“There is no greater agony than bearing an untold story inside you.” ~ Maya Angelou, I Know Why the Caged Bird Sings
This week, I am excited to present another story from a fellow physician as part of the physician wellness anthology. Although the intention of a book length anthology remains, for now, I will continue sharing some of these stories individually for all to enjoy.
I am truly honoured that these physician authors have entrusted me to share their stories. Some have multiple stories to share that touch on a variety of topics including experience with addictions, burnout, and stress-related conditions.
All submissions remain unedited in the author’s original words. So, without further ado, I am pleased to present our second submission from Dr. Dawn Baker.
“Becoming a Patient – My Self-Care Odyssey”
Two of four years had gone by already. I fancied myself as a hard-working Anesthesiology resident and a good physician who cared about her patients. But my stress management skills were so poor that I was literally making myself sick. While seeking to preserve life for others, something inside of me was dying. I could taste the bitterness building in my blood, and the cold hospital air further crystallized the acids. As fellowship applications came due and other residents mulled over their future possibilities with excitement, I couldn’t even fathom the concept of practicing medicine after graduation. My health, relationships, and psychological state were all suffering…. Was this all worth it?
All the while fulfilling clinical duties, I had volunteered to write case reports for publication, pioneered a new research project, and resolved to pass the yearly practice board exam. My studies spilled over into weekends and free afternoons, leaving little time for my husband or any self-care. In an effort to lose weight I had slowly gained due to poor eating habits over the past two years, I woke up extra early to perform short bursts of exercise and tried a very restrictive diet. However, my well-intended discipline only served to lay the groundwork for major binge eating on call shifts. The activities I once loved, like rock climbing and hiking, fell by the wayside… along with my friendships. I was burning the candle at both ends and surviving on the fumes.
Changes in my physical health began to surface. I had difficulty waking up for my early morning work duties, which often required me to leave the house before 6 AM. The fatigue from basic activities – like walking stairs – was surprisingly debilitating. My skin turned sallow, and for the first time bags formed under my eyes. My clothes were tight. Most concerning, I had not ovulated in several months. While I chocked this up to the ongoing stress, I had just turned 35… My husband and I were considering starting a family. How could I physically or mentally become a mother under these circumstances? All the discrete aspects of this situation formed a hill of evidence that I was sinking. I finally carved out time to go see a physician, who ran some lab tests. One of my hormone axes, the one that signals estrogen, was completely non-functioning. While this pattern is most commonly associated with premature menopause of extreme exercise or anorexia, it can be seen in cases of undue physical or mental stress. My doctor said, “It’s rare, but I have seen it, and it can probably be reversible after you finish residency.” PROBABLY reversible?
In The Gifts of Imperfection, Brene Brown distinguishes the term courage from its colloquial synonym of heroic by pointing out its original root meaning as “speaking one’s mind by telling all of one’s heart”. Courage is thus not necessarily about being brave in a life-or-death sense but about being openly vulnerable. I had to find my courage for the next inevitable step…. With the blessing of my residency directors, I decided to take a leave of absence from training.
FILLING MY BLACK BAG
In the era of house-calls, physicians would carry their own black bags containing a bevy of tools to facilitate healing. In keeping with this practice, all physicians should construct a virtual toolbox for self-care. Sadly, few people stop the march of their daily lives to consider the possibilities. I was forced to look at them head-on, having a new-found abundance of time on my hands. Thus, I spent significant time during my leave of absence researching and practicing different stress management techniques in hopes of figuring out what would work for me.
I first focused on sleep. Sleep is one of the most important factors in our well-being, but unfortunately it is often overlooked. Many best-laid interventions addressing mental and physical health will fail to make a difference if sleep is not addressed. Anesthesiology residents learn this during rotations in the Chronic Pain Clinic, where sleep can even be the missing link to improvement in patients’ overall pain perceptions. Out went the alarm clocks and electronics; in came the dark shades and sleep masks. I made a goal of 8-10 hours per night.
In an attempt to repair my ailing metabolism resulting from a combination of sleep deprivation and over-reliance on energy-dense but nutrient-poor processed food and caffeine, I next focused on nutrition. I began eating “real food” again, renewing my interest in cooking and allowing myself to eat slowly without interruption. The cravings for sugar were still strong, but I found healthy alternatives to junk food, Diet Coke and bars.
Many books and media resources exist that address issues of stress management, mindfulness, and present-moment thinking. The library was my first go-to resource. The concept of reading anything outside of medical texts had become completely foreign, so I naturally gravitated toward books that were succinct in their explanations of problems and practical with their solutions. I also found a vast array of internet material, from blogs with shared experiences to mobile applications for short meditations or yoga practices.
Results of my DIY approach were significantly augmented by seeing a counselor; this step proved crucial to my overall wellness. Steam of consciousness conversations with an objective party turned out to be incredibly therapeutic. While she mostly listened to whatever I wanted to say each week, she offered some further ideas when I needed them. She inspired me to try the one tool in my black bag that has become indispensable: journaling. Because I love to write, journaling works very well to bring perspective to daily events, decisions, clarification of values, and overall self-knowledge. I found my passion to start my blog PracticeBalance.com through initial attempts at journaling.
I next reflected on my physical health. Given my lost love of athletics and outdoor sports, I attempted to integrate these back into my life. Again I started slowly, electing to go outdoors for short rock climbing days with my friends and husband… but I mostly rested on the sidelines. I went to the gym occasionally. My husband and I took a few extended camping trips. While these activities were fun and relaxing, my low energy level persisted. Despite getting good quality sleep, I still felt very fatigued whenever I tried to exert myself. I used to go on long mountain bike rides and take hour-long runs post-call… what had happened? I mused about these things out loud but more often in my journal (one of my new self-care go-to items), all the while having a nagging feeling that something was still very wrong inside me.
I continued to see doctors. I now had a generalist and an endocrinologist ordering tests, bloodwork and offering potential prescriptions based on their theories of what was wrong with me. I still had no period. I was even diagnosed with osteopenia, which prompted one of my docs to say, “It’s troubling because the timeline doesn’t seem to fit. The degree of osteopenia seems too high for this to only have been going on for a year or two.” I wish I had listened harder to this foreshadowing comment. It was suggested that I get an MRI “because even though your bloodwork doesn’t show it, you could have some sort of a tumor.” I scoffed. It all reminded me of a term I learned in medical school: a “zebra chase”. Everything else seemed to be slowly improving thanks to my new-found black bag of stress management tools!
BECOMING A PATIENT
I returned to work feeling rejuvenated but wary of the potential stressors that might put me right back where I started. Medicine and Anesthesia itself were fairly easy to integrate back into my life. Many of my supervisors and fellow residents commented on the positive changes they saw within me. This fueled my motivation to continue my current self-care practices, but as months went by I felt little improvement in my physical state. My fatigue and weakness continued to gnaw at me. I occasionally struggled to perform procedures, especially those that involved visual-spatial skills. Any physical exercise was increasingly difficult. My weight continued to increase. Concomitantly, I had developed an insatiable appetite and persistently strong cravings for sugar.
One day, I ran into my reproductive endocrinologist in the Pre-Op suite while preparing to take a patient to surgery. He was pleasantly surprised to see me and stated that I was looking “much improved” compared to the fall. I assured him that while I did feel better, I still had some nagging symptoms that refused to subside. Our interaction was cursory, but I sent him an email later to expand on my comments. Could we retest my hormones? A blood test slipped in between OR cases confirmed that my estrogen levels had not budged. He sent a stern email:
“I am now going to insist that you get that MRI.” – MG
In the time it took to get an MRI on the Saturday morning before Easter (begrudgingly arranged to fit my crazy work schedule), my life changed 180 degrees. The radiologist called me into her reading room, an unusual occurrence even when the patient was a physician. I flippantly said to her, “Well, you can show me anything you might see… I know I don’t have a tumor.” But there it was, staring at me on the large, wall-mounted computer screen. It was relatively sizeable and not at all subtle, its fusiform shape similar to an octopus with its tentacles wrapped around my optic nerve. I walked out of the MRI suite into the cold morning air and was immediately blinded by the sun’s reflection on the hospital’s external metal skeleton. I gasped. I was suddenly in a place I had never been before. I had become the patient: scared for myself, worried about how to tell my family that I had just been diagnosed with a cancer, curious of the many possibilities for how to eradicate this tumor….
Within a week of my diagnosis, my family had descended upon my home and I was wheeled into the OR for a tumor resection. The tumor would be approached through the nose, but my surgeon warned me that there was a possibility he would have to perform a complete opening of my cranium to retrieve the tumor if he ran into any problems. After all, it had taken deep residence in my sella, exerting its expanding mass on my optic nerve for several years. I donned the demoralizing hospital gown, stripped to nothing underneath, in the same Pre-Op area where I met my own patients. I felt the warmth of many curious eyes on me as one of my “bosses” from the Department of Anesthesiology wheeled me down the hallway to the operative suite.
Fortunately the surgery went well, and despite some emotionally and physically trying times in the hospital of which I will spare the details, I stabilized enough to begin my own rehabilitation at home. Not wanting to take any further time off of residency, I foolishly thought I would return to work the following week! Reality was a different matter, and after one month I was able to continue, with a strong focus on mere survival and self-care, my remaining four months of residency.
Stress is both relative and individual. We all experience stress differently, and I was forced to embrace this concept when I resentfully questioned my own need for a leave of absence during training. The other residents seemed fine; why was I having so many problems? Stress for me was contributing to physical symptoms (which in hindsight was complicated by the truly organic physical process of cancer), yet residents in even more demanding fields such as surgery seemed to be faring well. Of course, comparisons are futile, and the reality is that an event that incites a breakdown for one person might be nothing but a bother to someone else. In addition, effective stress management methods are particular to each individual. What works for one person as a stress reliever, such as using a journal to write down feelings, may paradoxically incite stress in another who hates writing. We all have different gifts and strengths which contribute to how we learn and how we are most easily motivated. Taking some time to experiment and cultivate self-awareness is the key to learning which methods will be right for you.
Do not ignore physical health maintenance. I thought I was burning out, as the interplay of my tumor symptoms affected both my physical and mental wellbeing. Everything I experienced was nonspecific and could have been attributed to stress. But in the midst of my odyssey to learn about my own self-care needs, I ignored some nagging physical symptoms that could have led to a swifter diagnosis. My period had been absent for many months before I mentioned it to anyone. The deep fatigue I started to experience with just light exercise was cause for more concern than I attributed to it. My struggles to perform visual-spatial procedures at work should have prompted me to have my vision checked. And I decided to initially forgo a brain scan during a diagnostic workup in which the already-obtained results did not seem to add up. I put off appointment after appointment for the sake of my own work schedule. While time constraints present a serious barrier to seeking their own medical care, physicians need to place this as a priority, especially when unexplained symptoms arise.
Becoming a patient will forever change how you view your own patients. I was relieved to finally have a diagnosis – a reason for the strange, nonspecific, non-“me-ness” that had been going on for the last two years. But I was now in an unfortunate and (sadly) not all that exclusive club of cancer patients. The label is a powerful one with lots of meanings: concerns for discrimination (Can she DO this job? Will we need to cover her calls if she gets sick again? Who will cover when she has to see the doctor? Will her vision loss affect her ability to do procedures? Etc…), the constant question of insurance coverage, and the ever-present reality that, no matter what heroic measures are taken, a cancer de facto can always recur.
Physicians often feel that they are somehow different from their patients, impervious to illness. This perpetuates the myth among us that we should focus on our patients’ wellbeing above our own. But in the end, we are all human beings. Roles and labels are stripped away when one is lying naked on an operating table or fighting to survive in the hospital. There I was, suffering postoperatively in ICU with horrible headaches, swelling and constipation, in a noisy hospital room next to a prisoner admitted with acidosis and altered mental status because he had imbibed moonshine brewed in his cell toilet! And I was just as vulnerable, powerless, and dependent on people and the system as the 80-year old grandmother down the hall who had fallen and broken her hip.
It’s all practice. The balance of work and life exists on a continuum, a moving fulcrum. Like the practice of medicine, the practice of yoga or the practice of piano, there is no particular endpoint. But we must make self-care a priority in order to engage in this practice. It will in turn improve our capacity as physicians, leaders, caregivers, family members, and any other roles we assume in our lives.
Bio – Dr. Dawn L. Baker
Dr. Baker is an attending Anesthesiologist at the University of Utah School of Medicine in Salt Lake City. Prior to practicing medicine, she worked as a chemical engineer and earned a Master’s degree studying water purification systems. She became interested in the topics of stress management and wellness for professionals when she experienced her own health challenges during residency training. This prompted her to start PracticeBalance.com, a blog dedicated to discussing current issues in self-care and achieving work/life balance. In her leisure time, she enjoys traveling, rock climbing, strength and conditioning exercise, walking with her husband and dog, making jewelry, and other frivolous activities.
You can read more of Dr. Baker’s works on her blog – PracticeBalance.
If you are a physician, resident or medical student, and you are interested in contributing to this project, please feel free to contact me.