There’s something about airports that gets me in the writing mood. It’s probably because any time I’m in the airport, by default it means that I’m not on call/working at the Day Job. (Okay, that’s kind of a fib. I totally just logged off the EMR where I was putting out a few fires right before this plane boards. Anyway.)
 
There’s a saying in medicine: “You want care that is Good, Fast, and Cheap? Just know that you can’t have all three – you have to pick two.” Yes, there might be some public health folks who disagree, but just go with me on this one, because in broad brushstrokes, it’s true.
 
You know what else is true? I can’t have Medicine, Manuscripts, and Mayhem all at the same time. I have to pick two to focus on at any given time. As writers, we’re always picking two out of the three things. Or sometimes we’re choosing two out of four or more aspects of our lives for our focs! We’re making that seesaw balance, back and forth, all the time.
 
A weekend on call where I had hoped to edit 50 pages of manuscript? That plan got blown to bits with the 3 C-sections (1 crash section, 1 emergent) and ten adult admissions (2 into the ICU on vents, one of whom got transferred later that night). Did I get Medicine? Yes. Did I get Mayhem? Check. Manuscripts? NOPE.
 
What about when I was on call for a holiday but only had two admissions? You betcha I edited for all I was worth. Medicine + Manuscripts. But no Mayhem (thank goodness).
 
And what about the time I tried to outline a brand new book and series while on a busy vacation where my burnt-out brain didn’t want to work? Mayhem + Manuscripts. But no Medicine.
 
As authors and as humans, there is only so much we can handle at any given time, and at the end of the day it’s all about getting that seesaw to level out. Each person has to find that balance point, whether it’s writing + family + illness + work + moving + crazy life. Sometimes, though, it takes all of our effort to get that stupid seesaw back to level. But when we do? It’s magic.

We’ve heard so much about burnout. There are articles in my medical journals about physician burnout, Posts about burnout for writers, and articles about physical burnout in my trail running magazines. In each of these documents, the guidance is clear: take time for yourself. That’s cool.
 
But what happens when you don’t have the time to take?
 
What happens when everything fries at once?
 
So, quick update for those of you who don’t know me yet. I’m a family doc who does deliveries (FP/Ob) near  The End Of The Earth. It’s rural, and no we don’t have specialists. FP’s do most stuff. In my clinic, I’m it for Ob – we don’t have another FP/Ob on site for my group, so I workity-work as long as I think I can go, then get a locums doctor to come in and cover for a few weeks while I try to recharge. Only this time, nothing is recharging. I pushed beyond what was prudent over the past three months and it caught up to me in a nasty hurry.
 
Prior to and through this time, writing world was pushing and draaaging along, and right when I finally sorted out my words to complete a project…the publisher closed shop. Like, one day open and the next day done. All of a sudden, I found myself self-publishing the last two books in the series. Learning curve: vertical. Effort input: much higher than before. And to say that I’m doubting every step of the way would be a vast understatement.
 
THEN, mix in physical exhaustion. Not just from the Day Job, but also because >someone< is dumber than two bricks and decided that training for and running her first ultra-distance trail race would be a super duper swell idea. Because, who the hell needs time or sleep for 5 months of training? Fast forward in time, and 2 weeks ago I completed my first 50K trail run. It took more than a physical toll – I was completely unprepared for the cognitive and emotional drain that occurred. Thank God I was off an extra day after that weekend, because I couldn’t put a cogent thought together for a solid 72 hours after the race. Immediately after the race, hubs asked me a question, and I’m told the answer was in some form of gibberish. I don’t recall that moment.
 
So: perfect storm. #1) Fried from day job due to not much help and maintaining a massive patient load and up at night doing deliveries #2) Fried from writing job due to crippling self-doubt plus the Sisyphean task to suddenly pivot and self-publish my work and #3) Fried from emptying the physical reserve tanks far below E.
 
All those pithy self-help articles on burnout don’t really have a chapter that covers what to do when you blow through reserves in every aspect of your life ALL AT ONCE. The past two weeks have been a muddy, numb blur. Week #1, I couldn’t run, and focused on getting through work without making a mistake or sleeping through a hospital call. Week #2, felt guilty for not running and started to run (ouch) and felt guilty for not doing more with the writing stuff, even though my thinker still wasn’t thinking clearly and my "create-or" wasn't creating at all. To be fair, the home stretch of this last book felt like running through muddy quicksand. And I’m sure the 4 labor/deliveries and 2 emergent c-sections that week didn’t help the ability to buckle down, complete that final edit, and set up all the metadata/ad copy etc.
 
So what’s a gal to do? Luckily, I’m currently Far Far Away on a serendipitously timed vacation. But all the stuff I planned to do while on vacation? Nothing’s happening. Nothing is working. Everything is numb. I’m sitting and staring out the windows and cannot read or write or even think. The usual pep is gone. I spent the first 2 days remembering how to sleep for 8 hours at a time without compulsively checking my phone to see if I missed a hospital call.
 
Even just opening up a book to read for fun is too much effort. The idea of outlining another manuscript and starting to write it? Haha. And thank the lord above I don’t have to care for another human being for another 2 weeks. That would be an abject disaster and maybe a little dangerous.
 
The one area that brings relief and has started to fill up those tanks? Supportive hubs and family, of course. Supportive coworkers who are doing their level best to take as much of the Day Job workload off my shoulders. The supportive writing/medicine community on social media and IRL.
 
Most importantly, it’s the recognition of the state I’m in that gives me power over it. Maybe I can’t get super productive in the next few weeks, but I have the support and tools to get back to normal brain/creative mind/physical state. At some point soon, I hope to get back to baseline multitasking ability (that is to say: "functionally hypomanic") and back in the swing of things.

This is going to be a long post, but it needs to be written. It has to do with a developing leader being told to speak up – but not speak up >too< much. It has to do with a seasoned physician being presented with a terrible choice: remain true to herself or become someone else’s definition of success.
 
And it has to do with trusting that one’s core values and self are really … perfectly reasonable and adequate, after all.
 
First of all, folks, let me set up this situation.
 
#1) Recruiting physicians to a rural area is the hardest recruit in all of medicine. When we see a quality applicant, everyone knows that this applicant is looking at several other locations, all equally in need of good help. Other locations do not have the constraints that my group does; we cannot throw a boatload of money at a candidate because of the way the larger organization is structured (our constraints involve maintaining Medicare designation, nonprofit status, etc.) What that means is this organization, unlike others who are also recruiting as hard as they can, is required to offer industry standard rates for things like salaries. We have to be careful with extra incentives like financial bonuses or created directorships to help the employment package. That’s cool, though. In the end, we doctors who want to be here for the right reasons. Just understand that candidates are not beating down any doors -- anywhere, given supply/demand in the market these days. And especially not FP/Ob (family docs who do obstetrics). They’re like the Sasquatch or the last of the white rhinos.
 
#2) I have been fortunate to do some work toward an advanced leadership degree over the past few years. One of the key components of that degree involved recruiting/retention studies. Not to toot my own horn, but that background uniquely positions me to provide best practices in the realm of recruiting.
 
#3) The group of physicians I work with comprises an eclectic bunch. Every last person is dedicated and nice. But God help us, we have our quirks. (This must be typical in rural areas. Every place I’ve worked, there are quirky characters in each group.) In meetings, we are outspoken and also support and respect each other.
 
There’s your background.
 
 
So, our medical group, like every other group across the country, is challenged to get enough physicians. True enough.
 
We successfully recruited a candidate early last year, and he is a nice person who will be joining us in 2019. (I should have AARP membership by then…) Then we had three additional interviews. One candidate decided to do a complete 180 and went with Indian Health Services (IHS) approximately 10+ hours from here. Totally different practice setting than here, and you know what? It’s A-Okay for folks to use their interviews to figure out what they are looking for in a practice/community. I’d rather they figure it out ahead of time than sign on and change their mind after starting practice.
 
Second candidate’s husband refused to move to our town and insisted that she move to his family’s town, even though the opportunity was more beneficial for her here. Hey, it’s a joint decision, I get it. Seemed rather draconian, but each couple has to find their own way.
 
Third candidate, we had a vey nice interview though she was a little quiet but that’s okay. She ended up going with a local rural health center (RHC). In light of the funding uncertainty of RHC’s, I question the decision from a fiscal stability POV, but she feels this is a more missional job. (May I posit herein that anyone going into rural primary care is mission-minded, but that’s merely one poor, overworked doc’s opinion.)
 
Se we had another interview scheduled for last month. Great candidate on paper and sounded great on my phone screen. Right attitude, right skill set, etc.. Everyone was jazzed about the site visit. We also knew he was looking at a minimum of six other places, some with the ability to provide a more juicy benefits package than we could.
 
A few days before the candidate’s visit, our physician leader sat down with me to “chat.” When I asked her why I didn’t have the typical hour to do a hospital/clinic tour with the candidate, but only 30 minutes this time, that’s when she said it: “Because you’re too intense. At least, that’s what a previous candidate said. So I’ve been told to ask you to be … less. Maybe talk less or don’t be as assertive.”
 
“Less?” I said, perplexed. Parenthetically, this physician leader is the highest energy person I have ever seen in my life and does not stop talking to breathe. My “manic-meter” goes off every time I’m around her. Pot, meet kettle. But okay. People can have opinions.
 
“We want you to be you,” she clarified. “But you know, just less … you.”
 
Honest to shit, it took me a full 15 seconds before I could respond. First instinct was to rebut this woman with her own reflection.
 
But that’s when it hit me. As much as her statement hurt? Yeah, I had pulled the same dick move on her 1 year ago prior to that 3rd candidate’s interview. Because this leader had not stopped talking for 20 minutes during the 2nd candidate’s interview. At that time, a few days before the 3rd candidate visited, I asked her to “tone it down”, which is pretty much the same thing as “be less.”
 
What we said to each other are both forms of “sit down and shut up”, which happens at a surprisingly high rate with women in leadership. There’s an unconscious bias or downward pressure that gets worse the higher up a woman dares to go. Let me give you an example:
 
Let’s say you describe Dr. A as
#1) forthright
#2) a patient advocate
#3) skilled
#4) outspoken
#5) intense
 
If you presume Dr. A is a man, then your response (based on sociological data from numerous studies) is more often positive. If you presume Dr. A is a woman, then the response is markedly more negative.
 
But the negative interpretation is magnified when it’s a woman telling another woman to “sit down and shut up”.
 
Worst of all? I should have known better a year ago. Now look, I cannot speak to anyone else’s personal/business ethics. But I can tell you that I disappointed myself a year ago by violating my personal ethics when I told this female leader to ‘tone it down’. Even worse -- I DIDN’T REALIZE IT at the time. Even worse? Another leader was present when I said it, and that woman said nothing, too.
 
It’s not like the world is tough enough without women freakin’ picking apart each other’s personalities and laying subtle blame for a bad outcome as a result of those personalities.
 
So I spent about three days stewing on what she had said and what I had said as well. The wrongness of the whole thing irritated me. The shame of being told to “sit down and shut up,” combined with the fact that I was equally as guilty? That really hurt.
 
Questions rolled through my head. Would I be successful only if I became “less” of a person? What did her assessment mean about my complete self? “Sit down and shut up” sends a hell of a horrible message.
 
A few days before the candidate’s visit, I had emailed him – tentatively and second-guessing every word – to welcome him and his wife to the community and offer an informal tour and coffee. Just wanted to be hospitable. But suddenly I was paralyzed: Was it too much? Too forward? Too pushy? Too … me?
 
Then the candidate wrote back that they would love to meet up. I wrestled with what to do and how to act. Should I be “less” – and if we were successful with me being “less,” what did that mean? Should I be “me” – and if we did not succeed with me being “myself,” what did that mean? It was damned if I do/damned if I don’t.
 
As hubs and I left our house to pick up the candidate and his wife at a local hotel, I still didn’t know what to do or how to act. Shame made me sweat. Uncertainty was paralyzing. It was an awful feeling and an even more awful decision to make.
 
We pulled up in the parking lot of the hotel and entered the lobby. A pleasant couple arrived a few minutes later, and that’s when it happened.
 
A switch flipped in my head.
 
My inner voice said (paraphrasing), “Fuck it all and fuck those people who told you to be quiet.” That inner voice was shocking and sounded a little like Tyra Banks and Amy Schumer combined.
 
And from there on out, we (the candidate, his wife, hubs, and me) had a lovely afternoon where I removed those “sit down and shut up” shackles and was – warts and all – myself. It seemed like we had a great time.
 
The next day, during the hospital tour, this candidate had many more questions for a hospital administrator and our tour was delayed. The tour ended up taking 1 hour, and it was an enjoyable hour. Know why? Because I was myself, showing the passion for what I do, vision for the future, and encouragement of someone like-minded to join me.
 
This candidate, bless his heart, mentioned in several group settings throughout that day how much he enjoyed the time my husband and I had spent with him and his wife. The expression on the physician leader’s face, the practice manager’s face, and the recruiter’s face told the tale: total surprise. Like, how could this be possible?
 
The typical evening candidate dinner was our practice’s usual raucous experience. Our physician leader was at least a solid drink into the dinner and honest to God, not coming up for air with the talking. But this time, I had a different perspective. In the filter of my own standards of social situational awareness, of course it’s reasonable to take a break and let the guest speak. But now I understand that my saying something to my colleague would do more damage than good. Support of who my colleague is and sending the message that she is perfectly fine as is – that was much more important.
 
At the end of a pleasant evening, I went home with hubs. We were happy that we had put our community and practice’s best foot forward. We felt that we had done the best job possible without being fake. The next day, I wrote a brief note, following up a few items from the visit and thanking the candidate for taking a look at our practice.
 
Two days later, I received an email in return. This candidate and his wife had a wonderful time, and he commented on how “real” everyone was, and how refreshing that was to see. He returned several weeks later for a second visit, whereupon hubs and I joined him and his wife again for even more time together to talk further about the practice and community.
 
With this second visit, there was no hesitation. I was me: big laugh, big personality, patient-centered intensity – all of it, right out there for the world to see.
 
My friends, as of this morning, this candidate signed the contract to join our practice.
 

Man, I hate to call them “resolutions” because the word sounds so formal, so big, and so insurmountable. But for the first time in a long time, I feel the need to make a list about the upcoming year, if only to bring focus to the next 365 days. Also, it’s scary to write these things down for all to see – but it’s important to keep doing stuff that scares me. So here goes…
 
Medical goals:
 
#1) Get better at saying “no” to more call/more duties/more meetings and not feel any guilt when saying “no”.
 
#2) Complete a 4-year longitudinal leadership course to create future non-clinical opportunities.
 
#3) Cease being afraid/too modest to describe my experience, background, and strengths.
 
#4) Focus on patient care, and try to ignore all other BS. If it’s not about patient care, I’m not spending time/energy on it.
 
#5) Seek out leadership opportunities.
 
#6) Champion development of a resident training program at my hospital.
 
 
Writing goals:
 
#1) Finalize books #3 and #4 to wrap up the Hell’s Valley series.
 
#2) Complete and submit new romantic suspense two-book series.
 
#3) Present workshops at new and large conferences (without fear of being an imposter).
 
#4) >super secret writing goal that I want so much that it cannot be spoken aloud – I’ll let you know if it happens<
 
#5) Figure out what works in book marketing and apply it (this item might be more of a joke, because who knows what truly works?).
 
#6) Increase newsletter by 200 readers.
 
 
Personal goals:
 
#1) Complete first 50K trail run.
 
#2) Take every last day of vacation allotment.
 
#3) Read 1 book for fun every week.
 
#4) They say authors shouldn’t be political, but enough is enough. Time to speak up for what’s right even more than before. Even if it costs me readers or friends.
 
#5) Avoid emotional leeches.
 
#6) Support other writers, medicine folks, and family members more.

​Recently, I responded to a series of colleague’s tweets regarding the way an intern was treated. https://twitter.com/CadenceDO/status/823300940895842311  The intern was part of a team that cared for a young adult in the ICU, and they had to withdraw life support. (I know nothing of the situation, but withdrawing life support generally occurs when brain activity is not present.) So, one of the most gut-wrenching events to experience not only for the family members, of course, but also for the medical personnel caring for the patient.
 
The tweet story went on to explain that once care had finished, the intern asked to step away for a few moments in private and collect himself. (Or herself. Interesting side question: would this story play differently if the intern were male or female?) The intern was then given a negative evaluation comment by the attending physician because the intern displayed emotions.
 
Because there are times when when I get drained and need to recover, this story generated a ton of thoughts and concerns.
 
#1) Are there instructors out there teaching our medical students/residents to “not feel”? Let me be clear: if medical professionals lose their humanity, then health care is no better than being treated by a robot. Quite frankly, I don’t want to be treated by people who have zero emotional response if I live or die. And also, I don’t want to BE a treating physician who has no emotional response to my patients’ situations.
 
#2) Let’s talk burnout. There is a direct correlation with suppressing emotional distress/stress and the development of burnout. There are papers upon papers written on this subject. People have developed freakin’ CURRICULUM about how to “talk through” these stressful times with peers, family, or counselors. Training a doctor to suppress the very thing that makes them human? Cruel. Destructive.
 
#3) Have I broken down in front of patients? Yes. A little bit. I’ve teared up, choked up, and got the tight chest before. It’s happened when someone is telling me something awful. It’s happened when I’ve had to tell a patient something horrible. And you bet I’ve stepped away to collect myself. I’ve sat in a quiet room and sobbed for a few minutes. After work, I’ve needed to take a long drive to clear my head. There are key people I talk to, when things build up inside.
 
#4) But doctors have to stay professional, right? Yes. That is a true statement. It’s a fine line. But basically, if I go to pieces, then no, I’m not able to care for my patients. So yes, there must be a degree of separation. A degree. Not total separation. Is it hard? You bet it is. Necessary? Yes. Does that mean I don’t feel as deeply? No way. What this intern did to manage his emotional response to a painful situation was completely appropriate. The attending physician completely missed the opportunity to teach, nurture, guide, and build upon this event. 180 degrees missed the point. So badly missed that I’m confident that it hurt the intern and anyone else who is subject to this type of training.
 
 
I have years of trying to learn how to manage the emotions on the job. With that having been said, situations always come up where that response occurs and we need to manage it.
 
Let me share my example. I was on call recently. The ER doctor called me. A mid-career colleague’s wife had unexpectedly died and they were in the ER. So I went to the hospital. Not for a patient, but to support my colleague. (He recently moved here, and has no family in this area.) Another colleague joined us, and there we all three sat, in the family room. Three physicians. One in misery, and two hurting in empathy. We chatted. He cried. The other supporting colleague and I teared up. After several long hours, I had to leave him to continue my call duties. Numb. (Nothing compared to my colleague who lost his wife.) But I still needed to function and help people.
 
The next day, after two intense hospice discussions with patients and families, I was drained. Then, that evening, I saw the name of one of my Ob patients pop up on the hospital list. I dropped by the ER. My patient was having a miscarriage. I had a choice to make: let the ER doctor tell her or I can go talk with my patient. The right answer was obvious. I waded through the thick emotions in her patient room and broke the very bad news to the patient and her husband. They cried. I teared up, but tried to stay present and available to help, either by answering questions or empathizing.
 
So at the end of a series of those days, you bet I’m drained. If I couldn’t step away when needed? I’d be useless for all of the other duties during that time. And I’d burn out. To a crisp.
 
But if I didn’t feel pain along with my colleague and patient? Then I’d be useless as a physician.
 
I’ve been lucky that along the way, a few attending physicians and colleagues have taught me how to step away and how to balance emotions and duties.
 
This intern? His attending physician taught the exact wrong lesson. The attending taught what NOT to do. Hopefully someone will mitigate the damage done. Because learning to suppress humanity will fry the average physician and any healthcare professional to an emotional crisp within a few short years. If we are going to succeed as professionals and as humans, we have to help ourselves so we can help others.