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.