2019 - The Year of Breaking Open

I'm not big into dates, but for some reason I love the start of the new year.  Even though there's nothing magical about the transition from December 31 to January 1, it always gets me reflecting on the previous year and thinking ahead to the next.  When I re-read my New Year's post from this year, I had to laugh at my intention for 2019:

"And what for 2019?  Mostly, I want to keep going on the path that I'm already on.  I want to remain in the present moment, enjoying it when I can and learning from it when I can't."

Learning from it when I can't describes so much of the past year.  I existed in a state of near-constant stress for months, and then I basically fell apart when the chronic stress became too much.  For weeks, I wasn't certain if I would choose to (or even be able to) stay at work.  It was horrible.

Probably the wisest thing I did, and something that was only possible because of my mindfulness practice, was stay present in the tough moments.  My mantra through that time, which I would sometimes recite multiple times in a day, was "Be patient.  Be present."  I somehow knew that, if I could just show up for those moments, that I would learn something important from them.

And I have learned an incredible amount over the past year.  I've learned that I am limited in how much I can do well (as is everyone), and more importantly, I've learned that I have the support of my institution to set limits on my work.  I don't have to overbook all of my clinics.  I don't have to work through weekends most of the time.  I don't have to say yes to every administrative task that comes my way.  I can (and absolutely must) say no.

I've also learned that I am very hard working, even though I don't always feel that way when I compare myself to the overachievers who seem to be everywhere in medicine.  I regularly go beyond what I need to for my patients, and I show up for them even on the days when I would rather pull the covers over my head.  I'm committed to the work that I do, and I put in the effort needed to be a really good doctor.

Overall, as hard as a lot of the past year has been, I'm really proud of myself for getting through it.  And for not quitting my job!  Because it's generally a pretty good one, and I do a pretty good job at it, if I may say so myself.

How I Almost Moved Into a House But Didn't

A few weeks ago, I opened up Facebook while eating breakfast and saw an ad for the perfect house.  Only a few minutes from where I currently live and still in a neighbourhood that I love, the house was the ideal balance between "old enough to be charming" and "new enough to not have knob and tube wiring*".  And it was for rent, which is probably the only way I'm ever going to get into a house, as I'm utterly terrified of buying something.

It took me only a few minutes to email the person renting it, and I stopped by to see it on my way home from work that evening.  When I walked in, the house was toasty warm and beautifully decorated for Christmas, and my heart said a very loud yes.  This is my home.  I want to live here.

For the next four days, I lived and breathed that house.  I posted about it on Twitter and Facebook, I dreamed of all the things I could do in it (Butterfly garden!  Bat house!  Little Free Library!), and I started rescheduling my upcoming vacation to include packing up my apartment and moving into a house.  I was 100% mentally there.

And then...I went back.  I went to see it again with my Mom and to work out the practical details, and the reality of the house started to sink it.  Houses come with lawns to be mowed and driveways to be shoveled and windows (so many beautiful windows) to be washed.  And the $400 more per month in rent was only the beginning of the increased costs - I would have to add electricity and water and gas and a home alarm system and alllll the things I would want to buy with double the space that I currently have.  Yes, I could host games nights in a stylish historic living room warmed by a gas fireplace, but I would also have to get up early on snow days to dig my car out of the detached and unheated garage.

I went home that night, and I thought and thought and thought, trying to figure out what to do.  It wasn't a question of whether I could afford it - I save a high percentage of my income, so there is money in my budget to move into a much nicer home than where I'm living right now.  The question was, why did I want to move into a house?

The answer, for me, was social.  I wanted to host games nights for friends and have my aunt over for coffee and drop in informally on the friend who lives around the corner.  All really good things.  But...none of them dependent on being in a house.  Sure, my one-bedroom apartment is limited in its ability to host big gatherings, but I'm an introvert who actually doesn't really like being around large groups of people.  Two to six people is about ideal for me, and my dining room table can comfortably seat six.  The size of my apartment isn't really what limits me socially - it's time and energy, both of which I'd have less of in a house.

The financial side of it, even though I could afford it, was also a big issue.  The added costs would be approximately equal to one month a year of income - that's huge!  When I looked at it that way, and asked myself "Would I rather have that house or an extra month of vacation every year?", vacation won without a moment of hesitation**.

So....I still live in the apartment where I've lived for nine years.  And...I'm good with that.  Work is a 6-minute drive when there's no traffic (and under 30 in even the worst of rush hour traffic).  I can easily walk to fabulous restaurants and coffee shops.  And I have time and money and energy to do the thing that's most important to me:  connect.

*Technically renovated to not have knob and tube wiring...but still new enough to not be a nightmare of old home disasters.

**Not that I'm going to take an extra month of vacation, as my vacation time is already pretty ridiculously amazing, and I do need to earn money.

How to Rest

As a resident, I had almost no time off.  I worked as much as 100 hours in some weeks, often in 24-hour-plus stretches, so I was basically always either at work or collapsed half dead on my couch.  I didn't have to think about the concept of work-life balance, because there wasn't any.  I worked, and I did what I could to survive the five years relatively unscathed*.

And then it ended.  And I was an attending!  With a better schedule!  And money!  And completely no idea of how to take care of myself in a long-term, I want to be happy and not die of a heart attack kind of way.

I knew that having a life outside of work was a priority for me, but because it had been so long since I had had one, I had no idea how to make that happen.  I also faced the new challenge of always having work to do.  Labs to review, patients to call, prescriptions to renew, presentations to prepare - I live in a giant game of medical Whack-A-Mole.  For the longest time, I tried to get everything done before I would "allow" myself to rest, which meant that I was always trying to work and never actually resting.

Except....I was wasting a shit tonne of time.  Like most people, I have a limited amount of mental and physical energy every day (spoons!), and once I use it up, I can pretend to be working, but I'm really not.  I'm checking Twitter.  Or Instagram.  Or Facebook.  Or going to Starbucks for another tea.  It feels like work time, and I resent it, but I'm accomplishing very little.

Earlier this year, when work seemed to occupy every waking and sleeping moment of my life, I was finally forced to acknowledge that I can only accomplish a finite amount of things.  And this amount is never as much as I want it to be.  Yet I was working myself beyond a sustainable limit, and for what?  Desire for more money that I didn't need?  A sense of obligation?  Conditioning from the medical system to never rest?  I was failing miserably at having a good life for really no reason at all.

I am incredibly lucky to have flexibility in my job and to earn much more than I need to, which as I've mentioned over and over again has allowed me to back off from work and regain some much needed time.  But just as importantly, recognizing my limits has given me permission to rest.  To designate evenings and weekends and long stretches of holidays as "not working" time, rather than "working but not actually accomplishing anything because I keep Tweeting about marshmallow peanut butter squares" time.

Which makes all the difference.  Because distracting myself on the Internet while I'm supposed to be working isn't restful.  Sleep is.  Yoga is.  Meditation is**.

Not doing is restful.

Next week I'm on call again, and I have a long list of things I would like to get done before I go back on call.  Some of which I will get done tomorrow morning, but once my designated work time is over, I'm going to stop.  I'm going to go to the theatre with my mom, and then I'm going to eat and drink more than is doctor recommended.  On Sunday I'm taking myself to a Nordic spa, and I can guarantee that I will spend the whole day moving from heated bed to hot tub to wet sauna to dry.  Because I will need all my spoons next week, and trying to work all weekend is not going to give any of them back.

*By the end, I had raging anxiety, was socially isolated, and had lost all self-care habits.  "Unscathed" is defined very loosely here.

** When my f-ing monkey brain isn't wandering all over the place, which it always is, so I take this back, meditation is not restful, dammit.

The Return of Happiness

Years ago, when I was early in residency training, I wrote a post on the first version of this blog called "Fundamentally Happy"*.  In it, I talked about how, despite the many challenges of residency, at my core I was happy.  Satisfied with where I was in life and with where I was going.

Earlier this year, I lost that feeling.  Not just for a moment, but for months on end.  I felt like I was working constantly and as if life was a perpetual slog through overbooked clinics and piles of paperwork.  In the beginning, I was having trouble staying caught up for more than the briefest of moments, and eventually I lost the ability to ever catch up.  I was slowly drowning.

It has taken a lot to come back.   I have drawn on every resource available to me to get through this, and I have been so lucky to have been met by nothing but support everywhere I went.  Support from friends, colleagues (remember the one who took three weeks of summer call for me?), and even my department head.  I am so thankful to have had a good experience, because I know that many physicians who burn out don't.

Life is different now.  My clinics are capped, so even on days when everyone shows up, I usually run (at least close to) on time.  I don't run over too often, and some days I finish early.  I still get behind on paperwork sometimes, but it's usually because I've taken something extra on (like travelling to a remote community to share my knowledge with a group of rural physicians) and not because the work load is too much.  And when I get behind, I can catch up again.

I can finally breathe again.  Not the shallow, panicked, desperate breaths that I was breathing for months.  Deep, calm, happy breaths.

Things are so much better.

*I think.  My memory is crappy.

Practice, Part One

I wrote a while back about how online dating got me into meditation.  While I only went on one date with the yoga-loving woman mentioned in the post, we have established a fairly close friendship over the past year, and after listening to her talk about her love of yoga, I decided it was something I should also do.

I had done yoga before, but only in a once- or twice-a-week, go-months-without-practicing kind of way.  Thanks in part to my friend's inspiration, as well as another friend directing me to a fabulous studio, I have now become someone with a regular practice.  I look forward to classes more than almost anything else I do, and I am sad that I don't yet have the stamina to go to a class every day - although I set a personal record of 19 classes in August, so I'm getting there.

In all my posts so far about burnout, I haven't yet written much about the role that yoga played, but ironically, I think it was a big part of why I burnt out when I did.  Before I started doing yoga, I was living with blinders on, getting through each day by focusing on the work and ignoring how miserable it was making me.  In yoga, I spend an hour or more each class inside my own head, and it's really hard to ignore how you're feeling when it's just you and your thoughts*.  Being present with my own emotions forced me to acknowledge them and, eventually, to do something about them.

Yoga also, in a very tangible and physical way, forced me to confront the fact that I am limited.  Doctors aren't supposed to be - we're taught from the beginning of medical school that we should be able to do any amount of work under any conditions without ever making a mistake.  And while I knew intellectually that this was utter nonsense, on an emotional level, this concept of what a physician should be was harder to let go of.  In yoga, my limitations are right there and are impossible to ignore.  If I go to a hard class one day, my muscles will be sore the next day and I won't be able to do the same poses.  I am limited and imperfect.  And I need rest.

Now, on what is hopefully the other side of burnout, yoga is a big part of how I'm rebuilding.  It's exercise and stress relief and a place that always feels safe.  On harder days at work, I take comfort in knowing that I can end my day on my mat, with a bit of calm and a bit of peace.  It's my happy place, and I'm incredibly grateful to have found it.

Namaste.

*and an instructor made of nothing but bone and muscle who can bend their body in super-human ways

How FIRE led me to Burnout

For a physician, I think and talk and write a lot about taking time off.  Two years ago, I committed to taking vacation every three months, and I have done a pretty good job of sticking to that ever since (I even took an extra vacation this year!).  I talk to trainees all the time about taking time away from work in order to maintain their mental health and have some joy in their lives.  So, until recently, I really thought I had the right mindset with respect to so-called work-life balance.

Except...underlying everything has been the idea of FIRE.  Work my ass off for a few years, save as much as possible, and then run away to a life of complete freedom and constant joy.  The dream!  While I still allowed myself vacations, the desire to have enough money to retire as soon as possible led me to make other bad decisions that were perhaps worse than never taking time off.  Sure, I'll add more patients to my already overbooked clinic.  Sure, I'll take on some lucrative contract work that I don't have time for.  Sure, I can do an extra Friday afternoon clinic even though I'm barely clawing my way to the end of the week as it is.  I convinced myself that I was being a good doctor by seeing more patients, but if I'm being honest, the real driver was the extra money that could go directly into my retirement savings.

And so, as I've already written about, I crashed in a somewhat spectacular way.

I'm actually kind of thankful for the crash (or, at least I think I will be when I look back on it someday), because it has forced me to reevaluate my decisions.  And two big things have come out of my months of self reflection.  First, continuing to work at as a physician is the best option for me, at least in the present.  I have contemplated taking a significant chunk of time off or quitting to pursue another career altogether, but when I look at it in the most practical of ways, doing so doesn't make any financial sense.  I could go part-time as a physician and earn more than I would doing most other jobs.  In the years it would take me to study to do something else, I could work full-time as a physician and save up most of what I need to retire.  My current reality is that I need to work to pay bills and save for the future, and medicine is by far the most efficient way of doing that.  As an added bonus, I also often like my job, at least when things aren't as overwhelming as they have been recently.

Second, and probably the more important, is that I need to stop making my decisions from a place of fear.  While part of my motivation for achieving financial independence has been a desire to not work, most of it has been a desire to not need to work.  To know that, whatever illness or mental health crisis or government overhaul of the healthcare system may hit, I am going to be okay.  Because as a single person with no one else to rely on, I worry a lot about my financial future, even when there's zero necessity to do so.  And that is a really unpleasant and unhealthy approach to money.

Thankfully, things at work are starting to get better.  I have only one slightly overbooked clinic left, and my clinics are going to continue to get lighter over the next few months until I achieve a point of actually being slightly underbooked.  I'm at the point where I can usually get my work done within the 45 hour a week maximum I've set for myself.  I'm scheduled to start six days of call tomorrow, and I'm not having panic attacks or suffering from intractable insomnia.

There are moments when I'm actually enjoying my work and remembering why I became a physician in the first place.

So I am going to keep practicing at letting go of all the things that have been driving me to burnout.  Letting go of my obsessive tracking of my net worth.  Letting go of the countdown to retirement.  Letting go of the belief that the future is going to be so much better than the present, and the desire to burn through time in order to get there.

I'm going to try, as much as I can, to live in the now.  To enjoy what I have, to be grateful for all the good, and to simply breathe.

When the Body Says No, Really

When I wrote this post three months ago, I thought everything was going to be okay. I had turned down a few things that were stressing me out, and I'd shuffled around a few patients so that I was only overbooked for the next two months instead of the next four, and I thought it was going to be enough.

Except it wasn't.

The stress kept getting worse.  I went from feeling anxious most of the time to feeling anxious all of the time.  I was constantly aware of all of the work I still had to do, and no matter how many extra hours I logged, the amount kept getting bigger.  I would push myself hard for days to get sort of caught up, but then a single busy call shift or clinic that ran over would undo it all.  I eventually stopped trying to get caught up, resigning myself to being perpetually behind and overwhelmed.

And then I started fantasizing about leaving.  Not random, fleeting thoughts of "I wish I could spend this beautiful day outside instead of in the hospital", but whole days of thinking "If I liquidate all my assets and live on a mustachian budget, how long can I go before I'd have to work again?"

I might have been able to hold things together if I'd actually stuck to my plan to say no to everything, but I didn't.  An offer came for me to present at a national meeting, and it felt like turning it down would have a hugely negative impact on my career.  So even though I was at my limit, and doing so would mean days of preparation and travel and time changes, I said yes.

The presentation went fine, but I was so tired afterwards that I could barely force myself to leave my hotel room.  I tried to go to conference sessions, but the speakers' words turned to static in my brain, so I wandered Montreal aimlessly when I should've been at the conference.  I bought books and sushi, and I spent almost an entire day devouring them both while hiding in my hotel bed.  I didn't want to be a doctor anymore. 

It was a week later that I crashed completely.  The weekend after the conference was Pride, and I decided to do all the Pride things all weekend, which is not a recipe for introvert happiness.  By the time I dragged my beer-soaked Blundstones home at 10 PM on Sunday night, I was a wreck.  And I couldn't sleep.  At 2 am, wide-eyed and jittery, I made my way to the computer and emailed the nurses to say I was cancelling a clinic.

11 years of clinical training and practice, and until then I had never missed a day of work for anything other than the direst of medical situations.

It was (at least, I hope it was) the wakeup call I needed.  It was my moment of realizing that slowing things down a bit in a few more months wasn't enough - I was in trouble now.  I could maybe muddle my way through six weeks of clinics until my next vacation, but there was no way I could do that and do two weeks of inpatient call.  I could not keep pushing myself.

The two weeks since that moment have involved a lot of soul searching and a lot of conversations with people who have thankfully been incredibly supportive of me.  The biggest thing - the thing that saved me and for which I will be ever grateful - is one of my colleagues took three weeks of my summer call.

Three weeks.
Of call.
In the summer.

I hope that someday in the very distant future I will be in a position to do someone such a huge favour, because if he hadn't done that, I'd be on stress leave right now.  Taking those weeks of call from me has given me a way forward, a bridge to a time when I can actually scale my workload back enough to make it tenable in the long-term.

He quite literally saved me.

There is so much more to say, but as I write that line and let the truth of it sink in, I can't think very far past it.

I am so glad that every time I'm in darkness, someone brings me a light.