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.

 

Hiatus

Time passed. One day became two. Weeks became months. What began as a temporary absence evolved into a void.

No writing. No journaling. No attempt at an opening paragraph. On occasion, I hastily blurted a random thought or two into a voice memo on my phone. But the recorded words stayed in coded form. Bits and bytes waiting to be transcribed and brought to life as words on a page.

For the better part of a year, I have worked on at least one piece of writing at a time. An idea or story. An outline for a book. Always some small part of my brain processing and playing with an idea, while racing through the craziness of my day.

But the last few months have been a bit of a hiatus.

The intensity of my work life and family life converged for a while, with quite a bit of travel mixed in. San Francisco for a conference. Klamath Falls, Oregon for a brief family Thanksgiving. Preparing for my son’s long-awaited homecoming for winter break back in Chicago. Christmas spent covering the hospital and ICU. Ringing in the New Year while working in an ICU in Elkhart, Indiana.

And somewhere between the West Coast and the rural Midwest, I got lost.

That little part of my brain stopped sorting new thoughts and ideas. Instead, I fed it a steady diet of Netflix, cryptocurrency and progressive politics. Comfort food for my cerebral cortex. And as the writer inside me took a leave of absence, I found other parts of myself taking a time-out as well. My running shoes sat untouched most days. My swim bag remained buried in the corner of the mudroom, as I went AWOL from my water polo team. Whatever exercise I managed was mindless and without purpose. As my writing and journaling stopped, so did my desire to physically push and challenge myself.

But I did not close my eyes.

I watched my daughter continue to face the challenges of being a sixteen-year-old junior in high school, navigating the ever-shifting landscape of friends, school and life. Juggling final exams and ACT tests, hours of dance and Poms, injuries, babysitting and a boyfriend. Like her dancing, She stumbles at times. But like she does when dancing, she pops right back up and continues moving forward, becoming more adept and able every time.

I watched my son face the challenges of being nineteen, while working on the universal yet uniquely personal battle between autonomy and dependence. Between freedom and restriction. More often than not, that process now takes place out of my sight, as he currently lives two thousand miles away. I am still coping with this. But each time our orbits align (and hopefully not collide), I see a little bit more of the man he is becoming.

I watched my wife challenge herself to tap into her mathematics and education degrees, putting herself out there to help neighbors, family and friends with the mysteries of high school geometry and pre-calculus. I saw this amazing cycle of confidence build. Not only in her students as they became better prepared for their quizzes and tests, but also in herself as she applied a unique approach to help each student fill in his or her specific knowledge gaps.

I watched. More passive than active. Letting events play out and unfold before me, often while stretched out on the family room couch. My sweatshirt and a comforter worked overtime, protecting me from both the falling temperatures outside and having to actively engage in the world around me.

But it is time. Time to leave passivity behind, along with the comforter and the couch.

Despite the cold, I went for a run outside the other day. A few years ago, running in sub-freezing temps was a no-brainer. Just put on the right clothes and go! Now it’s a bit of chore. It took more thought and effort to push through the inertia of inactivity.

It started with shivering. Time felt slow. Movement felt forced. But ten minutes into the run, my body heat began to build, and with it, the familiar warmth comforted me. The sound of air moving in and out of my mouth layered on the rhythmic sound of my shoes disturbing loose gravel and stone under my feet, brought me back to an old familiar space.

For the next forty minutes my joints ached. My calves and hamstrings burned. I sweat. It was snowing, and the falling flakes were cool on my flushed face as I ran through their vertical descent. And sometime during that relatively routine run that I had done countless times in the past, a small dormant part of my brain came back to life.

It’s time again to write.

A Family Reunion in Seattle and Newton’s Law of Attraction

Doc, I don’t see why I need all these meds. Can’t I stop them? Any of them?”

I hear this often from my patients. Sometimes they are right. They are on too many meds and don’t need them all. But sometimes it takes removing a medication for a period of time in order to truly appreciate its benefits.

It’s a crisp morning in Seattle. The sun is trying to break through the scattered clouds and there are waning remnants of fog coming off the harbor. I walk the three blocks to Pike’s Place and the public market, which is half empty as the fishmongers are making their way in. The rest of my family is still asleep, having all slept under the same roof for the first time in months. Months. That is what’s on my mind as I walk this morning. Thinking about plane rides, hugs, siblings and reunions.

I grab a few essentials for my sleeping crew: gluten free breakfast food for my daughter, a razor for my son, my own Venti Americano, Coke Zero for Becky, milk and cereal. I make my way back to our rental unit, buzzing for the start of our day. Our family of four. Four individual orbits that have come together here in the Pacific Northwest for a precious forty-eight hours.

We take the Link Light Rail across the city away from the harbor and skyscrapers, and make our way to the University of Washington and its traditional campus architecture. It is truly a picture-perfect fall day for a college tour. As I walk with Maya, I try to picture her among the students walking through the quad, the red square, and the union. Becky and Madison head in a different direction to enjoy some time together.

While Maya is occupied listening to our tour guide, my mind is free to wander. The day is truly magnificent. A perfect mix of cool temperatures, warm sun, a light breeze and a backdrop of trees with leaves full of fall colors. Discrete patches of thick white clouds move quickly across the sky. Not as static shapes, but dynamically altering their form as they twist and tumble, with a three-dimensional complexity I find fascinating. On the surface so simple, but with depth and layers that are mesmerizing. Their future as unpredictable as Madison and Maya’s.

We all meet back outside the Union. There is silly chatter, pictures and piggy-back rides. We joke and tease and smile. Yesterday’s travel to get here, and tomorrow’s departure, forgotten for the moment. There is a levity surrounding all of us, with no expectation or agenda other than simply enjoying each other’s company. The four of us are not just in close physical proximity to each other. The rhythms of our interactions are in sync in a way that has been missing for quite a while. Our individual orbits, for now, have become one.

Newton’s law of universal gravitation states that a particle attracts every other particle in the universe. In high school physics, I struggled with this concept, that the person ten feet away was exerting a gravitational force on me. But now I do appreciate the pull of my family’s orbits. A few months ago, the intensity and depth of our connection was present but not felt. Similar to my patients who appreciate the impact of their medicine  only in its absence, I am now more aware of the forces that bind and connect my family. And for the moment my world is perfect.

 

 

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.