Author: loneroo

Burn out

Posted on by loneroo

We are almost sort of not quite half-way through the year. It’s about the time that the new-feels excitement wears off and the next opportunity might feel far too far away. It’s also a time when people (you!) might be re-assessing your career path as job applications loom in the coming months.

Why did you get into medicine? Were you a post-doctoral cancer researcher looking for coal-face interactions with patients rather than laboratory mice? Were you a fresh-faced teen choosing between law, accounting, medicine, and engineering? Were you driven by hopes of taking your love of science and turning it into a way to help people every day?

I personally have no grand story of being destined for medicine. In fact, I distinctly remember a walk between classes in high school as my friends asked if I had ever considered medicine. “Ick,” I told them, “blood is so gross. I wouldn’t want to get dirty.” Several years later, walking to the train station with one of my best friends, she asked if I had ever considered surgery. “No! And if I ever do, could you please hit me over the head with a saucepan to knock me back into my senses!” I responded. It turns out people, and minds, change.

A lot of us, at our roots, love solving problems. We see patients come in with chest pain and know to do an ECG, a chest X-ray, and some blood tests. We know which questions to ask of patients with lower abdominal pain to break down the differentials to general surgery, urology, gynaecology or gastroenterology. We are trained to follow protocols, though they may differ slightly across hospitals, that have the same basic tenets.

The problem, of course, is that patients are not complex mathematical problems. Applying the answer of chest X-ray, two sets of blood cultures, a sputum culture, nasal swabs and empiric antibiotics to the patient with likely pneumonia does not help that person deal with the scary reality that they are in fact a mere mortal. It doesn’t help us explain in simple terms what is happening. And much of our medical training does not prepare us for the patients who flatly refuse our management guidelines. We are in the wilderness with patients who wish to tailor their own care. That is, in spite of all the buzz in the media about precision- and patient-centred medicine.

Instead of working through these issues with patients, it can often feel like an “us” against “them” situation. The patient just doesn’t “understand” what is best for them. As if we are their parents and they are an ill-informed child to be protected from themselves. The system doesn’t give us time to have the conversations that matter – conversations about the patient’s health-care views, or their previous frightening experiences in hospital, or the fact that their cat is unwell and the patient cannot fathom being separated from their most special friend (it’s incredible how many people have discharged against medical advice because of their pets, until you consider what you would do with your own pet in the same situation). And some people, despite all of your wisdom and many years of experience, just don’t want whatever it is you have to offer.

To make matters worse, for all the time we spend at work, the time spent with each patient is in the minutes. Probably in as many minutes as can be counted on one hand. Patients wait all day to talk to us, only to forget their most pertinent question when we arrive. And we feel pressured to get back to the computer, where we can assess and treat the patient as if they are a puzzle rather than a human with an entire life story. If the observations go this direction and the imaging looks like this, and the bloods look like that then we do this other thing… And often forget to communicate these changes with the patient and their family.

Above and beyond this, there appear to be growing numbers of checklists, electronic notes to write, and administrative tasks that are miles away from actual patient care but constantly divert attention and time from patients. The reasons for exhaustion make us all sound like broken records – the patients are sicker, more complicated, and living longer in a hospital system that can provide more care at more expense and with greater time required, with minimal growth in the number of people to provide that care. We give time and energy because it pains us to see our patients and colleagues suffer.

How many sporting activities, family dinners, study dates, or other personal pleasures (yes, I did just lump studying in with personal pleasures) have you given up because you got stuck at work a few hours late (again)? And how do you calculate the (recurrent) sacrifices compared to the suffering of each of your patients? And because there is no replacement-you to take over when 5pm comes around (or 7am, or…), you stay because there is a need. Walk outs and sit-ins are not options when lives are on the line.

So why did you decide to do this? And how can you make your daily life look more like the world of which you dreamed? If there was one small thing you could do to make this week better, what would it be? A reasonable night’s sleep? A more collaborative work environment? A lunch break? What small thing can you do to help make the coming work week seem that little bit easier? Because planning a holiday and going to see a movie on your day off won’t change the root cause of your fatigue.

If you’re looking for other reads on the topic, check out this recent article from the NY Times.

And if you’re feeling tired and burnt out, here are some resources for you:

Let us know if you have other burn out guides or suggestions. We would love to support you and hear your stories.

 

How could a doctor get sick? Eric’s journey with CML

Posted on by loneroo

The benign symptoms

Unintentional weight loss, weeks of night sweats, sharp decline in exercise tolerance. If a patient told you that they had this, you would most likely urge them to seek investigations to exclude the scary thing that starts with C.

The exception to this of course is if you are treating yourself, and then the differentials list quickly changes. The top differential is missed lunches, followed by lack of gym, normal aging or a broken scale. And of course, stress from preparing for the most intense exam of your life must be considered. After all, how could a doctor get sick?

Unfortunately, that was me. I had those symptoms for weeks without thinking once that maybe I should go see a doctor. It wasn’t until developing persistent chest pain which finally made it difficult for me to find a benign explanation. Admittedly, I did tolerate it for a week, thinking it must be of a musculoskeletal origin stemming from a recent chest workout at the gym. It was not until my significant other became concerned that she wasn’t strong enough to perform CPR on me that I finally went to see a GP.

The GP I saw I must say was brilliant, and while the initial diagnosis was pericarditis and even costochondritis, she was sufficiently and genuinely worried that she performed a set of routine blood tests.

The bad news

“You have to come back to the clinic today so we can talk about your results, and I think you should bring family or a friend with you”

Two days later the GP called with this.

It was not difficult to think of the worst case, and the most likely scenario. How can one be so certain of a serious medical condition from a routine blood test. But I tried not to think about it. The wait until the appointment was certainly uneasy, everything started to feel more real. Maybe it’s because everything else I had in mind like the upcoming exams, starting a week of night shifts, how to get the next trainee job, all of this didn’t seem to matter anymore. It was just me, my surroundings, and the bad news to come.

After a few hours wait I was in front of the GP. Very empathetically she started the consultation with,

“I know you came in two days ago for chest pain, but we have the results and it is not something we expected”

Knowing I could comprehend the results, she handed me a printout of my haematology results – WCC 265. Hb 87. Plt 560. “Marked leukaemoid leucocytosis suggestive of Chronic Myeloid Leukaemia”

Well, at least my cholesterol and BSLs were within normal range.

“Phew, at least it is treatable” was my first response. At the same time, a part of me was actually amused by these results, particularly at the amazing white cell count. That was probably what my doctor brain was speaking, not connecting with the fact that these were my results.

After being hospitalised, there was plenty of activity (hours of leukapheresis, driving around to attend investigations and appointments, and the countless visit from colleagues and friends which I am eternally grateful for) over the next couple of days to keep me from truly absorbing the reality of my condition.

The gravity of the situation did not actually hit me until a few days after the diagnosis. This was facilitated by a colleague, friend and one of my treating doctors who probably thought I was going through a doctor’s version of denial.

“Has it sunk in yet?” He said.

I felt I skipped most of the bargaining phase straight to depression. It was also difficult to direct any anger at anyone, except myself for ignoring previous parental advice for me to go see a GP for my weight loss. But ultimately none of these thoughts made sense. All that was left was for me to face the diagnosis and all its possible outcomes.

There were certainly tears, severe lethargy, lack of motivation, low appetite and difficulty enjoying certain activities (e.g. Netflix). Navigating through this depressed mood required the usual humanly strategies, such as philosophy, religion, friends and family.

“Try to be a patient, and stay away from uptodate and do not access your own results” was previously advised by the GP.

Despite this warning, I mostly sought solace in Pubmed and Medline. I probably spent the next two weeks looking into all the landmark trials, including the subanalyses of those patients in my age group and ethnic background. I finally understood why it’s important to apply research to the individual patient in front of you.

The ability to understand my disease and its treatment was probably a gift and a curse. It was difficult not to “over research”, particularly the worst case scenarios and the concerning case reports. I could not appreciate the reassurance offered by my treating team as I became aware of all other possibilities. Many times I challenged my team regarding whether I truly only had a mildly enlarged spleen (surely, I must have significant splenomegaly!). A Basic Physician Trainee, two Advanced Trainees, and the consultant’s correlating finding did not settle my concern.

After a period of time dealing with it did get easier, especially when I got out of the hospital. I started to get out of the house, walk the dog, see friends and family, and eventually went back to work. There were many hurdles preventing me from getting back to normal, especially the loss of confidence, confused identity (am I a doctor or a patient?), and having to make plans around medical appointments, but it eventually all worked out. Maybe that journey is a story for another time.

But so far, it has been exactly a year. I have survived, and I am well. While what I have cannot be cured in the traditional sense, I feel almost normal. I have my significant other, family and friends to thank for being there for me. Real support is not something I experienced until I truly needed it and it felt amazing. I guess you never really appreciate the pillars of your life until the roof over you is threatened to come crashing down. So, make sure you know what your pillars are and keep them strong around you.

Concluding thoughts

Thanks for reading up to here. You might as well hear what lessons I have to share from this experience, so here they are.

First, it is difficult to look after yourself as a doctor. The crazy overtime and expectation to study/do extracurricular activities make a strong deterrent for going to see the GP. Additionally, it is not easy to find a GP you can trust and regularly access. That is why I suggest finding and establishing a relationship with a GP you can call by their first name, know when they work, and what sort of dog they have at home. Go see them annually and do this before you get seriously sick.

Second, do not self-diagnose. We all know the mantra taught in medical school that you should never be your own doctor, but I realise now that you do this subconsciously. Ultimately this can be solved by seeing a doctor regularly which may be difficult due to the points above. I think another way around this is regularly voicing your own symptoms or medical concerns to non-medical friends and family. Then take their concerns seriously, and do not personally analyse it further.

Third, ambition has a cost. I am not advocating for people to not be ambitious. I was ambitious, and I do hope I can find that ambition again over time. But know that every inch you gain achieving your goal comes with a cost. Maybe that cost is spending time with family, doing a hobby you once had and enjoy unreservedly, or your health. The important thing is be aware of what you are sacrificing and be ready to not regret it later. You may do this by periodically writing down what you are sacrificing because it is not easy to recognise.

A few words on how you can help

Register Your Bone Marrow

For many people with haematological conditions, there is no breakthrough medications, or they fail to work. The only hope of long-term survival is an allogeneic bone marrow transplant. For many people without siblings or those with matching genetics, they rely on having a match from someone unrelated. Your registration increases the chance someone out there in the world of having a second chance in life. To register check this out:

https://www.donateblood.com.au/learn/bone-marrow-donation

Do this and I will treat you to a coffee (at where I work of course).

You are never alone

You are never alone

Posted on by loneroo

Surrounded by my colleagues at ANZAN, I immediately felt overwhelmed. Look at all of these doctors, young and old, chatting cheerfully, laughing and acting like Neurology is the passion of their life. Tired, burnt out and struggling to imagine myself as a neurologist, or as anything really, and following an election that left me gutted, I couldn’t bring myself up to chatting with influential Professors with my “good behaviour” on.

We all put on a facade at work, which we think others want to see. A facade of energy, enthusiasm and competence. For some this comes naturally, for others sometimes or always, this is an immense struggle. Paradoxically, this facade makes it harder for doctors, who struggle, to seek help. Conversations around mental illness and burn out occurred despite the underlying culture of fear that admitting to these struggles would be used against you. We put up with bullying and at times, inhumane conditions for a career. How hard it must be for those of us who work this hard for so long, then turn around and walk away?

Talking to friends away from the bright lights of sponsorship stalls showed me that many of us struggle silently. Many of my friends admit burn out. Others had periods in their career where they considered quitting and becoming something else altogether! An anthropologist! A model! An artist! The statistics show that this is common. The growth of sites like Creative Careers in Medicine, show that there are many of us who leave the well trodden path. We are discouraged from taking gap years, yet more and more of us take them and I haven’t yet heard someone come back regretting it. (Of course, many of us have responsibilities and cannot do this).

If you feel alone, please reach out.

Find a friend away from the bright lights and sycophancy. Sometimes official supervisors are less than helpful. If so, find someone you relate to. If the rise of unwieldy facebook groups has taught me anything, it is that there are such a wide variety of doctors and people out there.

In the words of Florence Welch, in trying times, we must “hold onto each other”.