April 2019
Feeling the sun beat down on me and waves crest over my body these past days, in the Caribbean, with one of the best friends I’ve ever had, I think I expected to feel.
I’m not sure what exactly I expected to feel (for life is all expectation management, in any case) – happy? content? rested? joyful? tranquil? when instead I mostly felt just…empty.
“Burnout” has become as much a buzzword these days as “wellness”, and I’m not here to write (another) diatribe about how we need shorter hours and more support and more sleep and less pressure to document our every eye blink into the EMR or how focusing on mindfulness as the solution to our ills is socially acceptable, institutionally-condoned victim-blaming.
I’m not sure why I’m writing this at all, actually, except I guess that sometimes messed-up stuff happens and in that same moment you get paged to fix another diet order and there are 3 more admissions to finish and another 4 families waiting to be discharged and, I don’t know – maybe you forget how to feel.
When I came to residency, I knew how to cry.
Oh, did I cry.
At my oldest sister’s wedding. At my college graduation. Upon finding I matched into the BCRP. Upon receiving a kind note from a longtime friend. The morning of my 26th birthday party, where far more people came than I had expected and I felt fulfilled and self-actualized (for a change). Upon saying goodbye to NYC, a city where I experienced what it was like to be young and surrounded by friends and family and stimulated by learning, all at once.
In my first months of residency, I retained this skill. I sobbed wholeheartedly into a co-intern’s arms after a rough 3rd pulm call where I discovered for the first time (of many more to come) what it feels like to be at work for 28 hours in a row and feel behind and inefficient the entire time. I cried when I missed the flight that would have allowed me to spend my first golden weekend in more than 15 days with my family due to weather delays, thereby missing an entire family reunion.
I cried when I got signout on an 18 year-old who had presented in severe DKA whose failure to take his insulin could hardly be perceived as anything other than passive suicidality – but failed to cry again when I discovered my fears were all too real when I learned of his passing only a few days later. I could not retain my own composure when a mother living with HIV whom I met on the BMC wards confessed her guilt as to how her less than perfect adherence to HAART had resulted in her developing a detectable viral load during pregnancy, thereby placing her infant at avoidable risk of HIV seroconversion; the tears did not stop when she then recounted the sexual assault that led to her own diagnosis of HIV in the first place.
I broke into tears when an attending stopped by the 9E workroom on a horrible GPA/B weekend to let me know I was doing a “fantastic” job, when all I felt was incompetent and slow. And halfway through GPC-nights, in a stretch only as bleak as a New England winter-holiday-cross-cover could ever be, I sobbed in front of the entire GPC workroom as I signed out the forty-umpteenth patient, a young man in his late 30s who had suffered a massive retroperitoneal hemorrhage without a clear precipitant in the background of complications of neonatal HSV encephalitis including spastic tetraplegia and global developmental delay. As I attempted to tell the story of what had happened overnight, I was accosted with the drama of the evening – attempting to call his 70-and-change-year-old parents, whom I had never met, at 4 in the morning to have something resembling a goals of care discussion while preparing blood to be typed and cross-matched and responding to serial direct accusations of ineptitude from feuding consultants with strong differences in opinion about the next most important step in management, and being soundly berated by an ICU fellow for calling an ICU evaluation for a patient whose hemoglobin had dropped from 16 to 8 in the matter of days before running it by my attending, when the fellow and attending in question had not been on board with my plan to scan his abdomen to find the occult bleed in the first place.
There is low, and there is low. And that moment was low.
But you know what?
A funny thing has happened. I haven’t cried at work – or at home – in months. Stories of loss, suffering, and abuse don’t move me in the way they once did. I admitted a 6 year old girl without her parents due to concerns for “NAT” (what messed up phrase that is, anyway – if we think it’s child abuse, why don’t we just call it that? Fear of a name increases fear of the thing itself, or so I’ve been told) and felt mostly tired and irritated by the extra documentation of that being my 8th admission that evening rather than moved by the sadness of her story. I had a mom scream at me for requesting the “drive by version” of her son’s recent encounter with the police when I was on a busy ERC shift and really was hoping for the 15- and not 60-minute version of events. I screen for resource concerns and domestic violence in my primary care visits and fervently hope that neither are present, far too often less out of genuine concern than out of a longing to finish my work and notes at a reasonable hour for a change.
You could say I’ve become more “efficient”. If residents had RVUs, you could easily measure an increase in mine. Maybe I’m better at “regulating” my emotions. Maybe – or maybe I’m just worse at having them in the first place. I used to find genuine joy in knowledge acquisition, learning, and sharing knowledge with others – and now I see facts as lists of work to be conquered rather than ideas to manipulate, understand, or savor.
And I have to ask – is this better?
Developing detached concern is an essential skill of effective doctoring, yes.
But how far is too far? Are daily moments of depersonalization the appropriate antidote to abusive remarks from supervisors, families, and nurses? These are incredibly adaptive in the short term, yes. Nothing like pretending like it doesn’t matter to allow you to update your signout and finish calling all the consultants you need in the nick of time. But the collateral damage?
Is this what the system should be creating?
Is the best message you have for me that I just need to become more “mindful”?
If the solution were that simple, America’s doctors – who consistently arrive to medical school with better psychological well-being and overall positive coping skills than those entering any other profession – would be progressively happier and better equipped to meet the demands of their work, not progressively exhausted and inclined to leave the profession in droves.
Right now I don’t know what my solution is, or if there really is one, at least while we’re in the slalom that is training. I do know that sharing helps, and I sincerely appreciate the opportunity to share my story.
Thank you for hearing my story – and may we continue to write ours together.
Dr. Rhodes Hambrick 