Monday, May 2nd, 2011
Once upon a time, 250 medical students sat in Colquhoun Lecture Theatre on Great King Street, Dunedin, listening to whom I presumed to be a psychiatrist talk about Stress and Distress. Spewing figures and facts she highlighted that we as a profession were at a higher risk of developing depression and alcohol dependence, and generally having a lower quality of life. She then went on to speak about the cluster of house surgeon suicides that occurred in New Zealand in the mid-90s. “How sad,” I thought to myself, before going on to ask my friend what we were doing for lunch that day.
I’ve always done med school well. Not that I was a Distinction student (far from it), but I could always manage. Sure I had my ups and downs, runs I did better on compared to others, but I don’t recall ever feeling out of my depth.
That is, until week six of work.
What I have to say next isn’t easy. As I commit these thoughts to paper I begin to have a physiological response. A part of me wonders if by admitting that I struggled I will be disadvantaged in my future application to the surgical training program. The last thing I would want is for the selectors to read this and think, “That Anna struggled with first year? We can do better than her. This other applicant is just as qualified and they never struggled.” It sounds silly and I am trying to convince myself it would never happen, but a part of me still wonders, and will always wonder… and worry.
That, in a nutshell, is the stigma against stress and distress which we doctors create for ourselves and continue to perpetuate. That is the culture of medicine. And if History has shown us anything, the only way to change a culture is by a grassroots, bottom-to-top, quiet revolution.
This is the account of my Rock Bottom.
This is my revolt.
* * *
After the string of patient deaths around Christmas I found myself heading into yet another 12-day stretch. At around the same time our team was caring for a young patient who, from a medical point of view, did not have any problems. However in the world of modern Western medicine in which we practice there was one potential serious diagnosis we had to rule out prior to discharging them home. To do this, a specific test was required, a test which kept getting delayed.
And when patients want to voice their frustrations to “The Team,” it will most often fall on you as the house surgeon to bear witness. In these situations de-escalation is key. Yet conflict resolution requires patience and an investment of time. Neither of which is easy to come by in the unforgiving and insanely busy wards we work in.
It is in this context which I found myself dealing with this particularly difficult patient. And with each day that passed I began to dread work more and more. This dread was strangely different from anything I have ever felt before. It was, quite frankly, a sense of impending doom. No, I wasn’t having a myocardial infarction. But each morning as I walked through the sliding doors of the hospital my world seemed to flick into slow motion and I found myself begging my Maker. “Please, don’t make me go back in there. Please, I’ll do anything. I can’t go back there.”
This Pavlovian response only seemed to get worse. The days dragged out. There was no ounce of joy in the work. Each day only felt like a bigger failure than the day before. My desperate coping mechanisms du jour began to fail one by one. And I found myself wondering why I kept coming back to do something I had absolutely no desire to do.
If insanity is doing the same thing while expecting a different result, then by that definition there was no doubt I was going insane.
The physical exhaustion drained me of my psychological and emotional reserves. Under normal circumstances I could easily shrug off the stinging words of a radiology registrar telling me I was incompetent. But when I was already running on empty every moment felt like I was walking on an emotional tight rope, and all that was required to topple me over was a whisper.
Being on call that weekend was unimaginably horrid. The workload, for one house surgeon, was impossible, and I was barely holding on by the tips of my fingers. After a post-acute ward round that lasted until noon and dealing with one particularly sick patient, it was already two thirty before I had a chance to sit down, let alone check the five pages of “Weekend on-call house surgeon” jobs left for me by my peers. I grabbed a sandwich then went to another ward to hide. All I wanted was a breather. A moment to myself to collect my thoughts. And as my thoughts were collected it dawned on me that I was completely shattered. At that moment one of the medical registrars happened to walk by. I’ve never been good at hiding my emotions and he must have noticed something was wrong because he asked me how I was doing. With that, I couldn’t stop myself from crying right there and then. [Yes, again with the tears!] This lovely registrar forced me to leave the ward for twenty minutes, but not before taking my pager and half of the on-call house surgeon job list. He was still helping me with jobs at six in the evening (despite his shift technically finishing at four).
No amount of baked goods could ever convey my gratitude. All my life, I will never forget his kindness.
I was back on Monday for Day Eight and, with that, back to being the punching bag for our impossibly demanding patient. This patient continued to flip-flop between being angry and distraught, placated only by my sitting next to them in silence, holding their hand for thirty minutes, and apologising for the situation they were in.
It was exhausting. Emotionally draining.
And with everything else that was going on I was on the precipice of burn out. I needed a day off. I went to the RMO Office, burst into tears, and explained to them what was happening. “Oh yes, we’re so sorry to hear that. Of course, we’ll try out best to give you a day leave,” only to later receive an email with the subject heading, “DECLINED.”
That was it. The final nail on the coffin that was my life.
I have never known what hopelessness felt like until January 2011. I have sat alone for thirteen hours on a hard metal bench in an empty airport in Senegal in West Africa surrounded only by French speaking African soldiers welding machine guns, with no food or flushing toilet and no sleep for twenty hours, with my flight query indefinitely delayed… yet even then, there was Hope.
I could never take my own life, as I personally believe that my life is not my own to end. But I understand now what could bring a person to that cliff-edge. More than sympathize, I can now empathize. When you cannot see any glimpse – not even a flicker – of light at the end of the tunnel; when the more you move forward, the longer the tunnel seemingly becomes; when you cannot envisage a time when things will be different… when all that exists is the blackness of Now, with no hope for tomorrow.
These are the thoughts that bombarded my head as I succumbed to Rock Bottom.
A few days later I picked up my friend on the way to dinner and as I pulled out of the driveway I broke down. I screamed, I raged, I cried; everything I had been holding in, the exhaustion, the frustration, the dragging heaviness of my heart, I let it all out and with that, let it all go.
More often than not, Rock Bottom sneaks up on us. It is a gradual build-up of seemingly insignificant ‘little lows’ which we keep hidden to ourselves. Your ‘little lows’ may be different from mine. They may build up faster or slower; maybe your week six will be pretty darn sweet. But the one message I want to leave you with as you head into your first year as a doctor is this: we ALL struggle. It is not just you. Those second years around you, those registrars, your consultants, each of them have gone through what you are going through now, no matter how on-to-it they may seem. We each of us have had those lows. We’re just not good at talking about it. Us Kiwis are so good at being nice, but we’re not very good at asking the ‘tough’ questions. “ARE YOU OKAY??” “ARE YOU COPING??” “YOUR ANSWER DOES NOT HAVE TO BE A NOD AND A SMILE.”
Never forget, you are NOT alone in your struggles. It does not make you any less of a doctor. No matter how hopeless it may feel, it is NEVER hopeless. And there is always someone you can talk to.
My Rock Bottom was driving home at ten thirty at night after yet another long day and wondering to myself, should I keep pushing the speed limit because, maybe, just maybe, my wheels would slip and… …that would be that.
Three months later, here I sit, sharing the one experience I never imagined I could share.
There is always Hope.
There is always someone you can talk to.
And never, never forget, you are doing a good job. You are a doctor. Everyday you are helping people with what you do. Never, never forget that.
Okay?
