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.

 

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 

Top 5 Lessons Learned for the New Interns

Welcome new PG-1’s! One day you wake up a medical student. Then by the afternoon you are a MD. A few short days later, you are now in the hospital no longer looking for someone to co-sign your orders in the EMR.

It’s a crazy time, full of excitement as well as an inordinate amount of stress.

My list is not for your first day of the first week. But maybe bookmark it for after you get your sea legs under you. After you know where to park the car and where to get that much needed cup of coffee. This is for after you figured out how to login to the EMR and PACs system and know the pattern (or lack thereof) to your days on your first rotation. Then, come back here and re-read. When you have the bandwidth to actually process. There are many pearls out there for new interns. There are handbooks, pocket guides along with Twitter full of words of wisdom. The five I have written about here I think will serve you well as interns and beyond.

  1. Don’t forget the chief complaint.

My closest calls and near misses over the years have been when I neglected to pay adequate attention to the patient’s chief complaint. They may be in florid heart failure with a pulse ox of 70% and not making any urine. But all they care about is the pain in their calf. While I am placing them on non-invasive positive pressure ventilation, nitro drip and Lasix, two hours later I find them in the OR for compartment syndrome. Their chief complaint may not be at the top of YOUR problem list, but it is at the top of THEIRS. It may not always end up being a life or limb threatening process, but then again, how do you know if you don’t check it out. Always respect the patient’s chief complaint.  If you do not bother to pay attention and address it, what else is your patient telling you that you are not hearing!

2. Ask that question!

If you are uncomfortable asking as an intern, how will you do it when you are an attending? I will let you in on a little secret. We (the attending’s) do not know what’s going on all the time. But I do know where to go to get help. What resources I have in the form of other colleagues, partners, consultants, etc. You are not expected to know everything. Definitely not as an intern. But we doctors can be an interesting bunch. We often feel like imposters, especially early in our training. That we do not belong. Yet we have pride and ego that compete with our feelings of insecurity.  This is an awful construct to have in your head.  Break it. Ask the question. I am willing to bet someone else on rounds has the same one. By asking, you encourage the next person to speak up. By sharing what you do not know, you foster an environment that encourages learning and is better for patient care. More importantly, you will recognize that this doesn’t stop after intern year. Welcome to being a life-long learner

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3. Approach with caution the patient with psychiatric illness.

It’s hard when the patient’s history of mental illness gets put up front during sign-out from the ED or on your chart review. Our biases often kick in whether we intend to or not. Often the patients ability to give a good history and report symptoms accurately gets called into question and their voice gets tuned out in the shadow of their mental illness.  Patients with mental health issues can just as easily develop physical illness. Which often in turn leads to exacerbation or decompensation of their underlying psychiatric diagnosis. Too often we dismiss out of hand their complaints or the “pan positive review of systems”. It is hard when someone’s psychosis or mania or anxiety is raging to discern what is the truth. But be disciplined and approach all patients with same level of concern.  Don’t stop listening and tune the patient out. That abdominal pain, even though it is the 5th time they have been to the ED, can still be an appendicitis. 

4. Don’t fear the family.

I remember dreading walking into rooms with family members. They were more able in body and mind to ask questions and were not so easily dissuaded by my quick in and out of the rooms trying to get thru my morning pre-rounds. I feared them. Not just because of the time they took that I did not have, but also, I felt they would expose me for what I was. An imposter. Unable to answer their questions, I feared more what they made me think and feel about myself.

They fear too. They worry about their loved ones. They are confused, out of place, disoriented and are trying to advocate in the best way they know how. Don’t fear them. Lean into them. Sit down. Answer questions even if it means saying you do not know. Start getting comfortable with diagnostic uncertainty and being able to talk about that with patients and families. Honesty combined with empathy goes a long way towards building trust and confidence.

5.   Recognize wins.

I have written about this before in  another post  10 Tips For New Interns For Surviving and Thriving in the Intensive Care Unit  but I think its important enough to include here as well. Learn to retrain your brain. As physicians, we tend to focus and dwell on what went wrong. The challenging patients and families. Frustration over missing labs or delays in imaging. The complications of our interventions. The bad outcomes. The deaths. This is where our brains go when we are most tired and beaten down after an exhausting and non-stop twenty-four hours. But in doing so, we miss out on celebrating our wins. We successfully shepherd so many patients through the treacherous and complex world of medical illness.  Treating a “routine” COPD exacerbation and managing them through their hospital stay to discharge without any drama or significant adverse event is no easy task. But we fail to value our role in this as a win. It is viewed as a baseline expectation. We need to learn that there is nothing given about a patient’s course. If we blame ourselves for the bad, then we must take credit for the good. We focus so much on what goes wrong or in our perceived failures to help or heal our patients we end up ignoring all the positive around us.

Best to all the new interns on the start of a new journey. Exciting times lie just ahead. If you enjoyed this post and want to hear more thoughts on medicine and work-life balance, please sign up to follow this blog!

Death, Dissonance and the Doctrine of Double Effect. 

This post was first published on Doximity’s Op-(M)ed “First Stab” Collection on 5/2/18 under the title: Should I Heal or Comfort?

Chicago, in February, was dark and cold. Even more so at 5:00 AM, when scraping ice and snow from my windshield before heading to the hospital. It was my first month as an intern in the ICU and my first day without my senior resident present. Working as a team, getting our patients through the day was challenging. Working alone, I felt overwhelmed. Knowing we planned to remove Mr. Thomas’s breathing tube only added to my angst.

A few days earlier, Mr. Thomas came to the emergency room by ambulance, in severe respiratory distress. In those chaotic first few minutes, the ER doctor intubated Mr. Thomas and put him on a ventilator. As the dust settled, and additional information was Read more