A Long Absence and Reflections on Burnout and Empathy

It is December 28, 2013.

The last time I posted anything in this blog was in July of 2009, 4.5 years ago. Where did those 4.5 years go? I could justify those years by saying: I finished my third year of medical school, discovered that I wanted to be an obstetrician/gynecologist, traveled abroad in my 4th year and confirmed my passion both for ob/gyn and for working abroad, got married, and started residency in ob/gyn...but those are just milestones. They don't explain the emotional changes I went through in those 4 years and certainly don't reflect my mental status. It just became easier to focus on milestones and goals and getting through things rather than on reflecting on my life, because sometimes those reflections were far too painful. If living life means living through each experience and gaining meaning and significance from those experiences, then it saddens me to think that I have merely been existing.

Outwardly, things appear perfect. I am happily married to my amazing husband, who puts up with my grumpiness, my love of shoes and Kate Spade bags, and tolerates me buying a 10 pound bag of sugar and 4 pounds of butter from Costco on a monthly basis because I bake so much. (I don't believe in "low-fat" baking. That is a lie that Hollywood celebrities want you to believe. Cookies need butter. Actually probably everything needs butter. Except for the best vegan muffins I made over Thanksgiving weekend.) I am a resident at my top choice residency program in ob/gyn and work at three phenomenal tertiary care hospitals. I love my co-residents (or indentured servants as one of my favorite Chief residents liked to call us and herself). I live in a great apartment in the heart of a pretty cool city and have a fearsome looking, excessively furry cat named Genghis who likes to sleep under radiators and eat flies.

Sounds TOTALLY great!
Is that for real?
Umm, no.

Reality check: I used to be a nice person. Now, I am just a raging bitch who eats my feelings and can only keep it together for my patients in the hospital. But just barely.

What happened?

As my education pulled me further and further into the sterile capsule of hospital life, I slowly let go of anything extraneous. As a third year medical student, I felt that these were temporary measures, even necessary measures, that would enable me to become a better doctor in the future, because how was I going to learn if I didn't make the hospital the center of my life? As a fourth year medical student, the hospital no longer was the center of my life, and instead, I was busy learning medical Spanish, traveling abroad, and getting married. I thought that the inordinate amount of time I spent in the hospital as a third year and the intense focus on medicine was a mere hiccup, a wrinkle in time, not the norm. Fourth year of medical school was so different from the previous year that I thought--being a doctor is great! I get to have fun and take care of my patients!

Now I realize that fourth year was actually a departure from the norm. I should have sensed that perhaps my relationship with medicine was not a healthy one. For example, for our honeymoon, I dragged my husband to Washington, D.C., where I was presenting a poster on my research at a national conference. Granted, both of us were broke and literally had no money to our name after renting our tiny apartment and couldn't go anywhere fancy for our honeymoon, but still, I left my husband for 4 hours alone on our honeymoon while I attended a medical conference. (Honestly, he was less trauamatized by that than the giant orphaned dogs who shared our breakfast space with us in our cute inn--he is not a dog person.)

To clarify: spending a LOT of time in the hospital is normal and actually necessary in order to learn how to practice medicine and to take care of patients. Patients need continuity in their providers, and to be fair, I am only working 80 hours a week, which is significantly less than my predecessors were working just 10 years ago. I am thankful that the regulations have changed, but in practical terms, does this mean anything at all?

A 2004 study titled "The Effect of the 80-hour workweek on resident burnout" published in the Archives of Surgery arrived at the following conclusion: "Despite successful reductions in resident work hours, measures of burnout were not significantly affected."

And burned out is what I feel. It is such a relief to be able to write this, so therapeutic to be able to verbalize it. I couldn't verbalize this even one year ago, but I came to the realization that this constant fatigue, this indulging in retail therapy or food therapy, the lack of reflection, everything I and my co-residents have felt--none of this is normal or healthy. And the only reason I could arrive at this conclusion was because as a third year in my program, I was able to take a research elective and leave the hospital for 6 weeks. Signing over my pager as "not available" with no end date was incredibly liberating. The 6 weeks allowed me to read, bake, cook, and travel. I felt like myself for the first time in years and even took my first spontaneous trip alone in 5 years(I ate my way through the city of Paris). For the first time in 3 years, I had enough free time that I felt bored! Boredom was a gift.

Then I returned to the hospital, and it was as though those 6 refreshing weeks had never existed. The problem is that it is not just the sheer number of hours you spend in the hospital--it's what happens there.

Bad things happen in hospitals. Even in my field, where people think we deliver bundles of joy, things can go wrong. There was a maternal death, and while it was not a patient I knew, the sadness among all of us was palpable for those next few days. A baby died before he could take his first breath. On the gyn wards, a patient died before she could ever go to the operating room. Another patient was discharged from the hospital to home hospice, and told us that all she really wanted was a fun funeral. I gave the diagnosis of metastatic cancer to one of my favorite patients.

These terrible events weigh on you. My first months of intern year, I was terrified of making a mistake and of my patients dying, so much so that I had nightmares and would wake up in the middle of the night frantically thinking that I had forgotten to write orders for my patients. The sadness of those cases made me cry, one time in front of my entire team when we were rounding in the morning. Yet there was no outlet--no one to ask me how I felt, no one to reassure me that my feelings were normal and ok.

Gradually, what happened is that those feelings began to shut down. It didn't do me any good to cry in front of my team--it just made me feel awkward and embarrassed. And by that point it was my second year of residency and I was spending so much time in the hospital that I never saw my husband or my friends. I became engrossed in being a resident, not by choice, but by default. My love of photography disappeared and my beautiful 1980s Canon camera sat on a dusty bookshelf. I stopped buying books and reading poetry. The only stamps/envelopes I used were to pay my rent. I stopped writing. I stopped doing yoga or exercising. In short, I became an automaton who arrived at the hospital, put in my hours, came home, ate, and slept. I was an efficient machine.

My marriage suffered. I thought I was going to get divorced. My parents complained that they never saw me and I never called home. I lost weight. Then I gained weight. I lived in scrubs, never wore real clothes, and never saw sunshine. I could deal with all of that. Worst of all was that my empathy was dying.

It was a subtle death. Every day as people asked me to do random things for which I never got thanks or acknowledgement, every day as I felt like a secretary who had spent far too many years in school than is sane or healthy, every day that I thought about residency as just a "job," chipped away at that empathy that I had so cherished. I became a doctor to take care of people. Instead, as I became more immersed in the world of medicine, I could barely take care of myself, never mind other people. Around Christmas time last year, I was working nights covering two different emergency departments for any gynecologic consults. I started to pray that I wouldn't get consults, because I just could not see any more patients. That was when I realized that I was in real danger of losing my empathy for patients, but I still couldn't change anything. The demands of being a resident were overwhelming, and I stayed afloat by not reflecting and by showing up to work, and it was one of the worst feelings to carry around with me--that if I felt too much, I would never be able to do my job.

Not all sense of self-reflection was lost, though. I did realize that I was losing the parts of myself that I cared about, but I was helpless in the onslaught that is the second year of ob/gyn residency. Now, as a third year resident, I am considered a senior, and the call schedule has improved. My life is more normal, and I am able to enjoy time with my husband and my family. I bake more often. I read more, and although I haven't started photographing yet, I have learned how to knit. Overall, I'm a happier person, and I'm kinder to my patients. However, this is something that I have thought about on my own. I have rarely talked to my co-residents about this. Our administration does not address burnout and there is no forum in which we can share our thoughts and feelings. However, there needs to be discussion and awareness about burnout. There also needs to be reflection around the bad things that happen in the hospital to our patients. Mortality and morbidity conferences are not sufficient to address poor outcomes as they presents cases with surgical precision and little emotion--there needs to be reflection around feelings of the providers, the patients, and their families, all of whom are deeply affected by poor outcomes. Doctors, especially ones who are just starting to practice medicine, need to be reassured that caring about patients is an essential part of their work, and that there is no greater gift that a doctor can give to her patient than that of empathy.