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.

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 

From Flowers to Dostoyevsky and the Road In-between

IMG_6416

I am sitting in the parking lot, waiting for the local bookstore, The Book Bin, to open. I am here because of a flower. And a pear tree turned maple. And a sense of time and space. And the writer Dostoyevsky.

Sipping my morning coffee, with the Jeep’s soft top down, I feel the heat and humidity of the day gaining momentum. I have ten minutes to kill, but there is no rush. I am in no hurry.

I am not a particular admirer of flowers or plants, nor fond of gardening. You will find no green in my thumb. I struggle to tell the difference between tulips and roses or what qualifies as a annual versus a perennial. Becky is both president and vice-president of landscaping and curb appeal for our home. But every year, after Chicago thaws out from another nasty winter, there is one pink plant I notice from July to the frost.

The routine is one I have done a thousand times. A long day of work followed by a quick drive home. I turn into my driveway, stopping short of the messy garage. I grab my evening Starbucks and step out of the car, making a bee-line for the front door. Just to the left of the brick paver walkway, pink flowers bloom on the tall arching hibiscus plant. Ten year ago, Madison and Maya won an Earth day contest resulting in a hibiscus plant in the front yard and a Pear tree in the back. Now, every time I see the pink flowers, a Pavlovian response follows. See hibiscus; think of Madison. The pink flowers stand out as the summer days get longer. But the reflexive thought is usually fleeting. I have a narrow two-hour window to play catch-up with the family, eat some food, and take care of some odds and ends before getting ready for evening water polo practice.

But this has been a year of change. More weeks off of work than on. Days slower, pressure lower. Options greater. Headspace clearer.

Yesterday, I got out of the car and looked just to the left of the brick paver walkway; pink flowers bloom on the tall arching Hibiscus plant.

I paused.

I deviated from pattern and routine. I literally stepped off the brick pavers and walked through the dirt. I kneeled, and for the first time in ten years, I looked. Not rushed and fatigued, but with the unassuming eyes of a child.

Was it the way the day’s light caught the blooming flower? Or its movement, as it swayed back and forth in the afternoon breeze? I stopped. I looked. Differently. Not with an expectation of confirming what I knew to be true. Not reflexive with a programmed response. But with eyes and mind open in a way they often are not.

Not a simple single color, but pink and dynamic, with pattern and texture. Not just petals, but a flower with a complex architecture that I forgot existed. I am mesmerized. I focus. I take pictures, trying to capture or preserve what my eyes see. There literally is a world of things present that I have not noticed previously, all backlit by light emanating from small slits in the petals left open at the base.

IMG_6337

I have written, in the abstract, about increased time and space since going part-time. But it’s concrete and tangible right here in this flower. My mind is unencumbered by the weight of a twelve-hour work day or a week’s accumulation of fatigue. There is no pressure of a two-hour window closing in on me as I stop to smell the roses; or in this case, the Hibiscus. I walk around to the backyard. A few years ago, we identified the pear tree correctly as a maple. I look up at what was once a six-foot tree which, to my surprise, towers overs me by at least thirty feet. Thick branches, once thin and pliable, have weathered quite a few storms over the years. Despite viewing the tree daily through the kitchen window, I have missed this transformation.

IMG_6375

Patterns and behaviors. Expectations and assumptions. Tools often necessary to get thru challenging days. They consume less energy, tapping less into one’s reserve, to operate more on auto-pilot or cruise control. But that path foreword is limited and constricted. One where the hibiscus remains just a pretty pink flower, and the maple six feet tall.

Time and space. Look left and right. Stop assuming. Be more curious, and have fewer expectations. Break patterns and rethink behaviors.

I didn’t read Crime and Punishment in high school or college. Over the years, when I came across references to the book and its protagonist Raskolnikov, I made mental notes to buy and read the book, but never followed thru. Too little time. Never made it high enough on the to do list. In a few minutes that will change. I am waiting for Book Bin to open and I am going to buy that book.

Time and space. Break Patterns. Rethink behaviors.

Madison comes home soon to visit for a week. He’s about to move into his own apartment in Oregon. Maya’s about to start her senior year, with quite of few colleges on her mind. Becky is gearing up to offer tutoring services in a more formal fashion. We are a family with quite a bit of transformation ahead. But despite the potential and promise of the upcoming year, I am in no hurry to launch myself forward.

Days slower. Headspace clearer.

I drive away from the Book Bin, Crime and Punishment in hand. I am ready to read it. With more time and space. With more curiosity and fewer expectations. And with unassuming eyes and a mind wide open.

IMG_6321IMG_6350IMG_6340IMG_6386IMG_6384