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Working In Medicine–How I Learned to Ignore My Health

“Learning to treat ourselves lovingly may at first feel like a dangerous experiment”—
Sharon Salzberg

 

This begins a three part series about working in medicine, how we have a hard time taking good care of ourselves, and what happens when we don’t. 

“I don’t think you should go back to work. Being on your feet all day could cause this to happen again. What would you do if a sick child came in at the same time you started bleeding? No one wants to make that decision.”

This is the conversation I had last week with one of the doctors that was taking care of me after I was admitted to the hospital for pre-term bleeding. I feel like I am repeating myself when I say, I was 30 weeks and had just finished a long shift in the ED when I started bleeding. Unfortunately, this is exactly what happened.

It was a very similar experience to the one I had during my last pregnancy. I was feeling good, I had no pain, but after working all day, I started to bleed. This time it was 3 am. I was getting ready for bed, and right before I left the bathroom, I felt liquid down my leg. I thought to myself, “please don’t be blood, please don’t be blood.” Then I turned on the light, and there were large red drops spattered on the tile.

There was no way I was waking my son up at 3 am to go to the hospital, so my husband stayed home, and I drove myself. After evaluation at our closest hospital, I was ambulanced to the tertiary care center—this time because my baby was only 30 weeks, last time it was because he was profoundly tachycardic. Thankfully I have had no additional bleeding and after 5 full days in the hospital, I was discharged with instructions to ‘take it easy, don’t go back to work, and if there is more bleeding,  we will keep you in the hospital until baby is big enough to come out. Also, if you bleed and don’t stop, we will deliver the baby.’

What has been so shocking to me is my reaction to this chain of events. I, like many of my colleagues, pride myself on my resilience. I am also proud of the amount of ‘grit’ I have developed throughout my career and my ability to “power through” challenging situations. I am a hard worker who is passionate and I truly love my job. I do not see myself as weak or incapable or often needing help.

But this, this was different.

The first night I was in the hospital, I thought, this is no big deal. We will be able to go home, I go back to my normal schedule, everything will continue as planned. I had developed an intricate, well thought-out work schedule to slowly decrease my clinical time as I got closer to delivery. This included me working close to resident hours during my second trimester to get all my clinical hours in. However, in the hospital, each day passed and every doctor that I saw (there was a different one every day) used increasingly urgent language to give their professional opinion and recommendations about my plan. They all recommended I didn’t go back. That was not the message I wanted to hear.

When the conversation was put in the context of my health vs. that of my patient’s health, I had a bit of an internal crises. I certainly hadn’t thought of it like that. Up until this point, I still was thinking about what I was comfortable with. About how I was going to communicate the fact that I would need to slow my life down a bit, how I was going to advocate for myself and how uncomfortable that made me.

The very thought of taking my health and well-being and putting it to the top of the list was agonizing. I struggled to sleep, and for the first two nights I woke up crying, thinking about how I would never forgive myself if something happened to the baby while working. These thoughts were juxtaposed with my compulsive feelings to finish what I started, to not ask for help, to ‘soldier on,’ as I was used to, as I was trained. It also was apparent to me that my personal self-worth was inextricably linked to my ability to perform my job.

These intense feelings have led me to consider their origin and to subsequently trace the trajectory. Somewhere in the medical school, residency, fellowship training and then as an attending I stopped caring about my own personal health. You hear this all the time. Doctors are very good at taking care of others, but few of us have regular doctor’s appointments, and few of us take our own health seriously.

Until we can’t ignore it anymore.

To be honest, I am not sure when it started. In my experience, in training, we are never told that it is ok to be sick or that it is ok to take a day off. Instead, the culture is one of reprimanding us and in combination with being judged for time away makes us never want to take time off, and also to be fearful of needing it.

As a medical student, this manifested itself as I worked through cough and cold season…priding myself on finding just the right combination of medications to get through the day without coughing on everyone or passing out, and doing it while not needing any additional rest.

In residency, I prided myself on my near perfect work schedule and never needing to call in sick. Co-residents who struggled with the schedule or with being pregnant during this time were labeled as ‘weak,’ and were whispered about behind their backs. During this same time, when I made a mistake and mis-scheduled my vacation time (as I have detailed before), the hard work and dedication to my job didn’t matter. I moved mountains to get my schedule covered, but my program director didn’t care, and I had to live with traveling across the country to see my family for a weekend instead of a week. I realized in this moment that my needs didn’t matter, my mental health didn’t matter, the job was more important.

When I got to fellowship, I do believe the system was more forgiving, but I had already learned some pretty significant behaviors about caring for myself. One early morning before a shift, I was vomiting, and came to work anyway. I continued to vomit every 30 minutes to an hour while on shift which I mitigated by getting IV fluids and anti-nausea medications from the nursing staff in the back between seeing patients. Eventually I was told to go home, but not before being admonished by the attending that was replacing me, she said she was having bad diarrhea, but “I guess I’ll come and replace you.” As if I was weak for leaving.

As an attending I had a miscarriage and an overwhelming feeling as though I couldn’t tell anyone. My D&C was scheduled on my day off, and my emotional recovery was put on the back-burner. I didn’t know how to prioritize my health and well-being. When my second miscarriage happened I used the only 24 hour period I had off consecutively to take misopristol, which induces bleeding. The next day I returned to work, still bleeding, still cramping, and emotionally numb.

When we are pregnant, however, we are no longer only in charge of our own health. We now have the health of the baby to think about as well. The problem is that this way of being feels so out of alignment with our core self that it feels wrong. I believe we can intellectually understand that slowing down or listening to our bodies will help the health of our baby, but it doesn’t translate into our actions very often. We have been able to force our bodies and selves to do amazing things, like 30 hour work days, 80 hour work weeks, living on little sleep and poor nutrition. We don’t understand that this is wrong, or that it should change when we are pregnant.

Our babies need us to take care of ourselves, which we aren’t used to doing.

In the hospital I desperately needed another doctor to tell me I couldn’t go back to work. Actually, I needed 4 doctors to tell me this. And I needed them to tell me this after I bargained with them about only working half shifts, and only at times when I would be surrounded by other physicians, so if I did start bleeding, I could leave. My trusted OB/GYN peers said ‘No.’

And I breathed a sigh of relief, and I cried with gratitude that someone else had made the decision for me.

So now, I am taking the month of December off. I am eternally grateful that I won’t be anxiety-ridden walking into the hospital. That I won’t spend my time working a shift and worrying about whether or not today will be the day that I start bleeding. I won’t spend my time thinking if I do start bleeding, whether I will call an ambulance or drive myself to the hospital, hoping I don’t hemorrhage on the way there.

I know I am not the only one who has struggled with this. Do any of you have stories to share?

Next week….Part 2–Experiences of Pregnant Physicians

Lessons Learned–How My Experience as a Patient Made Me a Better Doctor

“The good physician treats the disease; the great physician treats the patient who has the disease”

–William Osler

 

I was 37 weeks pregnant with my son when I started bleeding. I had finished a long day in the ER and was home with my husband, who was putting together the crib. I went to the bathroom and saw blood in the toilet. At first, I honestly wasn’t sure what to do. There was no pain, and everything else had been going well that day. But I quickly realized that bleeding while pregnant, especially this far along, wasn’t normal.

I called my doctor and we were instructed to go to the hospital. We thought we would be going home after a few hours, but the baby continued to have a very high heart rate and an ultrasound didn’t tell us much so we were told I needed to stay the night on monitors.

There was no room in labor and delivery, so we were stuck in a small back closet area. My husband was in what appeared to be an uncomfortable chair. Fortunately, I didn’t continue to bleed, but JP’s heart rate remained above 200 during the night. In the morning, we were counseled by the maternal fetal medicine physicians (the high risk OBGYNs) and I was transferred in an ambulance to the main hospital which had a level IV NICU. The doctor informed me I was not going home without a baby. This was unexpected, as I hadn’t even packed a bag! I also had over 10 shifts left until I was ‘supposed’ to deliver, so I felt totally unprepared.

Over the next few days, I had a different doctor every 24 hours and a different nurse every 12. We were in the hospital for a total of 5 days. This was the first time I really felt what it was like to be a patient. It didn’t matter that I was a doctor, and had been on a OB rotation during medical school, I still didn’t really know what was happening. I began to feel and understand the fear, frustration, and helplessness so common for patients in the hospital. I was scared. Things were said outside the room, decisions and conversations were had without my input, and I really hated how many different people were involved in my care. I also recognized that I didn’t appreciate when my nurses and doctors talked to me as though I was just a number, a presentation– ‘37 y/o G3P0 female here with bleeding and fetal tachycardia.’

I felt alone and without an advocate.

Initially, we tried to have JP vaginally, but I did not progress. After about 48 hours of pitocin, balloon dilators, and hoping that things would move along, unfortunately they did not.

The doctor that came on next was the one I will always remember. She sat on my bed. She told me that she knew it had been hard to be there, and that she thought it was time to make a decision about having a C-Section. She shared her thoughts on timing, we discussed anesthesia methods and she listened to my concerns. She saw me as a person, and I could feel for the first time since I arrived in the hospital that I had someone caring for ME, looking out for ME. She promised me ‘We will get this baby out while I am on shift. We have 24 hours to do it.”

I realized that in my own life, I have definitely come to the hospital to just work my 8 hours, to care for patients, but in a much more sterilized way. Sometimes life gets the best of me, and in those moments I struggle with hearing my patients, trying to do the best and what is right for them, and making sure compassion enters each of my interactions.

As a patient, it finally clicked. I realized sitting in a hospital bed that my patients invariably know where my head is at based on how I treat them, whether I sit, whether I look them in the eye, whether I talk to them in layman’s terms, whether they felt I was listening.

I recently read a book that put all of these thoughts I was having into words, In Shock, by Rana Awdish, a female physician who herself has had multiple harrowing experiences as a patient. She currently works in critical care, and with her writing has been changing the conversation about how we as physicians care for our patients.

After my experience, and reading this book, I came to the conclusion that I need to make it a point to do better. We as physicians need to do better. This last week #Doctorsaredickheads was trending on Twitter. It was very interesting to see patients describe their terrible experiences, but also fascinating to see physicians responding. There was a lot of anger over the fact this was trending, physicians defending themselves and our profession, rejecting the words, rejecting the notion that this phrase, albiet crass, could apply to any one of us at any given time.

I think the real lesson is that we as physicians are people too. We have bad days, and misbehaving children, and health scares, and working too much or too long. Sometimes we let our lives dictate how we show up to work. Sometimes that means we aren’t as compassionate as we should be, we don’t listen as much as we want to, and we don’t honor the sacredness of our profession. There are times when I am certain we are all ‘dickheads.’

I learned so much from being a patient. I’ll tell my full story at a later date, but since my experience, it has forever changed the way I come to work. I know that every family can tell if I am mentally there or not. They know if I am there to take care of their child, or if I am just punching the clock. Every family in the emergency department needs and wants to be heard, and navigating the system can be really challenging. Sometimes the only option a family has is to come to the ER, because it feels as if no one else is listening. It is my responsibility to then become the one that does listen.

Prior to every shift I make a true and concerted effort to leave my ego at the door. The work that I do is not about me, it is about trying to make sure that each of my patients get exactly what they need. Sometimes that is complicated care, sometimes it is to listen and create a plan to move forward.

I want every family to know that it is my job to take care of their child, so I will do my best to do that very thing. I also have learned that often, a parent knows way more than I do, and it always helps me to listen and to take their perspective into serious consideration.

I understand why we as a profession get the reputation we do, but don’t think it is because we don’t care, it is because we are still just people, with our own challenges and lives and families. Sometimes the things outside of our control affect us more than we would like them to. Sometimes we forget how to be compassionate and to put our patients first.

Do you have a story, of how you changed the way you practice based on an experience? Or as a patient you felt by the way a physician treated you? I’d love to hear it.