A Chasm too Wide to Bridge

chasm

This piece recently was published at Doximity’s Op-(m)ed.  I worked on this essay for quite a while for publication elsewhere. It does touch on many of the same themes I have already written about on this blog.  In that sense, it is not particularly revealing of novel, but it is put together in an original way.  I will continue to try and bring to BALANCE original thoughts, meandering and stories to you all. 

Best,

JT

In high school, I was more comfortable in the pool playing water polo than studying in a classroom. I struggled in math and science, so it was no surprise that medical school was nowhere on my radar. But near the end of my liberal arts education and collegiate water polo playing days, I decided to challenge myself as a student. I took first semester chemistry during the second semester of my senior year, and a spark was lit. Objective questions, with demonstratively right or wrong answers, were a better fit for me than the subjective political science essays I had been writing. After graduation, I enrolled in a post-bac program to complete the premed science requirements. By day, I tackled three-dimensional carbon models. By night, I waited tables at Chili’s. Once I was accepted into medical school, any doubts about my path were silenced by my wide-eyed fascination with the physiology of the human body. What makes the heart contract in a rhythmic and synchronized fashion? How do the lungs extract oxygen from air and transport it into the bloodstream? What consequences arise when these organs are injured or fail? That spark had turned into a flame.

I trained to become board certified in both internal medicine and pediatrics, eventually finding my true calling in the sub-specialty of pulmonary and critical care. I was intrigued by the skill set of the intensivist, filtering hundreds of data points to make quick, high-stake decisions, while needing a steady, proficient hand to perform procedures on the critically ill. The technical aspects of critical care drew me in. And when I widened my focus beyond the treatment of diseased organs and abnormal lab values, I was able to connect and communicate more meaningfully with patients and their families. I had found my calling.

Physicians can dispense difficult information in an accurate, efficient and sterile manner. Or they can engage with grieving families by sharing time, space and vulnerability in an anxiety-filled room. Even when discussing a brutal diagnosis or grave prognosis, there are opportunities for intimate and authentic connections full of compassion, humility and grace. My most meaningful memories are not white-knuckled life and death decisions. They are the quiet moments spent with patients and families, sharing their hopes, grief and fear.

After thirteen years in practice, I should be in the sweet spot of medicine; not too far from training to be out of step with the best practices in my specialty, but with plenty of experience and wisdom to offer in the care of my patients. I should be moving into leadership positions left open by retiring senior physicians and mentoring the next generation of wide-eyed future medical doctors. Instead, a year ago I cut back to part-time. Like many others in my profession, I am struggling to find the fuel to keep my flame bright.

Social media is packed with essays listing the “top ten reasons for burnout” or “five traits of happy doctors.” Position papers from medical societies and leading journals detail ideas for its prevention and academic centers are forming committees to promote physician wellness. Throughout this cacophony, if you listen closely, there is a common chord formed by the many disparate notes.

Physicians dedicate and sacrifice their twenties and early thirties developing a unique vision of how they will bring their experience, knowledge and compassion to their patients. Although that rarely translates perfectly in the real world, for many doctors the gap between the vision of what could be and what is has become a chasm so wide that it feels impossible to bridge. The doctors we aspire to be become the exception, rather than the rule.

After twelve years of practicing medicine, the divide between my ideal day and my reality was measurably fractured. Shifting gears between critically ill patients in the ICU, with impromptu and emergent family meetings, was emotionally exhausting. Ongoing trends to staff leaner ICUs stretched care teams too thin to care for the higher volume and acuity of the ICU population. Today’s shorter hospital stays generate outpatients with active medical problems and unresolved social issues for which my office is ill equipped. My thirty-minute lunch break morphed into an hour of phone calls and paperwork, with time spent battling insurance companies to authorize treatments and prescriptions. Electronic medical records (EMRs) that can be accessed from my laptop destroyed the barriers that once kept me from bringing work home. Four years of a frivolous lawsuit consumed my free time. I spent hours reading depositions and reviewing old charts, only to be dropped the day before taking the stand. Through it all, I struggled to prioritize the growing complexity of my family.

My ability to maintain the status quo crumbled. Multiple rounds of snoozing replaced early morning exercise. Interactions with my partners felt less collegial. Evaluations from medical students were no longer filled with high marks and positive comments, and eventually nurses and new residents stopped looking forward to my time on service. Worst of all, morning rounds in the ICU became technical and checklist oriented, instead of patient centered, as my capacity to recognize opportunities for deeper connections with patients and families deteriorated.

Naively, I clung to the idea that simple, transient problems were to blame. Maybe it was fatigue, the terrible stress of the lawsuit, a crazy flu season or being short staffed. If I could just push through to my vacation week, I could recharge. I wanted there to be a reason. A fixable external problem. But ultimately, I had to look at myself. I needed to make a change.

I am lucky that the other physicians in my practice are friends as well as business partners. They were genuinely concerned about the changes in my behavior. But they were also frustrated, because my situation negatively impacted their work environment. Ultimately, after twelve years, I gave up my partnership and cut back to twenty-three weeks a year. I take the same amount of call and weekend coverage as the rest of my group, but now have twenty-nine weeks away from the hospital instead of six.  Although we are still friends, my choices caused some challenges within the practice. I upset the balance of our group dynamic that had been based on an equally shared workload. In decreasing my own burden, I obligatorily increased theirs.

Initially, my patients were confused, worried I was abandoning them. A few transitioned to other doctors in my group. But most have been surprisingly enthusiastic and supportive of my decision. During visits, they ask what I have been doing with my time, if I have written anything new and how my family is doing.

My children, ages seventeen and twenty, enjoy their dad being more physically and emotionally present. As a forty-seven-year-old, I now have the unique opportunity to connect with them in new ways. I am a fellow student, heading back to school to earn a master’s degree at Johns Hopkins Bloomberg School of Public Health. My son and I play on the same master’s water polo team and I am coaching at my daughter’s high school. She likes having me there, but would prefer her friends not know what her dad looks like wearing a speedo.

My wife had a front row seat with a clear view as the intensity, passion and joy I once brought to work slowly eroded away. She encouraged me to make big changes, despite the impact they would have on our family’s financial security and the uncertainty they would inject into our lives. Paradoxically, she feels enormous guilt about not earning a paycheck since she stopped teaching twenty years ago, but is unwavering in her support of my choices to coach the high school water polo team, write for my blog, train for triathlons and go back to school. She has allowed me to pursue other sparks in my life.

As for myself, when I look back on this past year, it is obvious how much a change was needed. At the hospital, I am no longer disappointed in my rounds and am again connecting with patients, families, residents and students. I have regained the sense of satisfaction and purpose that I had lost. My weeks away from the ICU allow me to pursue my interests in writing and coaching, as well as being more present for my family. What started as a leap of faith onto an unfamiliar and undefined path has evolved. I am no longer simply taking a tentative step away from medicine to create much needed physical and emotional space. I am now striding towards a future that gains clarity with each new day. I know I am getting closer to that ideal day of mine. And I am comfortable knowing that many of them will not involve having a stethoscope around my neck.

Guest Post by Monisha Vasa: Red Lipstick and the Quest for Perfection

I am excited to bring another guest post to Balance, written by Doctor Monisha Vasa! Monisha is a psychiatrist, mother and writer, currently living in Orange County, California, but has strong ties to Chicago growing up in the southwest suburbs. I have had the opportunity to read through much of her writings and poetry on her website and appreciate the emotional honesty of her voice as she shares her own journey.

There were a quite a few posts that I could relate with. When I shared with Monisha the three or four I was thinking about using, she told me one of them was a favorite.  I find her words captures my thoughts as well…

“Taking small and big detours and not knowing and figuring it out as we go isn’t necessarily the life plan…But that is the truth of how we all unfold.  That is how we all grow towards whatever light we are each uniquely designed to find.  Whether we like it or not, and whether we share it or not, that is the reality of how most of us navigate our days”

RED LIPSTICK AND THE QUEST FOR PERFECTION

by Monisha Vasa

 

“You awake? :)))”

“Yes!”

“Do you have the energy for me to unload some of my crazy on you? :)))”

“Yes!”

And so our text exchange began, the type of long drawn out texting that unfolds late at night, when there is so much to release, and kids’ perky ears still awake and within earshot.  The types of text conversations that you can only have with dear friends who will respond to the 11 pm pings and whistles, happily and without hesitation.

On this particular night, my neurosis was indeed just that–neurosis.  I went on to share a certain pressure that I had been feeling.  A few blog posts ago, I had received some wonderful feedback about how my words had been especially meaningful to one of my readers.  I was so touched that they had found some wisdom in what I had written, and that, in a sense, my words had helped them.

After all, that is why I write.

But since then, I found myself chasing the high, if you will.  Trying to “knock it out of the ballpark” with another sage post.  Trying to say something important and unique and memorable.

To make matters worse, what wanted to be written lately was poetry, an art form that was entirely new to me.  I don’t know how to write poems.  In fact I know nothing at all about poetry.  But I love the chance to play and stretch and yes, suck at it too.  I love the vulnerability of expressing myself in an unfamiliar way.

What I didn’t love was the feeling of somehow falling short of my readers’ expectations.  What if my poems were not as meaningful as my other blog posts?  Where was the wisdom?  Was I disappointing my supporters?  In my poetry-playing, was I somehow depriving my readers of something they had come to look forward to, a post to learn from every week?

If you want to kill your creative spirit (and over-inflate your ego), try engaging in an entirely self imposed pressure to write a perfect, life altering, mind blowing blog post every week.

My phone lit up:  “Why are you doubting yourself and your work?  Your readers don’t want perfect. If anything, your readers want more of YOU.”

And yet another ding:  “You are putting too much pressure on yourself.  Remember why you started your blog.  For your children to read one day.  Remember them.  Remember your intention.”

Yes.  Thank you dear friend.

My intention from the beginning was to be real, true, and most of all myself, as I show up on the page.  I don’t want to be perfect.  I don’t want to save anybody.  My readers don’t need my “help.”

My readers need my honesty and transparency and my humanity most of all.  They need to feel my love, one shaky, uncertain word at a time.  The last thing they need is shiny wisdom, which inadvertently has left us all feeling inadequate and needy at one time or another.

We were texting about my blog, but as always, it was a reminder that writing mirrors life and vice versa.  My desire to get it “just right” has often paralyzed me from taking risks big and small.  I didn’t go for the English major because it wasn’t part of the pre-med plan.  I struggle with letting my kids be free to have a do-nothing summer because I fear a blank college application.  I wanted to take a couple of years off to travel but never found the right time or opportunity.

I don’t wear the red lipstick because I simply don’t trust that I can pull it off.

Letting it all hang out while we seek and screw up and struggle for answers in the dark isn’t how it’s supposed to go.  Taking small and big detours and not knowing and figuring it out as we go isn’t necessarily the life plan.  The unfortunate lipstick choices and dead ends aren’t the parts we are comfortable showing to the world.

But that is the truth of how we all unfold.  That is how we all grow towards whatever light we are each uniquely designed to find.  Whether we like it or not, and whether we share it or not, that is the reality of how most of us navigate our days.

I am grateful for the mid-night soothing of my (entirely unrealistic) anxiety to change the world one blog post at a time.  Because in some ways, we actually all need to be a little less perfect.  What if we could simply show up as we are, and share our stories as a way to let ourselves out and let others in? What if these words represented what we most long for–a relationship between you and me?

So today and in the week ahead, I invite you to join me in noticing where you might be imposing perfection upon yourself.  How does perfection paralyze you?  Are there small ways for you to show up just as you are?

With gratitude, Monisha

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.