A Journey From Burnout to Balance

I wanted to share a sincere thank you to Elizabeth Metraux at Primary Care Progress, for the opportunity to be interviewed on her Podcast, Relational Rounds. Becky and I were able to share our story from medical school and residency training to fellowship and private practice, navigating challenges along the way.  Elizabeth has a strong interest on the topic of physician burnout and has written about it at STAT:  I experienced trauma working in Iraq. I see it now among America’s doctors

After reading my post on How Do You Know When Someone Is Broken?  Elizabeth reached out to talk. She then asked to interview both Becky and I for what turned out to be a pretty interesting experience.  Attached below is a player linked to the podcast for those interested in hearing a little of what has gone into almost twenty five years of medical training and practice while trying to balance the needs of work, family and myself.

 

Doctors and their Mental Health: Time to Lead and Lean In.

Something was not right, and that something was the first-year resident in front of me. He had come down to the emergency department (ED) to admit a patient to the intensive care unit, full of a frenetic energy that was out of place for the midnight hour. I was the senior resident trying to “hand-off” a new patient to him. There is a shared structure and pattern to the efficient verbal exchange between physicians when presenting a new patient. It is learned early, used daily, and refined and polished during the first few months of residency. But this intern had me flummoxed. Despite several months’ experience, he was neither structured nor succinct. His eyes were unfocused and darting around the room. His arms were in constant motion. His frequent tangential questions made conversation difficult. As he left the ED, I briefly thought to call his senior resident.  But I chalked up his disorganized and chaotic behavior to the cumulative stress and fatigue of another night on call during a tough month in the ICU.

Days later, I learned that the intern had been in the middle of a manic episode that night in the ED. Fearful of repercussions from the residency program if he admitted his depression, he confided in another intern with just ten months of training, who prescribed an antidepressant. That medication precipitated the manic episode I witnessed. The intern’s fear and shame about his depressive symptoms jeopardized not only his own health, but that of the patients he cared for while covering the ICU.

Although that night was more than seventeen years ago, the culture in medicine, with regard to mental health, remains relatively unchanged. The same can be said about society as a whole. It is unfortunate that it takes the tragic death of a celebrity to move our discussions of mental health out from behind closed doors and into the public forum. For a brief moment in time, when the spotlight shines on someone famous, discussions about depression and anxiety are not talked about in muted tones in private moments. They are brought into our collective consciousness, amplified by the evening news and talk shows, written about in op-eds and shared throughout social media.

Anxiety, Depression, ADHD, Bipolar disorder

Suicidal thought, Suicidal attempt

Suicidal success

If you are not aware of these issues, on a personal level or within your very close network of friends and family, I ask that you take a closer look. Despite the significant prevalence of mental health issues, conversations about them are still taboo. Naming the “disorders” can be embarrassing and shameful. Symptoms are often explained away or hidden. The public faces people project can mask what is actually twisting and churning inside their heads and souls, locked behind closed doors.

When it comes to issues of mental health, the culture within the medical workplace both reflects and amplifies the attitudes of society at large. Physicians do not talk about or share their own struggles. The stigma and shame is too strong. The risks of disclosure too high. Physicians, like successful fashion designers or famous television personalities, are not immune from the suffering of mental health disorders. And statistics suggest doctors are at even greater risk of suicide, with more than twice the rate of the general population. Solitary resilience and individual fortitude are grossly inadequate approaches to the problem.

How can an issue affecting so many people be taboo? Maybe if we talk and share and acknowledge our challenges, it will help us connect and better understand our reality. People challenged with depression and anxiety do not need isolation added to the mix. What if we talked about anxiety the same way we discuss having a cavity and ask those around us for a recommendation to a good dentist? Why is there more shame in admitting to depression than poor oral hygiene? What if we could ask for the name of a good therapist by crowd sourcing on Facebook, the way we might post a request for the name of a good local orthopedic surgeon for a painful knee?

Maybe it’s time to shine a light on what is the norm. Maybe it’s time to start with myself.

I saw a psychologist when I was in grade school and junior high. As an adult, I’ve had two extended episodes where anxiety worked its way into my head. Where I was aware of every breath and beat in my chest. I suspect I have ADHD and have likely been self-medicating via my four venti Americanos a day. And a few years ago, I made a decision to see a therapist to process a multitude of issues that affect my life as husband, parent and doctor.

My wife speaks openly about her life-long battle with anxiety. She talks about her struggle to even admit she needed help, the medicines she tried that didn’t feel quite right, and how finding the right combination of medication helped her feel like herself again. Becky isn’t as open to therapy as I am. She goes just enough to feel like she’s got a handle on things. When she finds herself slipping into old habits that isolate her in a cycle of depression and anxiety, she has to actively fight her way back. One of the ways she does that is by talking. Talking with friends and family allows her to process things with the people whose opinions she values. She does not hide the challenges she faces and hopes that sharing her own journey will help normalize a path for others.

In 2016, nearly one in five adults in the country suffer from mental illness. Yet, for a group of diagnoses that affect more than 44 million people over the age of 18, it leaves a surprisingly subtle and almost invisible footprint. People who suffer physical injuries such as torn ACL can wear their external brace and talk proudly about their progress in physical therapy. Those with mental illness quietly suffer their injuries internally, and if able to pursue therapy, usually do the work required without any external praise or cheer.

The window of opportunity for widespread discussions about mental health opened and closed quickly, as the stories about Anthony Bourdain and Kate Spade faded from the news cycle. The medical profession and society at large have been lulled into a sense of complacency until news of the next prominent person to fall victim to suicide sparks another national conversation. I believe it is time for physicians and the medical community to fill this void. As a group that suffers in the same way as those we treat, we have a unique opportunity, if not responsibility, to care for both our patients and to ourselves. By sharing our own challenges and experiences, we invite others to speak up when they are suffering. If the medical community can normalize and destigmatize issues of mental health, it will make easier for those within our profession, as well as those that do not wear a white coat, to seek help. How can we ask others to be more open and honest if we cannot do so ourselves?  We need to take the lead in letting people know they do not suffer mental illness alone and make sure that paths to getting help are not made more challenging by silence and shame within our own profession.

This essay was first published on September 24th in Doximity’s Op-(m)ed.

Guest Post: Control

It is my pleasure to introduce to the readers of Balance, Dr. Rebecca MacDonell-Yilmaz. Becky is a pediatrician out on the East coast who has not only just completed a fellowship in hospice and palliative care medicine, but has just embarked on her third board certification, this time in pediatric hematology and oncology. We connected through social media and over shared themes in our writing. I have read many of her posts on her blog The Growth Curve and wanted to share her work with all of you. I am honored that Becky has offered to post a piece she has written and publish it first on Balance. I could spend some time describing to you all how her story resonates with me, but instead I will let the beauty of her writing speak for itself.  You can follow her on her blog or via Twitter @BeckyMacYil 

Control

By Rebecca MacDonell-Yilmaz

In the afternoon I’m asked to attend an urgent family meeting. I press the resident who has consulted me for details – a middle-aged woman with ailing heart and lungs – and scour the chart to fill in the rest. When she came into the hospital, they asked, inelegantly, “If your heart stops, do you want us to do everything or nothing?” and she chose everything. Never mind that her organs will fail soon, that putting a breathing tube down her throat and hooking her up to a machine is unlikely to lead to any sort of improvement and she will eventually die with the tube in her throat or when her family members make the decision to remove it. She’s deteriorating, and the prospect of intubation is becoming more and more real. Yet she seems to grow less and less sure of what she wants.

I enter the room and heavy conversation is already underway. The resident is explaining that no, she wouldn’t feel pain with the tube because she wouldn’t be awake. But we would also ensure that she wouldn’t feel pain if she chose to forego the tube, to “die a natural death,” as we put it when trying to convey to patients that even our most heroic-appearing interventions – in fact, especially those – are unlikely to bring them back.

She says that she doesn’t want the tube. “I’m tired.” We repeat back to her what we understand her choice to be; she confirms. Her son arrives. He is large – in habitus, tone, voice. He starts yelling immediately. This is the third time (fingers held up for emphasis) that he has been called in to discuss this. And she keeps giving the same answer every time. She wants the tube. She should get the tube.

Two days ago, though, she said she didn’t want it. She decided on comfort only, no more treating, no more fighting. Home with hospice and hopes for a peaceful end. Then he visited and she wanted the tube again, or said she did. And now this conversation that has begun ripping apart the moment he barreled into the room.

We don’t know that she won’t recover, he says – no one can say that for sure. I can say it with high likelihood, I say, with medical experience and knowledge. But anything short of certainty holds no clout. In fact, he points out, we must be asking these questions repeatedly because we don’t like the answers we get. From this point forward, he notes, waving his phone,  he is recording our conversation.

The thing is, if she wants the tube, I want her to have it. It’s not what I would choose, or what I would wish for her – I know what that looks like, that ICU stay, that death. But it’s not my choice to make, it is hers. And whatever she chooses, I want to honor it. But I want it to be truly hers.

More yelling. He knows she’s sick, knows she might not get out of here. But it’s her right to have the tube if she wants it. (And her right, I add – if I can finish, sir – to change her mind.) He doesn’t disagree with this last but wants us to stop asking; she’s tired. We all are. I thank everyone for their time.

Back in my office, it’s dark. I make tea, sigh, stretch, and sit to document my work from the day, my work listening, speaking, trying to hear and to help others be heard.

My pager alarms. She has changed her mind, the resident reports; the whole family has. She is tired. She does not want the tube. She wants a natural death, when death comes. This time they all agree.

On the drive home, with little warning, I begin to scream. It rips up my throat, tearing at my vocal cords. The silence afterwards reverberates, hums, and my muscles relax. I inhale and scream again, the deep breath before it like a silent meditation, the eruption a vehement release. Next comes more tearing. And again the relief.

*                      *                      *

I’m late getting home. My boys need to eat – the youngest to nurse, or to spit pureed foods at me; the oldest demanding waffles and syrup. My husband is on a conference call already so can I please distract them, feed, them, try to keep their voices down?

Attempting to head off the toddler’s impatience, I request his help: can he pull open the frozen packaging? Can he put the waffles on the pan? No, don’t touch the oven – for this part, please just watch.

I’m feeling accomplished with waffles ready, baby happy in highchair, toddler climbing hungrily into his seat. The special fork (the one with rainbow stripes) is ready, syrup is on hand, the prognosis for the evening favorable. I pour generous pools of syrup, slice the waffles into bite-sized pieces, and sink into my seat.

“Move waffles,” my toddler says. Move them? Move them where? “Move waffles.” I don’t understand. Show me; help me; can’t you do it?

The fork is suddenly waving in the air, cutting frustrated arcs. “MOVE! WAFFLES!” I hear the tears welling, the wail erupting, as arms and legs start to fly. Baby is whining, upset at the commotion, and also wanting more puree. The conference call is only a room away and voices continue to rise.

“This is not how we act.” I am seething, though I don’t want to be. I pick him up, move us into the next room where there is space to explode and calm down. I know it’s not the waffles. It’s the communication, the struggle to make his needs and wants known with language that has only just begun to blossom. It’s the control, the need to exert any scrap of ownership and direction over his life. And he’s tired. I’m home late, dinner took too long to even start, his brother needs me as well. And he needs food, sleep, reassurance.

Limbs fly through the air, crashing again and again onto the carpet. He yells and yells, face red, cries lashing out at us all. I sigh, grab the baby from the highchair and pull him onto my lap in the living room, latching him to my breast. It consoles him and he eats hungrily, fussing only when I reach away to pull his brother, who is now simmering, whimpering, to my side. I feel the tension seep out of him as I nestle him close, the molecules of my being reaching out to soak up his unhappiness. The cries die down: his, his brother’s, my own. The three of us exhale as one.

 

Rebecca MacDonnel-Yilmaz can be followed at: The Growth Curve and @BeckyMacYil 

From Flowers to Dostoyevsky and the Road In-between

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I am sitting in the parking lot, waiting for the local bookstore, The Book Bin, to open. I am here because of a flower. And a pear tree turned maple. And a sense of time and space. And the writer Dostoyevsky.

Sipping my morning coffee, with the Jeep’s soft top down, I feel the heat and humidity of the day gaining momentum. I have ten minutes to kill, but there is no rush. I am in no hurry.

I am not a particular admirer of flowers or plants, nor fond of gardening. You will find no green in my thumb. I struggle to tell the difference between tulips and roses or what qualifies as a annual versus a perennial. Becky is both president and vice-president of landscaping and curb appeal for our home. But every year, after Chicago thaws out from another nasty winter, there is one pink plant I notice from July to the frost.

The routine is one I have done a thousand times. A long day of work followed by a quick drive home. I turn into my driveway, stopping short of the messy garage. I grab my evening Starbucks and step out of the car, making a bee-line for the front door. Just to the left of the brick paver walkway, pink flowers bloom on the tall arching hibiscus plant. Ten year ago, Madison and Maya won an Earth day contest resulting in a hibiscus plant in the front yard and a Pear tree in the back. Now, every time I see the pink flowers, a Pavlovian response follows. See hibiscus; think of Madison. The pink flowers stand out as the summer days get longer. But the reflexive thought is usually fleeting. I have a narrow two-hour window to play catch-up with the family, eat some food, and take care of some odds and ends before getting ready for evening water polo practice.

But this has been a year of change. More weeks off of work than on. Days slower, pressure lower. Options greater. Headspace clearer.

Yesterday, I got out of the car and looked just to the left of the brick paver walkway; pink flowers bloom on the tall arching Hibiscus plant.

I paused.

I deviated from pattern and routine. I literally stepped off the brick pavers and walked through the dirt. I kneeled, and for the first time in ten years, I looked. Not rushed and fatigued, but with the unassuming eyes of a child.

Was it the way the day’s light caught the blooming flower? Or its movement, as it swayed back and forth in the afternoon breeze? I stopped. I looked. Differently. Not with an expectation of confirming what I knew to be true. Not reflexive with a programmed response. But with eyes and mind open in a way they often are not.

Not a simple single color, but pink and dynamic, with pattern and texture. Not just petals, but a flower with a complex architecture that I forgot existed. I am mesmerized. I focus. I take pictures, trying to capture or preserve what my eyes see. There literally is a world of things present that I have not noticed previously, all backlit by light emanating from small slits in the petals left open at the base.

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I have written, in the abstract, about increased time and space since going part-time. But it’s concrete and tangible right here in this flower. My mind is unencumbered by the weight of a twelve-hour work day or a week’s accumulation of fatigue. There is no pressure of a two-hour window closing in on me as I stop to smell the roses; or in this case, the Hibiscus. I walk around to the backyard. A few years ago, we identified the pear tree correctly as a maple. I look up at what was once a six-foot tree which, to my surprise, towers overs me by at least thirty feet. Thick branches, once thin and pliable, have weathered quite a few storms over the years. Despite viewing the tree daily through the kitchen window, I have missed this transformation.

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Patterns and behaviors. Expectations and assumptions. Tools often necessary to get thru challenging days. They consume less energy, tapping less into one’s reserve, to operate more on auto-pilot or cruise control. But that path foreword is limited and constricted. One where the hibiscus remains just a pretty pink flower, and the maple six feet tall.

Time and space. Look left and right. Stop assuming. Be more curious, and have fewer expectations. Break patterns and rethink behaviors.

I didn’t read Crime and Punishment in high school or college. Over the years, when I came across references to the book and its protagonist Raskolnikov, I made mental notes to buy and read the book, but never followed thru. Too little time. Never made it high enough on the to do list. In a few minutes that will change. I am waiting for Book Bin to open and I am going to buy that book.

Time and space. Break Patterns. Rethink behaviors.

Madison comes home soon to visit for a week. He’s about to move into his own apartment in Oregon. Maya’s about to start her senior year, with quite of few colleges on her mind. Becky is gearing up to offer tutoring services in a more formal fashion. We are a family with quite a bit of transformation ahead. But despite the potential and promise of the upcoming year, I am in no hurry to launch myself forward.

Days slower. Headspace clearer.

I drive away from the Book Bin, Crime and Punishment in hand. I am ready to read it. With more time and space. With more curiosity and fewer expectations. And with unassuming eyes and a mind wide open.

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