Saturday, June 2, 2012

My Postpartum Overhaul: First Physical, and Now Mental

OK, It's a rainy Saturday. I am not on call. My husband is watching our 2 kids (under 2 years old) so I can work out. I just jumped on our Spinning bike and banged out 15 minutes of hard up-down cycling, while watching Cupcake Wars (It makes the time go really fast, and I vicariously enjoy the cupcakes, while actually burning calories!).

I thought up this post in the midst of the workout, and I jumped off the bike. Now I'm sitting here, sweaty, trying to bang out the writing. Meantime I can hear my toddler boy yelling. He's got a cold and is just  cranky, and he wants me. The baby is whimpering, and Hubby will have to make her a bottle one-handed, while our toddler howls and hurls things around the living room.

So let me be brief.

Quick backstory: I'm a part-time internist in group practice, and I had my second baby 5 months ago. My last few posts here on Mothers in Medicine have focused on my journey back to fitness after baby #2. I was 4 weeks postpartum, and realized that at 5' 2" and 163 pounds, I was officially obese. In spite of the fact that I was breastfeeding exclusively, I was gaining weight (and yes, that is common). It was my eating habits. Carbs, carbs, carbs. Bowl of Cheerios here, toast with butter and jam there.

I was shocked, but motivated. I got on the South Beach Diet and I lost a ton of weight. Listen, folks, the low-carb diets work. (I get no endorsement monies from them, BTW) (Though I would take some in a second, if they offered :)

I also started exercising again. For the first 3 months, I just ran outside when I could (though to call it running would be exaggerating. More like jog-walking) and did some Pilates on the floor before bedtime. This month I added back the gym.

And in 4 months, I have lost 30 pounds, down to 133 pounds, only 10 pounds away from my goal. I am well out of obese BMI range, and I feel great. Physically.

However, mentally, I am sagging. Now, Babygirl is still not sleeping through the night. My husband travels for work, alot. Though we have great family support, it is just a hectic schedule. My reserve is low.

But, some days, I find myself just suffering through clinic. The day will start out OK and manageable, and then, as happens not infrequently, I will encounter a difficult patient, and I will just get so down. I mean, so down that I come home and start surfing the net for non-clinical doctor jobs.

Now, the vast majority of my patients are absolutely lovely. Honestly. I have been so boosted, even blown away, by the interest people take in me and my family; by the unsolicited support for my working part-time; by thoughtful cards or baby gifts; by positive feedback on my clinical work

But just one angry/ blaming/ abusive/ demanding patient, and I am just crushed. Even when I am in the right (like in diagnosing an alcohol problem, or not prescribing narcotics). Even when I know the patient has psychological issues, and is only acting out at me because I happen to be sitting there. The negativity will get to me, even if there is no overt confrontation, or raised voices, or complaints. If a patient is unhappy, I feel like a failure. I get shaken, even to the point of physically shaking. I feel like I will have a panic attack in the office.

Colleagues are supportive. We all see many patients a week, and we all have similar experiences, day in and day out. There is plenty of camaraderie, and I can always find someone with whom to vent, and feel validated.

But, at the end of the day, I hate these negative encounters. They make me want to quit my job.

I'm trying to look into this, to see what steps I can take to build resilience so that I don't feel like I need to please everyone; so that I don't feel a failure when a patient is unhappy. I used to be much better at this.

I'm currently looking at the concept of Compassion Fatigue. This is new territory for me. What do other MiM know about this? Is this something that applies? Or am I just an exhausted new mom with little reserve in a demanding profession having a normal experience?


14 comments:

  1. This comment was sent in by email:

    First of all congratulations. Two under the age of 2 and you got back to work and you're in great shape.

    But your hormones are still off at 5 months post-partum and you have a non-sleeper. So irritability is expected. It will improve.

    BUT - compassion fatigue is real. You need to toughen up and also to get a sense of humor about some of the nonsense. Patients can be fantastic, especially when you follow long term and wind up seeing THEIR children as I do now. But they can also be very difficult. The best comment I've heard, which really applies, is that "It's your sandbox and you set the rules". They're unhappy - so be it. You cannot survive emotionally by keeping patients "happy". You act professional, you do what is correct, you treat to the best of your ability, you're empathetic, and you're kind with how you address an issue. But you're not manipulated and you don't take garbage from patients.

    Hang in there - you're trying too hard!

    Dr.Nana

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  2. Not a doc but a medical pro and a mom. I second all that Dr Nana said in her incisive comment.

    I too am a pleaser and get upset when others don't like me or are unhappy with my performance; it has taken nearly 30 years to understand that not everyone will be happy with me and that's ok, too.

    Stay the course, you will be feeling better in a couple years and this will fade into the background.

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  3. Our job as doctors is to make people well, not make them happy.

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  4. Thanks all! Dr. Nana, love the "play in the sandbox" rules. Just had a bossting conversation with my nruse about a somewhat hostile chronic pain patient. My nurse says, "I hope you don'y let these patients get into your psych. You do so much for people; and you can only do so much for some people."

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  5. Burnout results from stresses in the work environment. Compassion fatigue aka secondary traumatic stress disorder develops as a result of one's work itself, specifically, the interaction between the caregiver and the patient.

    I'm a veterinarian with both burnout and compassion fatigue. Taking care of myself and changing my work situation to a lower-stress type of practice relieved my depression but did not resolve the compassion fatigue. Reducing my practice hours to part-time didn't fix the problem, either. Starting work in a part-time job where I don't see patients made a world of difference, and it's what I hope to be full-time ASAP. Honestly, for me, avoidance is the answer, because even if I work through the flashbacks and nightmares I'm still at risk of a relapse. Not interested, and I grieved the loss of my identity as a clinician a while ago.

    Early on I, too, heard the advice to "toughen up" and develop a protective layer. It never happened, though I did become suicidal for a while. As for "you cannot survive emotionally by keeping patients happy", well, if my clients aren't reasonably happy, they'll find another veterinarian, my appointment book will be empty, and I won't be able to pay my bills. Simple economics.

    Genmedmom, I hope you're suffering from sleep deprivation and a touch of burnout. Compassion fatigue is another animal altogether. It will change you.

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  6. I don't think comments like "get a thicker skin" and "don't take things personally" are very helpful. I'm like you and I want to act compassionately and not just put up a huge wall, which is the impulse when patients are being rude. Yes, our responsibility is to help people get better and not necessarily make them happy, but of course having a "therapeutic alliance", a good relationship with your patients, helps the healing process.

    I do try to see things from the patient's point-of-view. They've probably been blown off by other doctors before. They're frustrated, scared, and are often not in control of their emotions. I try to adopt the stance of "I'm sorry I haven't been more helpful." Then, I hope they're willing to work with me, to problem-solve together.

    In rare cases, the patient stays angry and abusive. In that case, I can't engage them. Then, I go into the "this is all I can offer you mode". Kind of a take it or leave it. Sometimes the patient takes it--e.g. a return appointment, a second-choice (for them) medication, etc. Then, they still might leave the office rolling their eyes or muttering under their breath. They're trying to save face, but damn, those days are hard.

    I've never fired a patient before. I don't think doctors should "give up" on their patients. I suppose the only instance, besides the threat of physical violence, where I would do that is if my staff felt abused. Then, I would ask them to document like crazy all instances where the patient was hostile.

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    1. Thanks- you have a very healthy and resilient attitude- I appreciate very much that "get a thicker skin" should not be the answer... But I do think that we should have the right to fire angry and abusive patients, we should not have to tolerate that kind of behavior, and people need to get the message that that kind of behavior is not OK... Sounds like a topic fo another post...

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  7. As a current hospitalist /nocturnist and mom of three now between 17 and 21. I would advise you to work on arranging your life to maximize sleep. I don't know how the part time is arranged but sleep is very necessary for resilience. Compassion fatigue in varying degrees also is real but I wouldn't make any drastic decisions till at least after you are sleeping and not breast feeding. Good luck and "it does get better" but we do need to keep working on work/life balance as life is busier we need to accomodate it.

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  8. Sleep. First, second, third, you need sleep. Then you can start working on other things...

    Where does your affirmation come from? Who is telling you that you're doing a good job, and are you really hearing it?

    I shudder at the advice to "get a thicker skin", because so often that means "shut yourself off from your own emotions", and that way lies much more trouble.

    I'm an internist and a hospice/palliative medicine physician, with one 12-year-old daughter. I have an easier time coping with angry patients than with difficult interactions with co-workers and bosses, but the need for resilience is the same. I have a great network of friends - some in medicine, some not - that listen to me process the hard stuff, and that's also why I started blogging in the first place.

    There is also a skill to managing those difficult encounters, and we can all learn to do it better - take a look at www.aachonline.org, especially their doc.com resource. I don't meant to suggest that it's your fault patients are angry, simply that there are skills we can learn to help us cope with those encounters, which are an inevitable part of medicine.

    And, finally, back to the affirmations. Where are the thank-you notes you get from patients? The cards they sent after the baby was born? The positive comments on patient-satisfaction surveys? If they're not hanging on a bulletin board in your office, pull them out and tack them up. When someone says something nice, see if you can give it the same power as those bad encounters. Think about it. Savor it. Ignore the voice in your head that says "oh, but she's just..." or "he only said that because..." and really enjoy the satisfaction you deserve.

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    1. Thanks so much- I'm looking at AACH online now, it's changed alot since I presented at an AACH conference years ago. What a useful site! Also appreciate your advice to savor the positives. Will post more on this topic.

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  9. I agree with everyone who has said that it sounds like you might feel better with more sleep. I know drs are supposed to be invincible and not need it.... but I know I am a completely different person when I am well rested.

    Second, when patients start to grate on me, it helps if I try to understand things from their perspective. This is not always intuitive, but it can help.

    Third, if the funk persists, you might consider pharmacologic assistance. My husband recently started taking an SSRI, and he reports that things that used to make him crazy just don't have as big of a negative effect on him anymore. He's taking a baby dose, so it could be all placebo, but he is so much happier that he says he'd take the placebo effect any day.

    That + sleep + in-laws departing + LO starting daycare has made the difference between day and night in our household. I'd imagine this might be a tougher balance to strike with two LOs, but I think (hope?) it can be done.

    The advice to "get a thicker skin" and "suck it up" has never worked very well for me (ironically it tends to have the opposite effect for me....). I do hope you feel better soon!

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  10. I am a therapist, a writer & a mom who works with a lot of new moms. Sleep is so critical. I hope you find a way to store up some sleep soon. I know it is hard when you have a little one. Also, self-compassion is very important for parents and for anyone who is a caregiver or in a helping profession. Please have a look at the link below. Kiristin Neff has a great book/website called Self-Compassion. There is a lot of research being done now on how vital self-compassion is to our well-being. Here is the link: http://www.huffingtonpost.com/kristin-neff/caregivers_b_1503545.html
    Take good care!

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