How do we find balance in our profession?

I turn to Disney’s summer blockbuster, Inside Out. Rather than pitting mother against daughter or displaying the perfectly balanced, beautiful (and always happy princess), Disney teaches some valuable lessons to both kids and adults alike, and one that especially applies to the modern woman in academic EM.

Inside Out takes a different spin on our gender and travels inside the mind of a preteen girl. If you’ve ever been a preteen girl (or parented one), you can imagine what a daunting task it must have been to create this movie. In true Disney fashion, they did it magically. I laughed out loud. I cried. I hugged my daughter tightly. The plot of the movie is simple: Riley is 11 years old and must navigate through the life change of being uprooted from her Midwest life to San Francisco. The challenge and success of the movie is the emotional navigation that ensues. Up to that point in her life, Riley had been a wonderfully silly and happy girl, where Joy had reigned. Yet when Sadness and the other emotions aren’t given time to surface, the system breaks down.

When Sadness and the other emotions aren’t given time to surface, our system breaks down.

Does this sound familiar? Do you ever feel like your “Joy” mode is always supposed to be on?  For our patients: provide a friendly service. For our students: Model the perfect physician. For our aging parents: Display a soft strength. For our significant others: Be the happy, fun-loving person they married. For our children: Be a warm joyful comfort. 24/7/365. No matter the hour of the day, or what we are feeling on the inside, we are on “Joy Call”. But this is what we signed up for, right? Bootstraps buckled and happy face on.  Put the other emotions to the side.  And be the strong one.

The thing is, this isn’t natural. Each emotion has an important role to play in our lives.  Emotions protect and comfort; to work properly, our emotions need to ebb and flow to the surface of our minds. Constantly forcing one sentiment to the surface while pushing others to the depths is akin to putting a lid on a volcano: At some point, the lava will surface. When it does, there may be a little spray at first – an argument, a less than ideal patient encounter, or a rough day. This is a warning sign. Without some attention to what’s going on inside, the natural progression is eruption, melt down.

Have you been there? I know I have been; more than once. I’ve pushed aside feelings because it’s not the right time or place to deal. Rough morning with the kids but no time to be frustrated; have to go teach medical students. Disagreement with my husband; best to not argue in front of the kids. Tragic news of a family member; can’t cry now, on my way to a shift. Just pronounced a 14-year-old dead; no time to process, have to go see the foot pain in room 2.

Ultimately, I break. I scream at the kids or my husband and apologize later. I am less than empathetic with my patients, and internally counsel myself to do better next time. Or, maybe I cry.

But only a little, because a meltdown isn’t on the schedule today.

Perhaps it needs to be.

These are small breaks. They help me stay afloat and tread water. But soon, the big break will hit. It’s inevitable. This big break can take on many forms, but at the extreme it leads to burn out, depression, nervous breakdown, even suicide. Could this be a contributing factor to the disproportionately high prevalence of depression and suicide among physicians and trainees? I used to think I was immune to this disease. Now, after burying my Godmother who committed suicide just last month, I have begun to reevaluate my perspective, my risk, and the risk of my fellow female peers in academic EM.

The problem begins in training, with rates of depression higher than the general population, at 15 to 30%. Medical professionals are prone to suffer from this disease process due to a myriad of reasons, such as lack of sleep, dealing with death, making mistakes, self-criticism, litigation, 24-hour responsibility…

According to a recent article by Robert P. Bright, MD and Lois Krahn, MD, when depression hits a physician, there are many barriers to detection and management: reluctance to seek treatment, self-diagnosis/treatment and receiving “VIP treatment” from colleagues. Additionally, women are at risk for postpartum depression, with as many as 19% of women reporting frequent postpartum depressive symptoms according to a recent CDC study. The estimated depression rate of 18% among female physicians is equal to that of the general population but is most likely underestimated. Fear of an impact on licensing and the need to appear permanently healthy and happy are likely contributing factors here. The more alarming data, according to Medscape, is that female physicians have a suicide completion rate equal to their male counterparts; a phenomenon not seen in the general population.

In a recent piece published in Emergency Medicine News, Dr. Sandra Scott Simons discusses her own struggle with depression in an honest and thoughtful manner: “I was the mental health equivalent of a little old lady with no physiologic reserve who would die from a hip fracture because if one more thing went wrong, I thought it would kill me.” As a lifetime marathon runner, she says her own breaking point came when she lost her ability to run. She sought help, started medication and decided to speak out on mental health for physicians. Her article, and others like them, can be found by using the hashtag #MH4Docs.

What’s the answer for the rest of us? How do we find balance in our profession? We need to make time for ourselves and exercise our emotional being just as we exercise our physical being. Without regular use, emotions become brittle and unstable. How to do this? If you live by your calendar like I do, schedule in some emotion time. This time could be used to journal, to take a walk on a sunny day, to see a counselor, or just simply think. Find time to do something that helps you process. As Sadness says in the movie, “Crying helps me slow down and obsess over the weight of life’s problems.”

Want to go bigger? Let’s start addressing the societal pressure and stigma of emotions. At work, let’s initiate programs that provide a venue to express these emotions. When there is tragedy, we should feel free to cry with patients and families. However, it should also be okay to express disgust and anger over some of what we experience in our line of work.

Secondly, rather than forcing happiness on our kids all the time, perhaps we should try to acknowledge their emotions and understand their outbursts. Since seeing Inside Out, I have already begun to adjust my parenting. Now I listen to my children’s feelings rather than immediately attempt to stop the crying with a tickle monster attack.

Lastly, and not the least of all, we should demand respect from all patients, rather than smile and push back the emotions that arise from a patient’s inappropriate comments or rude gestures, as these too fuel the fire.

With a more balanced and steady release of emotions, perhaps we can mitigate the roller-coaster ride that many of us experience. With the acceptance of human emotion in the medical profession, perhaps we can lessen the rates of depression and suicide in our colleagues. Just as Riley’s brain realizes that life is better when Joy and Sadness coexist, we can as well.

References

• Bright R. and Krahn L. “Depression and suicide among physicians” Current Psychiatry. 2011. Vol. 10, No. 04. Web 15 November 2015.
• “Depression Among Women of Reproductive Age” Centers for Disease Control and Prevention. Atlanta: Division of Reproductive Health and National Center for Chronic Disease Prevention and Health Promotion, 2015.
• Andrew, L. “ Physician Suicide”. Medscape, 2015. Web 15 November 2015.
• Simons, S. S.” ER Goddess: Suffering in Silence No More” Emergency Medicine News, 2015. Web 15 November 2015

This piece will also be published in the AWAEM Awareness newsletter.