Burnout Sometimes Looks Like This

Okay kids, storytime.

This is a story of me realising how burntout I actually am in my job.

I didn’t think I was burning out. I was still fine to wake up every morning and go to work. And when I had weekends or days off after working weekends, I was usually unproductive and felt like I would be better off at work and being productive. I haven’t had any leave since last Christmas. I had a couple of weeks of leave planned and requested, but due to the wonderful COVID19 era, and lack of anywhere to go, and my working in the frontline during the pandemic, I cancelled all my leave requests.

I kept telling myself I’d be fine. My roster isn’t that bad. I get most weekends off and days off post weekends and sleep days post nights. And there wasn’t really anywhere else I wanted to be or could be. So it’s all fine. I’ll just keep chugging on.

Spoiler alert: Not a good move.

So on this fateful day, I was working in the medical ED (AMU) as usual when I received a call from the hospital’s discharge lounge. (It’s this area with a bunch of LayZboy chairs where patient’s who are waiting for discharge papers or rides home sit patiently). Basically people who are completely stable and need no further treatment/management go here.

So a nurse calls me up and says “Good morning, I have a patient from your team here for a blood transfusion. She needs to be admitted and blood charted please!”

My first response was a big HUH? I work in AMU. Yes I have an acute medicine “team” in AMU that admits patients with simple conditions like a viral illness, but they get discharged the next day. And we certainly don’t take elective admissions and we DEFINITELY don’t take patients in discharge lounge. Needless to say, I was super confused.

The nurse on the phone didn’t really clear things up for me. She said the patient was under my team. And she’s here and she needs admission. Over and over. Strike 1. In the end I said okay I’ll ask my registrar and come sort that out, and hung up.

I approached one of my registrars and asked him what was going on. He said that he and the other registrars had received an email from a medical consultant stating that a GP had called her saying a patient who was 8 weeks post partum was still experiencing PV bleeding and had a low haemoglobin and she needed to come in for a blood transfusion. The email also had the line “In retrospect I probably should have asked the GP to discuss with OBGYN, but given she only needs this, I’m sure we can handle it under general medicine” And of course, the house officers (like me), who actually DO the admissions, were conveniently left out of this email. So we had no idea about this patient. The other house officers were otherwise occupied so I guess it was up to me. My registrar also said it was up to me to sort out.

I didn’t know blood transfusions happened in the discharge lounge but the medical consultant had specifically asked for the patient to be admitted to the discharge lounge. It struck me as odd because that wasn’t a place unwell patients should be at all. They didn’t have a lot of equipment for medical managment there.

But I went anyway. I went to see the patient and made sure she was consented to receive blood products and was about to take some blood tests (nurses at my hospital are not certified to do blood tests and IV lines themselves. Even though nurses at the other 2 Auckland hospitals are) when I realised they didn’t have the right blood tubes for the blood bank. I asked the nurses and they had no idea what I was talking about. I huffed and had to walk all the way back to AMU to get the right tubes and returned to carry out the blood tests. The patient’s nurse and the head nurse stood in the room and hovered over me, watching. They seemed just as uncomfortable with this patient being in discharge lounge as I did. Only they didn’t really want to help me. I passed them the blood tubes I had collected and they just placed them on the table next to me instead of sending them off. Strike 2. I was sending the bloods off myself when the head nurse pushed a piece of paper under my nose and said “please chart the blood”. We were still standing in the patient’s room.

I looked at her. I was getting more confused. We have e-prescribing at our hospital. All patients admitted to Middlemore had to have an electronic prescription for their medications. I asked why I couldn’t chart it online. She said “She’s not in the system. It’s fine we can use a paper chart”. I felt super uneasy about this. And so I said “That’s a bit unsafe isn’t it? If she’s being admitted for this, she needs to have an electronic chart for the records.”

The head nurse just looked at me and said “Well she’s not in the system. You can just chart it on the paper”

Strike 3

In that moment, I got super annoyed. At the entire situation. But most of all, at the consultant that orchestrated this difficult scenario. So I said that out loud as well. “You know I’m really going to talk to Dr. A about this. Patients like this really shouldn’t be admitted to discharge lounge”.

The head nurse turned around and said “You can talk about this in the nurse’s station. Not in front of the patient okay?” And then she walked away. There was a steely note in her voice that made me raise my eyebrows. I immediately shut up. I begrudgingly wrote the prescription on the paper like she asked and took it back to the nurse’s station.

I was about to leave when the nurse, Ronita, asked to speak to me for a minute. She took me into the drug room and started talking fast, with a strain in her voice. Like she was trying hard not to cry. She told me that I was completely out of line and I cannot talk to her that way in front of the patient. She doesn’t usually have patients like this in her discharge lounge and she was doing it as a favour to Dr. A and the house officers aren’t doing Her a favour by charting medications so I shouldn’t be so entitled and she was going to file a complaint against me.

In that moment, I probably should have been appalled. I probably should have argued. I’m not sure. But I didn’t. Because I wasn’t sure what exactly was happening. I said the thing that was most obvious to me. That I didn’t mean what I said to put her down. I didn’t really understand how she made that connection but she had assumed I was hinting she was incompetent and discharge lounge was a crappy place for patients. I hadn’t meant that. I was frustrated that Dr. A had decided to place a patient there and stress out me and the nurses. I tried to explain that as best as I could to Ronita. I apologised for what I said and reassured her that she was doing a good job and this wasn’t a reflection on her. She seemed somewhat appeased and let me leave.

The situation with the patient continued, however. Ronita called me again in the next 10 minutes after I had returned to AMU to say that the patient had online prescription available and I could go ahead and do that. So I did as I was told. She then called back and said blood back refused to provide units of blood. I didn’t know what to do about that. The blood bank called me and said it was irresponsible of us as a medical team to just treat the patient with a blood transfusion when she had ongoing PV bleeding that was not addressed. She said she had called Dr. A and told her this, but Dr. A had told her to call the person who prescribed the units of blood. That would be me. The blood bank head nurse told me to assess the patient properly and call OBGYN. Again, I did as I was told. I took a gynae history from the patient, something I hadn’t done in years, and referred the patient to OBGYN. As I went back to tell the patient, Ronita reported she’s going to file a complaint against Dr. A for sending this patient to discharge lounge without calling OBGYN first. She seemed warmer towards me since I referred the patient over to the right service and out of her discharge lounge.

What a debacle.

Time for reflection. I guess this kinda shows my burnout because of the things going on in my head at the time. From the moment I received the first call from the nurse, I was annoyed. Annoyed that I was asked to do something that wasn’t my job, annoyed that I was left out of an email that would have helped a lot initially, and annoyed that it was in a place that I knew had very little resources for medical intervention. My entire walk over there I was thinking how dumb this was and why it had become my job.

When I got there and realised the proper equipment wasn’t there I got increasingly annoyed because the number of jobs just doubled. I was annoyed that the nurses weren’t helping me more and annoyed that none of this was planned out properly so that I could just do my thing and leave.

Loosely, all of the above translates to me being annoyed by kind of minor inconveniences. I should have known that the nurses there aren’t there to do stuff like this and they were just as annoyed with the situation as me. I should have expected this to be long and difficult. But I chose to be annoyed by it. And I said something to a nurse that was taken the wrong way.

Bottom line, I shouldn’t have said it. Even if it was Dr. A’s fault, it wasn’t my job to say that. It would only make a hard situation worse. It wasn’t going to help anyone. And the consequence was a nurse threatening to complain about my professionalism. Something I value a lot about in the image of myself as a doctor.

While trying to reassure Ronita, I realised how numb I was. I talked like an automaton doing confrontation de-escalation 101. Without really processing what I was saying. The word complaint definitely sent a wave of fear through me and I wanted to fix the situation before that happened, but in general I just said a bunch of things that I didn’t really feel strongly about.

And then I did something worse. I went back to AMU and started doing jobs. I admitted a patient and carried out a treadmill test and said nothing to anyone. I didn’t take a few minutes to reflect. The word “complaint” still bouncing around in my head as I was doing everything. After I finished sorting that patient out, I felt gross. I didn’t want to show my face in discharge lounge again. I saw some friends in the cafe at lunchtime and made a dramatic show of retelling the story of what happened that morning. I said it as though I was the victim in this situation. Being good friends, my audience joined in with my outrage and agreed that Dr. A and Ronita shouldn’t have put me through that.

But later on, when I was alone in my car driving home, I wept silently. I didn’t like the way I talked to Ronita. Both what I said initially, and when I was trying to fix it. I didn’t like the thoughts in my head about Dr. A. I didn’t like the way I told the story to my friends.

I realised my entire outlook was toxic from the get go. Every day I show up to work and do work, but I take things out on others in subtle ways like this. It isn’t always clear who I’m annoyed at but it’s likely to affect someone compeltely unrelated. And that’s because of my headspace. I think so much. Twice, three times when I see patients these days. I second guess every plan and every examination. I dismiss things as “useless” and “dumb”. I have no faith in what others tell me.

And it all starts with me.

Me not having a break from work, me not taking the time to appreciate the good things others do, and the way the system works. Me just not being wholly in the moment and appreciating it for what it is.

It’s a form of burnout. I didn’t even realise it was until I had brunch with a friend and she told me her usual personality of being loud and animated had dimmed in the last few months and nothing seemed to faze her. Good or bad. She said she felt apathetic about everything.

It takes something like this to realise that you need help and you need to make a change. I vowed to change. I made a simple effort. Very simple. Every time my work phone rang, I would take 10 seconds before answering it. I would literally breathe, clear my mind of everything, be aware of those 10 seconds, before I answered the phone. No matter what was happening. I would listen completely without interrupting whoever it was on the phone and I would keep my mind as open as possible while they talked.

I would then approach my RMO admin and ask for a few days off work. Just a few days. Not heaps of time. But enough to really feel like a break.

The leave hasn’t been approved yet, but the phone thing is working well so far!

I feel lighter. I feel more in control. The situations haven’t changed. There’s still a lot of questionable things I get called about, but I feel less intensely about them. I feel like I can manage them a bit better.

And in making this change, I’m slowing down my burnout process.

I felt a lot of anxiety when I got the roster for my next rotation starting in September. I aim to have some leave approved during that time.

It’s really important to realise the subtle features of burnout. It can be so variable for every person depending on their personality. You’ve just gotta keep reflecting and realise that it can always happen to you.

On that note, if you’ve read this far, thanks for doing so. Here’s a reward:

Silent treee

A calming photo of a sunset. Hope you’re all well!

Coping

3 weeks of gastroenterology down! 

Hugely annoying three weeks. Despite my first day being full of potential and exciting, things brought me down really quickly. 

I was at ADHB during my trainee intern year. Ie my final year of medical school. I had found that year fabulous and the hospital to be a really great place. But now that I’m back….. it’s really lack luster.

Adhb is woefully behind on technology such as electronic prescribing and blood test ordering. It’s behind on referrals processes and radiology liaisons. They even changed the IV cannula needles I remember using in my TI year. 

What has happened?

And worse, the heriarchy that Adhb is famous for, reared it’s ugly head.

Gastroenterology is my chosen speciality. I love working in gastro and seeing gastro patients and attending endoscopy lists. But the consultants in my department seem to not care very much for my existence. 

I made it a point to introduce myself to the consultants and greet them every morning. But beyond responding with a lukewarm “hi” they don’t say much else, and what’s more, the same consultants are super nice and conversational to the registrars. 

I don’t get it. I’m helpful too you know. I’m keen on gastro too you know.

Ugh.

Thankfully at least my registrars are nice to me and invest in my learning.

But it does bring me down. Also the job is not very busy at all. I feel like I’m back on psychiatry where there’s nothing to do. 

Sighhhhh

And then there’s this situation at home. Currently my family is planning a big move to Australia. That they want me to be a part of. They want me to quit my job here and find one there and start all over.

There are financial benefits and family benefits to doing this, but I don’t want to.

I’m aware that I sound incredibly selfish, but I feel like I should have some autonomy over where I work and where I want to live. And I don’t want to leave NZ yet. I know I probably will eventually, but I don’t want to right now. And they are taking it hard. And I’m demonized everyday.

Life’s not in one of its peaks at the moment. 
The other day a friend of mine who I hadn’t seen in years asked me about work and what it’s like to be a doctor. One of the things he asked me was; “do you often get stressed about work? How do you deal with that?”

And to be honest, I hadn’t really thought about it until he brought it up.

I actually have really bad coping mechanisms. 

I can’t remember if I ever had good coping mechanisms but I’m sure I don’t now. 

I told him, I cope by sleeping.

And that’s true. Every time things get really rough for me, I choose to go to sleep. (Yeah a real man of action, I am)

I don’t know why. But it’s an escape I suppose. The only time I don’t have to think or stress is when I’m physically unable to. And that’s when I sleep. 

Ofcourse that’s not really coping at all because when I wake up the problems haven’t magically gone away, but I guess in some ways I had a break from it and that gives me some strength to deal with it all again. 

I don’t know. 

I’m just hoping it all gets better. I just wish I knew what the right thing to do was.

Stress Excuse 

Something that ticks me off to no end is when people use ‘stress’ as an excuse to feel entitled or to treat others badly.

When you’re stressed, suddenly everything seems like a huge problem? Everything someone does is wrong. Things that, in any other circumstance is not a problem, it doesn’t affect you at all, and was never intended to hurt you in anyway.

But you end up losing it anyway, and making other people feeling just as awful as you do.

Like I am sorry your life is so hard and stressful for whatever reason, but expecting others to tiptoe around you and secretly whisper to each other “oh don’t worry, they’re just stressed. Don’t say anything to set them off” is not on.

You need to have the insight that you’re stressed and that’s why suddenly everything seems unfair and offensive. Not because the world is suddenly out to get you. Just because you don’t have a decent outlet for your stress, does Not mean everyone turns into a punching bag or a chew toy.

If you’re the sort of person who stresses about everything, then please have insight about the kind of person you turn into when you’re stressed. The rest of us are not here to annoy you. 

Everyone is just trying to do the best they can to be happy everyday. 

Don’t say “sorry I’m just really stressed” and expect people to understand. Because hey, everyone has troubles and you’re not the first person in the world to be stressed or to face certain issues. 

Just keep breathin and breathin and breathin and breathin. 

And stop being horrible to others. 

Study Hard, Then Forget

I am studying hard for my osce at the moment. But as good students do, I was distracted by a conversation with a school friend I hadn’t talked to much recently. The topic turned to studying methods. She has finished her science degree and is currently working on her postgraduate degree.

She talked about how relieved she was that she didn’t have to “study” for tests, etc. anymore. And how I still did. She asked me whether I struggled to study. Or if the work I put in is enough. It struck me as an odd question. But I got what she meant.

You know how I keep saying I’m studying cramming? Well the truth is, I stink at that. I can’t cram info to save my life. There are those people who literally take photographs of their notes in their minds and regurgitate info in that 2 hour period they are expected to do so, then forget it all. One of my fellow med students actually said “Can’t wait till Friday, and then I can forget all this!”. She was referring to the day of the osce and the information she was trying to memorise.

Now this bothers me a bit. Truth be told, she probably won’t forget it. She’s the brightest student of my year and she studies 24/7. So no, she won’t forget it because I’m sure she’ll revisit this info again atleast 10 times. Just. In. Case.

But the statement itself, shows the attitude I suppose? Learn something long enough to forget it? Blech. Of course, the education system is partly the cause of this, as they expect students to learn texts word-for-word and spew it out in that exact form and order even though- lets face it- in practice, it’s not in that exact form or order. And basically you have to learn/do something else entirely. But that’s the basis of knowledge. I take issue with this. I cannot rote learn. It’s one of the reasons I’m not very good at anatomy as opposed to physiology. For me, things need to logically fit together. I can’t accept that X = Y because it just does.

If I lose marks because I didn’t understand a concept, I’d be okay with that. But I seem to lose marks these days purely because I’m not a robot that can download screeds of info into my brain or take photos/scans of pages of notes and reprint them exactly. Sigh.

Because of this, the ‘grades’ I get are, shall we say, average? But my friend and I were talking about how that’s probably the best for people like us. I don’t like stressing. Mostly because I don’t seem to handle stress well. And more because I don’t see the point in being miserable in order to achieve that extra 5-10% in marks. Like I’ve said before, the marks are the real thing that’s going to be forgotten in the very near future. And I value learning. I enjoy learning. I would be sad if I forgot the things I learnt. So I could never really learn something and think to myself I can’t wait till I can forget it after ____. Now this isn’t to say I don’t forget anything. xD I forget a lot of what I study. And often it’s numbers, drug names, genes names, etc. But I remember concepts pretty well I think.

I just hope that what I’m left with is knowledge. And that isn’t just book knowledge. That is the ability to refer to the right books and the right resources (google, in this day and age) when I need it and find that info as quickly and accurately and apply it appropriately to the situation. While keeping a cool head. Cuz stress does bad things to people. I have way too much experience with that. It can turn you inside out. It can make you crave things that you know are bad. It can make you turn on people who care. And to be honest, that just isn’t worth it.

Anyway. The reason I decided to write about this is that my friend did a lot to calm me down while I studied for my osce. To see the bigger picture.

I shall (hopefully) do well tomorrow. Hopefully.

But here’s a quote from Einstein that may apply here:

“Education is what remains after one has forgotten everything he learned in school…” – Albert Einstein

True enough.