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.

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.

The Nocturnists and the Healing Power of Storytelling in Medicine

A few years ago, I stumbled upon the Moth Stories.  Originally based out of New York, but now in cities around the country, people would come together at a venue to share and listen to personal stories based on a theme for the evening. Ten people, randomly selected one at a time, would go up on the stage and tell their story. I went to one in Chicago a few years ago not quite sure what to expect, but my experience was profound. There is such intensity and intimacy created by sharing such impactful and vulnerable moments to an open and receptive audience. I had the opportunity to share my own Moth Story  (which you can see here) at one of these events. I gained tremendous personal incite preparing my five-minute story. I also realized, telling my story in front of several hundred people without any notes was more stressful than running most ICU codes.

It is no surprise that this format translates so well to the medical world. In 2015 a second-year resident at UCSF, Emily Silverman, after seeing the Moth Stories herself, started The Nocturnists, a similar storytelling event but geared for the medical community. The program has grown over the years in the San Francisco area and there have been shows in Boston and this fall, New York City. Emily just completed the first season of The Nocturnists Podcast, which I finally, over the long weekend, binged on.

Each of the thirty-minute episodes, start with a ten-minute story, recorded live from one of the stage shows. The rest of the podcast is an interview between Emily and the storyteller, further unpacking their themes, taking a deeper dive into a range of topics:  The dehumanizing aspects of residency training and the impact on both doctors and patients, the competing roles physicians face providing hope versus reality, the anxiety of running a code and other procedures for the first time, the loss of autonomy for our sick patients and the impact on the doctor-patient relationship, end of life issues and advanced care planning, EMR’s, the opioid crisis and more.  Each of these vivid and personal narratives, through the voice of the storyteller, contain multiple themes that will feel familiar, formative and universal for almost all  health care professionals. For those whose lives are outside of medicine, the access “behind the scenes”, not just to the story but to the mindset and thoughts of the storyteller themselves, make the listener immediately invested and connected. Almost every story resonated personally; except for the one where the morgue refrigerator broke down one night, challenging the problem-solving ability of an administrator on call. You are going to have listen to episode #8 to learn more about that one.

The medical themes I have been writing about here on my blog; burnout, demands of residency training, dealing with and end of life issues, formative moments in the life of physicians, are all brought to vivid life in these wonderful and powerful stories contained in the podcasts. Just hearing them alone in my car all weekend long, has helped me feel more connected to the medical community at large, which I believe is the most valuable component of the Nocturnists. A lot is being written about “Narrative medicine” and the power of  stories to help our patients and ourselves; injecting some much needed humanism into the medical workplace. When people, with their varied backgrounds, have the opportunity to share their stories with each other out loud, the healing power of connection comes alive. I do not believe it is a coincidence that the growth and success of the Nocturnists comes at a time when physician burnout and frustration is at an all time high.

I invite you all to check out the podcast on Itunes or Stitcher and listen. I look forward to season 2, and hopefully for The Nocturnists to make their way to Chicago sometime soon!

Anyone who has appreciated my writing, will definitely find these podcasts  well worthwhile and thought provoking.  I look forward to the day the Nocturnists come to Chicago!

The pace and path to mindfulness

Fast

I eat. Fast. Often, I consume the food I place on my plate before I even make it to the kitchen table. It’s as if I grew up during times of famine, desperate for each and every morsel. On the rare night my family has dinner together, I am usually finishing just as they are starting, and by doing so, send a not-so-subtle message that I value family time together less than just eating.

I drink. Fast. That first beer stands no chance. After my first “sip”, I look sheepishly at my near empty bottle, while others are still using the bottle opener. The joy and satisfaction of a cold beer on a hot day is made all too brief.

I read. Fast. If I like a book, I will devour it in hours. I will keep turning pages until the first light of day sneaks in under the bedroom blinds, signaling me to stop reading and start getting ready for work. The more gripping the book, the quicker my pace and ironically less time to enjoy my escape.

I see patients. Fast. A necessary skill when the hospital is bursting with influenza, the ICU’s are buzzing with patients on ventilators, and my afternoon office is bustling with overbooked patients. I am relieved when I make it through the day without the weight of unfinished charting and unreturned patient phone calls still to be made. But back home, my escape is not without consequence. I feel a gnawing, growing internal uneasiness at the lack of depth and breadth of my numerous interactions.

Slow

I write. Slowly. Frustratingly so for someone trying to create content and build a platform. But I love to labor over sentence structure and word choice. Although slow, it is not painful. When I am able to put to paper the perfect sentence that captures what I see and feel in my head, it generates a soothing and intoxicating internal harmony.

I listen to music. When I do, time slows, regardless of its fast or slow beat. In my car or at a concert. The chords, notes and riffs are felt more than heard, resonating within. Sometimes I get lost within a space that only exists for a brief moment in time.

I cook. Measured and deliberate. I prefer the feel of certain knives in my hand. Cast iron more than non-stick and the warmth of the oven pre-heating behind me. Whether it’s making homemade pizza dough, baking gluten free muffins or smoking a brisket for the better part of a day, I don’t feel that time has been wasted.

I run. Sometimes for hours. Disconnected and separated from phone and home, my foot cadence becomes my mantra as I let go of the competing forces of work, family and social media. I dive deeper into unresolved thoughts and emotions.

Pace

I first learned about the concept of pacing in high school.  Figuring out a “steady” versus “race” pace was a skill needed to survive swimming thousands of yards day after day. I apply the same concept when training for and competing in Iron-distance triathlons. How fast can I push before burning out too quickly? How do I not leave anything in the tank as I cross the finish line? When I think about the activities and actions that bring me the most meaning and happiness, pace is a dominant factor.

Mindfulness often evokes images of yoga, crystals, incense and oils. But the truth is, when the pace is right, mindfulness comes into play without the need for any new age music in the background. Just as I appreciate the cadence of my breathing on a run or the layering of different tracks on a particular piece of music, mealtime can be transformed from mindless to mindful. Tasting the food and enjoying conversation, while being present and in the moment with my family around the table, becomes so much more than quickly ingesting empty calories.

Applying pacing and mindfulness to an otherwise generic patient encounter opens up opportunities to create a more qualitative interaction. Picking up on verbal and non-verbal cues. Recognizing that what is not being said may be more important than what is. Filling in and clicking on all of the blanks and boxes in the EMR might facilitate an orderly collection of important health data points, but it does not facilitate a natural exchange of information, nor does it create a comfortable space that promotes openness and candor.

We make thousands of conscious decisions every day. What should I eat for breakfast? What shirt will I wear? Do I go for a run or a long bike ride?  What will I write for a new blog post? But we rarely pay explicit attention to the pace of our actions. I have lived most of my adult life moving at a fast clip. Transitioning to part-time gives me the opportunity to slow down and be more cognizant about the pace I choose moving forward. By doing so, I hope to reclaim in my work world the quality that has been absent in some of my recent patient encounters. And when outside the walls of the hospital, I hope to capture more often, that internal harmony or resonance that is waiting for me.  If I can just find the right pace.