Guilt or FOMO?

 I'll say it up front lest the message gets lost: I'm extraordinarily privileged to even be writing this post. I am extremely grateful for what I have and the situation I am in right now. This is merely exploring some intangible thoughts and feelings that I've had in the back of my mind. 

So COVID. COVID COVID COVID. Last year this time I dare say virtually no one in the world was aware of such a thing or what these 5 letters mean. This year it's passed virtually everyone's lips. It's the pandemic cloud hanging over all of us. It's the reason why I'm seeing more depressions than I've ever seen in patients. It's why our interconnected world of travelling has ground to a halt. 

I'm lucky enough to be in a province with minimal cases. In fact, the least amount of cases in Canada -knock on head here- which is fairly low in terms of cases compared to the rest of the world. I'm also lucky enough to be able to keep practicing medicine almost the same as I have before, only with more masks and telephone visits than before. The only real major change for me is I've stopped seeing sore throats and coughs as would be the bulk of my visits this time of year. For the most part, people are following public health orders, calling the local health line and staying home for swab clearance. 

Despite my gratitude of this, however, there's something uncomfortable in the pit of my stomach. Something that stirs when I hear tales of my colleagues south of the border who are pulling triple shifts and intubating COVID patients on a regular basis. Even compared to my friends and former classmates in other provinces who are heading and chief-ing COVID wards - here I sit, seeing someone for a fungal nail infection. 

I don't diminish what I do - it's what I love more than anything else. I don't diminish the concerns of my patients, either. 

But it's hard not to look at the healthcare workers in full PPE for 16hr shifts slamming pressors and fluids and BIPAP to keep COVID patients alive, and look at my day of anxieties and skin rashes and med refills. 

There's a deep sense of guilt that I'm not on the frontlines with my colleagues. Guilt or FOMO? My partner pointed out the ridiculousness of it. It's along the lines of when I felt left out of the cultural phenomenon of staying home, isolating and baking/crafting/building a new staying home routine. I will not complain about being able to have a stable career during this time, avoid financial strains and maintain a relatively normal routine that I'm sure many people the world over would happily have at this time. But it feels like I missed out on something that most people experienced, you know? 

There's more guilt to this, of course. I'm also trained for emergency medicine and hospitalist care. I'm able to do COVID assessments. Again, I'm lucky I haven't been called on to use the training because we don't have as heavy a case burden as other locations. But shouldn't I be doing more? Why am I sitting comfortably at home over Christmas with my partner and eggnog while my colleagues a mere border away are holding the hands of dying patients on their wards? 

The past isn't really in the past

 I received two hauntings today. One from a former patient, one from a former paramour. 

Re: ex partner, as my friend put it: "that's some new age dating problem". I never thought a shared spotify account could come back to bite me. Shared is loose, I pay for the account and while we dated they had access to it, but I never took access away since breaking up. It seemed like a petty thing and wasn't a huge deal as we parted amicably. 

But as of today it seems they're trying to send messages via song titles by placing them in the queue of my playlist. Isn't that some new fangled thing? I feel like I'm 14 again. It wasn't a great year. Closer to 34 than I am to 14 now, I don't feel any wiser today facing this issue than I probably would have felt at 14. 

The ex patient is harder to deal with. They weren't exactly my patient I guess. A patient of the hospital I was based out of but not under my care. It was their community and legal involvement that caused me a lot of grief. Today they showed back up in my life in a different role, but very much present. 

I thought I left that community behind me forever when I ran away from it. Turns out I didn't run far enough. It's come back to haunt me. 

I spent most of today thinking and feeling that I was on a positive streak with minimal negative emotions this week, then I got whacked one after the other in the face by these two ghosts of poor decisions past. And it's already past Halloween, and not even Christmas eve yet. Anyone seen my scrooge hat, or maybe an exorcist? 

Imposter syndrome again and again and again and again

 I thought that after 3 years of med school and 2 years of residency the imposter syndrome would fade, not strengthen. Not the least of which because I'm expected to go into practice as a fully functioning family doctor at this point were it not for this +1 year. 

Yet here we are. My imposter syndrome has fed on what I can only assume is a steroid laden buffet of self-doubt and come raging out in full force. Yet this isn't quite the same beast I'm used to from the days of clerkship. Standing before a senior resident on internal rounds and being told to rattle off the costs of pancreatitis (I GET SMASHED) and only making it as far as "I GE" is imposter syndrome combined with simple lack of knowledge due to lack of experience. 

(Incidentally, I tried to use Google voice search to get the list of causes of pancreatitis appropriately summed up as the mnemonic above, and instead got recommended a list of ways to stay sober and manage a hangover. I appreciate the thought and the potential contribution to public health, but at <24hrs before my licensing exam it was less appreciated). 

These days the impostor feeling is associated less with my own work and knowledge base. I don't feel bad about the work I've done in the last two years and the associated knowledge and practice I have accumulated from it. In an average family medicine patient I'm pretty confident in my diagnosis, treatment, and bedside (tableside?) manners. 

What I do doubt is other people's confidence in my confidence. I've been developing literal shakes while waiting for a new set of preceptors (and a different one every day) to review my work and give me the go-ahead. I haven't been told by any of them in the last 3+ mths that I'm grossly incompetent, and have received very agreeable, constructive feedback that I can take into practice, but impostor syndrome does operate as such. 

I know part of it is that over the last year I've come to thoroughly understand the way my last preceptor prefers to work, I know her style and her approach to many diseases and treatments. She came to know mine as well, and as we shared an office side by side we developed a very cohesive working style. By the end her reviews of my patients were very much: "good, good, good, good, agree, yep" - which it should be for an end of residency student. 

I now accommodate the working style and preferences of at minimum 5 different physicians per week, across all different environments and systems. It's a little bit like being on tether hooks; never being comfortable in a single place/never feeling like I've quite got it right. 

I hope at the end of June next year at least some of this will go away, but who knows. The only thing every physician I've worked with has ever agreed on is that the impostor syndrome never goes away. Maybe I should look into buying some confidence...Think the wizard of Oz is available still? 

Checking privileges

 Today isn't the first time I've noticed the extraordinary privileges that I've grown up with, but I felt pangs of yuppie guilt on a subject I never have before. Being a first generation immigrant usually meant disadvantages and was sometimes a point of pity when I interact with those born in Canada. 

I had the extraordinary privilege of having parents who are both highly educated at post secondary levels, of coming from a solidly middle class and academic family in China (a boon not to be underestimated in a country with huge wealth disparities) and coming to Canada with legal approval.

By the above statement I mean I did not have to cross a border illegally. I at no point needed to fear deportation from my new home. I was welcomed first as a landed immigrant then a citizen. I proudly hold the blue passport of Canada (not incidentally one of the most powerful passports in the world). I have a citizenship card tucked in a drawer of documents somewhere. I have the freedom to travel in Canada and the privilege to work in legal employment. 

I do not have to accept substandard wages and poor working conditions because I am legally protected as a citizen. I do not have to avoid seeking medical care because I don't have health protection through immigration laws. I do not fear encountering the police on grounds that they might realize I am staying on a fake/expired visa. 

And what I learned today: if ever incarcerated, I would be much more equipped to navigate the system than someone who does not speak the language. 

For protection of identities, I will leave out significant details. 

There is no detention center for those facing deportation due to immigration issues and who are not currently under sentencing/have served their sentences. They stay in a prison until border services is able to escort them back to their home country. 

There is apparently minimal language support for those who are not fluent in English. I'm no stranger to working with those who do not speak fluent English, but I've had the much appreciated resource of interpretation services. These services are, apparently, not employed regularly by the correctional center I visited. 

This person had been in the prison system for some time without the access of any interpretation services. I happened to be visiting for a different reason and chance someone noted that I speak the same language as them. Coincidentally, we're from the same region of China. 

Setting aside many major concerns of the experience of this person in the prison system, the very fact that they couldn't navigate how to make a phone call out of the prison nor understand how to buy food and basic toiletries (again, setting aside the fact that these aren't provided in a center). Small things that in any bad day for me are things that make me feel more human. Things that many of us currently sitting comfortable in our stable homes take for granted. 

What most struck me about this person's story is their terrible guilt and shame in not being able to bring home gifts for their ailing family member. This family member (who due to medical issues has decreased cognitive functions) innocently requested chocolates and milk powder. And this person was desolate that they couldn't even bring home chocolates and milk powder to their family. The very basic of basic gifts that families usually request when a relative returns from abroad. 

On our first trip back to China after immigrating we also bought chocolates. The Walmart ubiquitous Pot of Gold chocolate boxes. These days my relatives have long come to expect designer purses and brand name jewelry, but they still request and receive the occasional boxes of chocolates and milk and protein powders. 

It's impossible not to draw parallels between myself and this person. We're from the same part of China, we both moved to Canada, but on sitting across from each other in a meeting room, I felt pangs of guilt. The pangs of guilt of having privileges that I never had to fight or work for. Guilt of being simply born into a privileged family where they were not. Guilt that I can buy a box of chocolates without any thought or concern. 

One of the people I visited the center with, upon hearing my thoughts on the above, made a point that I hope to keep in mind. What matters is that I do more than simply acknowledge my privilege. I am using the privileges I have (in this case being bilingual) to help those with less. 

So to conclude a long rambling, the prison system is terribly flawed, but hopefully the language services of this particular institute is something I can advocate for so that no further inmates have to guess what they're being held for. I'm also extraordinarily privileged to be a legal immigrant and now Canadian citizen instead of having to come through and live under constant fear of deportation and lack of basic human rights that citizenship of the country one is residing in grants. 

Being an immigrant is still a great privilege. 

Getting back into things

 5 weeks and a Labrador later I'm finally back to routine clinics. 

Some interesting patients as always, though today's the first day I had to work without an electronic system. The EMR is great but we've become so dependent on it that I couldn't physically see patients without it.

It's also the first time myself and the other resident in this program finally got matching schedules and sat down for dinner. Prior to this we've literally always been in different provinces. It's incredibly validating to have someone else say "oh yeah that was brutal" and "nope! Never knew that either". 

It can be a very lonesome experience being the only resident going through something. I thought I left the impostor syndrome in first year residency, turns out it was just on vacation. It's come roaring back full force - to the point of me having nightmares nightly of providing subpar care while in Labrador. One bad clinic day is enough to call in question all that I thought of me as comfortable and competent in. 

So it's very nice to hear someone say they still find it a struggle to keep up as well. 

The old problem arises again

I think every doctor has had this conversation with a patient:

"I'm tired/have no energy/feel generally unwell."

"Well your bloodwork checks out fine. What's your daily routine like?"

"I have no routine/I don't exercise/I don't eat well/I sleep with my phone and laptop both beside my face."

"...Have you considered not doing that/trying to change that?"

"Oh no! There must be something else wrong. Can you prescribe a vitamin/iron/some miracle pill?"

Believe me if I had that miracle pill I'd be a rich, rich woman cruising on a private yacht somewhere in the Mediterranean. 

It sounds painfully similar to the "I'd give anything to be/have ___ except work towards it!" 

I had this conversation with a patient in a completely unrelated medical appointment today. They preferred to take constipating iron pills that they don't need than exercise, develop a healthy sleeping habit or add any vegetables to their zero-vegetable and fruits diet despite my best attempts at counselling on a limited time. They even made it as far as realizing all their symptoms started with a 70lb weight gain, then failed to correlate the two. 

Trust me. I wouldn't be withholding a magic pill that gives people energy and makes them feel instantly healthy and happy. I'd be throwing that in the water supply.  

Revisiting

It's been a long time and a long journey. To briefly summarize I've realized the rural and remote life isn't for me. I made myself believe that's what I wanted because it's what 1) my former partner wanted, 2) what I thought was the safest and most steady career path, 3) I wanted to be the most well dressed, biggest fish in the small pond deal.

What I've realized: 1) a partner can't make up your whole life, and he/she should push you to be better than who you are. Sure, they should accept you, love you as you are, but having them in your life should make you want to progress, be better, journey together without stagnating in a rut relationship. 2) Safe and steady is not what I want. I came to Newfoundland to be challenged. I came to be pushed out of my comfort zone and to learn things I could never imagine I didn't know (insert things you know vs things you don't know speech here). That leads to an unfulfilling career that, no matter how much I tried to engage with it, just didn't seem worth it. 3) It's no fun standing out for reasons no one else considers as valuable as you, and when you're the biggest fish you have nothing left to push you to evolve.

What I've done: 1) My ex partner and I had a long discussion, over the course of over a year, and decided that love alone isn't enough. You can't love each other out of depression. You can't love each other into a meaningful career. You definitely can't rely on romantic, got-to-have-you-can't-live-without-you love to get through the mundane hardships of day to day life. 2) I wrapped up my residency - finally! - but chose to commit to a +1 year of enhanced skills on a whim. I hadn't intended to after having such a challenging time in rural residency, and never imagined I would be interested in flinging myself even further into rural Labrador and (!!) rural Nepal. I imagined going straight home to Ontario, starting locums and settling back into my old life. Then I thought, I left Ontario and home for a reason - that being I wasn't satisfied with just the status quo. Yeah, my circle of friends, cafes and visits back home to mom's backyard patio was wonderful, but if that alone satiated me I would have never left. I was incredibly offered the +1 year based in St. John's and, after about 30 seconds of pondering, said "hell yeah let's do it!", with my new partner. He's made the questionable decision to jump his own ship and come out to the island with me, so we're quite the match. And he is absolutely someone who makes me want to constantly improve and explore myself. 3) I'm the newbie all over again, I know nothing of refugee health, transgender medicine, care of the homeless from residency. My starting base is lower than I've ever known it - and I love it. I'm being pushed to learn again, to enjoy learning again.

Now it's time for the blog to take a different turn. I would still like to write reflective pieces, but I'd like to do a weekly-biweekly summary of my patient exposure (privacy protected of course). Personal life will always be intertwined, because to me you cannot know yourself as a professional without accounting for your personal. We don't evaluate our patients only based on the story they present us in clinic, we remember their family relations, their job concerns and their support circles. In my thinking, my relationships, my personal wellness and supports are just as significant determinants of me as Dr. Z.G.