Are You I'm Fine-ing me?

So I do this group for health professionals where we talk about self care and struggles at work. When I asked if their colleagues ever checked in on how things were going, they all said yes. However, their response was always “I’m fine.” All they can think about is getting home and drinking, or of jumping off a building - but “I’m fine”. “How are you doing?” and then being emotionally available for their colleagues. 

The irony that they are not emotionally available for themselves was not lost on them. They will give emotionally for everyone but not for themselves. 

We dreamed of creating work places that offer space and safety to let us say we’re not OK. Places where we are able to say “that was a really hard shift, can we talk about it?” Where no one is ridiculed for showing emotions or appearing vulnerable. Where as part of our regular feedback in training and from supervisors includes a review of our self care. 

When I left the group, enjoying how well it went, I noticed a colleague pretending that he wasn’t crying. He has been having quite a bit going on at home with a sick parent and a jerky daughter. I asked if he was ok, and he said, automatically, I’m fine. 

I tilted my head and said “Are you I’m fineing me?” (What is it about a head tilt that gets the truth out of people??)

“Yes”

“Do you want to talk about it?”

“Yes please”

15 minutes later, he feels heard and safe, I’m not burdened. Certainly not as much as I would be if he needed to take time off in the future for stress/addiction/post MI. Easy peasy lemon squeezy. 

This is a culture we can create folks. Any other ways you can think of making it happen?

Can we talk about the medical blues?

I mean when someone who is normally light and rainbowy starts to see the evil everywhere. When the world that medical peeps are in makes clouds drop over everything good in this world. When the dismal fog makes suicide seem like a legit answer when the question is “why am I getting out of bed for this?” 

(skip to the bottom for lessons learned if you want - I get pretty wordy here)

Before I decided to go to med school I worked in a copy shop. One of our regular clients was a family doc who made me laugh. He was awesome. He went above and beyond for his patients, making great learning tools on his own time. He was also a coroner in the area. When his assistant picked up orders, she confessed that she was worried about how much he was working and how much he put into his practice.

I began to notice that he often smelled of whiskey at 08:00. He was in a car accident a year after I met him that took his life. I can’t say for sure that it was suicide, but there weren’t any tire marks from brakes. His EtOH level wasn’t released so I can’t comment on that. It’s possible that he just fell asleep, but something in my gut told me it was a purposeful death. 

This is my story of fighting against the dark and twisties and almost failing. 

Flash forward to me getting into med school. Oh happy day! I cried happy tears all day. I’m an emotional person who feels all her feelings on the outside. This is me. That’s not going to change. When I went to see my family doc to get immunizations all up to date, I told her I was worried about my emotions. She told me to never disclose that I have a mental illness and suggested that I read Iron Doc by Mamta Gautum. She also told me I was going to be a great doc. 

I entered med school with eyes wide open. There are dark and twisty places in medicine and I needed to make sure that I was safe from. I read about how to stay sane in medicine from Mamta’s book, but then quickly stopped that practice because who the hell has time for exercise, hanging with family, etc. when you have a firehose of information coming at you? The one thing I did do consistently was blog about my thoughts about medical culture and my place in it. That blog was both a harsh reality for me and a way to express my gratitude for being allowed to be a medical learner, and then a physician. 

Residency was hard on me. I was an older than average, fat learner who did not fit the approved ideals of how a learner should look. I was either treated as a moron or as someone who was capable of doing everything without any guidance. There was rarely any in between.

 I became afraid to ask for help because when I did, well, badness. As a people pleaser, I worked harder and harder trying to get to the point where I would be seen as a good doctor. This was a futile mission, and I would likely see that now, but then, entrenched in those emotions of inadequacy it was impossible to recognize that I was surrounded by idiots. It must be my fault. 

I started taking SSRIs to deal with the sometimes crippling anxiety and depression. I had a hard time getting out of bed. My new family doctor suggested a leave of absence to give myself time to recover, but the thought of my previous doc saying to never admit I have mental illness rang in my head. As tempting as a medical leave was I refused to do it. Looking back, I’m not sure it would have helped. I was lying to everyone about how hard things were. I didn’t tell anyone that I was fantasizing about suicide. I was increasing my SSRI dose then telling my doc about it later. I was in hard core denial. I would likely have just spent the time beating myself up for not being strong enough to follow the program, and for letting down my husband who had been footing all my education bills for the past 10 years. 

Between residency and practice I took a few months off. I blamed it on my papers not being ready, but the truth was, I wasn’t ready. All I did was watch TV and sleep. I was not recovering my strength at all. 

I knew I needed to get a therapist if I was going to be a doc that my patients could rely on. Knowing that 1300 people needed me to be strong is what finally got me to the point of going for help.

How stupid is that?

I could have been a stronger learner the whole way through, but I had too much to prove as an outsider to medical culture. My discussion about being an outsider to a culture of privilege as well will come another day. 

The stress that I was under during my first years of practice was intense. I was diagnosing cancers almost daily. I was working 85 hours a week. Locums that took care of my patients refused to come back because they were too complicated. When I went to my colleagues and supposed mentor for help, I was told this is just how it is. That once I learned to stop being so nice, and stop caring about my patients everything would be better. 

I never want to stop caring about my patients. When I am no longer passionate about medicine and about keeping my patients well, it’s time for me to find another job. 

I lost a patient my age to malnutrition. 

Fuck. How the fuck does that even happen in the 2010s??? 

She had an opioid issue that I frankly hadn’t had time to address. She also had so many social determinant concerns that I was often at a loss at where to begin, but she also wouldn’t let me help. So there’s that. I will work as hard as my patients will to keep them healthy. If they’re not ready to work at it though, I will wait until they are. 

Other patients lost their family to suicide or homicide. Children died. I kept diagnosing cancers, many terminal. Patients went back to jail. They cheated on each other. They hit their partners and their children. So many kids were raped. OMG so many…

Stress piled up, so did paper work, and I missed a new cancer in a patient. He’s fine, all’s well, he kicked me in the ass to take a vacation. (btw, when patients are telling you to take a break, take a break.) On this vacation, the thought of having to go back to this practice with those colleagues was too much. I had a plan to kill myself while I was away. 

A plan. WTF???

Medical professionals know too much. We can make a plan that will make it seem like an accident, and we know that our colleagues in the coroners office are often implicit in this plan. No one is allowed to know how hard it is to be a doctor sometimes. It was a good plan. Murder mystery of the week quality. 

It scared me. 

When I got back, I called the physician health program in my province and went to see a psychiatrist. I quit my practice and am somewhere that respects physicians (and nurses, and social workers, and rec therapists - is this heaven???) I am significantly more balanced, but am not even close to being the person I used to be. 

Lessons learned

1. I am allowed to feel my emotions - they make me into a better doctor who will learn more from her patients.

2. EVERYONE in medical practice needs a therapist. None of us think we do. We have ZERO perspective on this. 

3. When your family and docs are telling you to take a break, asking if things are wrong, take a step back. Something is screwy. 

4. Things in our personal life are the first to go. I stopped crocheting and making Sunday dinners for friends. It might be running, clubbing, walking the dog. 

5. The last thing to go is our capability at the office. This is when alarms had better be flashing in your brain. When you can’t hold your shit together at the office, you need a vacation, you need help. Ask for it. If your colleagues are useless tools, ask outside your group. 

6. Lots of med peeps turn to substances for help. Alcohol, morphine, fentanyl. If you NEED a drink when you get home from work, or are considering diverting to enjoy a fix, please get help. 

7. There are some fantastic resources available to med peeps if you ask for them.

8. There is a MONSTEROUS stigma around needing mental help in our profession. I am still not allowed to say I suffer from anxiety on my college app in case I get denied. Colleagues act like illness is a weakness (even cancer, that’s another story, not mine, but really eye opening). Find better colleagues. They don’t all suck. 

9. I am the hugest proponent for mental health for health professionals, but I am still only confessing this in an anonymous blog. Our culture needs a huge change. My side blog >fckya professionalism focuses more on self care since I think that self care should be honoured as professionalism more than not being drunk in public. 

10. Even the strongest, most go - to person you know may be suffering. When I told my colleagues I was fantasizing about suicide, they thought I was joking because I was such a strong person. 

This was hard to write, but I need to let others who were in similar situations know it gets better. I don’t want to lose more colleagues to suicide. 

"How are you able to continue working after witnessing a death like that?"

I had a great question from a very insightful medical student after the first case of our day was to Code Blue that did not get any better. The code was on a young patient in my primary care. She was very unwell, and I'm sure nothing would that have changed the outcome. Tragic, true, circle of life type stuff. 

Initially, I felt really upset with myself. How could I just move on? I know this woman and her family quite well. Should not I be more upset with what just happened?

With every death, every code, I ask my team to do a quick debrief with me (longer if needed) to ensure that we did all that we could, and needed to do. I go over everything in my head as well. Where could I improve next time? Were we all wearing PPE? Did I speak with the family in a respectful, clear manner ?

This time around, the police were with us. We're a small town, so all tragedies involve them. It's great, because they call victim services if needed, get in contact with distant relatives, chase after teens who "can not take it" and run off. They are a really good bunch. They surrounded me and checked in on how I was doing. Asking if I would talk to someone if things went poorly. I am telling me I was a rock star in the trauma bay, That the family completely trusted me and was incredibly relieved to know that I would be the one working on their loved one. Basically making sure I do not get PTSD from the event - something I try to do for them all the time but was not used to having it in return. 

I was a bit upset, but felt like I was not upset enough. That I was a big faker pretending to care. 

It was not until yesterday that I was able to figure out why it is that I can just pick up and go on. This was the third patient that description fit that died in front of me this year that I was able to continue working after their pronouncement. 

I have a therapist. Everyone should. She helps me figure out things like this that niggle in the back of my head but that I do not take the time to work through. She helps me figure out when the culture of medicine is nutso and I'm right to ignore the culture and do what is right. 

Here is the answer, finally, med student of mine. I have an incredible resilience built around patient deaths. 

When I first got into med school, I knew that someone like me with a soft hear t might have a hard time with death so I sought out situations where I would be challenged. I thought about each deat h as an unavoidable event and looked for the way that I could make it the MOST comfortable for the patient and their family and (even when the patient is a baby). I learned that I could cry with family in a respectful manner. 

Each of those links is a blog post I've done during my training and practice to reflect on death and my part in it. I see myself as separate from the patient and their family. I love them in a way that is not family or friend, but caregiver. My role in their life is just a step in their journey through this world. They hold the same role in mine. While our lives intersect, my goal is to make our lives both better for the experience. I learn my lesson, then a go to intersect with another life. The lessons I've learned stay with me forever, but they are not necessarily emotional. 

Sometimes they are. A patient died of malnutrition at a young age, and you bet your ass I got angry and looked to make change. But, because I want the rest of my patients to be healthy, because i was not dwelling on his passing. 

So, my thought process goes like this; reflect on the death changeable and my role in it, reflect on the interaction with family and colleagues, move on to the next patient who needs to see me. This might happen many times during the day following that death. I still wonder if I could have done more for my patient before she died, but that use as a way to be a better doctor, not to dwell on the past. 

Death is part of life. My job is to keep moving forward. I see my getting back to work and helping other people as a way of respecting my patients' lessons to me. 

Pregnancy in Medical School

"Remember people, well except medical students, typically reproduce before the age of 30."

MD, cardiologist

(via coffeemuggermd)

I’ve had this in my drafts for a while. It still pisses me off a bit. Not that it necessarily should, the cardiologist isn’t saying that no med students have kids before 30 but it’s atypical. 

What pisses me off, is that those who recognize that their life starts NOW, not after residency, or fellowship, or any other magical time, and want to have children are treated as wackos by most of our community. I know I rail on about medical culture and why it is not reflective of reality, but I’m going to do it again. This is another example of thinking that we need to change. 

There is research on just about everything that med students do. You’re the easiest population for medical researchers to bug, so they do.

However, I can’t find much research on being a parent in medical school.  This focuses on mothers (wall free article). It’s the only paper I could find (lots for residents by the way, probably because they are also leading a lot of the research). A lot of the young women I’ve spoken with felt they were treated poorly by the fellow students because they were getting “so many” allowances for time. The new dads in my class felt like they were expected to carry on as if there wasn’t a new sprog at home.  

Back to the paper, “Medical School-Mothers” in the Rhode Island Medical Journal. I’ve never heard of this paper, or this journal and I’m pretty damn excited about all things undergrad medical education and feminism. That’s disappointing. (Have you heard of it and I was just under a rock?)

They don’t tell us how many medical students were interviewed. I want to know what several means - is it 4? Is it 34? Help a sister in research out.

They also don’t discuss fathers. I get that women in medicine is new and all, but I want my colleagues to be good dads. I don’t want any of my colleagues to be fondly remembered by their grandchildren because their own children never saw them. 

“As part of universal precautions, all female medical students who are sexually active with men should be mindful of potential pregnancy.” BARF. Shouldn’t our male medical colleagues also be mindful? This reminds me of the episode in 2014 where a female medical student was at risk of losing her funding to study in Cuba because she “fell pregnant”, while her XY partner was not reprimanded. BARF I say. IUSs, condoms, and access to family doctors for all med students who want them!!

This article is mostly focused on what Student Affairs type people need to know (which is fantastic). 

But. 

What I would like to see is something that talks to many more students to provide curious students with help making decisions, something that gets more into the pros and cons of an educated choice. No one knows when the time is right to have children. Everyone has an opinion on it though. 

I’d also like to see a nation wide mentorship program - to be paired with an attending, hopefully in your chosen field, who also was a parent in med school. Knowing you have someone who has been there and survived. 

I’d like a handbook for parents in med school. Tips tricks and downfalls to avoid. I’d like this to be an open topic of discussion that starts in Year one. I want the parental leave policy to be pointed out to all students during orientation week. 

I want to know how much post partum depression and anxiety are present in the learners having children. We are all pretty crappy at taking care of our mental health, and how many of us have med studentitis? (Pregnant med studentitis is like that on freaking crack - everything that could possibly go wrong, will and you will blame yourself, even though you would tell your patients to think better of themselves. My friend had 10/10 stress through the last 4 months of her pregnancy. Uncool.) 

I want there to be scheduled check ins with Student Affairs during pregnancy and post partum to ensure this isn’t an issue. My suspicion is that the numbers of sufferers in the medical community are high. 

I want to get rid of the shame associated with wanting to be a good parent when you are ready to be one. Seriously. If we don’t stop acting like families in medicine are bizarre while we’re in first year medical school, how can we expect attendings to respect their colleagues and learners’ choices?

One of my colleagues is pregnant. I’m over the moon for her and her MD husband. The amount of stress they underwent preparing to tell the rest of the team about the (wanted, expected) pregnancy was overwhelming to ME. I’m not having a baby. Jeepers. They felt they needed to make it very clear that they do not want to stop practicing for more than 2 months each (like it’s not bad enough that they don’t get parental leave from our governing body). They were shamed into divulging the information much sooner than they wanted due to morning sickness. Our colleagues (all XY but me), have children with stay at home moms and incredibly twisted senses of what parenthood should look like with a physician parent. 

This has got to stop guys. We need to treat each other better and watch each others’ backs. 

What would you add to my list to make it happen?

Just get over it

During my first year of practice, I was told over and over again that I should "just get over it”, that things get better in 5 years, that what I was experiencing was normal.

 When I noticed that I was diagnosising at least 5 cases of cancer per week, I confessed to a friend that I was concerned and a bit freaked out. She told me to get over it. That's what family doctors see and do all day. (It's not, especially not in a small rural practice, but I guess surgical residency makes you cynical). I was also told by a colleague that I should expect lots of cancer in my first few years because I will be seeing people who haven't been reviewed in years. But then he walked away.

 I missed a few cancers because I was so far behind on my paper work. They came to light and the patients will survive despite me. This concerned the hell out of me. I asked for extra staff to help me stay on top. I was told to make my staff I already have work faster. My staff that is already overworked with the difficult set of patients we have. There are parables about beating overworked animals, I definitely wasn't going to add to my staff's excess burden.

 When I received my second death threat in 8 months, I told my colleagues. They laughed and told me that I was a real doctor now. (Apparently two of them had received one threat in the past 15 or so years. The rest had received nothing.)

 There was a tragic, horrible, incident on my watch. Then, my colleagues surrounded me and offered help. Looking back, I do wonder how much was because they were worried I'd get the yips and need to stop working the ER. They did do a good job though.

 Seeing patients with more mental health concerns than years in their lives, listening to stories of horrific childhood trauma, being manipulated by personality disorders and drug users was exhausting. When I brought it up I was told to fire these patients, to not ask them questions (I didn't, they offered me their horrific stories on their own), to not let them speak. This advice suggests that I completely ignore my values and put my license in jeopardy.

 I burned out very early in my first year of practice. Looking back, reflecting on the times I asked for help and the lack of actual help I received, it's fairly obvious to me why. I expected my fellow family physicians to care about people enough to care about me. Now I see that I was making a mistake. Everyone has been working for themselves and doing what they can to keep their heads above water, even my good friend. No one is able to help someone else when they aren't able to handle themselves. This is why I now have a therapist. It's also why every new doc needs a dedicated mentor. Someone who has time carved into their schedule just to help the new doc and answer all their questions, let them know what is reasonable and what is not. Knowing at least one person will listen and not tell you to just learn to deal with it is vital to keeping your new docs in practice.

Screw it

I’m just so tired of having to be persistently pleasant while at work, in the grocery store, on email. If I’m not, I’m seen as a bitch. Other (read male) physicians are allowed to be as moody, rude, blunt, cruel as they want to be. If I’m not smiling constantly and holding peoples’ hands I’m the bitchy doctor. 

Screw this. Screw gossipy nurses who still treat me like I’m not a physician. Screw the backwoods attitude that men are held to a lower standard and that women are supposed to be soft, pink, and fluffy 24/7. Screw “business feminists” who write crappy leadership literature that perpetuates these ideals. Screw jackass patients that don’t like hearing the truth. Screw the parts of my professional life that are unprofessional and make me lose my temper. 

Fluids are Magical

Everybody feels better after fluids. When I'm working ER I call them my fairy dust. Everyone who looks bad gets 'em. 

Kid who is pale and crying and sleepy? Enough Advil that she can latch and get all the breast milk needed to get her up and dancing. 

Lightheaded and falling down? Litre of saline and his blood pressure is stabilized and he's ready to go home. 

Head splitting in half, vomiting, pneumonia, and fever of almost 40'? 2 litres, some metoclopramide and she's ready to go home with antibiotics. 

And yet, I'm just starting to drink something myself 13 hours into my shift.