key: cord-0909505-rpiwzy00
authors: Graham, Tim
title: Physician, heal thyself
date: 2021-10-18
journal: CMAJ
DOI: 10.1503/cmaj.210794
sha: cb03ba459106079276b7368b90c6a39ec806c3ef
doc_id: 909505
cord_uid: rpiwzy00

nan

I n my two decades of emergency medicine practice, I have encountered many patients who have attempted suicide by medication overdose. Most attempts seemed impulsive, with a poor understanding of the lethality of the drugs taken. When my own suicidal thoughts got out of control, I found myself relying on my medical training to calculate a lethal dose.

During residency, I was proud of being able to manage stress. But when newly hired into a large teaching hospital, I found myself struggling to keep up with the intense work and plagued by selfdoubt regarding my knowledge base and skills compared with my colleagues. A lack of ability to cope with these feelings was the first inkling of a long, steady decline that would deeply affect my life and those around me.

My dad calls this post-residency career stage "the busy time." I have come to understand that many physicians feel as I did during this period that is characterized by a growing list of work-related responsibilities (more shifts, research and teaching), family pressures (more children, a spouse's career), and a drive to excel. The demands of the clinical academic-industrial complex are insatiable. I found myself in the throes of these pressures, trying to solidify my clinical skills while pursuing an administrative interest in health informatics, supporting my wife's developing academic career and dealing with an intractable repetitive strain injury from typing a thesis and carrying around chunky infants.

Almost none of my training time in the late 1990s was spent on the wellness and resilience skills that are now commonly taught. None of my colleagues or mentors -and I had some great ones -mentioned self-care. The only skill I mastered to deal with the increasing stress was denial. By my late thirties, things had gradually deteriorated and I experienced progressive burnout, with symptoms such as sleep disruption, irritability, poor concentration and lack of empathy for my patients.

My residency project topic concerned how to care for families of those experiencing critical illness in the emergency department but, gradually, I found that I was doing everything in my power to avoid emotional conversations. On one occasion, I broke into tears while disclosing that three family members had died in an accident. I think showing some emotion can be appropriate in that situation, but increasingly, my overwrought emotions interfered with my responsibility as a physician.

I dreaded going to work. I would suffer insomnia the night before or sit in my car for many minutes before a shift, trying to summon the energy to go in. I began experiencing anxiety attacks with increasing frequency and severity. In retrospect, it is hard to believe that I was still working at this point. But I strategically dropped shifts that others picked up, and barged ahead.

My wife had been very supportive but finally came to her wits' end trying to convince me to get help. Selective serotonin reuptake inhibitors (SSRIs) alleviated my anxiety attacks but put me to bed for days at a time, with intractable headaches, nausea, and urinary and sexual dysfunction. Stabilized on bupropion, I felt less anxious, but numb; without it, my monkey mind took over, featuring an internal running commentary of self-loathing, -criticism and -deprecation, which made me feel worthless. I cycled on and off the antidepressants to minimize adverse effects, while my frustration and feelings of worthlessness grew.

Eventually, I internalized the thought that my wife and three children would simply be better off without me. It seemed my cycle of listlessness, hopelessness, anxiety, feelings of incompetence and worthlessness would continue indefinitely, and my suicidal thoughts started to coalesce into a plan. My medicine cabinet had full bottles of bupropion, two SSRIs, zopiclone, postwrist-surgery oxycodone, ibuprofen, acetaminophen (all promising) and a salbutamol inhaler (useless). None would be fatal on its own but, I was pretty sure, as I calculated dosing, I would be unlikely to survive if I took them all with conviction. One day, I started finalizing my doses and calmly thinking through the logistics.

In the end, it was an image of one of my children finding me on the floor that stopped me. Some still-logical part of me recognized that finding a dead parent would leave a profound negative impact on those little people. After dithering for several minutes, I called my wife.

My wife supported me as I sobbed uncontrollably, trying to articulate what had happened, feeling worthless and ashamed. She presented something of an ultimatum: go the emergency department or call the Alberta Physician and Family Support Program (PFSP). Now. The thought of a colleague seeing me in this state was mortifying, so I started with PFSP. Physicians are very lucky in Alberta (and some other provinces) to have access to such a peer-driven support program, and despite trepidation, I was soon talking with a physician who ensured safety and expeditiously referred me to counselling in conjunction with my family physician. With close support and a few weeks off -truly off, this time -my symptoms gradually came under control.

Physician burnout has many causes, including distress at not providing the highest-quality care, lack of collegiality within and between medical specialties, concerns about fair pay, a feeling of alignment with medical leadership, work quantity and pace, dealing with regulations and using electronic health records. 1 There is a growing emphasis on physician wellness, but remediation of these factors is challenging. In addition to the chaos of the COVID-19 pandemic, in Alberta, the whole PFSP program is now in danger of having government funding withdrawn, and the relationship between our medical association and the government is often described as being at an alltime low.

In some circles, the discussion now leans toward a wellness overload, where some (myself included) feel guilty for not attending the latest wellness seminar or activity, in addition to feeling burned out. Paradoxically, those who might benefit are often too busy to attend or not in the correct headspace to accept it. I hope we can have empathy for colleagues who are acting uncharacteristically angry, receiving complaints or exhibiting disruptive behaviour in other ways, while recognizing that a lack of collegiality has been shown to be a substantial cause of stress and burnout for others and needs to be properly managed by medical leadership.

After much help, self-reflection and self-care, I am off medications and consider myself to be in remission -not cured -of my illness. My monkey mind is all too willing to chime in with negative and melancholic thoughts. As I approach 50, I contemplate what I would tell my younger self if the opportunity arose. What are my lessons learned? I would highly encourage my younger self to develop a toolkit for health that emphasizes sleep hygiene, physical exercise, a healthy diet and, most critically, a mental health practice that includes meditation. Books like Why We Sleep, by Andrew Walker, 2 outline the incredible physical and mental health consequences of poor sleep, and strategies to improve it. In high school or university, my peers would probably have voted me least likely to ever practise meditation or yoga, but there are important lessons in a meditation practice that give insight into managing stress and anxiety, and it is not hyperbole to say they have radically improved my life. Mobile applications such as Waking Up or Headspace make learning meditation easy, and managing my thoughts and emotions is now a fundamental pillar of my self-care.

Things may feel hopeless at times, but it is possible to come out of depression and suicidality with a new and improved outlook on life. Part of this is fostering a support network. Literally and figuratively, my wife and children are the reason I am still here, and while I still struggle to accept their love, I am blessed to have supportive parents, friends and extended family and be aided by the professional services available through PFSP. I recognize that self-doubt is common, and maybe even healthy, if focused on a drive for continued professional development.

Lastly, I would tell young me that no matter how important I think work is, I am really just another cog in the never-ending gears of the health care system. Once internalized, this knowledge was liberating, and it gave me permission to prioritize myself and my well-being. In the end, if you die tomorrow, your employer will replace you, but your loved ones cannot.

Edmonton Zone, Alberta Health Services; University of Alberta, Edmonton, Alta.

Factors affecting physician professional satisfaction and their implications for patient care, health systems, and health policy

Why we sleep

This article has been peer reviewed.Acknowledgement: I would like to thank my wife, Samina Ali, who provided insight into this article in so many ways and saved my life (twice), and my children, whom I love so much. You fulfil my life.

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