Saturday, April 1, 2017

Mistakes, I've Made A Few

When I started medical school, I believed wholeheartedly that physicians were perfect.  I fully expected that, over the following 6-9 years of training, I would fill my brain with everything I needed to know about medicine and that I would learn how to use this information correctly, in every patient encounter, with 100% accuracy.

I'm not sure where I got this idea from.  Certainly I recognized (probably too clearly) that I was a fallible human being, yet I somehow thought that medical training would beat the fallibility out of me.  I envisioned the epic 28-hour-plus call shifts transforming me into someone perfect, someone who never wrote down the wrong drug dose and who never froze, uncertain of what to do, in the middle of a code blue.

It was a shock to me then, as I progressed through my training, to discover that my human imperfections didn't go away.  I certainly learned to be much better - to double check my orders and to write list after list in an attempt to never miss anything - but the promise of perfection has remained elusive.  Sometimes I slip up.  Sometimes I forget to do something important, or I fail to take something into consideration when making a treatment plan, or I misjudge just how sick the patient in front of me is.

Imperfection feels horrible as a trainee, but it still feels bearable.  As a trainee, right up until the last day of fellowship, there is always someone watching, someone double checking.  Someone who ranks higher than you on the list of people responsible.  Someone who retains the burden of final responsibility.

And then you graduate.  And now you are the person in charge.  And suddenly the weight of the work you do, the importance of every decision you make, seems ten times greater.  Double checking becomes triple checking.  Minutes of insomnia turn into hours.  Precious time outside of work, which is finally not quite as rare as it was in training, is spoiled by endless questioning and self doubt.

Did I screw something up?

Is someone going to die because of something I did?

And the worst part of it is, almost no one talks about it.  If you ever dare to talk to a colleague about your fears, they will minimize them, reassuring you that you're one of the good doctors.  You're not one of the ones who makes mistakes.

Almost no one acknowledges that we all make mistakes.  And that it isn't enough to learn how not to make mistakes or, more realistically, how to make fewer of them. What we really need to learn is how to cope with the fact that we are fallible humans, called upon to do superhuman work despite our inability to ever be superhuman.

Monday, February 20, 2017

Usted Esta Aqui


M and I just came back from a lovely week in Cuba.  It had been seven months since my last true vacation (a week off at home for our local theatre festival in July), and I was starting to crack a bit under the strain of constantly having to be on for other people.  A week of sun and books and more alcohol than is recommended was somewhat desperately needed.


The setup was perfect for relaxing.  We were in an all-inclusive resort, so the most strenuous thing required of us was walking from our table to the buffet to refill our overflowing plates.  And yet, despite being on vacation, I found it hard to turn off the constant chatter in my brain.  When eating, I would be thinking about the books that were waiting to be read; when reading, I'd be wondering what was going to be served at our next meal.   When on the beach, I'd be wondering if I would've been happier spending the day in Havana; when in Havana, I would dream about the beach. 


My distractible brain, my ever present companion at home, had followed me to paradise*.


I am so accustomed to my constant thoughts about what else I should be doing and what needs to be done next that it took me days to recognize how ridiculous they were in paradise.  My moment of clarity happened on the beach, when M was snorkeling in the shallow water and I was walking beside her.  I had just come out of the water myself, and I was feeling a bit chilled, and all I could think about was wanting the walk to be over so that I would be back at my beach chair and wrapped in a warm towel.


And then I paused.  And I thought "Why on Earth am I wishing this time away?"  Wanting to be back at the beach chair wasn't going to make the distance any shorter or make M swim any faster.  All it was going to do was rob a perfectly good moment of any potential for happiness.  So I stopped, and instead of feeling my usual impatience, I took a look around me.  At the people and the palm trees and the mountains all glowing in the warmth of the late day sun.  And I realized that I was literally in the middle of a postcard.


A postcard that I had almost missed, because all I know how to do anymore is rush from what I am doing to whatever it is that comes next.

*I recognize that I am very privileged to view Cuba as "paradise", as that isn't the experience for many of its citizens.   

Saturday, February 4, 2017

Making Peace with My Food Budget

When I first put myself on a budget about 2.5 years ago, I had to cut out a lot of things to make it balance.  Things like clothing and online shopping got essentially eliminated.  Travel changed from fancy overseas vacations to trips within Canada that I purchased with AirMiles.  Visits to my favourite independent bookstore were replaced by the public library.

But one area that didn't get cut much was eating out.  Throughout training, eating out was my main form of entertainment and relaxation.  It was also an essential way of staying connected with friends and family at a time when my apartment was too messy and my fridge too empty to ever entertain at home.  So despite being ruthless with my spending in many areas, I averaged about $300 a month on eating out throughout my training.

And then I became an attending.

At first, I stuck to essentially the same budget, as I was somewhat obsessed with reaching a net worth of zero.  Once I had worked for about nine months, and I had achieved the long-dreamed-of positive net worth, I started to relax a bit more.  We started eating out a bit more often than before.  And ordering a few cocktails or a bottle of wine with our meals.  And dropping $100+ on dinner at a fancy restaurant, instead of $20 at one of the tasty dives that had previously been our favourites.

When I reviewed my spending for 2016, I was absolutely appalled to discover that I had averaged $600 per month on eating out.  SIX HUNDRED DOLLARS!  Which is utterly ridiculous.  And to make it even more crazy, that only accounts for my contribution to eating out.  My girlfriend was also paying for restaurant meals, and although she tends to pay for the less expensive meals given that she works for a non-profit agency and doesn't earn a physician's salary, she was probably still contributing a few hundred dollars a month to our eating out budget.  And, the $600 was an average for the year.  At the beginning of the year, it was closer to $300 a month, meaning that it was well over $600 a month by the end.  RIDICULOUS!

So in early January, I said enough is enough and put myself on a slightly strict eating out budget of $300 per month.  I figured that I had lived with that level of spending as a fellow, so it wouldn't be all that hard to go back to it.  I motivated myself with calculations of how much $300 a month would be worth at retirement (about $138,000 if I retire in 20 years).  I promised myself that it wouldn't be the end of eating out, but just an opportunity to recalibrate my spending.  I was ready.

I lasted approximately two weeks.

It took me two weeks to realize just how many of my favourite moments happen in restaurants and how much I would miss out on if I based my spending on an arbitrary budget instead of conscious choice.  In those two weeks, I spent a Friday night eating takeout with a friend and her young baby while talking about the crazy rollercoaster ride that is being a new attending.  I spent a Monday night at a ramen bar with another friend hearing about her struggles with infertility.  And I spent another Friday night with my partner eating in a cheezy 80s style Greek restaurant because we were both too worn out from the week to even think about cooking.

After the two weeks, in which I didn't quite manage to stick to my eating out budget, I realized that food is my sacred cow.  I'm quite happy to live in a modest home and drive a car that my physician friends make fun of and never own a Coach purse.  But I'm not happy saying no to friends or my partner when they want to get together over food.

So bring on the ridiculous food budget.  I'm ready for some tapas.

Sunday, January 22, 2017

What is Done, and What is Left to Do

It will probably come as no surprise to anyone who reads my blog that I am feeling pretty burnt out at the moment, as the few posts that I've had the mental energy to write over the past few months have been all about work stress and feeling exhausted and being too much of a grouch to even want to buy Christmas gifts.  I think I've done a decent job of hiding my dissatisfaction at work, but my poor partner, M, has had to put up with some pretty spectacular wallowing when I haven't been working.  It is frustrating, and frightening, to have put 16 years into training only to find myself feeling this level of unhappiness with my work.

So I've been thinking a lot (i.e. pretty much all the time) about what to do about it.  I've been reading blogs and journaling and talking M's ears off in an attempt to figure out some way of becoming happier.  (I haven't been exercising or meditating, of course, because those things might actually work.)  I even bought a book about physician burnout, despite absolutely hating the last physician burnout book I read.  And, much to my surprise, the book has been kind of helpful.

One of the ideas in the book is that, as physicians, we are always focused on what remains to be done: how many letters we need to dictate, how many patients we need to see, how many bloody multi-page forms we need to fill out.  By constantly thinking about what still needs to be done, however, we inevitably feel like we aren't accomplishing anything, and we get discouraged by the seemingly neverending to-do list.  Instead, we'd be much better off putting our focus on what we've already done, so that we are positively celebrating our accomplishments instead of always negatively dreading the work to come.

It's a pretty simple idea, and it requires pretty minimal energy and absolutely zero time, so I decided to try it out this week.  No longer was I going to count the patient files on my desk that needed to be dictated (about 20 at current count); instead, I was going to count the ones in my outbox that were already done.  Instead of focusing on the number of patients remaining to be seen, I was going to focus on the ones that had already been dealt with.  Pay attention to the positive, not the negative.

It sounds cheesy to even write this...but it kind of helped.  It made me realize that my list of things that I have already accomplished is pretty enormous, and it dwarfs the few hours of paperwork that I left undone at work on Friday.  It felt surprisingly good to be a bit of a cheerleader for myself, instead of the evil taskmaster who is always yelling at myself to work harder! and faster! and better!

It worked so well that I decided to apply this mindset to an area of my life that causes my unnecessary anxiety:  my finances.  I'm in pretty good financial shape for being 17 months into practice, yet I waste a lot of energy thinking about how far away I am from being able to retire.  This week, instead of constantly thinking about the minimum of 10 years of work that I will have to do to save up a decent retirement fund, I took a few minutes to list the major financial accomplishments I've made over the past 17 months:
  • Saved up enough money in my investments that I could pay off my line of credit if I wanted to;
  • Saved up enough money that, between M and me, we can make a 20% downpayment on a nice house in our chosen neighbourhood; and
  • Saved up enough money in my investments that I could live at my current level of spending for approximately one year (or for a very long time if I stopped eating out so frequently).
That list makes me feel vastly better than saying to myself "I have to work at this miserable job* for another 10 years before I will feel happy again" all the time.

I know that there are still a lot of things that I need to do to feel happier with my work, but I think that changing my mindset has been an important first step.  Despite being on call again this week**, I've been in a much better mood than I have been since my really stressful department meeting.  I now have six weeks of no call, which includes a one-week trip to Cuba, so hopefully there are even better things ahead.

*My job isn't actually all that miserable.  I'm just feeling so exhausted by it that I am having a hard time seeing the good things.  Which I'm working on.

**I sat down this week and figured out just how much call I've been doing lately, and I realized that I've been on call 1/3 of the time for the past 3.5 months.  That's the amount of call that I should be doing in a 6-month period, and it's equal to the maximum amount of call that a resident is allowed to do.  Suddenly I don't feel so guilty for feeling tired!  As a result of this realization, I've reviewed my call schedule for the upcoming year and identified a few similar problem periods that can hopefully be improved by a bit of swapping with my colleagues.

Friday, January 20, 2017

Today's Patient Encounter

The waiting area for my clinic has a big-screen television, and it was of course* broadcasting the inauguration ceremonies this morning while I was seeing patients.  I called a new patient into my examination room just as the swearing in was about to start, and as we were walking away from the waiting area she said:

"Oh thank God you came when you did.  I can't stand to watch that vile man become president!"

My patients are awesome.

*By "of course", I in no way mean that I "of course" chose to show the vile man becoming president.  I share my waiting area with multiple other physicians and sadly have no say over what is played on the tv.

Sunday, January 8, 2017

2017 - The Year of Saying No

I suspect that I'm not the only person in medicine who is a people pleaser.  Since elementary school, I've always been very academically successful, and the resultant praise from teachers and relatives has given me a lot of pleasure and personal satisfaction.  Going to medical school and becoming a doctor took this to the next level, as suddenly patients and even strangers were regularly praising me for the work I did. 

The big problem with getting so much validation externally is that you start to be dependent upon it.  You need people to tell you how important you are and how no one else can do what you're doing.  And so you constantly seek ways to keep that validation coming.  You say yes to giving one more presentation or fitting another patient into your clinic or teaching one more tutorial.  Even when you don't really want to be doing any of those things.

Over the past few months, I've been feeling depleted, as I keep telling my partner.  I've been feeling overwhelmed by work; I've been having difficulty sleeping; and I've been hit with a bone-weary exhaustion that reminds me of my residency days.  I had hoped that a recent trip to a cabin would fix things, but four days away just wasn't enough.  I'm tired. 

And despite this, people keep asking for more.  Start a research project.  Do more training.  Teach another academic half day.  More, more, more, when all I want to do is stay in bed with my cats.  It has reached the point where I feel anxious not only when my pager goes off, but also when my inbox pings, signalling the arrival of another email asking for my time and energy.

So this year, I'm going to learn to say no.  Thank you for the opportunity, but that isn't my priority.  My priority needs to be finding balance, a level of work and engagement that I can happily sustain for the next 20 years, not saying yes to every single request that comes my way.  I need downtime and sleep and yoga classes and running and home-cooked food and time with the people I love, not another item on my to-do list.

No.

It sounds straightforward, but it goes against the very essence of medical culture.  Physicians pride themselves on being able to work a 28-hour shift and then go climb a mountain on their post-call day.  Medicine is the North American worship of busyness and achievement taken to the extreme.  Saying no means being inadequate and not measuring up to the standard.

And Medicine doesn't always listen to no.  A few weeks ago, I was emailed a request to help someone out with a presentation.  My stomach sunk when I read the email, because it was something that I really didn't want to do, even if I had had an abundance of time in which to do it.  So I sat on the email for weeks, debating the merits of saying yes versus no, until I finally got up the guts to sent a polite email declining the request.

The response?  Within seconds, a return email that basically said "Can you do part of the work for me?".

No! 

I'm still completely flabbergasted by the response.  Why is my attempt to protect my happiness and my time not respected?  Why am I expected to say yes to every request that comes into my inbox?

Learning to say no isn't going to be easy.  It's going to mean letting go of the need for other people to tell me how wonderful I am and what a good job I'm doing.  It's going to mean letting go of the belief that if I were just better, just like every other physician, that I would be able to say yes to everything.  It's going to mean ignoring the blogs of the overachievers, who have a medical practice and children and exercise daily and cook healthy food, and setting my own standards for achievement.  Because ultimately no one cares about my happiness as much as I do.  And no one else in Medicine is looking out for my well-being as much as I am.