Wednesday, June 1, 2011

The Pressure Cooker

I had dinner the other night with my med school friend T the other night, and we got to talking about how residency changes you.   There's the usual stuff, like how you have to force yourself to stay in bed past 9:30 am because your body is just so used to getting up early, or how I suddenly wear much more formal and girly clothing when I have the opportunity to, to make up for lost time.

But there's a major thing that changes in everyone, perhaps some more than others, in a way that I wish I could avoid.  We all become meaner.  By this, I mean my patience is shorter, my expectations are unreasonably higher and my shoot-from-the-hip reflex is quite a lot sharper.  Things that I might have let slide years ago, like a friend flaking out on me for a scheduled hang-out suddenly become massive transgressions.  I get into fights with people whom I have barely even disagreed with in the past.  I hold everyone to a standard which, to me, is totally reasonable but everyone else seems to think is unachievable.  Looking at myself from the outside, I can see a thin fishing-reel line connecting me to the young obnoxious attending I will soon become.

The origins of this are obvious, of course.  All you have to do is take one 24 hour call in which the pager goes off non-stop, the ER gets mad because you haven't seen the new patient with a chronic leg wound while you are managing two life-and-death emergencies in the ICU, the medical resident calls you with five new consults (none of whom she has the name, medical record number, room number, original chief complaint or labs back) all while your student gives you attitude when you ask him to collect the vitals, and you will see what I mean.  Nobody can be that nice when all of this is happening.  It just isn't possible, and if it was, it would disadvantageous because it would allow everyone else to walk all over you.  Part of working in medicine means triaging the emergent from the urgent from the routine, and having to say "no" or "not now" sometimes to a person who doesn't want to hear it.  Soften your heart here, and you will pay for it in spades.  Being mean allows you to be efficient, and sometimes that is the only virtue that will save you during a bad call.

Unfortunately, the trade-off is that this behavior becomes so hard-wired in you that you can do it instantly at any time of the day or night, without thinking, and you become a nasty bitch to everyone else who drops the ball for a brief moment in everyday life.  Even while on vacation, feeling more relaxed than I have in several months and quite happy with my life, I took my mom to town for butting in where she didn't belong (nothing new, of course), I spanked my friend for re-engaging in a toxic relationship, and my sister for not having my travel information ready to go.  In my head, everything I've listed here can be thoroughly defended to a T.  I'm exceptionally sure that I was in the right, the other person was in the wrong, and a cold hard look at the facts means nobody else will disagree.

But they will, because I wasn't nice about it.  I didn't give anyone a break.  It's true others dropped the ball, but "Can't you just chill out?" is a phrase I hear a lot.  Not surprisingly, it isn't one you hear in surgery - the expectations are set for me in advance by my seniors, and the bar is high.  I meet it only because someone told me I had to, and that's how I learned to be good.  I can't chill out anymore.  Even when I think I'm being chill, I'm not.  It's like I've turned into a vicious deer, one always ready to jump and run when a car shines its headlights on me at 2 am, but not before I've bitten the front bumper and dented the passenger side.  And as a result, I lash out at people in response to their failures, regardless of whether that's the best way to affect change or not.

I can't tell you how much I hate this about myself.  It's like having an awful argument in my head all of the time.  I feel like if I relax, it means I'm dropping my guard.  Not just with other people, although that's certainly a consideration, but many times with myself.  If I get chill and relax, I won't be as good as I am, and I'm already not that good.  If I tighten it up more, I'll just lose more people in my life because I'm not fun to be around.  Whether I use a knife or cautery, I'm still making someone bleed.  Is it better to take the attitude of "as long as it isn't me"?  I'd like to say no.  But "as long as it isn't me" is how you survive in a residency.  You can see how the vicious cycle goes from here.

An attending once told me that perhaps it was all from lack of confidence.  I thought it a ridiculous idea at the time, because one of the major criticisms I get is that I am overly confident.  In surgery, confidence is a positive trait because it is better to be confident and wrong than to be indecisive, because surgery is about making a decision and committing to it.  But perhaps the attending was right.  When I stitch, I am a better stitcher if I can take a deep breath and relax my hands.  I am a better resident on call if I can take a deep breath and remember that everything always works out by the time the morning arrives.  One could argue that these are exercises in confidence, and the lack of confidence in me manifests itself as tension, which of course leads to anger.

If it's true, I don't feel so great about it, because confidence in the greater scheme of things comes with time and experience and knowledge, things that I can't wait for.  If I wait for those things to arrive, I may become so hardened that I can't go back, like an abscess you sat on and now has to get I&D'd in the operating room instead of the oral antibiotics you could have taken weeks before.

What I realize is that I need (and I can't believe I'm saying this) a medical solution, and not a surgical one.  I need a way to stop the stress before it gets so bad that someone has to cut me to keep me from cutting someone else.

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