Weathering the anniversary storm

I had a sudden urge to slap a patient yesterday afternoon.  I didn’t act on the urge and was in no danger of doing so, but it rattled me all the same.  I’ve never before felt like I wanted to hit anyone (with the possible exception of my brother when we were kids, at times of peak annoyance).

For confidentiality reasons, I cannot reveal the content of the consultation which triggered such an out-of-character emotional response in me.  In general terms, the patient has an unhealthy dose of the “poor me” mentality, a stark lack of insight into, or compassion towards, others, and is causing her loved ones distress and harm.  We not uncommonly see patients like this and she was not an exceptional example.  I normally handle such patients perfectly calmly. She just happened to inadvertently say exactly the wrong things at exactly the wrong time…. wrong for me that is.

My response was not about a heartsink patient, it was about a heartbroken doctor.

I have become really good at separating my “stuff” from my patients’ “stuff”.  Caring about, but not self-identifying with, patients’ problems.  Not contrasting or comparing.  Being very mindful (ie present, aware and non-judgmental) during consults.  Providing genuine empathy without taking others’ emotional burdens.  It has taken time and a heap of deliberate practice to do this well but the rewards have been oh so sweet.  Career saving.  I’ve got back my clinical work mojo. I once again love seeing patients.

But not yesterday.

Yesterday,  communicating with patients and staff felt forced. Conveying empathy felt fake. Working like that is draining; utterly exhausting.

Why were things suddenly so difficult?  Why was I feeling so vulnerable?

You are probably familiar with the acronym H.A.L.T. which, in a medical practitioner’s work context, stands for Hungry, Angry, Late and Tired. Being hungry, angry, late or tired not only affects our sense of work satisfaction but increases our propensity to make cognitive biases in our clinical decision making, and for medical errors to occur.  The idea behind H.A.L.T. as a self-monitoring tool is to:

  • encourage us avoid these states as much as we can (eg by prioritising sleep and nutrition),
  • recognise when we are affected by one (or more) of them, “halt” what we are doing, ask ourselves what influence being hungry, angry, late or tired is having on our performance, and then try to minimise its impact.

In contexts such as addiction recovery, “Lonely” is substituted for “Late”.  Same principles: halt, reflect, rectify (when possible), avoid negative impacts.

I was not working while hungry, angry, late or tired yesterday, but the principles of H.A.L.T. did apply.

Yesterday was my partner’s birthday.  And today is the anniversary of his death; two years since he was mowed down on his morning jog by an impaired driver. Two years ago today, I got the phone call we all dread. The phone call that informs you there’s been an accident involving one of your immediate family. The phone call that tells you that the person you love most in this world has been killed, changing your life forever.

I always find anniversaries hard, and with two dead partners and two dead daughters, I have had plenty of experience with them.

Should I have gone to work yesterday? The practice I work for is brilliant about such things – everyone there would have been utterly supportive of my taking the day off despite us being understaffed at the moment. Why then it is so hard for me to admit that, despite how far I’ve come and how well I’m doing overall, I’m not always OK? And that is OK to not always be OK?

I’ve told at least four stressed patients this week that it is OK to take sick leave for mental health reasons. I’ve counselled. I’ve written medical certificates. I’ve told them to put themselves first etc etc.  With the greatest sincerity and not a hint of irony.

I teach about doctors’ health and wellbeing all around Australia, and beyond. I’ve written a play about it (“Physician Heal Thyself”).  I’m extremely passionate about doctors’ self care, almost one of those annoying crusader types. And yet I find it so hard to practice what I preach.

Today, I have halted. I’m having a quiet day and I’m feeling much more settled.  Tomorrow I will start marking 1400 odd GP exam papers (the FRACGP written exams are being sat today around Australia). And on Monday I will walk back into the surgery, hopefully with my ability to empathise intact and my mojo restored.

The waves of grief come far less often and with less intensity as time goes on. The short storms that hit around anniversaries are precious reminders of what I’ve lost and how far I’ve come, and as such, should be treasured.

I’m positive that this one, like the last, will clear soon…. revealing clear skies and calm seas.  For underneath the currently choppy surface, I am at peace.  I’m happy, I’m fulfilled and I’m loved.  Truly loved.

Most of all, I’m grateful.  I’m grateful for many things, including the silver linings of the storm clouds – the wisdom, strength, opportunities and sense of purpose which have been given to me by that which has been taken away.

Plan A didn’t work out for me. Neither did Plan B or C.  But Plan D is working pretty well, and I’m buoyed by the knowledge that there are 22 more letters in the alphabet if I need them.

(15th July, 2017)

 

After the storm… with Amalie’s tree in foreground

Advertisements

Lived Experience

“The problem with young doctors,” a GP supervisor of mine used to say, “is not that they don’t know enough or even that haven’t doctored enough – it’s that they haven’t lived enough.”

By “lived”, he wasn’t referring to going bungy jumping in New Zealand – unless of course that particular experience had resulted in being in traction with multiple fractures. He preferred to employ doctors with lived experience of being ill or injured, of having children and, preferably, of caring for a beloved parent or grandparent in an aged care facility as well.   He wanted doctors who really understood what it was like to be a patient and/or the loved one of a patient. To him, a personal health record was far more important than a professional one.

The transformation of doctors by personal illness or tragedy is not an uncommon narrative. Hollywood has used variations of this plot numerous times in films like The Doctor (1991).  On the small screen, many a Grey’s Anatomy, House or Chicago Hope doc has been forever changed by a personal brush with cancer/trauma/addiction/leprosy.

Albeit without the glamour of a Dr McDreamy standing by, I too have been profoundly shaped professionally by personal illness and the loss of loved ones.  These experiences have taught me things that years of medical training did not.

Physical illness has taught me why patients need patience. Experiencing days when it feels like I’m trying to walk up the down escalator has brought home to me why people with chronic illness can get so drained doing “routine” things.

My most valuable lessons though, have come from seeing my loved ones suffer, and from being the one left behind and thus coming to the realisation that a patient’s death is not the end of the story.

As an intern, in 2000, I lost my then partner, Adam, to testicular cancer.  At such an early stage in my career, as a medical student and then a very junior doctor, watching a loved one struggle with and ultimately lose his battle against an incurable disease was particularly influential in my development as physician.

loving memory tombstoneI learned firsthand that treating cancer is so much more than trying to cure. That it’s more than trying to alleviate symptoms when cure is not possible.  I discovered that it is about how whatever life left is lived, and ultimately, how one dies.  This philosophy sat comfortably with me and helped me help countless patients over the years.

Much as I loved and respected Adam’s mother, I didn’t really understand her response at the time. She was in the “chance of cure at any cost” camp, wanting any treatment which had even the remotest possibility of success. This drive persisted even when it became painfully obvious to me and to Adam’s treating doctors that cure was impossible, and that Adam’s aggressive treatment regimens were causing terrible suffering.

But now I get it.  I understand now how maternal love can be so powerful that it overwhelms intellect, logic and fiscal responsibility.  For I too became a mother… and lost a child.

In December 2014, my only child, Amalie, died of neonatal sepsis. It had taken me 9 years and 5 miscarriages to meet her, and our time together was tragically short but will be forever treasured.

When she was in the NICU, fighting for her life, I would have given anything to see her pull through. In those frightening moments, no treatment would have been too extreme, no cost too great.

I thought I understood intellectually why the death of a child is so devastating for a parent.  Now I understand it viscerally, and realise that I had no idea what it is really like.

It is too recent and the emotions are too raw for me to incorporate this “lived experience” into my clinical practice in a meaningful way right now. But I will.  As I have done before.

Adam and Amalie have made me a better doctor.  They’ve made me a better person. I owe them so much.  I can’t pay them back but I am, and will be, paying it forwards.

I think my old GP supervisor would be proud.

First published in Medical Observer, 24th April 2015