Self-Doubt

My mind has been all over the place, going around and around about whether taking a leave was the right thing to do, for weeks or maybe even months I guess. Yesterday was my second workday off. I meditated, chose a challenging 50 minute yoga practice, cleaned another trouble zone of the house, took a walk, did a little knitting. I was feeling good - this is exactly what I needed - some time just to be by myself without people asking me to do things every 30 seconds. I felt in control and at peace. I reflected that it is a measure of my degree of burnout that whenever someone asks me to do something now it feels like a punch in the gut. It is not unreasonable for me to need to do things for people. I appreciate that this is my job. Somehow I got to the point where I have no reserve left, and even things that should be simple became almost impossible.

This time is sort of like the vacation I have needed but haven’t been able to take, literally and figuratively. When I am on vacation with my family, it’s great that I don’t have the responsibility of work, but instead I have responsibility to my kids and spouse. I have wanted time to myself so badly that I found myself becoming resentful of what they ask of me. It isn’t the way I want to be. Also, our office has been struggling to maintain adequate provider staffing. My “week off” between Christmas and New Year’s was already shortened by a working weekend at the end, then I added in a full day of patients to help cover for other providers’ absences. I asked for the April vacation week off, and was allowed to take Tuesday through Thursday, but not Monday or Friday, because that would have reduced the office staffing too much. This relentless and bottomless need takes a toll.

Everyone I know seems to be working harder than ever, with more and more constant demands, yet they are completing what is asked of them, even if there are many other things they'd rather be doing. Is there something wrong with me that I can’t get my work done and maintain focus without breaking down? I mean, something other than burnout? Maybe I shouldn’t be a doctor, if I can’t handle the administrative work that goes along with it. It has been pointed out to me that it isn’t the tasks themselves that I can’t handle, but the volume. This is true, but what is the solution? What makes the volume of administrative tasks go down? Being responsible for fewer patients, I suppose, but which ones get asked to see a different provider? Also, there will be a financial impact on our family if I reduce clinical time, both in decreased salary as well as a smaller subsidy for our benefits. I could also take on fewer nonclinical responsibilities, but so much of that is why I want to practice at an academic center: the opportunity to teach and to take advantage of learning collaborations.

I'm struggling a lot with the idea of what is fair and what is luxury. Why do I get to just say, "that's it, I'm done, good luck" and step into a leave with no warning and no obvious endpoint? My colleagues are all suffering in the same way, dealing with the same stuff. I think they are, anyway. If they aren't, then either there is something different about the tasks that are sent to me, or something different about how I react to them. I'm trying to figure out what those differences might be because that is how I'll be able to get back to work, by correcting or modifying one of those things or another. We all have this same short-term disability policy that allows us to take up to 6 months off. By taking advantage of this, I have made the work harder for the rest of the providers at my office, which puts them at increased risk of burnout. And what about all the other people in the world who are struggling so much to get by, with not enough money, or not enough support for raising their children? They don't get to just turn off the world and take a break. Why do I deserve to have this time?

I opened the email app on my phone yesterday, which contains both my personal and work email, as well as my calendar. I continue to get messages specifically for me, asking me to do something or other by next week. As soon as someone enters my address into the "To:" line, a warning pops up displaying my out of office message. Everyone should be able to see that I am on medical leave before the message is even sent. Maybe I need to change my OOO message to say "I am on medical leave due to burnout and am unable to respond to any administrative or clinical requests." Then I get mad, because why is that necessary? I am trying to not look at my email and not respond because if I continue to respond to things, then it sends the message that I'm actually available. And the whole point of this leave is that I'm NOT actually available. I guess I have to imagine that I had a heart attack or something and really not let myself do things. I'm having trouble figuring out where the line is. In the meantime, things keep coming in, and one thing I really need to do is delete the thousands of emails sitting in my account, many unread.

Another thing I'm trying to balance is what I'm teaching my sons. They both want to stop doing things when they get hard. They look at a math problem, say they can't do it, and flounce into a chair. This is not the work ethic I want to instill in them and I try and try to encourage them to look at problems from different directions before giving up. When I look at my leave from the perspective of a 10 or 12 year old boy, I wonder if it looks to them like deciding a problem is too hard and giving up. I don't believe that is actually what they think - the message I've gotten from them so far was really mature, that they are sorry things got so hard for me and glad I'll be home more. But this voice in my brain wonders if I should have kept pushing, to show them how important it is. Again, though, they really have no way of seeing what exactly I was pushing through. They just saw me coming home late, tired, not wanting to engage with them - and that isn't what I want either.

This morning, Thing 2 announced that he didn't think he could go to school. The assessment from his parents - one a family doctor and the other also an allergy sufferer - is that this was nasal congestion due to plants waking up in the spring. One does not stay home from school for allergic rhinitis. It was not that simple, however. He is physically unable to blow his nose so he swallows mucus, and had a stomachache. I gave him medicine, tried to get him to breathe in some steam (he proclaimed that this hurt too much), and lay him on his stomach and rubbed his back to see if his nose would clear. Finally I told him he had to go to school, and he proclaimed, "I'M NOT GOING." He was less than pleased when he heard that this meant I'd be taking him for an acute visit at our family doctor's office, and that we'd better have tried everything we had available, which meant I was giving him some Flonase. He submitted to this harsh treatment and then was ready for breakfast - ate an English muffin and 3 pieces of bacon. This is leaving me again questioning all of my decisions. He's not really sick as far as I can tell, so he should go to school. He says he couldn't concentrate yesterday because of his nose, so he shouldn't go. He might be pushing the line to try to get some time with me, and I shouldn't give in to that, so he should go. My work has been hard on all of us, and he really probably needs more mommy time, so he shouldn't go. Bottom line is that he's staying home, I canceled my plans to hike with a friend this afternoon, I'm taking him to see the NP, we'll have some time together, he'll go to school tomorrow, and it will be okay.

I'll need to reread this later and try to break some of it down, explore it more. There's so much rolling around in my head. Right now, though, I need to make my smoothie and squeeze in a little yoga before taking Thing 2 to his visit. The robins and blackbirds are singing their joy at the changing seasons while snow falls from the sky - springtime in Vermont.

Irony or Inevitable Consequence?

2017 was, objectively, the best year of my career to date. I was promoted to Associate Professor and the residents voted me Teacher of the Year. I put together a two day conference on integrating behavioral health and primary care. In the fall, I learned that I was chosen to be one of the FACES of our medical center. I also received a large grant to fund our new educational and clinical program that will integrate reproductive health care into our primary care office, a project I have been working toward for years.

Today I started a medical leave to recover from burnout.

I am a dedicated, hardworking, intelligent, caring, empathic person. This makes me a great family doctor. It also means that I have poured everything I have into my work. If something comes to me that needs to be done, and I know that I could do it and it would be helpful for someone, I want to do it. I have done a lot of good for a lot of my patients, and also for the residents and medical students I have taught. I have great working relationships with colleagues in my department and across the medical center. The practice of medicine energizes me. I can come home every day and know that at least one thing I did made a difference for someone.

BUT! In between the office visits and the professional conversations and the teaching, I am haunted by the other, hidden work of medicine. People call or send an electronic message to ask questions or to get medications renewed, and much of this can't be managed by front office or nursing staff, and comes to me for review and advice. Every test I order means a result comes to me, and someone wants to know that result. If my patient sees a specialist or goes to the emergency room or is admitted to the hospital, I get copies of the notes and results from those visits, sometimes in duplicate. Some of these include important information I need to follow-up on or tests I should order, so I need to look at them carefully. If someone on blood thinners is going to have a dental procedure, the dentist's office calls to ask me what to do to prevent bleeding. All of this and more comes into my InBasket in the electronic health record. I try to address it during my administrative time, but those hours get broken up by meetings and errands. When I'm seeing patients, I am present in the office so in theory I could respond quickly, but my focus is on the people who were scheduled for visits. When I finish with one the next is waiting to be seen, and I don't want to extend their wait longer than I have to. Then I open the InBasket at the end of the day and am confronted with all the things people wanted me to do that I didn't do. Sometimes they have called back several times asking why I haven't done whatever it was yet. No matter which task I choose to address, I didn't look at something else that was important to a different person.

I am a good doctor, a great doctor, yet every day I feel like a failure.

I've been trying different strategies to manage this work over the last several years. I use timed periods of work followed by timed periods of rest, or I set an intention for which folder I will clear out. I have been able to keep on top of things for a period of time, then I spend a week working 70 to 90 hours as the supervising physician in the hospital, and the outpatient work is neglected. Often I would just about have caught back up when my next hospital week came around again. I increased the frequency of visits with my therapist, and started seeing my psychiatrist more regularly. We adjusted medications, adding a stimulant to improve concentration (though I never met criteria for attention deficit disorder before my 40s) and a benzodiazepine to manage my near constant anxiety. I appreciate the value of these classes of medicine but I have seen them cause so many problems in my patients that I was hesitant to take the prescribed dose and took half of each pill, first just when I thought it would be most useful, then every Monday through Friday. Each day, I swallowed my stimulant and my anxiolytic with the same swig of water and wondered what I was doing.

I worked hard to maximize self-care. Since January 4, 2018, there have been four days when I did not meditate. Two were because I was delivering babies, one was the day I got a new phone and couldn't access the app, and the fourth I sat down to my practice at 11:47 pm and when I finished realized I'd chosen a 15 minute session instead of the usual 10-12, so it counted for the following day. I found ways to exercise almost every day, even if only for 10-15 minutes. I chose to prioritize going to bed over getting more work done. I found my mental clarity improved dramatically, at least when I was face to face with patients. I was better able to appreciate what they were telling me even while typing the narrative, and felt at the top of my game when we talked together about what might be causing their symptoms, and how we should proceed. At the same time, the administrative work felt harder and harder. My brain would jump to anything other than the InBasket tasks in front of me. Email became completely impossible - I couldn't even justify the time to delete the garbage that comes in every day, because if I was going to be sitting at the computer I needed to be responding to the things that my patients needed, but my brain just wouldn't do it.

I had this experience to a certain extent during my second year of medical school. In college, I could study for hours at a time, and it was worth it, because the effort I put in resulted in measurable success. I scored 100% on organic chemistry tests, and at graduation my GPA was in the top 5 students in the College of Arts & Sciences. In medical school, my techniques no longer worked. It was no longer possible for me to achieve such a high level of mastery. I made it through, and felt a lot better once I was in the clinical years. I knew residency would be hard, and each rotation was a new challenge, but no matter how difficult it was, I knew that this would pass in a few weeks. I could do anything for a finite amount of time. Now, there is no final hurdle to overcome with a last big push. It feels like constant hurdles, one after the other or one on top of the other, and the strength of my pushes seems to be weakening.

In my 13 years of clinical practice, there have been a lot of different challenges, but I have always somehow turned it around. This time, it isn't getting better. My psychiatrist suggested a leave a month or two ago and it seemed ridiculous, impossible. Last week he mentioned it again, and coincidentally I was seeing my family doctor and my therapist the same week. I thought through the possibility of reducing work hours, but less clinical time would just leave me with more administrative time, which was the part that was making me crazy. I decided to meet with our medical group's physician relations specialist to review the specific things I was having trouble with, and found myself crying for most of our 90 minute meeting. When she told me the process of taking a leave, it seemed so simple, and it just felt obvious that I needed to proceed.

I did not and do not like the idea of burdening my practice partners and our office staff with the additional work of caring for my patients. I have always been able to do whatever needed to be done - but I guess it's true that we all have a limit. I'm hoping to make good use of a couple months without clinical or teaching responsibilities. Maybe writing about it will help me recover. In the meantime, I have to find a safe place for this little beast, because eventually I'll need to turn it on again.