Clinical, GME, Housestaff Wellness, Intern Year, Internal Medicine
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Battling Burnout and Our Quest for Perfection

The following manuscript was published as part of the March 2019 s/p The Match — One Year Later theme issue.

Two months ago, I woke up one morning at 5:30 a.m., as usual. I played my gym motivation playlist in the shower, ate oatmeal for breakfast, and headed out the door, as usual. I swore at the car that swerved into the lane in front of me without signaling, as usual. An hour later, I pre-rounded on one of my favorite patients, a man with wide, childlike eyes who had a great deal of difficulty expressing his feelings.

He had a slow GI bleed for the past few days and had required closer monitoring than the rest of my patients. I had become used to seeing him looking more tired lately when I had walked into his room, but I had remained on high alert for the smallest sign of decompensation for several days.

My pulse raced when I walked into his room that morning. He was hypotensive, reeling from the simple effort of sitting up, his eyes wild with fear and incessantly blinking as though hoping to signal for help with some kind of Morse code where words were failing. In a gesture completely out of character for this stoic man, he grabbed my hand and said, “I’m scared.” Unbidden, the thought that immediately crossed my mind was, “This is it.”

Thirty minutes later, he lost his pulse twice. It was the first time one of my patients had ever coded, and even with my lack of experience, I was not about to stand passively in the back of the room. All five feet and 120 pounds of me did chest compressions like my own life depended on the outcome. I vividly remember him bouncing on the bed like a rag doll, depersonified, as multiple people coded him. Another thirty minutes later, he was transferred to the MICU. I trembled as he left his room, although it was unclear whether it was out of adrenaline, frustration or fear. Another two days later, he was dead.

A week later, I woke up again at 5:30 a.m. and went through my routine. Hip-hop in the shower. Pants and black sweater today. Oatmeal again. Learn how to drive, what’s the matter with you?

Later that morning, as I struggled through typing a progress note and stared dully at the screen with glazed-over eyes, I realized that this was the saddest I had been in a long time. My baseline resting face already looks a little mean, but my smiles had become even more infrequent lately. I had been taken over by an overwhelming feeling of lassitude when I wasn’t at work, and the pressure at the hospital suddenly felt more intense than usual. It was exhausting to swing between those two emotional extremes every day, and it forced me to look for an explanation, to take inventory of my feelings.

It had been a rough few months. I had been dealing with ending a long-term relationship, as well as a family death and generally missing my parents and brother. My mind drifted back a week to the code, and I realized that he was the first of my patients who had ever passed away. I was so caught up in writing the perfect note, putting in orders, and demonstrating my medical knowledge that this minutia had somehow become a reflection of my personal ability and not of the care our team was providing the patient. I had placed so much emphasis on proving myself as an intern that to some degree, pride was driving my actions, not what was best for the patient.

Between this quest for perfection and the emotions that I had kept buried with no time to process them, the levees had broken. Not with a bang, but over time, with cracks that spread gradually through the façade until it burst. Physician burnout is an insidious process caused not just by long working hours. We make many of our life decisions because we relish a challenge, but forget to acknowledge our progress.

Being a resident is inherently agreeing to constantly be in a state of discomfort. We never know what the next day will bring, whether it’s complications with our patients or longer work hours than usual. Our best learning happens through our mistakes. Through this instability and the toil up the steep learning curve of intern year, we forget to measure our success for ourselves. We seek much of our validation from outside sources, such as our attendings or upper levels, and we fail to remember that our conviction in our work and effort is ultimately what matters, especially for the rest of our careers. Especially in stressful work environments, as with any job, supervisors will not always provide emotionally sensitive feedback without being prompted, and faith in oneself becomes immeasurably important, especially when lives are at stake.

After my patient passed away, the most alarming change I noticed in myself was an underlying sentiment that nothing mattered. On top of the rest of my emotional stress, it seemed that this was the metaphorical straw that had broken the camel’s back. I felt strangely empty. I had always been a spiritual person, but the senseless nature of this death had stripped away that part of me. It initially felt shameful to talk about these feelings because I felt like I had turned a patient’s death into a personal tragedy, when his family and friends had actually known him and suffered so much more. The superman complex of physicians and our difficulty expressing vulnerability have been chronicled many times, but it has to be experienced to be understood. After I put aside my perceptions of my weakness and made my goal the betterment of my emotional health so that I could provide optimal patient care, it made it easier to discuss the death and take steps towards feeling better.

My program director believes in a life outside of medicine and frequently talks about the philosophy that drives his life with us. One day, when I happened to be at an emotional low, he told us the story of what pushed him to search for the purpose of his career and strive for his dream job. He said, “I had been so focused on doing well that I forgot that I wanted to do good.” It was exactly what I had needed to hear. “Doing well” is a relative term based on realistic standards for your level of experience and the progress you are making towards your end goal. As long as your personal standards are unachievably high, you will never recognize the fruits of your efforts and be motivated to continue. But as long as the end goal of “doing good” is what drives your actions, rather than outward perfection, doing well is inevitable.

Image credit: Asystole” by Community First Responders.

Kshama Bhyravabhotla, MD Kshama Bhyravabhotla, MD (2 Posts)

Peer Reviewer Emeritus

Tulane University School of Medicine

Kshama Bhyravabhotla is a Med-Peds intern at Tulane University in New Orleans who is passionate about underserved patient care and teaching. When she's not at work, she can be found watching Atlanta sports, discovering good street art and live music, and alternating between eating her way through the city and running the calories off.