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.

Snow Day

I woke up to a blanket of white covering the ground. Unlike in childhood, this was not met with excited anticipation. Forced to skip my morning coffee, I layered up in my thermal gear and put on my boots, the blister on my heel reminding me to buy a pair that fits properly. I struggled to find gloves and settled on a mismatched pair as I braced for battle with the cold. I tried not to tweak my back while repeatedly yanking the starter cord on our stubborn snow blower. As I began to clear the thick snow off the driveway, the layer of ice hidden below was a reminder that I was not quick enough to clear the driveway last time. Obstacles and challenges now loomed ahead as I anticipate colder temperatures, icy windshields, hazardous driving, and ill-fitting boots and blisters.

When did snow become the enemy? When did it become a chore? When did it become something that added to the weight of my day?

I was nine years old when one of the biggest blizzards in Chicagoland history hit. My school day was replaced by a snow day. Multiplication tables and PE class were swapped for snowballs and snow angels, while mini-mountains of snow popped up all over the neighborhood.

I remember the frustration of trying to make a snowball out of fresh powder, the crystals sliding through my fingers like weightless sand. And finding success with heavier packing snow, hearing the scrunchy sound made while rolling it to form a giant snowman.

I remember hot chocolate in my stomach any money in my pocket after shoveling driveways in the neighborhood.

I remember a blizzard in Madison, Wisconsin. A snow day in college, of all places! Playing tackle football in powder up to my knees, my quads and hamstrings burning. Hot and sweaty, despite the cold air, and the sting of snow on my face after a tackle. The pleasure of finding that perfect balance, not falling backwards on my ass or forwards on my face, while skitching on the back of a car all the way down Langdon street.

I remember the joy in my son’s eyes the first time we went sledding, on a snowy day in Michigan City, Indiana. The cold air was no match for the warmth of Madison’s smile.

When I was younger, snow was white and light, scrunchy and fun. An invitation to play. An opportunity to explore. A far cry from its impact on me now.  Snow is now an obstacle to be shoveled, a hazard for my teenage drivers, slush and salt to erode the underside of my car. It’s work now.

My thoughts turn from snow to my relationship with medicine. Another area in my life that has evolved from joy and excitement to frustration and challenge.

I remember the first time I put on my short, white coat and entered a real patient’s room to take my first history. I was hesitant to cross the threshold, nervous I’d be discovered as a fraud, an imposter. But excitement trumped anxiety as I stepped into the room, introducing myself as a student-doctor for the first time.

I remember the pride of wearing a stethoscope around my neck. The thrill of learning and doing each new procedure, pushing through my fear of causing harm. My growing sense of accomplishment as I read up on an unfamiliar disease or diagnosis adding to my knowledge base. Each patient a potential puzzle of signs and symptoms to piece together, not knowing what the ultimate picture would be. It was unknown and exciting. A snow day.

Somewhere along my path, medicine, like snow, got flipped on its head. More electronic medical records and charting than direct patient care. More patients to been seen but not more hours available in a given day. Journals and review articles pile up, still left unread. And instead of hot chocolate waiting for me at the end of a long day, there are only unfinished documentation and lingering worries over difficult decisions made.

More work than play. More obstacles than challenges. More conflict and tension than excitement and possibility.

The other day, a medical student I’d hardly noticed on my ICU service asked to see a new admission. I looked up, and saw the enthusiasm in her eyes. And, for a brief moment, I saw what she saw. A giant snow covered sledding hill ready to be climbed up and slid down. And I longed to be there on that hill, launching myself off the edge and feeling the cold air stinging my face, not knowing when I might finally come to rest. Ready and eager to race back up to the top and do it again and again, until I no longer felt my fingers and toes.

And it feels like a snow day again in my ICU.

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My wife miscarried while I was on call. What this medical resident chose to do.

Scan 100

The day began the same as yesterday. As well as every day prior to that for the last few months. I was tired. Exhausted. The type of fatigue that envelops your brain in a dense fog, altering the way you see and hear the world around you. The type that impairs your ability to think clearly and process efficiently. It was the cumulative fatigue from too many nights of disjointed and ineffective sleep. My two children the culprits at home, my pager when at the hospital. The alarm clock told me it was 5:00 am and time to start moving. I was the senior resident on call for a busy general medicine service. I got ready mindlessly and drove to work, leaving my three-year-old son, ten-month-old daughter and pregnant wife behind.

The page from my wife would come a few hours later, while in the middle of hearing about a new admission. I called her back, expecting a generic morning update on the kids.

“I think I’m miscarrying.”

In my worn-out state, there was no reflexive response. Like the origin of a wave as a swell forms and the water gently rises, confusion first surfaced in my head. As the swell of emotions picked up momentum and power, sadness and feelings of loss crashed in. Then guilt over fleeting thoughts of being saved from even more sleepless nights another baby would bring. As the waves passed, I was left with loneliness. So far away from my wife at the moment when she needed, WE needed, to be together. I did something in that moment I had never done before. I called the chiefs and asked them to call in the resident on jeopardy to cover for me. Within a few hours, I was home at my wife’s side.

We sat together. We talked. We cried.

But as a few hours passed, the fact that someone else was covering for me caused increasing tension. Someone was doing my work for me. Admitting patients with my team, because I wasn’t there to do it. And as the sun set on the day, my wife turned to me and said, “It’s ok. Go back to the hospital. I’m alright.”

And I went back.

Thinking back to that moment, my stomach still twists in knots. How could I have walked away? How did the culture of medicine lead a fatigued, and emotionally exhausted, young doctor to leave his wife, who had just miscarried hours ago, to care for two young children on her own?

Did it start in medical school? Initial thoughts of self-doubt, and feeling like an imposter, slowly faded as we internalized subtle, and some not so subtle, comments from faculty. “You deserve.” “You belong.” We were told we were on a path to a higher and more noble calling, with great purpose and responsibility. Something bigger then ourselves. Whether from self-doubt or self-importance, we were driven to study. We spent hours reading and learning, dissecting and memorizing. We prepared for finals, mini-boards and shelf exams. And while doing so, our friends of old, no longer enmeshed in academic studies, enjoyed the perks and freedoms that came with new jobs and real incomes. We were too tired and too immersed in our narrowly focused world to connect with our friends. And as the dynamics started to shift in those friendships, we became a little more isolated.

Did it continue when we began our clinical rotations? The residents we looked up to as role models were always present and available. They taught us clinical pearls, ran codes confidently, and handled emergencies calmly. They were described as “strong.” So we emulated them, making ourselves present and available as well. For our assigned patients or a potential procedure. To be noticed. To be evaluated. To be appreciated. Those traits were deemed positive, earning merit. Never mind life outside the hospital walls. Reading a book for pleasure, enjoying a run along the lake, and being emotionally and physically available for our partners and children weren’t skills that made it into letters of recommendation.

Did it continue in residency? We took on more responsibility for our patients. Admit them, document them, draw their blood, administer antibiotics, check the labs, update their families, and plan their discharges. “To do” lists to be checked off before we could sign out and go home. In one month we would work twenty-six days. Seven of those were spent working overnight, non-stop into the next. Four days a month we were allowed to keep for ourselves. But those four days did not make up for being absent physically and emotionally for twenty-six. Not there to take out the garbage or help with laundry. A no-show for a friend’s birthday party. Too tired to take a turn rocking a child back to sleep in the middle of the night. Exercise or making a home cooked meal was off the table, when just keeping your eyes open for the car ride home from work was considered a win.

Did it continue in fellowship? Being on service or working in the clinic was not enough. There were patients to recruit for trials, night-classes to attend, and research to do. We needed to write another chapter and apply for another grant. That’s what our mentors and department chairs did. In the meantime, we weren’t there for our own children’s scarlet fever, chicken pox, recurrent strep throat, first steps and first words. What free time we had was spent moonlighting, as we tried to keep up with ballooning school loans, mortgages, and college savings for our kids.

 At every step on the path to becoming physicians, the messages were clear. Be present. Be available. Leaving early was weak. The students, residents and fellows who stayed were dedicated and serious. Impressions were formed based on being visible. Evaluations were determined by our perceived dedication. But if, in the process of being ever present and available, we struggled to make it through the day, how could we be there for ourselves? To rest and recuperate. To think and process. And if not able to care for ourselves, how could we care for others?

It’s no wonder that in a 2015 JAMA systematic review, average depressive symptoms among resident physicians was 28.8%, ranging from 20.9% to 43.2%. In a similar article in JAMA 2016, the prevalence of depression or depressive symptoms among medical students was 27.2%, and the overall prevalence of suicidal ideation was 11.1%. And these numbers don’t address other mood disorders, such as anxiety, or the dysfunctional and harmful coping mechanisms of alcohol and drug use. It’s not surprising that there are so many struggling or failed marriages among physicians, as well as rampant burnout.

In medical school, we are taught about cells, tissues, organs and systems. We learn to write histories and perform physicals. We are preached to about antibiotics and anti-hypertensives. But where in the curriculum are we taught to care for ourselves? When in residency were we told to go home and make sure to be there for our families? When in fellowship was physician wellness placed on the same level as grant writing and lab techniques? Why is focus on family merely tolerated by our peers, instead of modeled and emulated? Too be fair, there have been a few mentors and role-models who showed us how to not only set appropriate limits and boundaries, but taught us that it was acceptable to protect our home lives from our work lives. But they have been outliers. Exceptions. Too often their solitary voices drowned out by the masses.

For too long, the culture of medicine has promoted this choice as binary. Spending time in the hospital to learn and care for patients versus spending time with our families. A zero sum game. But it doesn’t have to be. Why can’t there be a culture that promotes both? So far, attempts to normalize and humanize training have narrowly focused on specific issues such as work hours and work environment. But the culture of training new physicians also needs to change. Setting appropriate limits and boundaries, as well the concept of physician wellness, should be as prominent in the curriculum as human pathophysiology. We talk about developing the skills required to be a life-long learner in today’s internet-connected fast paced world. So too should we talk about promoting clinical excellence and dedication, but not at the expense of their families or their own happiness. Spouses and children should not bear the consequences of a flawed system.

There are only a handful of things in my life that, given another chance, I would do differently. My choice to pursue a career in medicine is not one of them. I love this profession and the unique opportunities it provides to help people in powerful and meaningful ways. But I do wish I could go back to that day during my residency when my wife miscarried. I wish I had stayed home with her.

Will The Adults In The Room Please Stand Up

Uncertainty.  In particular, diagnostic uncertainty, would keep me awake at night, early in my career as a freshly minted critical care doctor.  Patients who deteriorated without explanation or haziness on CT Scans without an identified cause, fanned the flames of my insecurity. The scenarios would leave me edgy and uncomfortable impacting my life outside the boundaries of work. Like most doctors, over the years I learned to co-exist with this uncertainty.  Human sickness and disease can be challenging mysteries.

Recently, a new kind of uneasiness has invaded my world causing all sorts of havoc. With the politicization of health care reform and attempts at repeal and replace Obamacare, uncertainty is rearing its head with a vengeance. Twitter and Facebook give minute by minute updates on which senators are a “yes” or “no” and where public opinion currently lies. The evening television roundup details rumors that have leaked from behind closed door meetings. The background noise of it all is deafening. Most discussions are focused on the future impact potential budget cuts or regulation changes. But the uncertainty created by our polarized and tribal politics on any path forward for health care reform is having a real impact now. Every hour of every day, both in the hospital and in my office where I interact with my patients.

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