The events surrounding my transition from medical student to MD and resident were a tidal wave.  My education, training, mindset, social phobia, personal life, health all combined into what I can only refer to as the perfect storm. 

    Life stress #1 and #2 – The new addition and the move.

     We learned early in my last year of medical school that we were expecting a new baby boy.  He was due right about the time we would move, the month after graduation.  He was our second child.  Our timing it seems was traditionally bad.  My daughter was born 2 years earlier a week before I took step one of the USMLE medical board exams at the end of my second year of medical school.  Timing with my son was something else.  In order to have him covered by insurance we had to have him before we moved.  My residency began orientation mid-June.  

     Thanks to a very understanding OB, my life was induced into labor June 6th.  We packed up the moving van and my wife was discharged from the hospital 2 hours behind the moving van with all our possessions inside.

    We moved to by computer matched assigned city, which like medical school was hundreds of mile from any family.  It was thousands of miles from any of our parents in particular.  We purchased our first home with the hope of staying five years.  “I’m sure they will take me into the child neuro program as soon as I get the chance to talk to  them,” I thought, naively it turns out.  

     I owe a heavy debt of gratitude for the local ward (name for a Mormon congregation, similar to a parish) where we moved.   In a show of solidarity and sympathy for my young family, whom none of them knew at all,  upwards of 25-30 people showed up at our new home to completely unload everything in under an hour.  Meals were provided for us.  While helping others move is certainly a very common way Latter-Day saints help each-other out, this was hands down the biggest turnout I have ever seen for a Mormon move.

     However, We were still living out of boxes, trying to hook up services, even as I began my first day as an MD, training to take care of children.  My son would serve very nicely as a model for development and for practicing physical examination.  I felt curiously unattached though.  It disturbed me.

    Life stressor #3- the heart.

     In preparing for the move I went into the doctor for a checkup.  He thought he heard a murmur (never identified by anyone since) and sent me for an echocardiogram.  It turned out I have a rare condition where the pericardial sack that my heart sits in did not form completely.  While often not discovered or the cause of any problems, on rare occasion, part of the heart can get caught it the openning, strangulate, and rupture, causing sudden death.  I had an MRI done the day before my son was born.  I received a call that my cardiologist was discussing it with a heart surgeon (yikes!).  In the end, this was all much ado about nothing and I never needed the surgery, but that was up in the air for several months.  I cracked jokes with other residents, instructing them to immediately crack open my chest should I suddenly fall unconscious.  Death became a consuming theme in my thoughts.

    Life stressor #4- The Job.

    I was thrown right into the fire, which did consume me.  I began my Intern, or first year, of residency on what was the most difficult rotation for the year, the Neonatal ICU.  We had overnight call every third night and put in about 100 hours/week.  This was just prior to changes that limited resident work hours to 80 hrs/wk.    My head was absolutely swimming. 

     I had to learn emergency care for some very sick infants completely on the fly.  We dealt regularly with some very distraught parents in a variety of intense situations.  I had to make the dreaded phone call.  I had to learn to speak to the nurses.  NICU nurses are a special breed.  They are appropriately, extremely protective of the infant lain in their charge.  At times, it seemed their entire professional goal in life was simply to protect the infants from us poor, ignorant interns in training. 

    NICU nurses are wonderful, their relationship with residents typically is not.  What they do is marvelously important, but really was not conducive to the function of a social phobic distinctly lacking in confidence.   I performed miserably, telling myself that all interns perform miserably their first month.  To some extent this is true, the learning curve is indeed steep, but I later learned I faltered more than most.   I walked around like a zombie.  Some of the Nurse practioners became so concerned they had the residency call me one day and tell me to sleep.  People were always asking if I was okay.  I was constantly exhausted, even if I had slept through the entire day previous.      

      I moved from this to the general inpatient pediatrics service.  It should have been a relief, but I did not feel it.  I could not concentrate.  My thoughts were constantly racing.  I would sit on call with the other resident telling me about the patients I would be covering and what I needed to do and I would not hear anything past the first sentence.  My mind would start spinning out of control, imagining disastrous scenarios one after another.   This feeling, I later learned was a hallmark of generalized anxiety disorder.  

     The hospital was extremely large and imposing, much moreso than the one I learned pediatrics in at medical school.  On call, the pager went off at least a thousand times a day, it seemed.  We were truly alone with one interns responsible for the entire non ICU patient population.  We had one supervising resident, who traditionally, had very light call.  Too often, when asking for help the answer was, “figure it out for yourself, I had to when I was an intern.”  I felt incredibly alone. 

     With every page I jumped.  I was constantly tense and still  continuously exhausted.  Each critique and suggestion, and there were many, brought to me a new round of self flagellation.  I was miserable.  I began having some strange worries.  I wondered what it was that made people into child abusers.  I started having intrusive, unwelcome thoughts about hurting children.  I somehow convinced myself that I was really a monster, hiding beneath a facade.  This kind of fear is also a part of generalized anxiety.  There was no danger of me acting on these feelings, but they seemed real and distressing.  My life was enveloped in guilt.  

    During this time my wife left to stay for an extended period with family.  She was desparate for help with the children.  I came home to an empty house every night.  I began watching the same depressing movie over and over and over.   My eating habits were reprehensible.  I was living on donuts, boxes of cookies, anything that came in a box really. 

     The low point came when I was presenting a patient whose mother had factitious disorder by proxy, popularly known as Munchhausen’s syndrome.    In typical cynical, burntout MD fashion, we got to laughing about some of the very nonmedical complaints the Mother brought.  I began laughing uncontrollably.  My laughs turned into tears that would not stop.  I went on laughing and crying for at least 20 minutes.  All the pain, all the anxiety, all the insecurity, and all the misery of my training just burst out of me.  The tears were remarkably unsatisfying and bitter.  It was a strange emotion, a disturbing one I had never experienced before.

    My attending was shaken, she quietly and concernedly gave me the number of the Medical School counselor and encouraged me to go.    I resisted.  My senior resident came and told me to go and I resisted.  Finally, she went to the chief residents who told me to go, and I agreed but put it off.  Then our evaluations came in, my program director became involved and I was dragged into the counselor’s office, immediately suspended from clinical duty. 

to be continued….

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