Man, Medicine, and Mike

I had passion. I was driven by it. It consumed me. It pushed me forward. I had to follow it. I had no choice. Now I am ready, almost eager, to let others take over. What has happened to me?

I am tired. Years of pushing burned the candle down. I can flicker up at times but it never seems sustained. I seem to do things because I am supposed to. At times I want to but then wish I could retreat. I dream of just being able to sleep. To know what it means to really rest. For once to not feel so tired.

I feel beaten down by the repeated tasks that consume me. Rounding is not about taking care of patients or making a difference. It is about how to get through the list. How can I finish and keep up? Another note to write. Another question to answer. Keeping my inbox empty. And there is always another. And then the emails just keep piling up. And then the things that I want to do seem to keep getting undone – length of stay, readmission, survival, appropriateness – it all seems to just stay the same. I feel guilty that I have not achieved more and wait for someone to point out my flaws. Why have I not achieved the best in outcomes? Why have I not pulled it all together?

I am numb. Because I don’t know any other way. How can I keep going when the losses keep piling up? In a field where 90% one year survival is considered good, that means that we are forced to endure losing 1 out 10 of our closest patients. I am supposed to be strong, right? These patients all meant a lot to me! Chris, John, Richard, Patrick. The list goes on and on and it never seems to stop. And just when I get my confidence back it happens again. Another punch to the gut and I just take it. Don’t let it show. Don’t let anyone know. Because how can I?

I do have a bad case of FOMO (Fear Of Missing Out). I have a deep fear that I will get to the end of my life and have someone come up to me and say, “Surprise! You were tricked. You missed out on life because you were so busy living it that you never felt it – never actually experienced it.” I dream of retirement as a time when maybe I will be able to slow down enough that I can see and hear and feel again. I worry a little bit because lately people have been asking me if I am going to retire soon. I am ashamed to tell them I am only 53 years old and so I have a ways to go. I also am afraid that I will be like others who finally get to retirement and then dream of the past. They look back to the days that they had purpose and things to do. I think I am a fool.

What can I do to be able to live today? Is it possible? Can I come and play with the other kids? Or do I have to stay inside and work all day? Am I going to get to go outside while it is still summer or will I get tricked and only finish my work in time for the cold dark winter?

ADDENDUM:

I wrote this prior to my cancer diagnosis and my medical leave of absence. It is raw and honest. I never intended to post it. I wrote it for me but now am going to bravely post it. I intentionally left it with some sense of hopelessness and no real answers because that is really what burnout does to us. In all honestly at that time I did get to go outside and play, but burnout makes it so you are not able to fully enjoy it. Your brain remains inside and hard at work even when you go through the motions of going outside to play.

Now with the perspective of several weeks off I see a few answers:

Dogged Focus on Patient Care: We have to have the strength to be doggedly insistent on focusing on patient care. The pressure of charting in the EHR (Electronic Health Record) can drag us down and distract us. We need to have the EHR be the side item and still insist that the focus of our energy is on the patients. That is where the joy is. A less complete chart is a lesser sin then an incomplete care of the patient. (The EHR is breaking us. We MUST come up with better solutions. Perhaps the answer is scribes?)^[1]
Ring-Fence Your Personal Life: We must put a fence around our clinical or work activities. We have to have time to think, breathe and exist. When you are home, without shame, be home. When you are on a walk, look at the trees and the birds and don’t feel guilty about what is not yet done at work. The undone tasks will always be there whether you spoil your walk or not. Fight to protect work from creeping into the rest of your life.
Put Down Your Phone: Turn your phone off or put it down if you are not on call. If you cannot do this, give it to your spouse or friend when you go out. Ask them to give it to you only if there is an urgent matter that you must attend to. Get in the habit of having your brain free of work. Get free of the addiction to the phone. It is hard for me to do this but I have to. I get twitchy at first without my phone in my hand. Eventually I get over my withdrawal symptoms and start to become human again!
Go Away: Go to the national meetings. These always are inspiring and recharging.
Read Novels: I call these “sorbet for the brain.” Like in an expensive meal where they serve sorbet to “cleanse the palate.” It helps to restore your ability to taste before the next course. Novels can have a remarkable ability to do this for your brain!
Sabbaticals: I still think that physicians should have sabbaticals. A 4-week period to recharge could result in a re-energized far more effective physician. If only health systems could be wise enough to invest in their physicians in such a way.
YOU TELL ME! What else? PLEASE RESPOND TO THIS POST! I really want to hear what you think works!

There is an epidemic going on. The ICD-10 is Z73.0 and the term is “burnout”. The vaccines are not very effective. The treatments are still rudimentary and need a lot more work. Like many papers I think I will need this one to conclude, more research is needed. We desperately need it…

^[1]Interestingly the EHR issue is finally getting some attention. Please read this blog post for more information: https://www.healthit.gov/buzz-blog/health-it/strategy-on-reducing-regulatory-and-administrative-burden-relating-to-the-use-of-health-it-and-ehrs-released-for-public-comment

Johnny served two tours in Vietnam as a helicopter pilot. I was in college and working a part time job as a dispatcher for the hospital’s helicopter service. Johnny was one of our pilots. He was very experienced having flown helicopters in lots of different situations. The communication center was a common place and I loved it when Johnny would come in and talk with me. To a 22 year old farm boy his stories were better than any book or television show.

“Two tours in Vietnam? I thought that everyone just did one and then went home?” I asked him.

“I volunteered,” he replied.

I asked him back, “Why would you do that? Weren’t you scared?”

His reply struck me and has been with me ever since, “I was bullet proof and invincible.”

He continued, “I had plenty of close calls. I even got shot down once. I had friends killed and saw them die. But when you are young you never think it is going to happen to you. Every time you just shake it off and believe you are going to be fine. You are bulletproof and invincible.”

I went through flight surgery training in the US Navy several years later. There we learned a lot about aviation safety and the psychology of naval aviation. We were taught that most naval aviators do fine until about 1000 flight hours. Early on they are young and filled with optimism and exuberance. Over time the grind of all the safety training and the stress of the mishaps (aviation term for accidents) that do occur has a maturing effect on them. By 1000 hours, most of them will have had at least one colleague die. Something changes. They no longer assume that they are going to be fine every time they fly.

They are becoming mortal.

I remember doing the preflight on a marine H-46 prior to a fun flight from NAS Norfolk to Camp LeJeune. The senior pilot pointed out a key area that he inspects as he pointed his flashlight way up inside. “This aircraft is about as old as you are. If these break we lose that rotor. That means that we do a flip. That is something that we probably wouldn’t survive. I had a buddy that had that happen to him.”

As we finished the preflight inspection, did the preflight brief, and then climbed into the cockpit I questioned whether I was doing the right thing going on the flight that day. My wife and infant daughter were at home. Should I be risking leaving them alone? I don’t even know for sure if my wife knows I am taking this flight today. But I reassured myself. “Naah. I am going to be fine. This is going to be a great flight!” And honestly – it was a great flight. I had a lot of time at the controls and it was I think one of my favorite days as a flight surgeon. It was so cool just maneuvering myself at tree level over the countryside. I would do it again in a heartbeat!

But in class they taught us about the 1000-hour naval aviator. At this point they are forced to make a decision. They are no longer immortal. The question becomes, “Do they love naval aviation so much that they are willing to continue and accept the risks? Or is it time for a career change.” About half leave.

Recently I became mortal.

Oddly I wasn’t surprised. I knew when the ED doctor came back into the room and closed the door. It was inevitable that something would happen to one of us. I didn’t know which of us would be first. My clinical life has made me odd I suppose. My wife grew up with loss. We don’t expect things to always go well. It seems like most of the world expects health and prosperity and is shocked when anything goes wrong. We have always been so pleased with good things knowing that the world is a broken place.

Gut punches. The pager message, or the colleague calling to tell me, or the CT scan result, or when I obsessively check the labs or hemodynamics and they are bombing. The favorite patient is dead. Or had a horrible complication. I know the feeling so well. Like Harry Houdini (or perhaps like he was supposed to have done) I tense my abdominal muscles to take the hit. I guess I have gone past my medical “1000 flight hour” equivalent.” Numerous times it has been tempting to call it quits. Who really needs all of this? But in the end, I decide it is who I am and where the Lord has called me. And so I stay.

Back to the ED: Door open and closed. The look on his face. Tense my abdomen. “Ok. What is it?” And then it played out like some scene from a medical drama. It seemed so, “cliché”. Would we cut to a break for an ad for laundry detergent? It was me. It was serious. But there were a lot of unknowns. He showed me the tumor on the screen in the exam room.

The emotions came gradually. For me they hit with force about 36 hours later. I admire my wife so much for this part of the story. She let me be. She sent me off alone to work on my sailboat. The next morning she went to breakfast with a friend as she had planned and so that I could go to one of my favorite coffee and breakfast spots and just be. I am an introvert at heart and she knows that I need time to process. I needed time to become mortal.

Subconscious assumptions about the present and the future crashing down all around me. Frustration at a world that tempts us to go through life but never really feel the life that we are living. The people – the friends. They are SO wonderful and precious. Do we let them touch us? Or do we keep up a shield because if we let them they might slow us down? Do we gobble down the delicious meal so quickly that we don’t taste it? Music. Nature. People. Emotions. Do we appreciate it all?

A few days later my wife asked me to help clean some gutters. I was surprised at myself as I was being so cautious. I joked and explained that I was suddenly feeling, “mortal.” She understood. I am not bulletproof. I am not invincible. I am as a good friend and gifted speaker taught us, “fragile, fractured, and flawed.” All of us are. Some of us just haven’t learned that yet.

So what does it mean to be a mortal?

It means that I no longer feel bulletproof, nor invincible. I don’t feel it. I don’t feel like I need to either. I can admit that I am fragile.
I don’t have to be everything to everyone. I can ask for help and enjoy receiving it.
I can no longer live for tomorrow. I have to experience today for all of what it has – or at least try to do so.
I want to love people and be loved by them. I now see how wonderful they all are. They truly are. They are beautiful. How dare I not let myself feel it before! What a fool to not drink it all in. I have started telling people how much they mean to me and really believing it.

I know that the time that I have to live is not a promise. It is limited. None of us know how much time we have. Are we brave enough to live today? Will we insist on slowing down enough to taste our food? Will we insist on slowing down enough to see the faces and read the emotions of our family and friends. Will we enjoy them in the moment? Will we reread the page because it is so good instead of rushing to the end of the story? Will we look up and see the leaves, the sunrise, the grass? Will we taste each bite?

And Johnny? The last I saw him he accepted a high risk – high reward assignment flying helicopters for the Columbian government in the war against drugs. He was still bulletproof and invincible.

For me?

I am “fragile, fractured and flawed.” But that is really not a surprise to me or anyone. And I am ok with that.
I don’t know the future. Who really does? “I know whom I have believed and am assured that He is able.” It is going to be ok. I don’t know what is next. But I am ok with that too (mostly).
My emotions have come back. I can feel again. I am not just living life. I am tasting and enjoying life. I like it. I am not going to easily give that up again. Slow down.
No more superman for me. I never really fit in the suit anyhow.

“Fragile, fractured and flawed” is an amazing phrase that I was taught by Christian Thomas Lee. Here is his webpage if you would like more information about him: http://www.christianthomaslee.com/contents.html

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