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.