Self Care

When medical schools interview prospective students, the question "How do you deal with stress?", or some variant, inevitably comes up.  Having been an interviewer on a few occasions, I know that every interviewee with at least basic interviewing skills will come up with some combination of the following:

Exercise
Rest
Adequate breaks
Healthy eating
Meditation
Yoga
Time with friends and family
Etc.

When I said those things in my medical school interviews, just like everyone else, I was very earnest.  I legitimately thought I would find the time and energy for all of them in my medical training.

(Insert sound of my laughter here.)

Medical training was the hardest and most life-altering thing I have ever done.  Not so much the first two years - those were almost entirely classroom based, and I had long ago mastered the art of sitting in lectures and writing exams - but definitely everything that came after.  The moment I set foot on a ward for the first time, I transformed into a human-shaped bundle of stress and anxiety, constantly terrified that I was going to be responsible for letting someone die.  And unlike with many of my classmates, that feeling didn't go away for a very long time.

My strategy for dealing with this terror was to pretty much never stop working.  I would come in earlier than everyone else, work through lunch, and stay late.  I convinced myself that double, triple, quadruple checking everything would make me perfect and prevent me from ever making a mistake.  (Spoiler alert:  It doesn't.)  Any time I thought about putting in less than 100% of my maximum effort at work, I would remind myself of what was at stake:  People will die if you screw up.

Not surprisingly, my perpetual state of panic and overwork wasn't very conducive to taking care of myself.  I essentially stopped exercising on day one of my clinical rotations.  I gave up cooking for myself and ordered food so often that the receptionists at the delivery services recognized my voice.  And I started spending all the money I wanted, whenever I wanted, because "I deserved it". 

Yoga?  Did my stomach doing nervous back flips count?
Healthy eating?  If I bought my Coke and Nacho Cheese Doritos from the vending machine on the Cardiology ward, did that make them healthy?

I don't know how long I would have continued being so completely and utterly negligent of myself had it not been for a few key events.  The first was a crisis at work, which woke me up to the fact that I might not ever graduate and earn a doctor's salary.  (Spoiler alert:  I did!  And I paid off my student loans yesterday!!!)  Suddenly it no longer felt okay to spend more money than I was earning, so I discovered the great Mr. Money Mustache, started a budget, and got my financial life back in order.  The second was some upheaval at work, during which I reached out to some of the other attendings, and which ultimately led to me being connected to a wonderful performance coach.  While I have only seen him twice, I credit him with enabling me to let go of my self-destructive perfectionism and to forgive myself for being human.

The third thing wasn't a specific event, but rather years of working with people with lifestyle-related illnesses.  I spend a lot of my time at work counseling people about the negative effects of poor diet and lack of exercise, as well as treating them when their bodies break down after years of misuse.  Somewhere around the thousandth time that I said "Pop is basically poison", the message started to sink into my brain.  I'm not immune to the things that affect my patients.  I also need to care for myself.

So slowly (sometimes oh so painfully slowly) I have started to change the bad habits that I learned in medical school.  I've almost completely abandoned sugar-sweetened beverages.  I've started mostly eating brown rice* and brown pasta.  I cook a lot of my meals from scratch, and I try to pack them full of veggies and other healthy things.  I'm even exercising again and (amazingly) kind of enjoying it.

And so many other things, like getting enough sleep and meditating and taking enough vacations and quitting Twitter.  All of the things that I said I would do in my medical school interview 13 years ago, I am finally getting around to.  And it feels really, really good.

*This is huge for me, because I love white rice with a fiery passion and can happily eat two large bowls of it, smothered in butter and salt, in one sitting.

More Spoiler Alerts now that I have Watched the First Season of Stranger Things

So in the last episode of Season One of Stranger Things, there is a scene in which the Chief of Police has a flashback to the death of his daughter.  She is clearly dying of cancer, and the medical team is running a resuscitation code to try to "bring her back".

Why?  Why on earth would any physician run a code on someone with a terminal cancer?

One could argue that it's just television, but my understanding of the US medical system is that it isn't uncommon for people with terminal cancers to have CPR performed on them, to be intubated, and to be admitted to the ICU.  Which isn't at all the way things are practiced at the institutions where I trained.  Generally, when someone has a clearly terminal illness, the medical team will try to talk with the patient and his/her family to get them to choose a do not resuscitate order.  Sometimes the ICU will even refuse to take terminally ill patients.

Which to me seems to be the ethically right decision.  CPR is a horribly violent thing to put someone through, and few patients survive it to go on to have a meaningful quality of life.  For myself personally, I would only want resuscitation attempted if there was a reasonable chance of me recovering and surviving long-term.  If I had a terminal illness* and my heart stopped, I would want to be allowed to die without intervention.

And I don't think this is just my personal preference.  In my experience, most patients choose a DNR order when they are properly informed about what an attempted resuscitation entails and how low the survival rates are.  A refusal to accept a DNR is generally a result of poor communication from the medical team.

Thoughts?  For people in the medical profession, what have you seen in your institution(s)?

*God forbid, knock on wood, throw salt over my shoulder, etc.

The Weight of Work

I am caring for a lot of very sick people right now, which isn't typical.  Most of my patients have chronic, slowly progressive illnesses, so a lot of the work that I do is just checking in on generally healthy people to make sure that everything is okay.  Lately though, things haven't been okay.  I have patients going for major procedures, patients in hospital, and patients approaching the end of life.

I know that this isn't about me.  The people most affected by this are of course the patients themselves and the people who love them.  And yet, this is hard for me too.  It is hard to be witness to suffering, particularly when there is nothing in my medical bag of tricks that I can use to change the outcome.  I can of course offer comfort and support and symptom control, but dammit, sometimes I just want to fix it.  I want life to not be the way it is, with illness and death and all of the other bad things.

So tonight I'm lying low.  I've passed on trivia night, and I'm sitting in my sweatpants with a steaming bowl of spaghetti bolognase and a cuddly cat.  And I'm grieving all of the things I cannot change.

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.

Friday Night

For the past few weeks, I have been taking on an extra half day clinic per week to address the seemingly never-ending list of people who need to be seen.  While I actually kind of enjoy the extra clinical work, I don't enjoy having more paperwork to do and less time in which to do it.  By the beginning of yesterday, my desk was piled high with charts to dictate and phone messages to return and labs to review.  I have no clinics on Thursdays, so I spent the entire day in my office slowly crossing things off my to-do list.

It still wasn't enough. 

After clinic today, I ate lunch while dictating charts, and then I left the hospital to go to the other clinic where I work once a week.  And did more paperwork there.

I'm still not done.

I'm really hoping that, with experience, I will get faster at dealing with paperwork, because it is currently taking up almost all of my non-clinical time.  Time that I should be spending developing a research program (*ha*) or preparing presentations or teaching.  Fun things.  Non paperwork things.  It also exhausts me in a way that no other aspect of my work does, because I need to focus carefully on what I'm doing despite how tedious and dull it is. 

Thankfully, it's Friday, and for the next two days I can forget about the 45 dictations* that are sitting in my inbox waiting to be signed off on.  Tomorrow the girlfriend and I are heading to an independent cinema in our pjs to watch Saturday morning cartoons and eat sugary cereal.  Then on Sunday, I'm doing social activity #2** for the week and taking my nieces to a play about Harriet Tubman.  After I go for a run in keeping with my goal to work out three times a week.  And there will be sleep.  Lots and lots of glorious sleep.

I need this weekend.

*Literally.  Shit.

**Social activity #1 was dinner with my mom and my brother for part of a week-long promotion in which restaurants serve three-course meals at a discount.  The conversation was good, but the food was really underwhelming (including inadequately cleaned shrimp *shudder*).

Book Review - Doctored

"Among my colleagues I see an emotional emptiness created by the relentless consideration of money.  Most of us went into medicine for intellectual stimulation or the desire to develop relationships with patients, not to maximize income.  There is a palpable sense of grieving.  The job for many has become just that - a job."

 

At the end of my recent pseudo-holiday (home call but no clinics), I picked up the book Doctored:  The Disillusionment of an American Physician by Sandeep Jauhar.  I can't recall now how I discovered this book, but it was in my list of books to read at my local library, and it had been a while since I'd read anything at all medical, so I decided to order it.  The book is the autobiography of a junior physician who is starting his practice as a Cardiologist in New York City.  In the beginning, he is idealistic and has big plans for improving the care of patients with congestive heart failure at his hospital.  As time goes on, however, he quickly realizes that the salary of an academic physician isn't enough to support a wife and a growing family in Manhattan, so he starts taking on more and more work to try to cover his bills.  First it's paid lectures for pharmaceutical companies, then it's moonlighting with a private practice physician reading stress tests and echocardiograms.  Very quickly, he finds himself becoming burnt out and depressed as he spends too much time doing work that he doesn't love.

I loved this book.  Part of it was the perfect timing of discovering a book by a junior physician (especially a nerdy internal medicine sub-specialist) at precisely the time when I'm starting my own career as a junior physician (and nerdy internal medicine sub-specialist).  I could relate to the sense of uncertainty about how to structure one's career and to the testing out of different things (like paid lectures for pharmaceutical companies, which is an entirely different post) .  I understood his desire to finally start seeing the financial payoff for all of the years of training and his cognitive dissonance at suddenly viewing the patients he cared about as sources of income.  In reading the book, I started to forget that I was reading and to feel like I was sitting in a coffee shop commiserating with a friend about how medicine hadn't turned out the way we had hoped it would.

What I liked best about the book, though, was the solution that the author arrived at.  Without giving too much away, I will say that the book isn't just a rant against modern medicine and the failings of the American medical system.  Instead, it's an exploration of what it means to be a physician and of how physicians can find happiness and purpose in an imperfect system.  It's realistic yet hopeful in exactly the way I needed it to be.  I may actually go against my plan to avoid buying books and get myself my own copy so that I can read it again.

At the very least, I'm adding Sandeep Jauhar to the list of people that I'd invite to dinner if I could invite anyone.  I think he, Gandhi, and my Dad would make for some interesting dinner conversation. 

"How to prevent the burnout that is so widespread in the profession?  There are many measures of success in medicine:  income, of course, but also creating attachments with patients, making a difference in their lives, providing good care while responsibly managing limited resources.  It is whether you find that meaning in your work that determines whether you feel successful or not."