O n B e in g
a
D octor
A W ounded H ealer devoured books as a young girl. I particularly loved stories of survivors: orphans, runaways, people who had overcome illnesses or lived through natural disasters. I imagined how I would subsist if I were to find myself alone on an island after a shipwreck. I plotted how I would respond upon surviving a plane crash in the Andes. I pic tured myself alone in outer space, navigating my spaceship back to Earth. I memorized incantations that I thought might be use ful if I met a sorcerer. I practiced map reading. Imaginary kingdoms blurred with foreign lands, and fairy godmothers were as real as Seeing Eye dogs. I tried to prepare myself for anything and everything. I relied on my imagination to survive and make sense of the world because my home life was as dramatic and unpredictable as any I encountered in books. My father, a large man, towered over me like a giant and then yelled that I was stupid and unkind and undeserving. Ele told me we were best friends. He walked around naked, rifled through my things, and barged into my room. He sped through Manhattan streets in our family car while I sat in the back seat convinced we would die. He drove to a racetrack and bet on the horses for hours at a time while I sat waiting alone in the car. When he lost at the track or at the card table, he became particularly angry and explosive. Still, I loved my father and found comfort in his putting me to bed each night when I was little. I didn’t understand until years later that he masturbated as he lay on the trundle bed beside me. I cannot recall my father ever physically abusing me, but violence surrounded me. My father put a hanger in my sister’s eye during one of their fights. She ended up in the ER, and my mother told her the next day to lie at school about why she wore a patch over her eye. My parents’ screaming routinely woke me, and, when my brother left for college, it fell to me to get up at night to stop my father from beating my mother. My home world was inside out and upside down, but my world at school was ordered, peaceful, and safe. I worked hard, and my teachers rewarded me with affection and praise. I learned in my science classes that there were laws that governed the universe. I made good friends who welcomed me into their breathtakingly calm homes and shared their own hurts with me. I became known as some one who could keep a secret. By high school, I knew that I felt best about myself when I was helping others and spent time as a candy striper, an animal shelter volunteer, and a first grade tutor. Ironically, my childhood proved to be a good start for a career in medicine. Take a bright child, raise her in a home where she has to be self-sufficient and learn to care for others, wound her to make her empathic, teach her to keep secrets, provide an excellent education, show her that
I
the sciences can make sense of chaos, reward her for bury ing her own hurts in hard work, and you have someone primed for medical school, residency, and medical practice. My “preparation” for medical school was not without ill consequences. I became a doctor, but one who struggles with recurrent depression, low self-esteem, and nightmares. My first episode of major depression came before the era of Prozac, when I was 21 and nearing graduation from Yale College. I can still taste my despair and hopelessness. I had the good fortune to find a compassionate and skilled psychiatrist; she recognized the seriousness of my depres sion and recommended hospitalization. I spent 3 weeks on a locked ward in a private Manhattan psychiatric hospital. I recall the woman on my unit who spoke animatedly for hours into a disconnected pay phone. Overmedicated pa tients nervously picked at their clothing, and withdrawn patients slouched into dirty couch cushions. I remember thinking that I had no reason to keep living. My psychiatrist helped me to emerge from my dark ness, and 6 years later I was happily married to a native New Mexican and ready to matriculate at Stanford medical school. Although more insightful and confident than I had been a few years earlier, I arrived in Palo Alto still wonder ing whether I was worthy of becoming a physician. Could someone who spent time voluntarily in a mental hospital be capable of caring for patients? What would my class mates say if they learned of my history of depression? Would mental illness limit my options in the future? In spite of my concerns, I excelled both in my classes and on the wards. I felt proud when my classmates chose me to be our graduation speaker. I spoke openly on that occasion about my history of depression and my hospitalization. My career after my internal medicine residency at the University of New Mexico progressed along a familiar path: chief resident, assistant professor, associate professor, doctor in private practice. I was devoted to my patients, and they loved me as much for hearing their stories as for diagnosing and treating their maladies. I took it as a com pliment when the sickest, most traumatized patients found their way into my practice. I ignored the advice that I had shared in my gradua tion speech about the importance of self-care. I always be lieved that I could and should work harder, see more pa tients, know more medicine. I held tightly to my husband and my growing kids for balance, but I felt pulled in too many directions. My mother died in 2009, and I suffered a recurrence of major depression in 2010. My depression remitted with the help of medications, psychotherapy, reduced work hours, and a strong network of support. By the time my estranged father died in 2012, however, I was aware that my clinical work was contributing to ongoing psychic pain. © 2014 American College of Physicians 611
O
n
B e in g
a
D
octor
A Wounded Healer
As 1 grieved the deaths of my parents, I fell into a bottomless pit of neglected grief for the patients I had lost over the years. I thought about my childhood only to stumble on the endless pain of a thousand patient traumas. I worked to settle my parents’ estates only to feel over whelmed by the demands that patients made on my time. The trauma triggers worked in both directions: An angry patient yelling at me reminded me of being cursed at by my father, my pager going off in the middle of the night felt like being awakened by my parents’ fighting, an office packed with very ill patients felt as overwhelming as the chaos that surrounded me as a child. I realized that I needed a break from clinical work. I needed time with my family. 1 needed time to reflect on my childhood trauma and the trauma of medical practice. I needed time to think about how to practice compassion ate, evidence-based, cost-effective medicine in today’s health care system. I needed time to remind myself why I love taking care of patients. I needed time to sort out my past and its role in my present. I needed time to take care of myself and to heal. At the end of June 2013, I left my successful internal medicine practice. I was full of doubt. Was taking a break from the practice of medicine a wise decision? Would my colleagues and patients ever welcome me back into prac tice? Was I too weak to withstand the challenges of being a doctor? Was I being too selfish? Now it is March of 2014, and I write these words with an ability I did not have 9 months ago to witness and to
612
21 October 2014 Annals of Internal Medicine Volume 161 • Number 8
share my story. 1 am seeing patients part-time at a local community health center and have been precepting medi cal students as part of Dr. Remen’s “The Healer’s Art” class. I am excited about my future and about the future of medicine. I have much to offer my patients and my students and just as much to learn from them. I have many thoughts about how to make the practice of medicine more humane for providers, and I am ready to begin work on implement ing these ideas. I want to work to destigmatize mental illness diagnoses in patients and providers, and I am hope ful that what I have written here is one step in that direction. My time off has enabled me to know a truth about myself that I did not know even as recently as last June: I am a survivor. I am as brave and creative and resilient as the heroines of my childhood books. I am a wounded healer, with all of the vulnerabilities and strengths that archetype connotes. Elizabeth Lawrence, M D La Familia Medical Center Santa Fe, New Mexico R e q u e s ts f o r S in g le R e p rin ts : Elizabeth Lawrence, MD, La Familia Medical Center, PO Box 5395, Santa Fe, NM 87502; e-mail, elawrence @lfmctr.org.
Ann Intern Med. 2014;161:611-612. doi:10.7326/M 14-0690
www.annals.org
Copyright © American College of Physicians 2014.
a
D octor
A W ounded H ealer devoured books as a young girl. I particularly loved stories of survivors: orphans, runaways, people who had overcome illnesses or lived through natural disasters. I imagined how I would subsist if I were to find myself alone on an island after a shipwreck. I plotted how I would respond upon surviving a plane crash in the Andes. I pic tured myself alone in outer space, navigating my spaceship back to Earth. I memorized incantations that I thought might be use ful if I met a sorcerer. I practiced map reading. Imaginary kingdoms blurred with foreign lands, and fairy godmothers were as real as Seeing Eye dogs. I tried to prepare myself for anything and everything. I relied on my imagination to survive and make sense of the world because my home life was as dramatic and unpredictable as any I encountered in books. My father, a large man, towered over me like a giant and then yelled that I was stupid and unkind and undeserving. Ele told me we were best friends. He walked around naked, rifled through my things, and barged into my room. He sped through Manhattan streets in our family car while I sat in the back seat convinced we would die. He drove to a racetrack and bet on the horses for hours at a time while I sat waiting alone in the car. When he lost at the track or at the card table, he became particularly angry and explosive. Still, I loved my father and found comfort in his putting me to bed each night when I was little. I didn’t understand until years later that he masturbated as he lay on the trundle bed beside me. I cannot recall my father ever physically abusing me, but violence surrounded me. My father put a hanger in my sister’s eye during one of their fights. She ended up in the ER, and my mother told her the next day to lie at school about why she wore a patch over her eye. My parents’ screaming routinely woke me, and, when my brother left for college, it fell to me to get up at night to stop my father from beating my mother. My home world was inside out and upside down, but my world at school was ordered, peaceful, and safe. I worked hard, and my teachers rewarded me with affection and praise. I learned in my science classes that there were laws that governed the universe. I made good friends who welcomed me into their breathtakingly calm homes and shared their own hurts with me. I became known as some one who could keep a secret. By high school, I knew that I felt best about myself when I was helping others and spent time as a candy striper, an animal shelter volunteer, and a first grade tutor. Ironically, my childhood proved to be a good start for a career in medicine. Take a bright child, raise her in a home where she has to be self-sufficient and learn to care for others, wound her to make her empathic, teach her to keep secrets, provide an excellent education, show her that
I
the sciences can make sense of chaos, reward her for bury ing her own hurts in hard work, and you have someone primed for medical school, residency, and medical practice. My “preparation” for medical school was not without ill consequences. I became a doctor, but one who struggles with recurrent depression, low self-esteem, and nightmares. My first episode of major depression came before the era of Prozac, when I was 21 and nearing graduation from Yale College. I can still taste my despair and hopelessness. I had the good fortune to find a compassionate and skilled psychiatrist; she recognized the seriousness of my depres sion and recommended hospitalization. I spent 3 weeks on a locked ward in a private Manhattan psychiatric hospital. I recall the woman on my unit who spoke animatedly for hours into a disconnected pay phone. Overmedicated pa tients nervously picked at their clothing, and withdrawn patients slouched into dirty couch cushions. I remember thinking that I had no reason to keep living. My psychiatrist helped me to emerge from my dark ness, and 6 years later I was happily married to a native New Mexican and ready to matriculate at Stanford medical school. Although more insightful and confident than I had been a few years earlier, I arrived in Palo Alto still wonder ing whether I was worthy of becoming a physician. Could someone who spent time voluntarily in a mental hospital be capable of caring for patients? What would my class mates say if they learned of my history of depression? Would mental illness limit my options in the future? In spite of my concerns, I excelled both in my classes and on the wards. I felt proud when my classmates chose me to be our graduation speaker. I spoke openly on that occasion about my history of depression and my hospitalization. My career after my internal medicine residency at the University of New Mexico progressed along a familiar path: chief resident, assistant professor, associate professor, doctor in private practice. I was devoted to my patients, and they loved me as much for hearing their stories as for diagnosing and treating their maladies. I took it as a com pliment when the sickest, most traumatized patients found their way into my practice. I ignored the advice that I had shared in my gradua tion speech about the importance of self-care. I always be lieved that I could and should work harder, see more pa tients, know more medicine. I held tightly to my husband and my growing kids for balance, but I felt pulled in too many directions. My mother died in 2009, and I suffered a recurrence of major depression in 2010. My depression remitted with the help of medications, psychotherapy, reduced work hours, and a strong network of support. By the time my estranged father died in 2012, however, I was aware that my clinical work was contributing to ongoing psychic pain. © 2014 American College of Physicians 611
O
n
B e in g
a
D
octor
A Wounded Healer
As 1 grieved the deaths of my parents, I fell into a bottomless pit of neglected grief for the patients I had lost over the years. I thought about my childhood only to stumble on the endless pain of a thousand patient traumas. I worked to settle my parents’ estates only to feel over whelmed by the demands that patients made on my time. The trauma triggers worked in both directions: An angry patient yelling at me reminded me of being cursed at by my father, my pager going off in the middle of the night felt like being awakened by my parents’ fighting, an office packed with very ill patients felt as overwhelming as the chaos that surrounded me as a child. I realized that I needed a break from clinical work. I needed time with my family. 1 needed time to reflect on my childhood trauma and the trauma of medical practice. I needed time to think about how to practice compassion ate, evidence-based, cost-effective medicine in today’s health care system. I needed time to remind myself why I love taking care of patients. I needed time to sort out my past and its role in my present. I needed time to take care of myself and to heal. At the end of June 2013, I left my successful internal medicine practice. I was full of doubt. Was taking a break from the practice of medicine a wise decision? Would my colleagues and patients ever welcome me back into prac tice? Was I too weak to withstand the challenges of being a doctor? Was I being too selfish? Now it is March of 2014, and I write these words with an ability I did not have 9 months ago to witness and to
612
21 October 2014 Annals of Internal Medicine Volume 161 • Number 8
share my story. 1 am seeing patients part-time at a local community health center and have been precepting medi cal students as part of Dr. Remen’s “The Healer’s Art” class. I am excited about my future and about the future of medicine. I have much to offer my patients and my students and just as much to learn from them. I have many thoughts about how to make the practice of medicine more humane for providers, and I am ready to begin work on implement ing these ideas. I want to work to destigmatize mental illness diagnoses in patients and providers, and I am hope ful that what I have written here is one step in that direction. My time off has enabled me to know a truth about myself that I did not know even as recently as last June: I am a survivor. I am as brave and creative and resilient as the heroines of my childhood books. I am a wounded healer, with all of the vulnerabilities and strengths that archetype connotes. Elizabeth Lawrence, M D La Familia Medical Center Santa Fe, New Mexico R e q u e s ts f o r S in g le R e p rin ts : Elizabeth Lawrence, MD, La Familia Medical Center, PO Box 5395, Santa Fe, NM 87502; e-mail, elawrence @lfmctr.org.
Ann Intern Med. 2014;161:611-612. doi:10.7326/M 14-0690
www.annals.org
Copyright © American College of Physicians 2014.
