As I recovered from depression, I discovered a whole new ailment, anxiety. One of the first side effects the medication gave me was panic attacks. I had a lot on my plate, really. I had to toe the line, with no relapses. I worried incessantly about the future. I worried about my patients. I worried about the rumor mill surrounding me. I worried about the impressions, fair or otherwise, that others had of me. I worried about stigma.
My residency program had a reputation for regularly dropping people. I heard the stories, every year they had someone who struggled, and then no matter the improvement, was dropped. Often they just left, and ended up just fine at a smaller, less confrontational program. I slowly gained confidence as my performance quickly improved on lighter rotations. As my anxiety became more apparent, my counseling adjusted. I learned relaxation techniques, meditation, and learned to stop and evaluate my fears to see if they were founded in reason. I tried to learn to live in the now and not the future. While the consequences of failure were real, the fear and doomsday scenarios in my head were excessive and not helpful. It is much more helpful to see what I needed to do right here and now. The consequences of my social interactions were always far overblown in my mind.
My first big test came when I repeated NICU that spring. This time I was at a community hospital, so in addition to caring for sick babies, We were called emergently to deliveries at any time during the day to resuscitate babies, life support or CPR if necessary. I began frightened, I froze up at the first few deliveries, I took time to adjust to the situation, such was my temperament. I reluctantly started a low dose benzodiazepine as my fear and anxiety were simply paralyzing and, in this situation, dangerous. Being slow to warm to new situations is murder in the resident training paradigm. I was shuffled into a new hospital or service with different expectations and a different system monthly. Attendings were often shuffled mid-month with a different style to adjust to. I was never allowed to become comfortable with anything and the tension, worry and anxiety built because of it.
However, a miracle happened. By the end of that rotation, I could see where my knowledge, comfort level and ability had skyrocketed. I felt competent, especially compared to other interns I performed alongside with. I was climbing out of a huge hole. I realized for the first time that medicine, even intensive care, was something I was capable of. Unfortunately, I split attendings between the first and second halves of the month. The first was excessively critical and the second had no idea how far I had come. I was passed but would need to do the month again.
The program began to feel maybe I just wouldn’t survive with my fragile mental state. In my heart, I had achieved a great victory and a level of function that convinced me for I could do this job. For the first time, I believed in myself. Ironically, as the help they had me get started working and kicking in, the program’s willingness to let it work decreased. At my most defeated and cynical, I wished in my heart I had never learned to do so well in the NICU.
It was a source of endless frustration. Things started becoming adversarial. It is a difficult balance, I admit, learning to trust a trainee and let them take on responsibility and encouraging growth while at the same time protecting patients. One problem can cloud the other. An overconfident resident is dangerous, an underconfident one is ineffective. The first rule of medicine is do no harm, but we need to learn to act. The powers that be were torn in opinion of me regarding this issue.
In accordance with my career plans, I moved ahead with a child neurology interview. I was very open about my issues. The interview went very well. I felt my career was clearly going to be salvaged. I was accepted to a program near my wife’s family. My local program director was not happy. She told me I had to do three years of pediatrics to have any hope of competency, that I should have no expectation of finishing on time, and that I was being reevaluated on a month to month basis. Problem was, I kept passing my rotations, so they couldn’t actually do anything to stop me.
That changed two months later, when I did the pediatric ER rotation. like many of my fellow pediatric residents, I never felt cut out for emergency medicine. We tend to be on the anxious side of the spectrum. You have to overcome that in the ER. However, I wanted to really prove something here. Without consulting anyone I cut stopped taking my benzos. In my mind, I was better now. I needed to learn to perform without the drug. This was a horrible, stupid mistake.
We had an attending who was extraordinarily high strung. She had no use for people who “didn’t know what they were doing.” She, like no other attending before, could push my social anxiety button like there was no tomorrow. I froze up in several emergent situations and was told to “get out of my ER.” That was a bad day which evolved to a bad month which evolved to the most intense trial of my life. That was the start of the fight for my professional career.
I reintensified my psychology counseling. I had to buy objects from the store that required asking for help to get items off the top shelf, only to go and return them. I had to purchase objects at Target with a line behind me using only pennies. Eventually, I learned that annoying people isn’t the end of the world. They move on with their life, and so should I. I learned to become more assertive. That tool became invaluable as the squabble with residency administration escalated. I was flat out told to leave. I replied that I had worked to hard and come to0 far to start over and that I would not transfer out unless I was fired or I could get a second year position. Sadly, enough people by then had seen me do well enough, and my interest and ability in Neurology apparent enough, that they could not bring themselves to fire me, but they warned me that it would be over after one more mistep. It seems they believed I had the personality that was a great fit for my chosen career, but not a good fit for their program. The needs of the service were greater than the need to train. They wanted more than adequate residents. They wanted highly organized, efficient, confident residents that they implicitly trusted running their ERs and ICU services. In the case of this mammoth program, what made a good resident often had little to do with what made a good pediatrician. Even they admitted that many they had sent out flourished at smaller programs.
I developed a new strategy that kept me moving and motivated action, pure anger. It isn’t necessarily the best strategy for dealing with parents, or negotiating with superiors, or discussing things with residents and I had a few blowups, but my overall performance was unmistakeably better. I finished my remedial months with clear competence, capping it off with a NICU month where I knew more (I was now more experienced) than those who would supervise me. I became very independant. I argued directly that I needed to be advanced, that I had earned it. They feared I would not be able to handle supervision and the extra responsibility. I argued that they would really never know unless they gave me the opportunity. They conceded they would need to give me credit for my intern year. I made them put it in writing.
They had me do a Cardiology and an ER and PICU rotation prior to supervising any residents. After months of running on anger, I relaxed after this huge, hardfought victory. I was very leery of returning to that ER. It represented in a nutshell everything that had been traumatic about my residency experience. I slid through the Cardiology. I became scattered and disorganized. I had an attending who would not tolerate such things. I failed by looking past the “easy” rotation. It was over. I was never going to supervise or advance in this program.
They chose not to renew my contract after this second year, which I could not even get partial credit for because they would not let me do second year rotations. This was two weeks prior to the match and I was advised to scramble into a new residency. I refused to start over. I appealed the decision. I continued in the ER while on appeal. With my whole life turned upside down, I developed a focus and a purpose. I did just fine in the ER, which multiple attendings attested to. I did it in the worst possible circumstance. I proved to myself and to others that I was anything but a quitter. This is an accomplishment to me more than any other that proves to me I really had changed.
I lost the appeal. I lost my Child neurology postition. It was devastating. More than once, on the drive home over a bridge over the reservoir I pondered hitting the gas, falling into the water and drowning my problems away.
I began looking for alternatives to medicine. The first thing that came to mind was working for the insurance company so I could reject claims for a living and dictate to doctors what they could and could not do. As fun as that was to ponder, that was no career for me. I looked seriously and medical writing. It was very hard to find anything. I slowly tried to accept the real possibility that I would not be able to fill my calling in medicine. I did bogus limbo rotations for the rest of my contract.
I had to find a way to let go of some consuming bitterness and work with my program director to map out a career plan. I scrambled to find a research job. In Child neurology there is an actual research track where you need one year pediatrics and one year research. I tried to exploit this, but that really didn’t work. One year later, humbled and defeated, I entered the match for a medicine transition year (internship) and child neurology residency to begin the year after. My final option for Child Neurology without starting from scratch (I refused to consider this out of pride and exhaustion), was taking my pediatric intern year credit, do an internal medicine intern year and then start a pediatric neurology program.
This required all kinds of letters from, and cooperation with, my residency. I was later told that these letters were very confusing. People who read them could not decide if the program liked me or not. I think writers themselves were confused and conflicted. I was dogged and determined. No one could question my dedication to this goal at this point. As I expressed before, they seemed to feel Child Neurology was a very fitting path for me, but they needed to explain why they had done this to me at the same time.
The residency was run by committee and I had strong voices for and against me within it. It was very awkward. Through it all I needed to reach a peace with them. I needed to forgive. I needed to let go of anger, which was eating at my soul.
They found me a part time research position related to community pediatrics and medical education improvement. While working in tandem with some of the same administrators who had scuttled my residency, I had a great time. When it was over, they presented me a certificate of recognition for “outstanding service in community pediatrics.” I don’t know if I interpreted it correctly, but I took it as a moving and sincere apology. I was able to finally let go of my anger, well mostly anyway.
I took on a second part time job in order to meet the bills. We relied heavily on financial help from family. With a wealth of experience in the school of hard knocks, a dogged determination, a newly developed, hard fought self confidence, and a little luck, I pulled this off. I was accepted into a new child neurology residency and scrambled into a transition year. I am still astounded at this as I write.
I love what I am doing now. One deciding factor in making the plunge into medicine was the desire to force myself to overcome weakness. I felt medicine was a vehicle to help me become the person I wanted to be. I don’t know if I could ever have comprehended what that really would entail. I really don’t know that I would choose to experience it all again if I had the choice, but I have undoubtedly grown stronger, wiser, and better just as I set out to do.
I know not all bouts of depression end this way. I am very fortunate. I know medical professionals still don’t really know what to do with depression or anxiety, percieving it a weakness. This leads to hiding, lack of getting help, and in the end can be life destroying. I know of more than one doctor or medical student who have taken their life. Mental illness and its stigma destroy lives. I just hope that telling this story can in some way help others with either the stigma or the healing.