Saturday, August 9, 2008

Depression profile: Doc

Thanks to Doc for sending me his story. I found it quite moving. He is one courageous guy! I had to really cut it down to fit here so be sure to check out his blog to get the whole story.

Part I—The Pretender
I have always been painfully, exceptionally, extraordinarily shy. The technical term is social phobia. This has haunted and hamstrung me most of my life, but never at anytime more than when I decided I might have the ability, the drive, and the heart to be a physician.

After surviving the brutal application process, my medical career was born. In my mind though, I had fooled them. I slipped by the gatekeepers whose job was to sift out “losers” like myself.

I did quite well with the first two years of medical school which were all academic. I was a miserable third year for the most part. Surgery in particular was a meltdown month. Otherwise, I learned to keep a low profile and slide along. What I did not learn to do was to become comfortable in my own skin, put patients at ease, and feel like I had a clue doing a physical exam.

There was only one exception: kids. The intimidation factor was not there and I let my goofy self out. I had the patience to get farther with them than other students. My first exposure to them was in Neurology, where I had the luck of being assigned to the Children’s Hospital. I fell in love with it, was fascinated by it and, best of all, there was a massive shortage of pediatric neurologists. I found my calling in medicine.

Unfortunately, I was still compromised by my phobia: pacing around the hospital for 20 minutes to work up the nerve to talk to a nurse; avoiding waking up patients; being terrified of phone calls.

Then it was time to find a residency. I interviewed at every pediatric residency I applied to. Pediatric neurology is the red-headed step child of pediatric subspecialties. It’s claimed by neither Neurology or Pediatrics in training. It requires a partial residency in both which causes political problems.
The fate of the interns is determined by a computer—the infamous “match” system. It works by residencies interviewing great swaths of medical students and medical students interviewing with many residencies. Then the two parties form wish lists and the computer optimizes the list so both students and programs get the places they indicated they prefer to be. In pediatrics, 93% of medical students get one of their top three choices. In my case, due to politics I got into my fifth choice, my failsafe. It was a large program with all the clinical exposure I could want and a bunch of strangely unhappy pediatric residents. I had a deep sense of foreboding.

Part II—Meltdown
Life stressors #1 (the new addition) and #2 (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. In order to have him covered by insurance we had to have him before we moved. My residency began orientation mid-June. Thanks to an understanding OB, labor was induced June 6th. We packed up the moving van and my wife was discharged from the hospital 2 hours later. We moved to a computer matched assigned city which, like medical school, was hundreds of miles from any family. I also realized I felt strangely detached from my son, thinking of him more in clinical terms than fatherly terms. 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 in the opening, 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. Death became a consuming theme in my thoughts.

Life stressor #4 (the job): I began the first year of my 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 per week. My head was absolutely swimming. I had to learn emergency care for some sick infants completely on the fly. We dealt regularly with distraught parents in a variety of intense situations. I had to make the dreaded phone calls. I had to learn to speak to the nurses.
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 faltered more than most. I walked around like a zombie, constantly exhausted. 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 moved from this to the general inpatient pediatrics service. It should have been a relief, but I didn’t feel it. I couldn’t concentrate. 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 wouldn’t hear anything past the first sentence. My mind was spinning out of control, imagining disastrous scenarios one after another. (This feeling, I later learned, is a hallmark of generalized anxiety disorder.)
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. The many critiques and suggestions brought to me a new round of self-flagellation. I was miserable. I began having 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.

My wife, desparate for help with the children, left to stay for an extended period with family. I came home to an empty house every night. I began watching the same depressing movie over and over and over. 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 Munchhausen’s syndrome. In typical, cynical, burntout MD fashion, we got to laughing about some of the nonmedical complaints the mother brought. I began laughing hysterically. My laughs turned into tears that would not stop. All the pain, all the anxiety, all the insecurity, and all the misery of my training just burst out of me. The tears were unsatisfying and bitter.

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. I resisted. Finally, she went to the chief residents who told me to go. 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.

Part III—Acceptance
Here’s the funny thing: They told me I was depressed and I didn’t believe it. I took a kazillion question test, scored 98/100 on the depression scale, and I didn’t think I was depressed. I mean, aren’t all residents tired? Don’t all residents do nothing but eat work and sleep? I was not suicidal, hadn’t even had the thoughts.

I only knew this because I had had those thoughts before. My medical education alerted me to the fact that I had been in the throes of major depression previously. Junior high was not kind to me. I was an outcast, I was lonely, I was miserable. Young and unequipped to recognize and sort out what was going on with me, I struggled. I am likely the only Mormon kid who ever used to sneak into the chapel when the building was empty and just pour my heart out to God, begging, pleading for him stop the pain. I used to sit, staring at the bottle of Tylenol, wishing, just wishing I could get up the guts to down it all.

I never could. I always came back to the thought, “How could I do that to my family?” I knew they cared.

I moved past it on my own. I maintained high function in high school, having some happy moments and involving myself in extracurriculars and a small group of friends. I graduated fifth in my class. I received a 4 year tuition scholarship to Somewhere Else University.

I served a mission which was no small achievement for a social phobic.I took verbal abuse on what I believed and still presented what I had to offer in a spirit of love. I grew and matured. There was a period at the end where it was hard to do anything. I didn’t enjoy missionary activity or our liesure day anymore. It was a relapse, but I recovered.

Of course, when I returned to college I had my rough patches: periods of melancholy, lack of enjoyment, excessive tiredness. But, hey, I still kept my grades and married my soulmate. I made it to medical school. Sure, I was really disappointed by the general peds rotation, because I was doing something I loved got no joy out of it, but still, I wasn’t tempted to knock myself off.

Well, it turns out you don’t have to be suicidal to be depressed. I was referred to a psychiatrist, started on anti-depressants, and felt totally defeated. I wanted to be mentally strong. I didn’t want my secrets out. I didn’t want the prejudice. I felt like my medical career was slipping away, now that the pretender was caught.
On medication, disaster scenarios raced through my mind and thoughts of ending my life returned, again rebutted by the quandary of how my wife and kids would fare. While this kept me from giving in to suicidal thoughts, it sure didn’t help my guilt.

It took several weeks, but one day I found enjoyment in my old hobbies, in music, in joking around, in my children. I suddenly felt alive again, even though I had no idea previously how dead I felt for so long. I eased back into clinical duty, with a couple of rotations and with supportive attendings my abilities grew. The workload was less intense, but I was moving and thinking a thousand times better. I began to see how counter-productive my fear of weakness had been. I felt like Moroni, a prophet in the Book of Mormon, whom God told “And because thou hast seen thy weakness thou shalt be made strong” (Ether 12:37).

This was so foreign to my previous mindset. I thought I knew all about the wonders of God’s love, and what it meant to be born of God. I thought I had witnessed the transformative power of the atonement. I had read the Book of Mormon; the power of the story of Alma was burnt into my soul. Yet, somehow, I didn’t really understand these doctrines. I wanted to be great on my own, to achieve on my own. I was proud (paradoxically in light of my poor self image) and I wanted to face down my shortcomings on my own.

Part IV—Fight the Power
As I recovered from depression it brought to light my anxiety. One of the first side effects the medication gave me was panic attacks. I worried incessantly about the future, about my patients, about the rumor mill, about the stigma.
My residency program had a reputation for regularly dropping people, but I slowly gained confidence as my performance quickly improved on lighter rotations. Still, as a resident, I was shuffled into new hospitals so quickly it was hard to adjust, which in most medical situations was dangerous. I reluctantly started a low dose benzodiazepine.

As my anxiety became more apparent, my counseling adjusted. I learned relaxation techniques, 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. While the consequences of failure were real, the doomsday scenarios in my head were excessive. It was more helpful to see what I needed to do right here and now. My anxiety was mitigated but still took a lot of energy to manage.

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, the program began to feel maybe I just wouldn’t survive with my fragile mental state. Ironically, as the help they had me get started working and kicking in, the program’s willingness to let it work decreased.
In accordance with my career plans, I moved ahead with a child neurology interview. I was open about my issues. The interview went well. I felt my career was going to be salvaged. I was accepted to a program near my wife’s family. My local program director was not happy, but since I kept passing my rotations he couldn’t actually do anything to stop me.

That changed two months later, when I did the pediatric ER rotation. I wanted to really prove something here so without consulting anyone I stopped taking my benzos. In my mind, I was better now and needed to learn to perform without the drug. This was a horrible, stupid mistake. Things kept getting tougher and without the medicine the only coping mechanism I had was anger. I offended a lot of people and ended up losing my residency contract. I took some bogus limbo rotations and came up with a new plan. It had just one problem: I needed all the people who I offended to come to bat for me. It was awkward. But I knew 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.

Eventually, 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 it off. I was accepted into a new child neurology residency and scrambled into a transition year. It was absolutely astounding.

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 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.
I know not all bouts of depression end this way. Mental illness and its stigma destroy lives. I know of more than one doctor or medical student who have taken their life. I just hope that telling this story can in some way help others with either the stigma or the healing.

As always if you would like to share your depression story e-mail me at lolapalooza AT hotmail DOT com. Put "depression profile" in the subject line so I know you're not a spammer:)

4 comments:

Coffinberry said...

"I am likely the only Mormon kid who ever used to sneak into the chapel when the building was empty and just pour my heart out to God..."

No, you're not. I did that, too.

Elizabeth-W said...

Thanks for publishing this.
You'd think the medical community would be more tolerant, but it seems not to be the case. And, addiction is rampant. Hmmm...wonder why?
I'm hoping you stopped your benzos in a taper ;) Best of luck to you.

Doc said...

Coffinberry,
Thank you, it's always good to know either you aren't quite as wierd as you thought you were or at least their are other weirdos out there that think the same way.

Elizabeth,
Thanks for the kind words. The medical profession is among the worst when it comes to mental health among their own. We don't allow ourselves weakness, which makes weakness of course worse.

My dose of Benzos has gone down to almost nothing but alas, I remain on them. I am told to wait until I settle into my real job before I can seriously work on stopping meds, I guess that makes sense. I almost killed everything once, why try it again.

Miss S said...

Doc,
Thank you for sharing your story. In a sad way, it's refreshing to see that even doctors can suffer from depression... I'm on the road to what I hope will be a doctorate in Occupational Therapy, am a perfectionist, and a hard working student and I always hide my disease for fear of judgement. Your story has given me hope that while not glamorous, anyone can suffer from this pain, and thankfully can also overcome it with help. Even if we're on meds the rest of our lives, we are learning to cope. Thank you!!