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.

 

The Ties that Bind and the Weight of Connection

Traevelling 30,000 feet above the ground on my way back to Chicago, it’s hard not to think about distance and space. How people in the same room can still feel worlds apart while others can be physically separated by hundreds of miles and still be intimately connected. Traditional modes of measurement fail when it comes to matters of the heart. I feel the push and pull of these forces currently at play within me as I sit on a plane, wanting to distract myself with some mindless movie or loud music or just close my eyes and sleep. The plane, at its current altitude, disconnects my phone from the pages, texts and alerts waiting on the ground, freeing me for a short while from their intrusion.

To be intertwined with someone else. To belong to something greater than yourself. A family or community? To have purpose beyond ourselves. To give and receive. To be connected. These thoughts lead my brain back to chemistry and physics and learning of forces and attraction between molecules. I recall the weaker ionic bonds, able to be disrupted by water alone.  I remember organic chemistry and the tight sharing of electrons between carbon atoms, and its strong covalent connection. I think of the ultimate overwhelming gravitational force of a black hole from which nothing can escape.

In the past, those descriptions were just notes jotted down on paper. Simple lines to memorize to later regurgitate verbatim on a test or quiz. At the time, I did not have the capacity to truly understand those ideas. Now I find deeper meaning in these concepts. The invisible attraction exerted by gravitational forces and tight bonds cause visible and tangible effects. We learn of the “potential” within these bonds, to hold and store power and energy which I have felt in the pounding of my heart and in the heat of my salty tears. The paradox being that the strength within the bonds of connection that help withstand stress and strain can also cause disruption and damage.

How then to find equipoise and balance? Where this connectedness provides stability and strength to move forward, instead of collapsing under its own weight.

It is in this space that I am floating at the moment. Physically, 30,000 feet above the earth, yet right next to Madison in Southern Oregon and Maya back home in Northbrook. Can they feel me with them right now? Do they know how much they are in my thoughts? Do they feel the same tug on their hearts and in their core? And if so, does it feel safe and warm and a source of comfort and confidence? Or is it heavy and weighty and overwhelming and constricting?

The change of pressure on my ears signals the beginning of the plane’s descent back to earth. The thirty minutes or so left on this flight leaves nowhere near enough time to climb out of this rabbit hole in which I find myself.  But this is why I chose to go part-time. To find time and space to wrap my mind around these questions. It was too infrequent and rare to have the emotional energy and capacity to sit with and work through these issues

The plane lands and Becky and I disembark, still a bit disoriented with my ears plugged and cumulative fatigue of the weekend. I find myself adjusting to the changing forces of connection, now that I am two thousand miles closer to my daughter, but that much farther from my son.  But I sense this is a new theme in my life. Navigating time and space with those you love and balancing the benefit of the power of connection with the weight of its strength. And in this moment, these invisible forces couldn’t be more tangible,  as my heart is pulled in all sorts of directions.

 

Defending the Lob, Managing the ICU and Emotional Intelligence

The lob shot.

As a goalie, it’s my nemesis. It was my major weakness in college and even more so today. Standing (or more appropriately treading) 6’3″ tall, with an even longer wingspan, I have always been eager and ready to explode up and out of the water, my arms outstretched, to intimidate a shooter. My height, along with my gangly arms and a quick first reaction, are great tools to disrupt, alter and ultimately block my opponents’ shots.

But my kryptonite is the lob shot. It turns my strength against me. A patient opposing player, by waiting a split second, lets my aggressiveness work against me. By allowing me to rise up and out of the water first, a shooter can then release an agonizingly slow arcing shot, up and over my now sinking self, to then drop into the opposite corner of the net. I react. They wait. And I’m beat.

When I correctly anticipate the lob, it’s demoralizing for the shooter. With minimal effort, the ball is not so much blocked as “caught” in humiliating fashion, usually deterring the shooter from another. But when my legs have already committed to a direct shot, all I can do is swivel my head and watch as the ball takes its time, teasing and taunting me, just out of arms reach, and lands in the net.

In college, it took a while to develop patience. To dial back my brashness, my impulsivity. Wait that extra split second. Take in the arm angle and the eyes of the shooter. Trust myself and my abilities to make the block even if I delay for a brief moment. My teammates challenged me with lobs over and over again in practice, until finally a change occurred. Thinking, instead of just reacting. Using my frontal cortex, instead of my primitive brain. And for a while, I had the upper hand against my nemesis, and my opponents as well.

Tempering my first reaction has never been easy, either in or out of the water. My initial response to life’s challenges tend to be more reactionary and visceral. In one’s college years, that lack of patience and emotional intelligence is somewhat expected, if not the norm. Not so much when in mid-life and caring for the critically ill or teenage children.

The ICU will never be mistaken for an Olympic sized pool. And my children, despite how it may feel, are not opponents on a challenging team. But the unique nature of an ICU and family dynamics make both areas ripe with opportunities for a battle between my brash, impulsive tendencies and my more mature, deliberate and thoughtful side.

The space that exists within the confines of the ICU is awash with challenges. Rooms are filled with the tension that accompanies the acuity and intensity of critical illness. ICU physicians are tasked with navigating multiple health care professionals, who frequently have honest differences in opinions, and sometimes supercharged egos and attitudes as well. Families and surrogates of patients, residents, nurses and students all operate in this landscape, within their own sphere of swirled thoughts and emotions. There are a multitude of relatively quick decisions that need to be made. Do I intubate or not? Do I send them on a road trip for a CT or stay in the more stable confines of the critical care unit? Do I commit a patient to an invasive procedure with potential complications or hold off and continue with the status quo?  But it’s not just the decisions themselves. There is a qualitative component as well. Do I take the extra time to explain my thought process to the nurse, resident or student at the cost of delaying decisions for the next patient? Do I provide more than a cursory update to a family as I exit a room, or do I sit down and invite them to share their angst and fear. Do I do so at the cost of delaying the start of my office and the patients waiting there? Do I share my inner head voice and its whispers of fear, concerns and self-doubt? Or do I project unwavering confidence and certainty? Challenges lie not just in making decisions, but in the manner they are carried out and executed. To grow, not just as a competent clinical doctor, but as an empathic physician as well, one needs emotional intelligence to navigate such complex waters.

These days, back in the pool, I find my old nemesis is back to taunt and haunt me. My height and wingspan may be unchanged, but the same cannot be said about my explosive move up and out of the water. Over-eager and anxious to defend a shot on goal, I now have the added challenge of being a bit slower and quite lower out of the water. I don’t have the luxury of waiting that split second anymore.

I find history repeating itself, with my current teammates showing the way. They challenge me in practice, frustrating me with lob after lob. But they are not content to stop there. They let me know that I may be the only one in the net, but I am not alone in defending it. Through their efforts in games, fighting for position, and playing a team defense, they buy me back the time I have lost. They remind me to trust them. And in turn, trust myself, allowing me to tap into my thinking brain in order to defend the lob.

My experiences with the team continue to parallel my life. Just like success in the net is a result of a team effort, so it goes in the ICU. I’d be lying if I said the years have not affected the excitement and enthusiasm of the young attending physician I used to be. There is now a component of fatigue and burnout that I often need to shake off before rounds. Some days it feels that I am on an island when dealing with a crisis or challenge. That is neither true nor accurate. The nurses, residents and students, along with my physician partners are teammates too. Together, the challenge of taking care of the critically ill seems less daunting, giving me the time and space to harness my thinking brain.

There are moments when instinct and gut reactions are critical for success. But when I am able to bring both parts of my brain to a challenge, the enthusiasm that comes with  impulsivity and brashness along with the wisdom that accompanies maturity and thoughtfulness, good things happen. Not just in the pool or ICU, but in life as well.