The other side of training.

Congratulations if you’re still following after a near 2 year hiatus. Got stuck in a pandemic. Finished training a few weeks ago. Starting as a geriatrician in private practice in a few days.
So I know you want to know, what’s it like? What’s it like NOT BEING A JUNIOR DOCTOR?

At first it’s horrible. You’re so institutionalised you don’t know how to come out of your cage. You feel like a failure because you didn’t secure The Greatest Boss Job of All Time at The Most Prestigious Hospital (even though you’re not sure you wanted that anyway) even though there are no jobs because pandemic. And then as you get to know the new private practice you’ve just joined, who’ve been encouraging you to come on board for almost the last three years, you understand what life can be like. Your life belongs to you. You get asked questions like “what hours would you like to work?” and “we’ve sorted out all this stuff for you” and “we’re here for you”. Your life is your own now. Yes there’s still college requirements but they don’t require the begging and silent shame of never getting them done on time. People ask your opinion. All that struggle was suddenly worth it.

And here is the greatest kept secret the public hospitals don’t want you to know. Private work (which lets face it, is hardly American style billings and you’re going to bulk bill a lot anyway), is lovely by comparison because you’re in control of you. No more yearly distress over having to reapply for the same job you’ve been doing for years. No more being barked at by hospital admin for minor transgressions. You’re just simply, free. Keep your eyes on the prize trainees.

This is what burnout looks like.

  1. Crying in the car to and from work
  2. You can’t think straight
  3. Feeling really disorganized and like your notes make no sense, your handwriting is too messy etc.
  4. Thinking everyone can see you’re not doing a good job.
  5. Feeling like work is a relentless onslaught in which you can never do the job well enough because the patients just keep coming, and coming, and coming.
  6. Struggling to remember things you could remember before.
  7. Feeling super tired no matter how much sleep you’ve gotten
  8. Worrying you’ve got horrible illnesses because of the above symptoms
  9. Constant headache that just doesn’t go away no matter what analgesia you use
  10. Wanting to exercise but just not quite getting there
  11. Or overexercising into burnout then doing nothing for weeks.

This was me once.  If it’s you, go and see your GP, and organise some annual leave immediately.

1 year left.

It’s a really disorienting feeling being this close to The End.  I feel like I have vertigo.  I get a new resident and talking to them realise how far I’ve come.  In my head I feel like a resident half the time, so, so much to learn – but then I get a new one and I realise how much I have to teach (in a good way).  And every now and then I realise the conveyor built this is. This week I hit a point of realisation.  I’ve been tying myself up in knots about getting a boss job and suddenly woke up to the neverendingness of this.  The constant game of trying to impress.  We did it to get into med school, training programs, job interview after job interview, every year.  And it doesn’t seem to end when you become a boss (in the public system anyway), it is the constant performance with almost no time to rehearse.  Negative time if you have kids.  I don’t want that anymore.  I’m so tired of dancing to someone elses tune.  Of the endless rotation of what defines ‘good at your job’ which is hospital dependent anyway.  And at the same time I fear leaving the public system because that’s where your relevance as a doctor lives while you’re in it.  There’s almost no information as to what lies in the great beyond.  All I want really, is to take care of my patients, and do a really good job of it.

Final year.

***Warning:  this post contains confronting themes including domestic violence, traumatic death, and bullying.  Details have been altered to protect the patients***

On Monday I start my final year of training.  It’s surreal that I’ve been writing this blog since my final year of medical school, albeit increasingly less frequent over the years as other commitments have taken over and I’ve often lost my words.  Something happens to you towards the end.  This rising tide of anger at all that you’ve been through, something inside you just wants to quit right before the end, burn it all to the ground.  You say things like “back when I was an intern”, even though when you were an intern you hated that.  And you tell stories about your internship and beyond that seemed perfectly normal to you, but through the lens of the post-bullying, post-metoo world, were actually really traumatic.  And then you realise just how very much you have supressed over the years, when you start telling your resident about a rotation and suddenly the things you had forgotten roar into your consciousness.  And you realise you barely processed them at the time.

To the lady broken and bruised all over from years of domestic violence, finally ready to leave, you are a hero.  I’m glad he went to jail and I hope he’s still there and that you’re okay.  To the guy in his forties who died of tumour lysis syndrome in front of me while calling for his mother, I’ve never forgotten you.  To the lady who died with her lungs filled up with cannonball mets, who had a small child, I’ve never forgotten you.  That nice lady with fevers who had a lung filled with MRSA that was picked up a day too late, I can’t think about you without tears, even though it was 8 years ago.  To all those kids with ‘adult’ cystic fibrosis, I wonder if you’re still alive, if you were responsive to ivacaftor and friends when it came in long after I’d moved on, I wonder if your lives are better now, if you’re still alive now.  To the guy who nearly bled to death in front of me, when I’d been made to work 24 hours straight as a second term intern, I hope they fixed it.  To the young guy crying in pain from liver mets, when I was too junior to understand that you would die that day, I hope you weren’t in pain when you finally went, and to this day I feel the sting of realisation that you were going to die that day, so young  To the beautiful husband of the lady that died suddenly, who we couldn’t contact because you were too poor to have a phone, I have never forgotten the heartbreaking grace you displayed when you arrived that day.  To my darling indigenous uraemic renal patient who I know must no longer be with us, you made me love medicine.  To the young man whose life was destroyed by tuberculosis, no one ever quite believes me when I tell people your story.  To the racist aggressive guy who abused the nurses, I have never regretted telling you I would chuck you out if you tried that again.

To the man who died because the system broke down, I can hardly think of you without suffocating.  You deserved more time on this earth.  To the little boy who became the first and only child I had to break bad news to, whose mother who had turned her life around and was dying before you, I hope I didn’t fuck it up, I had no training and I did my best.  I hope you’re okay and surrounded by love.  To the lady with the massive saddle PE who got me at my most junior running the arrest, I’m glad you lived.  To the lady with pneumonia that wasn’t pneumonia who wound up on ECMO, I prayed silently during every single ward round when we saw you.  I saw the religious icon in your room and I prayed to it.  I still don’t know who it was.  To the man crying in the emergency department as he died of a heart attack, I’m sorry I didn’t fight harder to get you the midazolam faster.  To the ED Registrar who heard me questioning your ability to read an ECG after a horrible arrest, I’m really really sorry.  I was out of line and I’m mortified at my own behaviour until this day.  I was traumatised by what I saw that night and I didn’t realise it – I hope you’re ok.  

To my renal patients, each and every damn one of you, I will never, ever, forget you or your faces.  And you June, I will never forget you, telling me to just be as I am, no matter what.  That you could be so giving, so kind, even though you must have known.  And to C, I looked after you for three months and because the night doctor forgot to tick a box, had to pull you out of the fridge in the morgue to certify you and I’m so sorry.  Neither of us ever wanted that.

To all the consultants who have berated me, locked me in dark rooms, threatened me, bullied me to ‘make me better’ – I hope one day you get the help you need and realise what decades upon decades of built up and pent up vicarious trauma has done to you.  I am not better because of you, I am better in spite of you and I will never, ever, be you.  To every single workforce administrator who bullied us via the rosters, who threatened our jobs, who weren’t there when we needed you – your time is up.  To the new age ones who listen and roster appropriately, thankyou.

I could do this all night, I have so many more memories of it all.  I’m currently at the loveliest department, on the loveliest campus in the world.  And yet I walk around it, constantly on edge, waiting for the other shoe to drop, waiting for someone to find some fault, for a horrible horrible arrest to happen.  And it doesn’t.  But every day, echoes of those experience follow me around, burn me out a little, even though the real burnout is long gone.  Every time the supervisor report comes around, little memories spring up, the dark room, fear the responses out of proportion to my performance spring up and I wonder how badly I’m going to do.  And every time I do really well, and every time I don’t see what they see.  I still see that intern, failing cannulas, being berated at the weekly meeting in front of an entire department for not using the right ICD10 codes, standing helpless in front of patients dying from diseases that are long past the window for cure, if there ever was a window at all.

And as I walk into this final year, slowly I start to realise why most consultants aren’t full time anymore.  I start to realise just exactly why there is no shame in walking away from this, of going to the community where you have the most opportunity to make a difference.  To prevent these situations, to have those crucial discussions that protects our patients dignity and quality of life.  I don’t ever want to completely leave, but it’s been a long long road and reliving all of that, by working in all of that for decades is something I’ve realised I don’t really want.  I do want to heal from all of that, and for that reason this year is all about that, of letting it go, of doing the rest of my life on my terms, whatever that looks like.

On being a healer.

If you’re an idealistic sort of person, applying for medicine is all about helping people.  It’s that vocational calling, not really rooted in anything rational, just this deep desire to connect with people, and help them in some way.  You know it’s a calling because when people question you on it, tear you down on it, laugh at it, tell you that it is not as valid a reason as loving anatomy or physiology, or science in general, it holds up.  It just holds up anyway, in the face of all that because that’s what conviction is.

Now nearly ten years since I finished medical school, I think a lot about what helping people really means, especially in that strange paradigm that’s a public hospital, that place of a million competing interests, not all of them patient-centred.  I watch as we treat illnesses, as the numbers recover, their colour returns, I call their families and try as best as I can to set the tone and make sure there are no surprises.  I try and keep their spirits up by telling them it’s going to get better, that home awaits,I thank them for their patience – I was in hospital for 4 days after a baby and practically self discharged, they’re in for weeks and rarely complain.  And then I learned that people with delirium frequently develop PTSD.  The things they see and hear, none of them rarely good, remain as memories.  We don’t talk too much at work about people might be feeling, if not only because the whole thing is so overwhelming for most that they don’t even know how they’re feeling until it’s all over.

The first time I ever thought about doing medicine was when I was 15.  I idolized my Dad and thought I could become a doctor like him.  When I asked him about it he just looked at me sadly said “oh my darling, you don’t need to become a doctor to be a healer”.  At the time I took it personally – did he think I wasn’t good enough?  And it took me a very long time to understand what he meant.

Healing is much more nebulous than treatment protocols for diseases.  It’s not in that bag of IV Ceftriaxone.  It’s not even necessarily your patient.  It’s their families, it’s you, your colleagues – everyone around you needs healing in some way or another.  Healing is that moment of “everything’s gonna be okay” that you feel when you wake up and aren’t sore or that terrifying fear you had is unfounded.  It’s when the air is warm after a long winter and your body relaxes and stops using up so much energy to warm itself.  It’s in that moment in a family meeting when you say “let’s stop for now, that’s a lot of information and these times are just so hard on you all”.  It’s the look on someones face when you validate how shit everything is right now, and that while you don’t have all the answers, you’re right there with them.  It’s in compassion and kindness and friendliness and reassurance, in those warm moments when someone says “hey I get stuff wrong too” instead of the cold “I’m perfect and obsessive” or when you sit down and just listen instead of telling someone you have to go because you’re so busy.  It’s in relaxing in that mire of hospital-anxiety and doing it your way instead of the way you’ve conjured, that correct ‘this is what a doctor is supposed to be’ that you try to shoehorn yourself into in spite of it being the antithesis of you.

Healing is all about you.  Healing is treating yourself with that warmth and kindness and friendliness that seems so absent sometimes and realising that in doing that, you’re truly helping others because the way you treat yourself is ultimately the way you wind up treating your patients and colleagues.  But more than that, it becomes the way you treat the people in your life.  And in doing that, you’re more than someone who helps someone, you’re someone who heals.  As a doctor, if you can be both that person who can manage the illnesses well, with a degree of knowledge, competence and confidence, and in addition, be someone warm who validates their suffering without having to be told.  Be someone who is endlessly kind and collegiate to their colleagues and doesn’t try to ‘teach them lessons’ by rejecting their requests, or belittling their missing details, instead offering to help them find them, or gently suggesting where, then my wonderful reader, you are both doctor and healer.  I see these colleagues from time to time and they are something very special.  The specialness comes from the kindness you display to everyone around you.  Don’t discount it, don’t let it be discounted by those who don’t understand it or are so far behind you on the path that they see it as weakness.  Let the best part of you come through in spite of that noise, you and your patients will be better for it.

None of us are getting out of here alive.

Dramatic no?  But as much as we might rationalise it, that’s medicine.  I’m PGY a trillion now, but strangely enough, Friday was the first time I’ve ever had to tell a perfectly cognisant person that they were going to die in the next few weeks to months.  Seriously. I’d never done it before.  I’d told family after family, held their hands and passed them tissues, made cups of tea many times over.  I’ve done actor training on breaking bad news, and then more actor training, and then more actor training.  And then some more.  But every single one of those training sessions was on breaking it to family.  Never to the patient.  It’s not something we are taught to do.  And in the public hospital system I’ve noticed it is something very much not discussed and hugely shied away from.  Sure we discuss with each other that someone is going to die.  We talk about the ‘futility’ of certain testing, of changing our approach, of discussing it with the family (but only once palliative care or geriatrics tells them to!) but to their face?  An elderly person?  When on earth do we do that?  Most of the time people are too unwell to be told.  But not this time.

I wont lie, I put it off for a week.  My resident and I talked it over and over and over.  My boss offered to help me.  I’m ashamed to admit I was too proud and declined and I bloody well should have let her show me how it’s done.  The problem was that we really like our patient.  She’s been with us for weeks.  And she’s going home soon anyway.  But she’s reached a point where the unique diseases that she has means they can’t be treated anymore.  And in the state I work in now, all the specialist services seem to operate almost solely in an outpatient capacity and tend not to have those discussions anyway.  I miss Sydney for this reason, I miss the absence of general medicine (apologies to my gen med colleagues, it’s just my normal).  I told her family first.  Secretly I was hoping they’d do the old ‘don’t tell my parent they’re dying unless they ask’ thing – but they didn’t, and finally after procrastinating so hard I couldn’t even look at myself anymore, I took a deep breath, walked into her room, pulled the curtain, and sat down JD style and told her.

I framed it in the way I’d done all the actor training, the words slightly altered.  “Oh no”, were her first words.  And then she cried.  She asked me if I was sure nothing more could be done.  I told her I was sure, that when it came back, we would treat her anyway, but it was unlikely to work, but we would treat her.  “Oh please“, she said, “Oh please try”.  She cried some more.  I cried a little too, but only for a second because she reached her hand out to me to comfort me and I realised, this was her sorrow, not mine.  I should be comforting her and not the other way around.  I fumbled around with my words, told her that this was going to happen to all of us, that we would all meet again one day, in one way or another.  And that right now, in this moment, the disease was surprised, right now she was as well as she could get and I didn’t really know when it would come back.  It could be weeks, or months.  She admitted she thought about dying all the time, and then the wave of grief subsided and she asked if she could be left alone to watch TV.  I gave her hand a squeeze, quietly left, and went back to the nurses station where I, the resident, and the NUM all cried because she is such a kind and lovely patient who we’ve grown attached to.

But now, as I write this, I feel an anger at the nihilism in medicine.  Especially toward the elderly.  I face it every day.  We take patients rejected from private hospitals and public rehabilitation because ‘too old’.  I get archly told by doctors senior and junior to me that a test is pointless, a treatment, because ‘what would it solve’, ‘what is the goal here’, because they never see the face of a patient asking, ‘oh please, just try’.  They never see their family saying ‘we know they’re going to die, but we just want to know’.  I get the same people waxing on about ‘costs to the health system’, like they are both the bearers and managers of that cost, forgetting in those moments that they are doctors and we are here for our patients first and foremost.  They never say these things to their faces.  I’m not arguing for a heart transplant in a 90 year old.  But one more trial of antibiotics, a brain scan, an arthrocentesis – none of these things are big asks, but they bring a lot of peace of mind.  Once you know, as a person grieving, either for yourself or a loved one, that everything that can be tried has been, once you know the hard diagnosis, instead of the presumed one, plucked from the air with the certainty of the ignorant, you can accept your grief.

My patient has children.  Grown children.  Grandchildren.  And she’s not done yet.  She’s not ready not to exit from their story, or her own.  As much as I can help see as much of the rest of her life I will.  As much sadness I have for her story as it is now, I’m also humbled by that conversation because in that tiny amount of time, I became a vastly better doctor.

What to Do When… #1 (A cheat sheet to residency)

Forgive the incoherent title, it’s late and I’m tired.  But now that the new juniors have started, I thought I’d share some tips to not letting the shit get you down.  So for my inaugural what to do when, I thought I’d talk about….

What to Do When Someone is an Arsehole to you on the Phone.

(Yeah I can’t capitalise, I’m so tired I can barely see).

Okay so you’re calling for a consult or your calling the radiology reg.  These are the most likely two circumstances in which someone is going to be a complete prick to you.  Some hospitals give out awards for blocking consults or reviews.  Down the phone their tone is dripping in sarcasm, they ask if you’ve considered this clearly obvious thing which had never even occurred to you, your self esteem is in your shoes and you’re trying not to cry because you’re so stupid you should never have done medicine right?

Wrong.

You never considered that thing because you’ve just finished medical school in the last one or two years.  Or maybe you never learned that thing.  And also you’re not psychic.  And also you’re calling for their expertise, they’re not calling you for yours.

So #1, you’re not psychic, and you’re not stupid, they’re just being an arsehole.

Then they say “what’s your name, I’m going to have to tell my boss about this”.  That’s it. You should quit right now right?  You’ve been found out.  You shouldn’t be there.  You’ve been an impostor all along right?  Wrong.  Wait for it, waaaait for it – they’re just being an arsehole.

#2.  They don’t know you.  No really.  They’ve never bloody met you.  They have no idea who you are, what makes you tick or what you eat for breakfast.  So threats to tell your boss and eat your firstborn because you’re clearly incompetent are just hot air.  They literally don’t know you.  Anyone who tries to judge your performance from a 30 second phone call is demonstrating their own incompetence.  Assessment takes time and repetition, you need to demonstrate progression – it is not what happens in a phone call the first time you speak to someone.

Then you inevitably get some set of demands about how they can’t believe you don’t know xyz, what their cat ate for breakfast 6 years ago, and the knife through the heart…you should know that.  The most useless phrase in medicine.  People who say this are simmering angry, they’ve got so much shit going on that they have no insight into that it comes out in this ridiculous way.  No you shouldn’t know that.  You’re ringing them for their help.  You might not be serving up what they need on a plate, but you’re ringing someone for help.  And when someone in a position of power gaslights, intimidates and says ‘you should know that’ to a person in a much more junior position, not only is it an abuse of power, but wait for it….they’re an arsehole.

#3 You’re ringing for their help and expertise in the care of a patient.  Don’t be afraid to remind them of that but don’t take it as a moral failing that you didn’t have all the information.  And if it was something simple, like maybe you forgot to get the HBa1c for an endo consult – don’t beat yourself up.  Apologise and say you’ll have it for them and move on.  If they go on about it – they’re an arsehole.  And they will.  But if you’re the sort of person who learns from their mistakes (like, you know, most people), you will have it ready for next time and that’s how you know you’re good at your job.

And then you get to ‘well I’m not coming to see the patient until xyz is done’.  Alright there champ, commit to having to take two phone calls.  One of my biggest lessons as a registrar is just see the patient.  You don’t need all the information, just a good clinical question and some background and a request to the caller to find out some more for you.  That’s it.  Anything beyond that is just mucking around.

#4 Get the info and call them back.  You’ll have learned something and they’ll have just created more work for themselves.

And finally, you get off the phone feeling really crappy.  You feel like a failure, you feel down in the dumps, you can’t even articulate all the thoughts behind your feelings.  It affects your work and everything seems to slow down while you battle with your unconscious brain and all the feelings it’s having in the background.

#5 Phone a friend.  Find a trusted person (not the competitive person who will also gaslight you and tell you they have no problem getting consults).  You will inevitably find that the person who gave you a hard time over the phone, gives everyone a hard time over the phone and is reknowned for their behaviour.  Bullies never operate in isolation.  If your workplace has an anti-bullying reporting service I highly recommend using it.  Nothing will get done off a single complaint and that protects people from spurious complaints (some people think getting feedback is the same as being bullied – it isn’t), but slowly and over time, as complaints collect, those slow grinding wheels of medicine move into place and the person either gets the help they need or get moved along.

But just know that when these things happen – it’s not you.  No one deserves to be treated with disdain at work, no one deserves to be barked at for not having all the details – even if it’s a recurrent problem, it needs to be dealt with in a formal way via a supervisor meeting, not belittled down a phone.  Expect better from your workplace.  This isn’t about whoever is the smartest wins.  This is about who cares the most about their patients and colleagues wins.  That’s what gets you the job you want ultimately.  People trusting you to look after their mother.  If they see a complete arsehole to a junior, they’re going to assume that’s how they behave to everyone – including patients.  So don’t accept that behaviour, and don’t ever engage in that behaviour.

I hope that’s not too heavy handed and angry, and I hope even more that it cheers a few of you up.  💖

Mojo.

Last night after writing that, I sat there and read over the last near-10 years of posts.  What hit me was how obviously hard-working I was, and the other thing that hit me was the gaps, and all the things left unsaid.  Reader, deep down I always thought I was useless.  My self-esteem has been so poor going through all of this, that I truly thought of myself as borderline-remedial.  And while it’s done a lot of growing up (because what else is low self-esteem really, than a small frightened child?), looking back over my posts broke my heart a little.  The enthusiasm, the genuine concern for her patients.  I always wanted to be that ‘star’ resident, that ‘star’ registrar.  And my career choice (not that I have regrets), has been very shaped by that poor self esteem.  I truly believed I would have no hope in certain specialties, and now I realise I would have been great in them, and would have been welcomed, if only I’d posessed a little more self-belief.  What makes you get hired?  Caring about your patients.  Being personable.  Not bringing your personal shit to work.  Clicking with the right team.  Not being so wound up and twisted-in-yourself-anxious that you can barely form sentences because when you’re like that, people can’t get to know you.

And then there’s the gaps.  2013, where the workload, the bullying, a miscarriage, and all the stuff that has made its way into the news now was my reality, where I truly fell apart.  2014, where I failed the written but had a baby which put everything in perspective.  2015 where I passed the written and the clinical with a tiny baby, but still so broken from 2013 I didn’t think any training program would take me because there was something inherently wrong with me.  I did no pre-interviews, no meet and greats and there but for the grace of whatever deity there is, I was offered a job in geriatric medicine.  2016, where I moved interstate with a baby, got no time off work and suddenly found myself in a new state with new systems, and a constantly daycare-sick kid broke me in a new way.  2017, another miscarriage.  2018, another baby, maternity leave.  And here we are now, 2019, two kids, full time work. So. much. change.

My new job feels like I’ve been hit over the head repeatedly like a hammer.  I am stunned.  Stunned by the flow of information coming at me, the meetings, the workload.  Slowly I find myself coming to, but at the same time slipping into that I’m-not-good-enough mentality.  It’s always hard when you start a new term.  You have to forge new relationships while remembering that everyone there has just lost a relationship with the last doctor, who mostly, they’ve grown to appreciate.  You can’t possibly fill their shoes.  They talk about your predecessory fondly while looking at you suspiciously, and by the time you’ve earned their trust and their love, it’s time to move on, only to do it all again.  And every little slip that I make, I feel like a knife.  Coupled with the fatigue that two small non-sleeping children bring, I find myself thinking ‘how can I possibly measure up?’.

When it comes to having a good short term memory and an excellent recall of exam-level knowledge, I don’t think I can.  I can be just good enough I think.  But I make up for it in other ways.  I make myself freely available to my patients and their families.  I tell them I don’t have the answer and that we can find it together.  I hold hands with unconscious patients.  I sit with crying adult children.  I’m painfully honest about what I haven’t done or don’t know to my boss because it’s the fastest way to trust when you can’t be that star.  But oh to be a star!  Oh to have that endless mojo of my resident youth that lent me the energy to walk 13km a night and do endless cannulas and want to change the world of medicine.  I hope it comes back soon.  I feel the weight of the years, of the impossible juggernaut that is the public hospital system in which it’s so difficult to enact change in the face of that endless historical resistance.  And the older and more established the hospital, the harder it is.  But I still hope.  I hope for a bit more sleep, for the motivation to exercise, to read studies, to be better.  I hope for my mojo back.  Hey two posts in two days – something has definitely changed, and I think for the better.

I am so tired.

Well it’s not quite a year since I last posted so I must be winning at something right!  This blog has been running since 2010 – I can’t believe it!  Pity it’s not more frequent but eh, you can only do what you can do.  So, 2010 was final year of medical school, 2019 is second last year of advanced training.  Can you believe it?  I know, I probably should be done by now but there’s two babies and two mat leaves and some part time training in there, so I’m not doing too badly.

When I look back over the last 9 years, it’s like looking over a series of mountains.  I can’t see the starting line anymore.  I’m not the same person by any stretch.  I’m harder in some places, softer in others, I’m pretty sure I’m much stupider than I was but I make up for it with lots and lots (and lots) of hospital experience.  And I’m also pretty tired of hospitals.  Some people never get over the merry-go-round and just love the acuity, the intensity, the perpetual high-functioning anxiety of it all.

But oh, I am so tired.  I haven’t slept since 2014 when my first was born.  I churn through patients and patients and patients and never quite get enough time with them because I’m drowning in paperwork and meetings and projects.  Every single little thought I have, every email I get, every meeting request gets scheduled, reminder-added, double reminder, or added to a task list with another reminder.  I get home from work and jump straight into my beautiful, relentless, children.  The evening routine of play-feed-bath-put to bed gets me to 9pm.  We wrangle dinner.  No time to make lunch if I want to sleep.  And my nights are filled with rocking my non-sleeping baby and breaking all the sleep-rules.  And then back to work, with it’s dizzying array of people, requests, and frightened, vulnerable patients and families.  I never, ever, thought it would be like this.  I had no idea.  It is just push-push-push all the time.

But less than two years to go now.  You sort of think after exams it will quieten down but it’s just a different kind of intense.  So many more competing demands.  And today I was sitting in meeting #92034783297892 and I started daydreaming about getting my letters.  Letters!!  FRACP!! I daydreamed about standing up at the lectern wearing a cap and a gown and shaking some dudes hand and getting a certificate, but really what it means is that I’m shaking that hand and walking through to my freedom from changing jobs every 3-4 months.  It will be ten years of a new job, every few months by that point.  When you think about it, it’s fucking ridiculous.  But that’s medicine.  So much of it is a level of ridiculous, delivered with full seriousness, gaslighting you into believing it’s normal.

So much is coming out into the media now, so much of my old normal which I never realised until later was overt bullying, sexual harassment, discrimination, abusive work hours.  I’m glad I’m out of all of that (mostly).  Junior doctor life, depending on where you land, is like Lord of the Flies.  It’s awful.  And maybe one day when I have my letters, I’ll have more perspective on it and maybe I can help.  But I’m so tired, I’m out of fights.  My former indignant, and usefully outraged self has been replaced by this pleasantly comatosed and somewhat zombie-like human who pastes on a smile and tells herself and everyone around her that it will be okay, that this too shall pass.  Less than two years to go.  My secret inner-catastrophising mind whispers “what if something bad happens and you never get to finish?!” Things that keep me up at night.  I have thrown myself at this wall over and over and over and the thought of that makes me feel ill.  But hey, they’re just thoughts, not realities.

I’m so tired.  And I can’t wait to be done.

Classroom anxiety.

I’m sure there’s a whole bunch of you studying for those infernal clinical exams, or know someone who is.  I do not look fondly on those days (few do, occasionally you get a misty-eyed consulting waxing lyrical about how they loved carrying their briefcase away), partly because they were, well, horrible and partly because I have classroom anxiety.  There.  I said it.  In public (of sorts).  I don’t know when it started and it was a very very long time before I realised it was a problem, but sometime between high school and med school, I became extremely afraid of classroom environments.  It probably got worse in medical school – there’s nothing quite like being an arts grad in postgrad medicine, busting your arse comprehending a chapter in your physiology textbook, fronting up to class the next day armed and proud with your newfound knowledge…and then getting absolutely owned by your cocky PhD wielding colleague who just happened to do their doctorate on that very subject.  And variations on that theme.  Daily and weekly, for a good two years.  Being the dumbest person in the room for a protracted length of time broke something in my brain and I didn’t realise it for a long time.

It started with avoiding lectures.  Especially the ones where the lecturer was known to pick on people.  The thought of being picked on, of not knowing the answer, of everyone discovering that I didn’t belong there, that I was in some way illegitimate was just too much.  Then suddenly when I began to study, learning new information became anxiety inducing.  I fell into this strange hopelessness that whatever I learned would never be enough, someone was always going to know more, be better, be more worthwhile, which in turn would reinforce that I was nothing.  So I began to avoid studying too.  Then my fears would be reinforced when I did front up to a class, and be berated for not doing the pre-reading, when all my other conscientious colleagues would dutifully know the answers.  The berating then deepened the anxiety and the avoidant behaviour got worse.  Eventually even when I did study, it got to the point in classroom situations that my memory became impaired by the anxiety of it all, and even if I had learned the right answer, it was gone.  Either it never went in from study anxiety, or it couldn’t come out due to classroom anxiety!

Occasionally I would have bursts of ultra-effectiveness, learn something really well, show up to class and know the answer…and then feel like an impostor because I’d learned it the night before and didn’t do it consistently.  Sometimes in your own mind there is no winning.

Clinical exam practice was particularly painful.  You have to show up, or you fail.  So I did.  I still remember being shouted at “DON’T FREEZE UP! YOU CAN’T FREEZE UP ON THE DAY!!” in front of everyone.  And while I showed up, I was still so impaired from the fear of it all.  I couldn’t pre-read because when I did, all I could think about was how I was never going to know enough or be good enough, or be like that awesome colleague who just studied consistently and practiced and did everything right.  I cried every day from that anxiety, and I was very very lucky that I had colleagues who stopped me in corridors and hugged me, or made me laugh to distract me.  Your colleagues are your everything in times like these.

These days I still freeze up.  I still hide in the back of the classroom hoping I wont get picked on.  In medicine people love being the one that knows the most, they love it when someone gets something wrong because we all love to show off our knowledge, it’s like a reflex.  But I still show up and don’t avoid, and sometimes the class is on a topic I know something about and even stick my hand up to answer.  It seems like such a small thing doesn’t it?  I take a lot of notes that I never seem to read, mainly to focus and calm down.  I look at my higher functioning colleagues, the consistent ones and these days I’m in awe.  I’d love to be that person asking the intelligent questions.  Maybe one day I will!

I look back over med school and my early career and wish I didn’t have this anxiety.  How amazing I would have been if I wasn’t so worried about everyone finding out.  Of letting go and allowing myself to be seen as stupid.  Of just letting go in general.  I’d get better marks, get along with consultants better – ah c’est la vie!  And the problem with anxiety is that it’s your normal – you don’t know you have it.  Your brain protects by coming up with perfectly reasonable excuses not to study, not to attend class, your ability to justify it is simply amazing, and you’re generally affronted if someone suggests anxiety to you because you’re so unaware of it.  Excuses are your reptilian brain’s way of protecting itself and it’s so hard to break free of them.  As the exam looms, try to notice it.  You don’t have to ‘fix’ it, just notice.  Through the practice of noticing, you find a new voice that takes you by the hand and leads you around the excuse, it allows you to put the anxiety into words with your colleagues, it allows you to start becoming that amazing persistent person.  And if you notice that it’s a really big problem – find a psychologist! It’s a really really really fixable problem and any performance coaching psychologist or educational psychologist will work with you and tailor a program to take it down from destructive anxiety to the best functional kind.  My very best friends have this amazing ability to take their fear and turn it into relentless study.  I’ve slowly developed the skill over time, and I’m very glad to be able to write this post because admitting it means it’s finally conquered.

Yesterday was Crazy Socks 4 Docs Day and this post was written in support of physician mental health.  We all suffer in this job and we are all in it together – I hope by admitting one of the things that has crippled me, that my readers can find a little solace.