Once More For Those In The Back: Choose Survival First
Just a quick direct post of the text from my article that I posted on my good friend, Kathy Tsapos Parmele's blog www.healthyworldhealthyself.com. In case, you know, you might have missed it. Also for those who hate clicking extra links.
Ok fellow healthcare folks, stop me if you’ve heard this one before: High school student commits to a life in medicine. He works his butt off, does all the right extracurriculars, gets the grades, and aces the exams. He goes to the right college, gets a safe science degree again with good grades and those “extras”. He goes to a “strong” med school, matches in a “strong” residency, maybe does a specialty fellowship. He practices for years. He even succeeds in treating countless others. After all of that, he starts to question if maybe that very first step might have been a mistake. “Oh shit” he says, realizing he’s dedicated so much of his life to the exclusion of all other personal growth. He feels like he doesn’t know how to do anything else. Know anyone like this?
Well then how about this: What identity does this person have if not a doctor? What if he has spent over half of his life getting to this point? What if during that quarter century he did this at the expense of pretty much anything else meaningful? Oh sure, maybe he has had some hobbies and side interests, maybe even showed some talent in those pursuits. But the only thing he has ever really done was be a doctor. It is the only thing he knows and certainly the only thing he can do to make a living. “Don’t quit your day job” he would say when doing any of his hobbies.
And that very same identity now weighs on his conscience. “I’m a doctor,” he says to convince himself to go to work each day. “I have patients who depend on me,” he says as he drives to the hospital. He says to himself there is no alternative, and that he chose this. But it’s no longer his voice that he hears. Rather, it is all of the people who have built up expectations about him. It’s what his med school professors would say. What his classmates, so many of whom are successful doctors, would say. What his residency attendings who spent so much time training him would say. It’s what his current colleagues would say. His partners. His nurses and staff. His patients. What his family would say. His spouse. Even his kids. “Dad, you told us always to keep fighting and never quit.”
Okay, maybe that last paragraph lost you a bit. So you’ll just have to imagine this person; or maybe you won’t? Just maybe you know someone like him. Originally he or she was fueled by a passion for a career that seemed the perfect goal. It was the perfect mix of knowledge, skill, compassion, caring, and yes, reward. But despite this idyllic calling, if it was not the right choice to begin with, what good is the ideal now?
Doctors burning out is not a new thing. You’re reading a blog about just that. We now recognize AND address burnout more, recognition alone being only as good as saying “Yes Mr. Smith you have cancer, have a nice day.” Recognition and treatment for Physician Depression has also gained ground, if only very gradually. Despite increased acceptance of mental disease in society, it always surprises me how so many doctors still feel a stigma exists around it. Even ones who prescribe antidepressants may be loathe to acknowledge a mental disorder in themselves. But here too, as they say, the first step to recovery is admitting the problem, blah, blah, blah.
That’s just it, though. Sometimes even addressing physician burnout/depression cannot generate a solution if the physician knows truly that this is simply the wrong career. Trapped by that sense of identity, they struggle with shame and guilt––and helplessness. Know any doctor who has the feeling of being a rodent trapped in a cage with only a hamster wheel in it? Without any other skills, if running in that hamster wheel is the only way to keep your house solvent, then run that wheel you must.
Okay, by now most of you have stopped saying “Hey, I know someone like that!” and instead realized that this is just an autobiographical rant. A pretty self-indulgent one at that. Sorry. But if this is a blog about the “healthy self” physician, then perhaps mine could be a cautionary tale. I could be the poster child for the Physician Wellness blog’s “What not to do”. I was that rodent in the cage. I was running the wheel until my body literally started to break. My mind had already broken long before that, I just couldn’t recognize it. Once I did, I still couldn’t admit that I had mental illness. And even when I did finally admit it, rather than try to treat it, I tried to analyze it. Was I depressed because I hated my job or did I hate my job because I was depressed? While I uselessly pondered this Chicken-or-Egg question, my depression grew to consume me. So much so, that one sunny Saturday as I rounded on patients in the hospital, I stared out of a patient’s window at our shiny new high rise medical office tower. I still have no idea what that patient was saying to me as my mind could only process one idea: throwing myself off the roof of that shiny new tower. In a near fugue state I left that room and walked toward the tower. Only a page from a nurse interrupted this reverie, and, as if nothing had passed, I altered my course and resumed rounding. That wasn’t the first time I’d resolved to end my life, nor was it even close to my worst moment, nor would it be my last.
This [www.healthyselfhealthyworld] is a blog about Physician Wellness. Its tagline includes “thrive” and “recover,” words that imply figuring out how to be a healthy doctor, body and soul. But the other words are “survive” and “share.” For now at least, I’ve learned how to survive. Some of that was a simple matter of a boatload of sertraline. But while medication has mostly backed me away from the literal ledge, I have still had to contend with constant self-loathing, self-criticism, and self-doubt. Therapy helps this. As does writing.
If you are anything like many a doc I know, you’ve had a voice inside that keeps you moving, keeps pushing you to strive harder, higher, and better than everyone else. It’s what got you into college, into medical school, into (and through) residency, and into practice. Well I have that voice too. Mine is a total asshole. Just a huge S.O.B. that is incapable of turning itself off. Ten months of therapy. Ten months to learn to recognize the voice for what it is (an asshole), to acknowledge it (oh hey, the asshole is doing that thing again), to counter it (hey asshole, at least I have done some good in the world), and sometimes to conquer it (shut up, asshole). But it will always be with me; it’s who I am. Surviving doesn’t mean winning every battle. Sometimes it means just coming through the other side alive. No one gets through unscathed, but getting through is what matters.
I quit medicine completely a little over six months ago. I had committed to leave medicine almost two years ago. The 18 month interval between was supposed to be spent figuring out my next step, my next career. Instead, I spent it just trying to survive. As I continued to work, I fought the demon telling me life was not worth living or that I was the cause of all of the problems my family and I faced. All the while I was an outwardly personable surgeon who maintained respectable productivity and of course had good outcomes. When the time came to finally put down the scalpel, I had no job prospects at all. Not a one. I had lined up no big career change, no change in practice or locale, not even any locum tenens jobs. My income went basically from surgeon’s salary to zero. I remain unemployed to this day.
Do I have answers? Do I have the key to wellness? Can I explain physician depression to you? Am I an expert on career change or physician burnout? Nope to all. So many have written more eloquently, more effectively, and more profoundly about suicide than I ever will. So I’m not much help there either. And I have no illusion that my case is a universal one with which you all can relate. All I can say is this: survive first, figure out everything else later, one day at a time. But survive first. To do that we need to recognize, then address. And sometimes to address the problem we need to make the impossible choices. Turns out, survival makes the impossible possible or at least a hell of a lot less permanent than the alternative.