How Do You Know When Someone Is Broken?

How do you know when someone is broken? When their spirit is fractured? When their sense of self no longer aligns with what once was. When you feel as if you have woken up in a foreign land, but that sense of displacement is coming from you, not your surroundings.

In television shows and movies, that moment for a doctor is obvious. The scene in which a physician cries in the stairwell, knees bent, head hanging dejectedly. A downward spiral into drugs and alcohol that leads to a near-miss in surgery. Or a final, explosive ranting monologue, that alienates the doctor in front of patients and peers. They have snapped. They have broken. At least until the next scene or episode.

Real life rarely follows a Hollywood script.

The slow burn of a physician breaking is usually far more insidious and is often masked by their own defense mechanisms and denial. Fatigue. Frustration. Irritability. Impatience. Complacence. Disconnect. Sadness. Anxiety. Anger. Depression. When something loved becomes something tolerated. When the excitement and potential of each new morning is replaced by the dread of what might lie ahead. Problems, that were once challenges to be solved, become roadblocks and barriers seemingly designed to thwart and frustrate. When it feels as though patients and staff are no longer expressing themselves, but are instead complaining and whining.

I do not consider myself a weak person. I have completed six Ironman triathlons. I finished the marathon portion of one after a bike crash left me with road rash covering the right side of my body. As a water polo goalie, I’ve had my eyelid split open and my nose broken. I survived four years of medical school and four years as a resident in internal medicine and pediatrics, enduring countless sleepless nights on call that were often calmer than nights at home with two young children. I asked my program for help only twice during that time. Once on the day my wife miscarried and once for the seventy-two hours after the birth of my daughter, our second child.

I pride myself on taking these challenges head on, and coming out standing tall and strong on the other side.

However, I was not immune from the cumulative burden and increasing stress that my life in medicine created.

Was it twelve years of highs and lows and the hectic pace in a private practice covering three busy hospitals and ICU’s? Was it working with a revolving door of hospital administrators, nurses, residents and medical students? Days filled with code blues, rapid responses, packed emergency rooms, understaffed floors and overworked nurses?

Was it the increasing size of my outpatient practice and the increasing medical complexities and call volume of my patients? Was it the increasing “obstructionist” insurance plans with the increasing number of prior authorizations to fill out and denials to protest?

Was it the never-ending documentation? Clicks required to satisfy the electronic medical record (EMR) or requests to modify charting to make sure diagnosis were “present on admission” or upgraded to the highest level of severity. Or documentation not designed to facilitate communication but to prevent potential litigation down the road.

Was it the stress of multiple impromptu and emergent family meetings for critically ill patients, rapidly synthesizing old documentation with new clinical information. Committing to an accurate and sound working diagnosis, while concomitantly initiating aggressive life-saving interventions. All while simultaneously and effectively communicating this crucial, but overwhelming, information to people I might be meeting for the first time?

Was it the frivolous lawsuit I was dragged into, by virtue of having been on call for the hospital that night? Or the multiple depositions I gave and read and reread, combined with more than four years spent anxiously preparing for a trial from which I was dropped without ever taking the stand?

Was it the challenges of being present and available for my family? Trying to support my children, whose lives grew more complex with age. Being present, but not intrusive. Being aware of, understanding and monitoring social media in a world of ever changing and shifting norms.

I found myself exhausted and tired. I became more callous, impatient and terse with my patients, residents and medical students. With my physician partners and nurses. With friends. With family.

At first, I failed to acknowledge what was in front of me. I’m just tired, or it’s the lawsuit, or we are short staffed, or I just need to get efficient with the EMR, or it’s the crazy flu season, or I just need to get to my vacation week and recharge. I wanted there to be a reason. A fixable external problem. Because if not, then maybe I needed to look internally. At myself.

Was I too weak? Was I not strong enough? Did I not have enough fortitude, endurance or “grit”? With those thoughts of weakness, came feelings of shame.

I started talking about taking a break or cutting back. I envisioned teaching at a high school and coaching water polo. I thought about going back to school to figure out different ways of using my knowledge and skills. I thought about spending more time with my kids and having the emotional and physical energy to be patient and present, not irritable and dismissive. I thought about writing on patients that had a tremendous impact on my life, of decisions made and opportunities missed, and the challenge of finding balance in my life.

And then instead of talking and thinking, I did.

I hedged a bit at first, cutting back to half-time with an option to return to the status quo after a year. I dipped my feet in the water. It felt cold and chilly on my toes, and I was not quite ready to dive in.

A few months later, I jumped all the way in. And as I made that leap, I felt weightless, a fluttering in my chest, like driving fast over a rise in the road.

It has been approximately nine months since I went part-time. I am still getting used to the feeling. More time, less income. More freedom, maybe not enough structure. I am wrestling with a number of things. Financial choices are harder. Retirement is less certain. But those fears are fading, as I adjust to my new normal. I am also adjusting my sense of self. My identity. Who I am. Before, I was a partner in a successful yet crazy, busy practice, providing for myself and my employees. I was a teammate with seven other doctors, taking on challenges as they came, just as I have my whole life. But now, I have to ask the questions; Am I no longer that partner, that provider, that teammate, because I failed? Was I not good enough? Capable enough? And if so, what does that say about me? What then am I?

Somedays, I just stop and reflect, writing in my journals. And I try to answer those questions. Who am I? I close my eyes and let my thoughts and recent actions fill the void.

I am a parent taking my kids on college visits. I am also a college applicant, applying to Hopkins School of Public Health and Policy, where I hope to start in the winter. I am a high school water polo coach working with an amazing bunch of teenagers. I am a water polo goalie for my Master’s team. I am a triathlete training for another Ironman this fall. I am a husband celebrating and tackling these mid-life challenges, together with my wife. And I am a part-time doctor who still loves the challenge and privilege of taking care of patients when they are at their sickest and most vulnerable.

And I think to myself, I am not broken. I am just getting started.

Crater Lake and the Weight of Snow

Minutes into my early morning run, the howl of a lone coyote broke the silence in the basin. A second one responded, and then two quickly became three. Other coyotes joined in, their howling echoing all around. On previous trips to Oregon, I’d found comfort and hope while running on this path. I had also walked here with my family, under a brilliant rainbow that offered a well-timed distraction from the tension building between us. This weekend, I had travelled here to celebrate my son’s birthday. Although excited to see him, I was still nervous about how the next few days would go. I was not inherently superstitious, but I could not help but wonder what type of omen howling coyotes on a brisk March morning might portend.

I returned to the warmth of the hotel, leaving the coyotes behind, and checked the Crater Lake webcam for a visibility update. The website was down, which did not bode well for the day. Hoping for the best, I began the twenty-minute drive from my hotel to the Oregon Institute of Technology campus, which took me around Upper Klamath Lake. As I drove along a sharp bend in the lakeshore path, four deer revealed themselves just to my right, frozen still on a front lawn. They were unfazed as I pulled over and grabbed my phone to take a picture. One deer, the largest of the pack (does four equal a pack?), was focused intently on me, its eyes unblinking and staring. Animals and nature declared themselves the themes of the day.

Although only fifty miles away, the GPS indicated a ninety-minute drive to Crater Lake’s south entrance. Madison and I left Klamath Falls, with a glassy smooth lake on our left and imposing mountains on our right. The mood was light and easy as we listened to a podcast, pausing every now and then to point out a striking view or to dig deeper into the finer points of League of Legends, the topic being discussed on the radio. There was an absence of tension. No hidden agendas. Just a dad and a son spending time together.

As we hit the base of the park entrance, snow announced its presence. Starting as a light layer on the road, it steadily increased as we wound back and forth on our drive to the top. The guard rails, visible at the start, disappeared under the increasing depth. The towering Ponderosa Pines and Douglas Firs lined the road with their branches and needles covered in heavy powder. The trees appeared burdened by the weight, their branches bending downward towards the earth.

Thirty minutes later, we exited the car at the top of the park, 8000 feet higher. We stretched our legs as we breathed cold air into our lungs. The sun was brilliant, made even more so by bouncing off the pure snow that crunched beneath our boots as we walked to the rim. As the lake came into view, it did not disappoint. The reflections of the mountains on its blue surface was pristine. Not one cloud disrupted the sky or interrupted the sun. The snow was bleach white and bright. The water was still and glassy. The air was crisp and cool. And I was with my son. For a moment, there was clarity in the simplicity of those things. Air. Water. Sun. Snow. Family.

We spent some time taking in the view and took pictures that failed to do it justice, eventually making our way back to the car to start our return trip. As I focused on the ice and snow on the road ahead, movement to my left caught my eye. A chunk of snow slid off one of the branches of a Douglas Fir, breaking up into infinitely smaller and smaller pieces, as it made its way to the earth. The branch, no longer encumbered by the weight, sprang up, angling towards the sky.

As we finished our descent, my breathing felt easier. Maybe it was just due to the decreasing altitude, but I believe that our trip helped shake off some of the “snow” that had been constricting Madison and me. We were able to pause and sit with our thoughts a bit, instead of letting them race through us. To look beyond the next few hours and days and be open to a vision of what else is possible. That changing dynamic was infinitely more important than figuring out the hidden meaning of howling coyotes or glaring deer

The rest of our weekend was as beautiful as Crater Lake. Conversations with depth and breadth. Board games and movies, with some lap swimming mixed in. The morning of my departure, we hugged and said goodbye, before I started the hour-long drive back to the airport. Although it is still winter in Oregon with a fair amount of snow around, it feels like spring might have come early for Madison and me.

 

The Ties that Bind and the Weight of Connection

Traevelling 30,000 feet above the ground on my way back to Chicago, it’s hard not to think about distance and space. How people in the same room can still feel worlds apart while others can be physically separated by hundreds of miles and still be intimately connected. Traditional modes of measurement fail when it comes to matters of the heart. I feel the push and pull of these forces currently at play within me as I sit on a plane, wanting to distract myself with some mindless movie or loud music or just close my eyes and sleep. The plane, at its current altitude, disconnects my phone from the pages, texts and alerts waiting on the ground, freeing me for a short while from their intrusion.

To be intertwined with someone else. To belong to something greater than yourself. A family or community? To have purpose beyond ourselves. To give and receive. To be connected. These thoughts lead my brain back to chemistry and physics and learning of forces and attraction between molecules. I recall the weaker ionic bonds, able to be disrupted by water alone.  I remember organic chemistry and the tight sharing of electrons between carbon atoms, and its strong covalent connection. I think of the ultimate overwhelming gravitational force of a black hole from which nothing can escape.

In the past, those descriptions were just notes jotted down on paper. Simple lines to memorize to later regurgitate verbatim on a test or quiz. At the time, I did not have the capacity to truly understand those ideas. Now I find deeper meaning in these concepts. The invisible attraction exerted by gravitational forces and tight bonds cause visible and tangible effects. We learn of the “potential” within these bonds, to hold and store power and energy which I have felt in the pounding of my heart and in the heat of my salty tears. The paradox being that the strength within the bonds of connection that help withstand stress and strain can also cause disruption and damage.

How then to find equipoise and balance? Where this connectedness provides stability and strength to move forward, instead of collapsing under its own weight.

It is in this space that I am floating at the moment. Physically, 30,000 feet above the earth, yet right next to Madison in Southern Oregon and Maya back home in Northbrook. Can they feel me with them right now? Do they know how much they are in my thoughts? Do they feel the same tug on their hearts and in their core? And if so, does it feel safe and warm and a source of comfort and confidence? Or is it heavy and weighty and overwhelming and constricting?

The change of pressure on my ears signals the beginning of the plane’s descent back to earth. The thirty minutes or so left on this flight leaves nowhere near enough time to climb out of this rabbit hole in which I find myself.  But this is why I chose to go part-time. To find time and space to wrap my mind around these questions. It was too infrequent and rare to have the emotional energy and capacity to sit with and work through these issues

The plane lands and Becky and I disembark, still a bit disoriented with my ears plugged and cumulative fatigue of the weekend. I find myself adjusting to the changing forces of connection, now that I am two thousand miles closer to my daughter, but that much farther from my son.  But I sense this is a new theme in my life. Navigating time and space with those you love and balancing the benefit of the power of connection with the weight of its strength. And in this moment, these invisible forces couldn’t be more tangible,  as my heart is pulled in all sorts of directions.

 

Two Doctors, One Patient, the Chicago Cubs and a Common Goal

This piece was written together with a friend and colleague Chadi Nabhan, an oncologist and current Chief Medical Officer at Cardinal Health. This was originally published here in The Oncologist.  

The crowd erupts with joy, champagne bottles pop open, and everyone around me is stunned. The Chicago Cubs have just won the World Series for the first time in over a century! I heartily share the exhilaration of others in my adopted hometown, but my elation quickly deflates as my mind wanders back to 2013 and to one particular patient with one particular disease, which showed that the doctor-patient relationship is not limited to the oncologist but often involves others.

The oncologist: The oncologist’s schedule can be counted on to be overbooked, busy, and regrettably, dominated by patients with cancers that are rarely curable. It is not surprising that oncologists, myself surely included, yearn to see a lymphoma diagnosis in their crowded roster of patients. For when we see a lymphoma diagnosis, we immediately hope for a curable one, such as large cell lymphoma, for which the odds of a successful treatment are much higher than those of other lymphomas. I was thinking about this when she walked into my office, unabashedly in full Cubs gear, even down to her socks. Her husband was by her side, in a male version of the same outfit. Hardcore Cubs fans who were getting ready for another hopeful season, until the C word struck. Cancer. She had been coughing for few weeks. Ultimately, a chest x-ray was ordered, after antibiotics failed to improve her symptoms. She had a diffuse large B-cell lymphoma (DLBCL) and was only 48 years old. Our visit lasted an hour; we reviewed the data and I ordered additional tests to stage her disease in order to formulate a treatment plan. A few days later, she walked back into my office with her husband by her side. She was wearing the Cubs attire again, head to toe. I was ready to deliver good news of her earlystage disease when she interrupted, “Just tell me I will live until the Cubs win a few World Series.” I smiled in return and countered, “More than a dozen, I hope.” She had early and curable disease—the cure rate can exceed 80%. I happily explained how confident I was about her chances. I recommended chemotherapy and we reviewed possible side effects, along with how we would treat or prevent them. We both agreed against radiotherapy and I ended our conversation by making clear that our goal was to attain a cure with little disruption to her lifestyle, especially because the baseball season was starting. Time passed, and my optimism, and her smiles, dissipated. She developed fevers and chills while on powerful chemotherapy and was so sick, unable even to watch the Cubs on TV. Her DLBCL was not following my plan and proved unrelenting. I diagnosed refractory disease; the synonyms for “refractory” perfectly summed up my patient’s disease: stubborn, recalcitrant, and unmanageable. I was upset, angry, disappointed, and speechless. This was the disease I should have been able to cure; this was the diagnosis that cancer specialists enjoy treating because of its favorable outcomes. As the three of us sat in a quiet exam room, I with the white coat and they with full Cubs regalia, we discussed options. “We still have hope to cure this,” I explained. I recommended a stem cell transplantation, using her own cells. I was steadfast in my optimism and determined to project confidence. When she asked about percentages, I avoided the answer. I advised her to focus on the mission at hand and to ignore statistics that could easily eclipse our hopeful march forward. More chemotherapy, more tests, more visits, as we forged toward a transplant. Her transplant was thankfully without complications; she was discharged 14 days after her stem cells were reinfused. The nurses cheered her as she exited the hospital and headed home. The baseball season was over. The Cubs did not win, but her Cubs hat remained a loyal guardian angel, covering her bald head and emphasizing her resilience as she fought this lymphoma tooth and nail. On day 45 after her stem cell transplant, I saw her back. She was not feeling well; the anxious looks in her and her husband’s eyes stabbed me in the heart. The three of us knew her disease was back—it probably never went away; here we were again. The room was quiet and we started talking options. We talked about doing another transplant, but this time using stem cells from a donor and not her own. We then discussed the inherent risks, clinical trials, and novel therapies. Before decisions could be made, the options vanished, one after another, because her disease was as remorseless as it was tenacious. A few weeks later, I was preparing to leave for the International Congress on Malignant Lymphoma in the morning—a gathering of researchers, scientists, and clinicians where I would be presenting data on large cell lymphoma. I got a page from the intensive care unit (ICU): my patient had just been admitted through the emergency room with severe shortness of breath. Imaging showed her lungs were filled with “something funky.” The resident offered an opinion that infection was likely and that his team would start aggressive antibiotics. He was maintaining hope, just like he was taught in medical school. The ICU team would monitor, as the fear of sepsis was looming. I hung up the phone but could not get back to sleep. As I stared at my bedroom ceiling, my mind was racing, both sickened and infuriated by the irony.

The intensivist: Every other day is an “on-call” day for the critical care team, and today was one of them. Taking admissions for 24 hours in the ICU is a mixed bag. No one wants more work on top of the already challenging cohort of patients on the service, but the opportunity to take care of patients in the midst of critical illness is a privilege. As an intensivist, more often than not, I haven’t met my patients before they are admitted to the ICU. For the doctors who have known them for years, as the internist or specialist caring for their chronic illnesses, trust and comfort has been built up and earned over time. I rarely have that luxury. My access to patients’ worlds is born out of the necessity of their critical illnesses: the onset of something acute or the progression of something more insidious. I get to ask the most personal of questions, place a stethoscope on their chests to listen to their hearts and lungs, palpate their organs to search for pain or tenderness, and put my hand on their skin to feel how strongly or weakly their blood flows. With this privilege of such intimate and personal interaction come amazing opportunities but also heavy responsibilities. To help heal and comfort. To offer hope and calm, amid the fear and angst that come with critical illness. The charge nurse shouted a quick summary, alerting me to a new patient rolling into the ICU. Late 40s, refractory lymphoma, maybe pneumonia, short of breath. Only four pieces of information, but they painted a picture. No positive mental images came to mind. Angst and foreboding filled my chest. A quick scan of the chart, more words and phrases, and the picture went from bad to worse. “Multiple failed rounds of chemotherapy.” “Status post stem cell transplant.” “Progressive lung infiltrates without a clear diagnosis.” “Increased work of breathing and short of breath.” “Unclear” diagnosis. These were not words you wanted in your medical records. I saw the date of her diagnosis and wondered how she and her husband dealt with that blow. Were they overcome with fear and despair? Did they get angry and defiant? Were they united in their reactions? Did they struggle together or separately, lying awake in a darkened bedroom before the light of dawn? I read about the rounds of chemotherapy, but it didn’t tell me about the nausea, the vomiting, the loss of her hair and weight and possibly her sense of self. I saw the date of her relapse. But it didn’t tell me if she took the weight of those words in stride or if they shook her to her core. All told, these words described a young woman who was running out of options and time. I knew this patient, like many with severe illness too early in their lives, had kept hope near her side. Carried it with her through it all. This is the worst part of my job. Along with the opportunity to help and heal, cure and comfort, I have an obligation to explain the painful truth about the limits of what medicine has to offer. The ICU is often a place where patient and doctor, disease and medicine, are all thrust together. Where hope meets reality. Now I needed to go into the room. Knowing everything. Yet knowing nothing.

The oncologist: Before leaving for the airport, I headed to the hospital to visit her. It was early; her eyes were closed; her husband was resting on the bedside couch. I sat down on a chair by her bed, looking at the monitor’s green lines jumping up and down, showing her heart rhythm. The noises from various monitors punctuated my sullen thoughts. She opened her eyes and offered a gentle smile. She said, “I thought you were leaving today.” “Yes, but I wanted to check on you,” I replied. We both knew her current state was not due to infection, even though we held onto this improbable hope. Hope, however, cannot replace reality; her cancer was getting worse and it was winning the battle. We sat in silence. “Are you ready for your presentation?” she inquired. “Yes, but I will be further preparing on my way there,” I replied. “Good luck and be safe,” she said kindly. I had to leave; I stood up and was at a complete loss for words. What could I say? I wanted to wish her a speedy recovery, but knew that wasn’t even an option. I wanted to tell her and her husband that I would see them upon my return. But would I? I knew deep down that I would not and that saying so would be a lie. I struggled to find the right words. I wanted to keep the hope going, but wanted to be realistic. I wanted to wish her luck, but didn’t know where to find luck when you needed it the most. Our journey was ending. I mumbled something as I exited her room. To this day, I can’t even recall what I said.

The intensivist: I saw the oncologist leaving the room. I felt his anguish as we conferred briefly before he had to leave. The reality is that with growing trends toward hospitalists, a majority of admitted patients will be cared for by physicians they have never met, especially during times of significant decompensation in their health. Most oncologists, however, continue to be an exception. Their relationships with patients are forged in the midst of a life-altering event: the diagnosis of a life-threatening illness, when patients are forced to face their own mortality. At a time when a patient is most fearful and vulnerable, the oncologist has the ability and the mandate to help ease fears and provide a path of hope. With trust and a bond earned over weeks and months of therapy, the highs and lows of treatments, and follow-up scans and labs, they move forward with a common mission and purpose. I often admire the powerful and deep relationships oncologists have with their patients. But I do not envy the burden those doctors carry, one of providing and maintaining hope. I walked toward her room, soon to be the newest doctor in her life. In the next few minutes, I had some basic tasks. Establish a physician-patient relationship. Provide or confirm existing information about her disease. And outline the options for care to her family and her. The challenge was to do this while earning immediate trust, being honest and accurate about the severity of her terminal disease, fighting my own human instinct to present things in the most hopeful of terms, and emphasizing possible options without lingering on how few remained. I didn’t want to hurt her any more than the cancer already had. I wanted to be honest without crushing her spirit. This was where hope met reality. How could I do this? I had no script. I headed to her room with a weight on my shoulders. But whatever burden I felt paled in comparison with hers. As I walked into her room, I saw her for the first time. I noticed her shirt, baseball hat, and socks. This was the first thing I learned about her. I knew her heart bled Cubbie blue. I offered my hand and said hello.

REFLECTION: She died during that hospital stay. Although several years have passed, she was one of the first people we thought of when the Cubs won the World Series. The physician-patient relationship is not one sided. Hope, and the comfort it brings our patients, touches our hearts as well. Doctors are not immune to the emotional challenges of recognizing, accepting, and communicating when our shared hope is no longer consistent with reality. For baseball, hope springs eternal. But unlike the Cubs, she did not have the luxury of an endless number of seasons to start over and try again.

Chadi Nabhan can be followed @chadinabhan
Jeremy Topin can  be  followed @jtopin1