own and in large part my attendings will exist as a safety net. This is quite different from how you work as a medical student, where you have really no autonomy and there is always someone looking over your shoulder.
I will change the site name in about one week. It doesn't look like there's a forwarding service that I can set up, so don't forget!
Thursday, June 13
Residency training, day #1
Things I learned from my first day of residency training:
1. Lower your expectations.
2. Be on time.
3. Pay attention.
[3a. If you're falling asleep, hold your breath until your brain thinks you're dying, freaks out, and floods your system with adrenaline. Problem solved! You are now awake, if twitchy and a little pale.]
4. Don't make excuses for your stupidity.
5. Don't harbor regrets for your stupidity.
6. I am probably as ill-prepared as I think I am, if not more.
7. Things will probably be okay anyway.
I'm doing a bit better spiritually/ emotionally, by the way. It's incredible how the Lord comforts us in our struggles. My attitude toward residency isn't settled yet, but it'll get there.
1. Lower your expectations.
2. Be on time.
3. Pay attention.
[3a. If you're falling asleep, hold your breath until your brain thinks you're dying, freaks out, and floods your system with adrenaline. Problem solved! You are now awake, if twitchy and a little pale.]
4. Don't make excuses for your stupidity.
5. Don't harbor regrets for your stupidity.
6. I am probably as ill-prepared as I think I am, if not more.
7. Things will probably be okay anyway.
I'm doing a bit better spiritually/ emotionally, by the way. It's incredible how the Lord comforts us in our struggles. My attitude toward residency isn't settled yet, but it'll get there.
Sunday, May 26
Wherever there is jealousy and selfish ambition, there you will find disorder and evil of every kind.
I wrote this a week or two ago, but followed the advice of a wise friend who suggested I wait and make sure I could handle this much transparency. I'd be lying if I said this issue is closed, but I've already sat on this post in one form or another for months and I'm starting to feel like I'm hiding it. That's not okay. I don't want to give the false impression that this walk with Christ has no stumbles or sharp turns in it, and I don't like keeping secrets. So here it is.
I often get the sense that real struggles with sin are not okay to talk about in a lot of church circles, but I don't currently have any thoughts on eschatology or the latest Joyce Meyer book, so this will have to do for discussion. Let me start by saying that I'm still really ashamed of the content of this post, which is proof that this internal journey is nowhere near finished yet. But it would be dishonest of me to pretend this isn't going on, and it's something that many, many doctors (Christian and not) have a hard time with, so it should be brought out into the light and examined with the eyes of truth.
The real story of my winter and spring is not auditions, or rotations, or matching, or medicine. Those things just form the backdrop for the action. The real story of my past six months is how, for the first time since coming to know Christ several years ago, I fell unresisting into sin - the sin which some have said lies at the root of most other sins, pride. I have almost no idea how to even talk about it. It's so hard. It came about so gradually at first, over years, that I didn't even notice it, and it started with something very simple and not wrong at all: I liked emergency medicine more than family medicine as a potential career.
You all know that for me, the FM/EM fight has been raging for years, and I always put it like this: I feel like FM has big strengths and undeniably lends itself to missions, but I just honestly like the ER so much. And that sounds good. But I didn't realise that other things were building up around that, things like: ER doctors get to tell cooler stories. All family physicians get to do is drudgery, and they don't get any respect. I would really like the flexibility that comes with shift work. I don't have fun managing diabetes and such. My feet hurt when I walk the floors on internal medicine. I would hate to have to run a business so I'll never be a clinic doctor.
I have listened to so many incredible doctors warn about how obstacles to serving Christ creep in and take the form of our desires for comfort, stability, respect, and choice. And you know what? I still have let all of those things creep into my heart. And I was so sure that everything was fine that I let it get worse. By fourth year, my thoughts went more like this: yeah, I'm going to be an emergency doctor. I'll do all the interesting stuff. I will be the Christian who survives in a demanding secular environment. I will be the spiritually sound one who still has the trendy job.
Pastor Mark Driscoll did an interesting sermon series this year about identity, and he mentioned something that resonated like a bell for me: when you commit identity idolatry, that is, when you define yourself by something other than your relationship with Christ and put great worth in that identity, you eventually get extremely nervous. This is because you can sense that whatever or whoever you have pinned your identity on is not reliable enough to keep you stable. I recognise this in myself during audition season. I had let my career become everything to me, the deepest part of my desires for my future and the center of my self-image; and the strain was starting to show. My anxiety about matching into family medicine vs. emergency medicine was profound. I probably cried about it 2-3 times a week for months. It became very important to me that I match into an EM residency, although I still didn't realise why. I just knew that I had to match into emergency medicine. I had to. That was all there was.
Except I didn't, did I? I matched as a family medicine resident with a Christian residency program. (How I was brought there when I was essentially running full tilt in the other direction is a whole other post.)
I wish I could tell you that I'm thrilled to start at this program. I should be. It is an incredible place, filled with deeply admirable people, and they deserve better than I am giving them. And it is really sick that I can look at their graduating class and think, I really want to be like each of those people both as doctors and as Christians, and yet I feel shame when I tell people that I am going into family medicine. During my spring rotations I had to constantly interact with ER attendings and residents and a hot little knife of embarrassment jabbed me every time.
I haven't been able to pray with a whole heart since October or November. I feel like I'm fleeing from the Word even as I seek it. I have no peace about my immediate future even though it's settled now. I am terrified that I am denying myself joy in the beginning of my residency. I've admitted to myself that I crave recognition and am full of self-righteousness, that it's possible I never wanted EM for the right reasons, and that part of me wants to simply switch those terrible reasons over to my new field without working on my heart so that I can keep my pride. There have been many layers to this repentance and each is more painful than the last, and I'm still not finished; at this point part of me doesn't even want to continue, which is why I persist in this spiritual listlessness. I feel like a fraud and I feel an inch tall. I wonder how the Lord could possibly use me for His purposes when I am such a sinner. I wonder why on earth He would inflict me on such a good Christian ministry when I am anything but an asset to them right now. And part of me can't help but repeat that maybe if I'd loved Him more, if I'd been a better Christian, I would be headed to work in an ER right now - which is totally theologically unsound. The Lord doesn't work that way. I know there is victory and freedom in Christ, and I have reveled in that in the past, but I am so far from that now. And I worry that I don't know how to truly seek the ways of the Lord instead of the world.
So there you go. I am lost and I feel like time is running out. I trust God's promise that He is with me always, even to the end of the age, but I also remember Jesus' clear warning that following him requires taking up your own cross - a metaphor for death to self and a call to sacrificial living. My faith is small right now. I'm glad all He asks is a mustard seed's worth.
I often get the sense that real struggles with sin are not okay to talk about in a lot of church circles, but I don't currently have any thoughts on eschatology or the latest Joyce Meyer book, so this will have to do for discussion. Let me start by saying that I'm still really ashamed of the content of this post, which is proof that this internal journey is nowhere near finished yet. But it would be dishonest of me to pretend this isn't going on, and it's something that many, many doctors (Christian and not) have a hard time with, so it should be brought out into the light and examined with the eyes of truth.
The real story of my winter and spring is not auditions, or rotations, or matching, or medicine. Those things just form the backdrop for the action. The real story of my past six months is how, for the first time since coming to know Christ several years ago, I fell unresisting into sin - the sin which some have said lies at the root of most other sins, pride. I have almost no idea how to even talk about it. It's so hard. It came about so gradually at first, over years, that I didn't even notice it, and it started with something very simple and not wrong at all: I liked emergency medicine more than family medicine as a potential career.
You all know that for me, the FM/EM fight has been raging for years, and I always put it like this: I feel like FM has big strengths and undeniably lends itself to missions, but I just honestly like the ER so much. And that sounds good. But I didn't realise that other things were building up around that, things like: ER doctors get to tell cooler stories. All family physicians get to do is drudgery, and they don't get any respect. I would really like the flexibility that comes with shift work. I don't have fun managing diabetes and such. My feet hurt when I walk the floors on internal medicine. I would hate to have to run a business so I'll never be a clinic doctor.
I have listened to so many incredible doctors warn about how obstacles to serving Christ creep in and take the form of our desires for comfort, stability, respect, and choice. And you know what? I still have let all of those things creep into my heart. And I was so sure that everything was fine that I let it get worse. By fourth year, my thoughts went more like this: yeah, I'm going to be an emergency doctor. I'll do all the interesting stuff. I will be the Christian who survives in a demanding secular environment. I will be the spiritually sound one who still has the trendy job.
Pastor Mark Driscoll did an interesting sermon series this year about identity, and he mentioned something that resonated like a bell for me: when you commit identity idolatry, that is, when you define yourself by something other than your relationship with Christ and put great worth in that identity, you eventually get extremely nervous. This is because you can sense that whatever or whoever you have pinned your identity on is not reliable enough to keep you stable. I recognise this in myself during audition season. I had let my career become everything to me, the deepest part of my desires for my future and the center of my self-image; and the strain was starting to show. My anxiety about matching into family medicine vs. emergency medicine was profound. I probably cried about it 2-3 times a week for months. It became very important to me that I match into an EM residency, although I still didn't realise why. I just knew that I had to match into emergency medicine. I had to. That was all there was.
Except I didn't, did I? I matched as a family medicine resident with a Christian residency program. (How I was brought there when I was essentially running full tilt in the other direction is a whole other post.)
I wish I could tell you that I'm thrilled to start at this program. I should be. It is an incredible place, filled with deeply admirable people, and they deserve better than I am giving them. And it is really sick that I can look at their graduating class and think, I really want to be like each of those people both as doctors and as Christians, and yet I feel shame when I tell people that I am going into family medicine. During my spring rotations I had to constantly interact with ER attendings and residents and a hot little knife of embarrassment jabbed me every time.
I haven't been able to pray with a whole heart since October or November. I feel like I'm fleeing from the Word even as I seek it. I have no peace about my immediate future even though it's settled now. I am terrified that I am denying myself joy in the beginning of my residency. I've admitted to myself that I crave recognition and am full of self-righteousness, that it's possible I never wanted EM for the right reasons, and that part of me wants to simply switch those terrible reasons over to my new field without working on my heart so that I can keep my pride. There have been many layers to this repentance and each is more painful than the last, and I'm still not finished; at this point part of me doesn't even want to continue, which is why I persist in this spiritual listlessness. I feel like a fraud and I feel an inch tall. I wonder how the Lord could possibly use me for His purposes when I am such a sinner. I wonder why on earth He would inflict me on such a good Christian ministry when I am anything but an asset to them right now. And part of me can't help but repeat that maybe if I'd loved Him more, if I'd been a better Christian, I would be headed to work in an ER right now - which is totally theologically unsound. The Lord doesn't work that way. I know there is victory and freedom in Christ, and I have reveled in that in the past, but I am so far from that now. And I worry that I don't know how to truly seek the ways of the Lord instead of the world.
So there you go. I am lost and I feel like time is running out. I trust God's promise that He is with me always, even to the end of the age, but I also remember Jesus' clear warning that following him requires taking up your own cross - a metaphor for death to self and a call to sacrificial living. My faith is small right now. I'm glad all He asks is a mustard seed's worth.
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