“I’m not okay”: words that medical students won’t say

I’m not okay.

I didn’t think I’d be saying those words this year.

I’m not okay.

I think I’ve hit the bottom so hard I bounced twice.

I’m not okay.

This is nothing, my feelings and problems are insignificant, I have everything anyone could ever want.

I’m not okay.

 

Only days after finding out I had only passed my psychiatry exam by one point, I received this on my evaluation for my internal medicine (general adult medicine) clerkship:

Brandon was personable, polite and seemed enthusiastic about patient care.  However, he was noted by seven out of eleven evaluators to have difficulty staying awake during rounds which made him appear disengaged and disinterested. He was also noted to be asleep during a significant portion of the clerkship orientation. (emphasis mine) Team members generally found him to be helpful, however, and he did what was expected. He showed a natural rapport with patients and worked to ensure they viewed him as an important person in their care. His history taking was appropriately thorough and his physical exam identified major findings. His written admission histories and physicals were solid with good chronology of events and evidence of hypothesis driven data gathering in the HPI. The assessments and plans had reasonably complete problem lists, good differential diagnoses for the main concerns and clinical reasoning. Oral presentations needed few alterations and were well done. Brandon was clearly reading about his patients and is working on increasing his participation in team discussions. He was beginning to analyze and interpret data to argue for or against diagnoses and he could prioritize patient issues well.  In summary, this was a satisfactory clinical performance over the two months of the clerkship and Brandon’s performance on the NBME shelf exam was good.

For those of you that don’t know, during third year of medical school we get grades (fail, pass, high pass, or honors) as well as comments from those we worked with during the rotation. These people are residents and faculty physicians who give us clinical feedback which accounts for usually 50% or more of our grade. We get two kinds of comments, those that are “formative” that are for our eyes only as a way to help improve and provide good feedback. The other are “summative”, which are a general overview of our entire performance. More importantly, those people who select residents at various programs across the country will see only these “summative” comments. Despite being a sort of “compliment sandwich”, which is a technique used to deliver bad news or a less than positive critique to someone, this is a fairly damning few sentences.

Something within me finally gave away as I read this at 2am a few nights ago. I broke down. I cried.

Cried uncontrollably. Called my mother. Cried some more. Repeated the same phrase over and over again, just like Dane Cook once said. I believe mine was, “I f*cked up” and “my life is over”. I had realized that months of feeling terrible and letting my school performance slip was actually a problem. That I couldn’t keep going on the way I had been. That something finally had to change, and for good this time.

–

It had started back near the end of my pediatrics clerkship. Or maybe longer than that, I had lost track. I had started off with a bang, absolutely crushing my surgery and OB/GYN rotations. I had moved on to things that I had a lot less interest in, but still wanted to learn. However, my motivation to study had started to wane. Honestly, it was never there much in the first place, because I really, really hate studying. I’m not sure why I went to medical school considering there’s so much of that. Regardless, it started like that. Then, on family medicine, it had progressed to starting to play video games a lot more than I should have. I would stay up too late because I’d be playing, then not get enough sleep (sometimes 4 hours or less), and come into work for my family medicine rotation on the verge of passing out. I’ve got a group of guys I have played with for years, and the unfortunate thing is that most of them are still in undergrad, so they have a heck of a lot more free time than me. And looking back, I had started to use video games as a crutch and a getaway from my feelings, which they had before been a fun, competitive hobby.

I had also started progressively exercising less. In my move to the big city of Indianapolis from little ol’ Bloomington, I had lost easy access to 24/7 pick up basketball. I had lost the people and the program of martial arts that I had trained 4-5 times/week throughout my first and second year of medical school. I had lost the flexible schedule I used to have, and instead worked anywhere from 9-12+ hours/day. I had lost the church I had loved so much, the familiar environment, all of it. Indy has been great, but I haven’t established some of those same connections up here. I had been in Bloomington for 6 years, after all.

I had let all those pieces of me fall to the wayside. With excuses of “I don’t have time” or just a general loss of energy. There were moments where I’d get back to it and worked out for 2-3 weeks straight or something, but I always fell off the horse so to speak when my exam would get close or something. My performance in school, however, was still okay during this phase. I even managed to rock a very early sub-internship in surgery, which I will credit as the best rotation of my medical school career (which hopefully I’ll get the motivation to write about some day).

However, all of these things set the stage for internal medicine. I was no longer working 80 hour weeks like on my sub-internship, and had a little more time. I was now on a rotation that I still liked, if only because learning medicine is pretty cool, but it started to wear on me. I was trapped in a cramped, windowless team room for most of the day. I rounded for hours instead of for an hour. I spent a ton of time doing clerical work and writing notes, where one note took as long as 10 surgery notes. No offense to my classmates wanting to go into medicine, but medicine (as opposed to surgery) isn’t the life for me. It’s a pretty stark division: medicine vs. surgery. And all of us in medical school know how different they are.

This was the time where I felt progressively less happy, less motivated, and started playing more games in order to cope (in some twisted way) and staying up later. Playing with my friends and talking to them was fun, it became my one outlet. In turn, this obliterated my ability to stay awake even more than it was already impaired.

(Quick aside: anyone who has known me throughout high school and beyond can tell you that I fell asleep a lot in class. It didn’t matter how much I slept, I always tended to just fall asleep no matter what the subject was. Unless I was actively engaged (or even doodling) or my attention was really held, I had a high probability of falling asleep. I’d unfortunately managed to perfect being able to sit up perfectly straight and fall asleep. My teachers, classmates, and others can vouch for this. Even when I was engaged, it would still happen. I could get ten hours of sleep and still fall asleep in class. This was the case in college, but I had worked on it in medical school to the point where it was less of an issue. However, it was still present)

Turns out, my sleep problem came back with a vengeance. In combination with sleeping less, we would sometimes “table round” on internal medicine. This means that instead of going and walking around to all the patient rooms as a big team, we’d just go see our individual patients and then talk about them around a table. Sometimes, this would go on for 4 hours. Which is a long time to sit around talking, especially for someone like me who has attention and sleep issues. In combination with my lack of sleep, it made me start to nod off during table rounds and otherwise. Unfortunately, I didn’t start either standing up during table rounds or chewing gum early enough, and it kept happening. I started getting more and more down on myself, I felt worse, and therefore slept less. Even when I did sleep, I was still nodding off during rounds.

This later devolved into more and more areas. I exercised even less. I even started missing mass on weekends (something I had pretty much never done), would not go to the grocery for weeks at a time (so that I’d eaten leftover Oreos and Nutter Butters for dinner because my dad left me a big box of them, since he works for a company that packages treats), started becoming more reclusive, and would simply sit around on weekends when I could go be with people. I’d occasionally go out drinking since it’d let me forget everything for awhile, and I could pretend to go out and have fun. Seeing my friends did help a little bit, but it didn’t feel the same as it once did. It felt blunted, and I’d be right back to square one once I went home. I let my apartment become a mess (that I’d try cleaning up occasionally, but usually just failed to do so) and even stopped reading my emails for over a week at at time (resulting in me missing some key applications for positions I wanted to do, like being on my med school’s admissions committee).

I saw the good ole’ healthy Facebook feed showing my friends out buying houses (how is that even possible?! I thought as I looked at my student loan bills), having babies (I can’t even take care of myself or a cactus, let alone a person), and getting married. My two best friends who are my brothers in all but blood are getting married this month and in December. I have wedding invitations from more friends. And there I was: sitting at my computer, wearing my last clean pair of underwear, firing up another Dota game, eating my 7th bag of fruit snacks because I didn’t want to order Papa John’s again, and feeling slightly guilty that I wasn’t studying. That is the exact same situation I found myself in last month on psychiatry. It had all come to a head, ironically on my psychiatry rotation of all things. I used to love to cook, exercise, see my friends, and sometimes studied. Now I did all of that. And I couldn’t drag myself out of that hole. I was crushed, but I let the cycle continue. I continued to try to escape from it all. It didn’t work. I almost didn’t pass the psychiatry test. I felt like a sloth, unlovable, un-dateable, and like I wasn’t becoming a better man. I was better at most of this in high school. I had regressed. It felt terrible. I felt terrible. I wasn’t okay.

–

That was the storm of things that I cried out two nights ago. It felt good to admit I was out of control, that I wasn’t who I wanted to be. That it was all going downhill. Although I do feel kind of dramatic about it, this whole medical school thing has chewed me up and spit me out, then picked me up and started to chew me up again. I’ve had a lot of great times, but I’d be lying if I said I haven’t had some of the lowest lows. I think it all goes back to my USMLE Step 1 when I had failed (in my own eyes) in a massive way, and I haven’t been able to do better than average on my exams no matter how hard (or how little) I studied. Being mediocre or average isn’t something that us psychopaths of med students take well.

The comments on my internal medicine rotation were what woke me up into realizing I was screwing up big time. A few other of the comments were things like:

“Has a beginner’s knowledge, skills and attitude towards patient care. He needs to work on his differential diagnosis on a consistent basis and stay awake.”

“H&Ps were very good.  Thorough and succinct.  Hard worker. Difficulty staying awake during rounds, at time seemed disengaged.”

“I enjoyed working with Brandon.  He was a hard worker and willing to help the team out. I encourage Brandon to work on being more involved in discussions, as he sometimes seemed quieter than others with difficulty staying awake so it was harder to assess his level of knowledge and involvement.  This does not mean that he should change his personality, but try to be more involved in discussions when able, especially around his own presentations.”

Thing is, internal medicine was bewildering for me, and I was terrible at it to start, and it was an overload of information for a very one-track mind like me. I was struggling regardless, and my sleeping issues made it worse. Thing is, so many of my evaluators (residents and faculty) noticed my sleeping problem. However, only two of them said something to me, and  one of them was only in passing. The other was fairly more, and that was only after I had to meet with the director of the clerkship regarding the issue. I had to meet with him about 6 weeks into my 8 week rotation, and it was basically the first time anyone had sat and had a real freaking conversation with me about it. When I looked back on this, I started getting angry, and here’s why:

When a medical student is starting to fall asleep during rounds, what should be the thought that occurs? To me, that should be indicative that SOMETHING ISN’T RIGHT. To me, that’s spelled out very boldly. Whether it’s a personal or medical problem, that’s not a normal thing a medical student does. Instead of being met with compassion and genuine concern by all of these people who so clearly noticed it, I was reported to the clerkship director (who ironically, seemed genuinely concerned about it) and it was written in my evaluations as basically incompetence and disinterest. While there are a number of ways this year in which we are treated like children and like we aren’t trusted by our administration (i.e. good luck getting off for a doctor’s appointment or being sick a day on internal medicine without being nearly crucified, or being threatened with “professionalism deficiencies” or “negative grade modifiers” at any hint of not being on top of all things at all times), this struck me straight to the heart:

My falling asleep wasn’t viewed as a cry for help, a sign of a medical problem, or a legitimate problem. It was seen as a character flaw, a sign of being unprofessional, of not caring.

Freaking ouch. OUCH. I’d like to think that when I’m a resident and I have medical students, I’m going to ask them what’s going on. I’m going to actually get to the root of the problem. Isn’t that what doctors are supposed to do? To care for human beings around them? To notice things others don’t? To extend a hand when people are in need. The thing is, most of us don’t know we need help until we hit the bottom. We are never the first ones to recognize our problems. That’s the key behind the whole, “the first step is admitting you have a problem” thing. While it’s pretty clear that sometimes we are the only ones in our own corner in certain situations, I didn’t expect it to be that way in a room full of medical students in doctors. Thing is, I accept my role in all of this and can’t make excuses for my behavior. It IS my responsibility. Fact of the matter was: I needed help and for someone to notice, someone to care.

In light of just coming off of psychiatry, this hinges on what is still a gigantic issue in medicine: mental health. We, as doctors and medical students, don’t take great care of ourselves. And what’s more, there is still an ostracizing of people who have legitimate mental problems in medicine. It’s characterized as “weak”, and even though we have made strides, the fact of the matter is people are still scared out of their minds to admit it. I’ve heard to never mention if one struggled with depression to a residency panel, or to ever show a sign that you could have a problem. There is a story (whether true or not, the fact that it even exists at all is scary) one of my classmates told me about a psychiatry physician who interviews residents to take them having a history of depression as a negative thing because “we don’t want them as a resident, we never know what they might do.”. What the heck is that?! That’s absurd, especially in light of all the fluffy “wellness emails” we get that tend to never get to the core of the issue are are very superficial.

Thing is, we just had a second year med student die. While she passed in her sleep and “didn’t wake up”, it’s pretty clear to read the writing on the wall: it was most likely suicide. This is not an isolated incident across the nation, even let alone here at IU. We had one of our top graduates who went into a top residency program commit suicide in his intern year (which was the first year I was in med school). He suffered from bipolar disorder, and was not only afraid to get help, but people around him noticed it as well, as it was very evident.

We’re all afraid of admitting it. Talking about how we feel, talking about our struggles, opening up that guess what: we’re human too. I’d say our battle isn’t complete until someone who had thoughts of suicide or was depressed could sit in front of a residency interview and say those things openly without fear of repercussion. Right now, a classmate finding a bottle of Prozac or an SSRI on our nightstand, or a member of our team finding out we had ADHD are mortifying thoughts. And if you wanted to take time off of a rotation to see a psychologist? Good luck first of all getting that approved, second of all not getting judged for it by a faculty member.

I’d like to think the culture is starting to change, but it’s coming slowly. We have upcoming days DURING THE WEEK (WOOOOO!) next year which we can use for appointments or taking care of daily things. Normal people could take a day off of work for themselves. Currently, we’d be “negatively grade modified” for something like that unless we’d already made a suicide attempt or had a “real” sign of mental illness (quotes there are “air quotes” for sarcastic emphasis). It’d be ideal, as one of my classmates who is very passionate about this issue said, if all medical students were mandated to meet with a counselor or psychologist once a semester or something like that. That way there’d be no stigma, no judgement. It’d just be a normal part of our lives, one that we might even be able to talk about more. It’s odd to think that medical school can be so isolating and we feel like we’re alone, but the thing is I guarantee there are hundreds of medical students here at IU that have felt/are feeling the same way that I am, to one degree or another.

Then it comes around in my mind: I have so much going for me, and with all of that, who am I to complain? I’m in medical school, nearly one year from getting my M.D., I’ve got a roof on my head, food on the table (even if it’s only Oreos), a nice computer on which I’m typing this, the ability to go to the gym or wake up without fearing for my life, able to go out to dinner or see friends, the list goes on and on. It’s a trap to think that my feelings, my inner (or outer) struggles, or my low points aren’t real. This is how doctors end up with drug addictions, with broken marriages, with crippling depression: by minimizing and putting away our problems because we walk into work and there’s someone in their twenties dying of a rare cancer. Thinking we can’t show weakness because we are surrounded by such strength and very accomplished, very intelligent, very hardworking people in what is often a doctor-eat-doctor world, and the people who let us get to that next step are often weeding people out. There are 7% of US medical school seniors who don’t match into residency every year. That’s scary. We don’t want to be the weak, the rejected, the not okay.

I’m not okay.

That’s the first step towards being okay. I’m going to go to a psychologist and my primary care physician to make sure I don’t have a medical condition that is causing me to fall asleep. It’s been going on for so long that I think I need to at least do my due diligence. Maybe it’s a new “Sleeping boredom disease”. Who knows.

The bigger issue is that it’s more than just a sleeping issue. I’m likely going to have to go my entire residency interview trail providing an explanation for those few sentences I quoted at the beginning of this post. I’m going to have to defend it, to defend myself, to prove how I’m better now, I’m stronger. Honestly, I’m still scared that talking about this, even though it’s a battle versus myself, is going to drag me down and get me passed over as a candidate for some residencies. And I think that’s a bit screwed up. Unfortunately, I can’t hide from it now, it’s out in the open, and will be on my transcript for all to see. The issue of mental health among medical students and physicians is the same way: it’s going to escalate and escalate until we can’t hide from it. I hope by then we’ve started making real progress.

I’m not okay. 

And that’s okay.

-B

(This post isn’t a cry for help. Take a minute and reach out to someone you can tell is struggling. We’ve all got those people in our lives, and you can tell when a good friend is struggling. Send them a text, maybe a call. Reach out.)