Changes

Today, I drove home from work post-call, crying. I had a busy, largely sleepless night, with the lovely addition of the onset of a head cold. I made it through the call shift, made it through my work shift in the morning, then headed to a feedback session with one of my course directors. The course was "Empathy" and involved interns listening to comments made by patients on tape, then delivering empathic responses back.

Most of us had a hard time with this.

One intern said she felt like she couldn't respond to the happy patient because she only sees suffering or she assumes the patient is manic or borderline--she didn't know how to treat someone who was just happy. My responses felt to me like I was still using them as questions to extract more information, instead of just interjections to let the patient know I was listening and perceiving what they said.

My course director said I had done a good job, and that I had "a practical, pragmatic approach" that she felt would become less self-conscious and improve over time. I started to say something in response and instead tears welled up (I've cried in front of her before, so I doubt she was shocked).

I told her I felt like I used to be better at empathy, at understanding where patients come from and what they're going through, and trying to connect, and that I've lost something this year. That I used to enjoy trying to connect with patients, and now I find it difficult (I didn't tell her that often, I don't bother trying).

As I drove home, I started to cry again. At first, I couldn't tell what was bothering me. I assumed it was tiredness + being sick. It felt too bad to be that simple, though. When I get really upset, I feel a squeezing pressure in my chest that seems to wring tears from me (yes, I'm aware this is psychosomatic). I tried to think, what was bothering me? Then I realized I was still crying over what I'd lost this year. But why am I so burned out, empty? What have I lost?

I think a combination of forces has dried up my empathy well (maybe it wasn't very deep to begin with?). Call it soul, or humanity, or empathy, or sympathy, or "being with"--whatever--I feel like mine has shriveled a little (or a lot) under the blaze of a ferocious burn out.

(A note about burn out: when high school seniors, or college seniors moan about being "so burned out on school right now", that is not the same. This kind of burn out leaves you feeling hollow and empty. It invades your personal life, your marriage, your quiet time, and your dreams, even when not at work.)

I'll point a finger at chronic sleep deprivation. I've been working around 60-65 hours per week (which is not that much, really, by medicine standards; please, surgeons, don't hit me) and taking 5-6 calls per month for the past 6 months. I don't feel recharged between calls, and I think over time my reserves have gotten lower. I've taken some vacation time and tried to catch up, but it seems to only take one call to flatten me out again (I like my sleep, so sue me).

That's not the whole story, though. Part of it is the patient population I treat. On call, the most memorable patients are the substance-using (usually cocaine or alcohol) homeless narcissists (or antisocials) who are in it to get a free bed. I used to fight this, but I've given in to the system where I work. This system pulls these patients in and suckles them for a while. Aww, did you relapse for the 40th time? Was that placement not nice enough for you? You didn't make any of your follow up appointments (often, despite having benefits, bus passes, or special transportation) and couldn't be bothered to take your meds (given out for free), but that's okay, come here baby, I have a bed and a tray for you. I strongly feel that this system thereby encourages these patients to continue this behavior. There's no need to make choices or take responsibility when there's always a cushy safety net. Just say the magic words ("I'm thinking about hurting myself", but don't have a real plan) and you're in. I don't mean to suggest that all my patients are like this, but enough of them are (and they all seem to come in crisis at 3 am, because they know an intern is on, rather than during the day when the attending will send them to outpatient rehab) to be grating. I said in a previous post that there are few true psych emergencies at 3 am, and I still hold that to be true. There are some, and I'm happy to treat those, but most 3 am consults to the ER are for someone who's crashed off cocaine, feeling suicidal, and completely oblivious to the idea that cocaine could make them feel this bad. They want me to fix their sadness, but don't want to give up the high.

Some few of these patients can be verbally abusive, which makes it oh-so-exciting when I get to call the police or security to escort them out.

I hate the stigma against the mentally ill, even though I recognize some of it within myself. I recently treated a patient with delirium tremens who had a CIWA of 21 on my exam. The reason for consult was "rule out other psychiatric issues". My note politely stated that I would reassess other psych issues after pt was more alert and oriented (not A&O x none like on my exam) and that the primary team should consider increasing the lorazepam drip. Agitated patients who cannot give a clear history of alcohol or benzo use are often shuttled to psych while having withdrawal. I've seen patients not receive appropriate treatment of surgical or medical conditions with no other explanation than "due to psych diagnosis". (I also hate inappropriate medicine consults by psych because someone forgot how to look up the dose on a blood pressure med, so I'm perfectly aware that this is a two-way street).

Of course, when I went to the dentist last week and saw that my chart said (in Magic Marker on the front cover) "depression, nervousness, psych problems", I nearly cried in the dentist's office. I mentioned having a history of depression and anxiety during my intake, but I had no idea it would be proclaimed on the front cover of my chart like that, for all the office staff to see. So I understood my patient last night who told me she had lied to her psychiatrist about her previous suicide attempts because she was too ashamed, so she said she'd never done anything.

I believe a lot of my burn out is related to having been an intern for nearly a full year. Internship and residency are tough (yes, even in psych). I also believe that I would be pretty burned out no matter which specialty I'd chosen.

But a part of this burn out is psych itself. It's the overuse of meds, the overuse of diagnoses, the stigma against psych patients and psych doctors (but man, are you glad to see us when you need us!), the massive pharma scandals (Seroquel, Zyprexa, and Abilify all come to mind), the overmedication of children who need appropriate discipline (and the recent revelation that the data supporting stimulant use was oversold to us), and the overwhelming feeling that I'm not cut out for this like I thought I was. I'm not as good at psych as I thought I could be, which is tough for me, as I'm usually good at clinical work (for pete's sake, I won an award for best clinician of my med school class when I graduated!). I doubt I'd be a terribly skilled therapist, and I believe that therapists should be skilled. I have some sensitivity to what people are feeling and am able to read between their words, but I'm finding that doesn't seem to be enough. In other words, I'd probably be a competent psychiatrist, but not an excellent one, and that's not good enough for me.

So for all these reasons, and one other big one (and maybe a few I forgot), I'm switching residencies to internal medicine. The other big one, obviously, is that I like medicine and miss it. I think I'd be pretty burned out right now if I'd just finished a year of medicine internship, so I'm trying to think pretty realistically (although sometimes I'm so desperate to escape my burn out that I get "grass is greener" syndrome and wish for medicine to fix my problem). I wasn't a fan of medicine as a med student, largely due to a certain attending who tore me a new one and then said I should go into medicine (which is a dumb reason to avoid a whole field, really). I clicked with medicine as an intern, though. I was good at it. I was my usual gets-too-flustered-when-paged, OCPD-I-might-have-missed-something self on medicine just like on psych, but I was better there. I was better able to see the big picture on medicine than I remembered, and less able to see the big picture in psych than I thought.

So there, that's my big announcement. Will switching residencies solve everything, or anything at all? Maybe not. It's not that I hate psych, because I don't, despite all the mean things I just said about her. After all, you have to care about something to get angry about it. There's nothing magical about doing internal medicine now (and many of the same problems exist there as well); I still don't know exactly what my career will look like from here (which makes me nervous), but I realized at some point in the fall that I could no longer see myself as a psychiatrist, and in November I realized I could see myself as an inpatient medicine attending, or supervising residents in a clinic, giving lectures to med students--in short, similar plans to what I had for psych, only now in medicine. I'm doing psych consults this month, which is giving me some closure (which I needed). I'll miss psych, especially during the sweet 3rd and 4th years of psych residency when they work 8-5 M-F and I'll be a ward upper level on medicine. I'll miss the intern class I came in with--they're wonderful people, and it has been a pleasure to watch them learn how to be doctors. The psych department is full of people who are special to me and I will miss them.

Fortunately, I'm staying within the same medical college, so the switch is relatively painless. I'll be a PGY-1.5 for 6 months, then start PGY-2 in January. This will put me 6 months behind for medicine, but 6 months ahead for psych. I still plan on doing a fellowship, so I'll be a trainee for a long time ahead.

I've thought about combining medicine and psych, and I think that's a definite possibility. I could run a primary care clinic for psych patients, for example. My psych program has offered to let me come back in the future if I want to do so; I haven't ruled this out (although I do NOT want to be a trainee for the rest of my life).

So now, on to different things. As of next Wednesday, I will no longer be a Tiny Shrink. As I've already changed the handle on this blog a couple of times, I think I'm going to close the blog out and maybe start a new one. If I do that, I'll post a link. As I struggle to find my identity as a doctor, I'm not sure it's fair to make my blog struggle with me. It's kind of like CSI picking a new lead actor when Gil Grissom's character left (or maybe not). So I think this is goodbye for now. I really appreciate anyone who has read this blog or left a comment (or indeed, made it to the bottom of this circumstantial, rambling mess of a post), and I thank you.