Trigger warning: This post contains references to burnout, depression, and a brief and non-specific account of my friend’s suicide.
I was reluctant to write this post, but I can’t get past it to write others until this one is out there. I’ve been mentally ruminating on what I should say for weeks. I’m convinced this topic, although widely discussed and written about by physicians, is still in the stage where sharing our personal experiences might be what helps someone else fend off their own struggle with burnout and depression, as there are few institutionalized solutions or strategies for dealing with it. And perhaps for myself, sharing without shame is a form of therapy.
2010, residency interview trail. In my smart gray suit and burgundy blouse, I focused on maintaining eye contact and a slight smile as I introduced myself to my interviewer, a heavy-set man with a bushy mustache and friendly face, somewhere in the Southeast. First question, “So I’ve looked through your CV, and I have to ask you…what are you doing here? You and I both know you’re not going to rank this program.” Well, actually I’m couples matching with a neurosurgery candidate, so I’ll be ranking all programs and your program has a good cardiac surgery department and research capabilities, so…awkward. Ok next question. “You are like the medical version of a gym-rat. You like never leave the hospital. Don’t you know you’re going to burn out?”
I was adamant that I was doing what I liked. Of course I was not going to burn out, thank you very much.
2014, 3rd year of general surgery training. I was edging ever closer to entering the integrated cardiac surgery track I had committed to during my 4th-year med school away-rotation. The advice from my wonderfully supportive mentor, Dr. S, back home echoed in my mind, “If you go up there to do this, you have to follow through. Don’t punk out. Don’t be one of those women who gets washed out.” The problem was, I was conflicted about cardiac vs. trauma in med school, and I remained so those first few years in residency. I reasoned that in the worst-case scenario, I could just do the integrated cardiac training and then be a trauma surgeon; it’s just an extra year of training, that’s doable, right? In any case, I was not going to quit.
I have had a few other instances in life of not knowing when to quit. In the first grade, my teacher gave explicit and strict instructions to not interrupt her lesson for any reason; I’m pretty sure she gave the example of not even for the bathroom. And then I had to go really bad. But I said nothing, and her lesson seemed like it yawned toward eternity, and of course, I ended up sitting in a HUGE puddle of urine as my neighbor silently laughed his head off. I was quite confused when my mother and my teacher both admonished me to simply raise my hand and ask to leave next time I had to go that bad.
To get a discount on my prom dress, I posed as a “human mannequin” in the mall. I could go hours without moving a muscle. Teenage boys would try to get me to move or smile, and I was so determined that I would have tears rolling down my face from dry eyes before I gave in. I was also undefeated in staring contests; I still do not know my upper limit of standing still.
3rd year of med school, Dr. S informed me that there were no residents on his service that week, so if I showed up I could scrub all day every day and be 1st assistant. Needless to say I was PUMPED. By the end of the week, I was taking 600 mg of ibuprofen before every case to deal with the neck pain, but having a blast. We had a case that was going great, and so true to routine he ordered for the room to be warmed up in preparation to come off pump, but then we weren’t actually able to come off pump for quite a while. The surgeon ran through various maneuvers and waited patiently for the right constellation of labs and monitor feedback. Minutes stretched into hours, and I could feel beads of perspiration dripping down my shirt and legs. The room was over 80 degrees. I started to feel faint, and so I held a valsalva maneuver to get my blood pressure up; that helped. I tightened my leg muscles, shifted back and forth, flexed my calves, and kept myself from passing out at the table. This went on for another couple of hours. If I relaxed, I got light-headed and the room would start going dark, so I’d tighten everything back up. Finally, at a point where I was starting to hear that high-pitched screech that comes right before you really pass out, the surgeon told me to go scrub out and take a little break, since it was obvious it would be another 30 minutes. I went to the locker room, collapsed on a bench and ripped off my dripping wet scrubs. I looked down at my legs and saw that they were covered in petechia up to my thighs. I put on fresh scrubs, guzzled a glass of water, and went back in to finish the case.
There are other examples, but I’ll wrap up this digression by saying that I might be one of those few people that Angela Duckworth references in Grit who really doesn’t know when to quit.
So back to 3rd year, I was flying high after coming off of one of the hardest but most enjoyable rotations in residency, where I was the senior resident with one of our most respected and demanding surgeons in the program. I had also just returned from my trip to Ukraine with Novick Cardiac Alliance, where I learned how much potential there is for advanced-level surgery care in lower-resource settings.
Having wanted a career exactly like Dr. Bill Novick’s since med school (He founded cardiac programs in low-resource countries all over the world), I should have been sure of my direction, but small doubts were persistent as to whether cardiac was the right field for me. I was more interested in the bombings on the Ukrainian border a short drive away from our site than in our pediatric cardiac cases. I couldn’t deny that I was a little bored with cardiac, which was a very troubling concept, but one that I shoved aside. I couldn’t quit.
I felt great going into my thoracic surgery rotation, which was a big test for whether the integrated cardio-thoracic spot would officially be mine. Only a couple of days into the rotation, I felt myself faltering. After a couple of weeks, I was drowning. Nothing I did was right, nothing I said was right, I was never where I was supposed to be when I was supposed to be there, and I felt like my brain was 10 steps behind me at all times. I confided in trusted mentors that I didn’t know why I was failing so miserably. I didn’t get it and I was frustrated and terrified of failure.
One of the fellows, T, knew Dr. S from back home. He gave me compliments every day, telling me how highly Dr. S thought of me and all the nice things he would still tell people about me. T was a meticulous clinician, and shared with me his routine for rounding, which was truly exceptional. I tried to emulate him. He was probably the nicest person I’ve ever met, especially within the hospital, and his encouragement kept me going.
At our program, we have chief conferences for every rotation, where we go to the fancy auditorium, get onstage in our suits, present our cases from the rotation, and field questions from the staff. It’s a nerve-wracking event for all the senior residents, and we spend hours and hours preparing. I met with multiple staff to go over my case list. I studied for 15 hours one Saturday that I wasn’t working because I needed to make up for my poor performance on the rotation. I kept trying to meet with one particular staff member who would be leading the questioning for my conference, and who always met with residents regarding the conference in the past. She rescheduled with me no less than 10 times, even rescheduling a phone-call with me, and always at the last minute. Finally, the day of the conference she sat down with me, looked at my list, said it looked good with a finality in her voice that did not invite further discussion. I left that meeting knowing that I was about to get massacred; it was just obvious. Sure enough, despite my preparation, I fielded a rapid-fire of questions on controversial topics, and my brain was stuck in red-alarm mode. I could see the paper sitting in my bag discussing how there was no professional consensus on a certain topic, but my mouth just couldn’t say the words that demonstrated what I knew.
The next morning, my typically formal, reserved and always gentle attending greeted me with the words, “I was so PISSED last night! That was BEYOND inappropriate.” I had cried my eyes out after the conference, but I felt responsible for it all. I should have been able to do better. I should have done lots of things better. I took the blame despite more admonishing that it wasn’t fair to me. What’s fair got to do with it?
The remainder of that year was a downward spiral mentally. I had never outright failed professionally before. I continued to force myself to fight for something I didn’t really want. I relived all the moments of shame and humiliation over and over again, all day every day. I became irritable and would pick fights with my husband. During a car ride, I even heard myself say, “I am yelling at you because you’re the only person I can yell at that will listen.” Things had gotten very dark for me.
I was at my workstation getting vital signs one morning when I got a page. Our friend T was missing; he hadn’t shown up for work. So uncharacteristic and worrisome. I paged my other friend on a rotation with T to find out what was going on. I got another page, returned it, was told to sit down. Two days after supper club and movie night where we had a great time, laughed and joked, where I consciously perceived that his presence was like a port in the storm for me, T took his own life. I wailed in the workroom, felt sick, then felt numb. I rounded. Cried, felt numb. Scrubbed into my first case, cried at the sink, went numb. Did the case. My attending asked what was up. I told him, cried, went numb again. Did another case, actually thankful for the distraction. My group of friends stayed in close contact all that week, tried to get together as much as possible. We were all scared, although we could say exactly why or what we thought would happen to us at this point. I couldn’t understand how such a kind and gentle person could…it’s still too painful to write.
I slipped further into a dark, heavy, and bleak state. I functioned at work, had rebounded to some level of good performance, but every day I felt like I couldn’t keep up with all the tasks on my to-do list. My mind frantically begged for a pause button. Weekends off weren’t enough to recharge; vacation time didn’t help either. Every day started with a panic over how much needed to get done and seemed to end almost instantly, with nothing but shame on my part for not getting to this or that. My life felt like it was careening forward at breakneck speed, and I couldn’t slow it down, keep up, or catch up.
I had no emotional reserve. I received feedback that I seemed miserable from my intern, but I felt like I was doing all I could to simply function at work. My marriage suffered.
Then, my elderly, cancer-ridden, sweet greyhound, Pfeiffer, died. We knew it was coming for months. But this tipped me over from what was probably severe burnout to full-blown depression.
One of my trauma mentors, Dr. M., had talked to me a few times over the years about a particularly hard rotation he had in residency, and he described his emotional state during that time as “suicidal-enough.” He didn’t have a plan, but said if his car happened to run off the road or something like that, he wouldn’t have been disappointed. That’s also how I started feeling. But I also became convinced that my husband would be better off without me, my friends were only friends because they felt sorry for me and were nice people, and although my parents loved me they would actually be better off without me too. I had intrusive thoughts about my car running off the road every time I drove. I thought, maybe with some measure of hope (if that’s what we can call it), that perhaps I would develop a terminal illness.
I also felt trapped. My fate as a cardiac surgeon was still unclear, or at least for the integrated spot. I wasn’t ready to quit because I didn’t want to be a quitter. I agreed to go back to thoracic for another audition rotation. I did fine but not stellar. Whatever, I didn’t care.
I recognized my symptoms of depression and was acutely aware of the danger I was in, especially after my friend, who was much kinder and gentler than me, had recently succumbed to it’s pain. I took an online questionnaire that pegged me as “severely depressed,” and instructed me to seek medical attention. I shared this information with my mother and told her I needed advice but I didn’t want to go to the doctor. Could we just talk it through? I thought her wisdom and love could pull me out of it. I didn’t want “depression” in my medical record, and I didn’t want to tick that box on professional forms in the future.
I researched strategies to combat depression. I exercised regularly, tried to get outside on every sunny day, eat healthy, connect with friends, talk about it with my mom, Josh, and my best girl-friend.
I longed for some canine companionship and so decided to volunteer to walk dogs with the local greyhound rescue group. I met up with them and instantly connected with a big yellow staghound. I picked him up on the first 50-degree Saturday of the year, and we went to a hiking trail.
There was still a nice covering of snow on the ground that sparkled in the warm sunshine. It was a glorious day. I smiled and my face literally hurt because I couldn’t stop smiling and laughing as we clumsily jogged up and down the rutted out, snowy trails.
We stopped at a bridge and just sat together, and the dog literally hugged me, draping his giant neck over my head and just resting there long enough for me to snap a selfie.
Ramble had a gift for making everyone feel important. Indeed, he convinced everyone that they were important with his confident affection. I thought about many things sitting on that bridge, including what my options were in life. I could do so many things still… I could learn a foreign language, write creatively, read some books, adopt this dog! I could be a trauma surgeon if I wanted. Suddenly, there were a dozen sunny paths before me instead of the claustrophobic walls of a dark dungeon.
Of course I got the dog, and named him Ramble. I created the life-motto of, “If I’m too busy for a dog, I’m too busy.” I decided I would never cross that line again; it was too dangerous. I made room for all the things mentioned above. I apologized to my husband and started doing fun things with him, like seeing as many indie-rock shows as humanly possible. It was a blast.
I sat through the meeting where I was told I did not get the integrated cardiac spot. One loud thought started flashing across my brain…I’m going to start a family! So we did. And I went all-in on trauma/critical care, and that felt so, so good. Trauma is just more fun, and I loved every day of my fellowship year. And thus, What-is-More-Fun finally became a guiding light.
What actually changed for me that day with Ramble? Only one thing: Perspective. All of those possibilities in life were always there, but I couldn’t see any of them. I went from trapped to in-charge. It was a sudden revolution, but one that I’ll never forget.
I made some mistakes on this journey. I got lucky that I made it through; but not seeking medical help was a huge risk that is not worth taking. I know of residents with the most stellar reputations, who have won the biggest campus-wide leadership and teaching awards possible, who are open about being on anti-depressants. Anyone with symptoms of depression should seek professional help. One other excuse that I made was that my symptoms hadn’t been going on that long, so I couldn’t really be depressed, it was all situational, blah blah blah. Again, I urge anyone who recognizes these symptoms in themselves or a friend or relative, seek and encourage others to seek professional help. It’s just too important, you are too important, to settle for less.
I hope that I am able to spot the symptoms of burnout among my future residents. With my performance level dropping, seeming tired and overwhelmed by the schedule, even after asking for help and understanding from my staff, the signs were fairly apparent. Yet, I had only one single attending ask me during the course of the year whether I might be depressed after I confided that I felt overwhelmed with my to-do list every day (and at that point I summarily denied it). It seems that this is a common experience during 3rd year of general surgery, but it can happen at any time. I hope that by sharing openly about this issue, that someone feels less alone, and less trapped. The biggest lesson to overcome burnout for me was that I was in charge of my life. No one else could be expected to carry me to my desired destination, but I absolutely had the freedom, and responsibility, to make it happen. I learned the importance of knowing oneself and being honest about what I really want rather than what is expected of me.
Another concept from Dr. Angela Duckworth’s Grit is that having an overarching purpose in life helps one have grit, because even if you fail at something specific along the way, you will just find another way to continue the long arc of achieving your greater purpose. I’ve always wanted to do humanitarian medical missions. Indie Docs is about intentionally, methodically, making it happen. Several studies and sources have published that humanitarian medicine can combat burnout among physicians, and the reasons are fairly obvious. By helping those with less resources, we get that “givers high” and feel like we have an awesome purpose, and I truly believe there is nothing better in life than that.
There are many other great posts and discussions on burnout, but the one that really got my attention several months ago was the ChooseFI podcast with guest The Happy Philosopher, where he talked about his burnout and recovery; this got me reading his blog, and there are numerous fantastic posts about purpose, meaning, and his own story about burnout. This is a great resource to start with if you are struggling with it. I hope that my little contribution to the subject might connect with someone and help you know that you’re not alone, you’re not weird for feeling this way (over half of physicians have symptoms of burnout!), you’re human, you’re the boss, and you can make your life into a fantastic story that you’ll be happy and proud to live out.
Feel free to email me at joy@indiedocs if you’re struggling or just want to share your experience, or share your own story in comments below. If you have thoughts of self-harm, please call the Suicide Prevention Lifeline at 1-800-273-8255 or seek help at your local emergency department.