I had just wanted it to be different for these kids.
3
Everybody Here Looks Perfectly Normal
All the doctors are gathering in the great room tonight to hear about our schedule for the next five days.
There’s a lot of chatter, the din of excited people.
Mick sees me standing by the door and walks over to give me an enormous hug, the hug you give a friend you haven’t run into for years. I’m really glad to see him.
“I’m so happy you came.” He does sound truly happy.
“Me too, but I’m hoping this isn’t a Jonestown kind of thing.
“Too late now.”
There are about fifty doctors here. Everyone is milling around, saying polite hellos. Chairs and cushions are spread out in a semicircle. It’s obvious that some people are stuck on choosing between chair and cushion, worried about looking stupid. I already look stupid, because I’m at Weirdo Doctor Rehab in the Woods, so I choose a chair.
The doctor who co-leads the program rings a bell. His name is Ron Epstein. I read his book about mindfulness and medicine before getting on the plane. Actually I read half of it, underlined a bunch of things that seemed important in the first few chapters, then started to feel hopeless, which gave way to feeling resentful, because all of it sounded correct, the ideas sounded nice, but it’s a bit late for swimming lessons when you’re drowning.
The bell’s vibrations linger in the room. A theatrical quiet descends.
Who are all these people? Men and women, all ages, all colours. Nametags that say Boston and Texas and Montreal and Australia. All screwed-up doctors, just like me?
Ron welcomes us. He talks about what we’ll do over the next five days, how we’ll spend our time together. He advises us to leave our phones in our rooms and tell people we can’t be reached, but this seems like a step away from Hare Krishna. I’m keeping mine in my pocket.
There will be a lot of sitting. We’ll push each other, and we’ll support each other. We’ll create a community.
Do I do community?
For the next ten minutes, Ron says, we should talk about why we’re here.
We drag our chairs into small groups, clustering around tables. People speak self-consciously. Some ramble. Some only say a little, fumbling on a handful of words.
I’m totally burnt out.
I don’t enjoy things anymore.
Gotta get back to my factory settings.
I’m hoping something can remind me why I became a doctor.
I lost my husband.
I’d like to care again.
We move around to other tables. We say the same things to other people, answering the same question again but choosing different words.
I’m not present in my life.
I feel so disappointed.
I want to figure out whether this still matters to me.
I’m looking for something to make me feel better.
I study these people. It’s too early for me to tell whether anybody else in the room is more or less screwed up than I am. They mostly look perfectly normal. I suspect I do too, aside from my hair. A bit of bright blue interspersed with the rest of my brown mop is my shark’s fin, my signal that I’m just a little unpredictable. A signifier. Or maybe it’s a warning.
I think about my boys, wonder what they’re doing, picture them in their little pyjamas, with damp hair and storybooks. A rush of longing. Breath, caught in my throat. Eric putting them to bed, brushing their wet curls aside, kissing their cheeks as he settles them in. That visceral need for them to be in my arms, pressed into my body, their faces against the crook of my neck, little chests rising and falling against my sternum. The smell of their heads. The little whorl of hair in the centre of their scalps, curving like markings on a lollipop.
I’m a good-enough mother, but I’d like to be a better one. Not a mother who bakes her own sourdough or holds a Food Channel–calibre birthday party, just one whose mind is in the same place as her body, who isn’t thinking about a student or a patient or a lab value while reading Frog and Toad.
Why am I here? Why are any of these people here?
If medicine and I were in couples therapy, I’d confess that I still love it. I really do. It’s written on my heart in indelible ink, next to the names of my husband and children and the rest of my family. Loving it isn’t voluntary; it’s reflexive for me, the connective tissue between who I am and what my heart drives me to do in the world.
So why am I here?
I’m here because Mick invited me, Ron.
Why am I here?
I’m here because Siddhartha found everything in his life in a stream. The meaning of his life. The sound of the water like a chorus of children. The sweetness of human voices. Maybe I will too.
Why am I here?
I’m here because medicine has left me a little bit broken. I’m here because I’m not really here anymore, haven’t been for a long time.
Because I would like to find a way back into my life.
4
Committed
I don’t remember anything about my first day of medical school. The room it was in, who I sat with, what was on my mind. I do remember that, at several points, I was thinking, shit. It seemed as if I’d made a big, terrifying mistake. I knew how to dissect a sonnet, not a cadaver. I tell medical students I remember what it was like to be in their shoes, but back then I actually felt as if I wasn’t wearing shoes or anything else. I felt naked.
I went to a medical school called McMaster. It was and still is a cutting-edge and world-renowned place, started in the ’70s by idealistic, intellectual hippies who were upset at how antiseptic medical education had become. My hazy early memories of Mac have been replaced by a more generic mood memory, a visual Muzak centred around the edgy ’70s lecture hall, with its angular lines and palette of greens. There is the odd specific: a formaldehyde tear leaking out of a cadaver’s closed eye in the anatomy lab. A young boy with a neck mass. A woman with seizures and a thick, grey, rope-like braid down to her waist. A windowless call room. A pager that felt like a live grenade. A constant sensation of being in an elevator prone, without warning, to sudden drops.
There were good times, though—moments with friends, spells of laughter and deep connection. Nights in the medical lounges, eating together, debriefing, plotting, commiserating. Hours spent with patients who made me laugh and cry. Sara on Pediatrics, a toddler with Down syndrome who banged her metal cup on the siderails of her bed every morning when I came to see her. Ellie on Psychiatry, who whispered to me that when she was a kid she saw a funnel cloud and tried to ride her bike into it. Fanny on Internal Medicine, an elderly Jewish lady with a leaky heart valve who invited me to her retirement home for bacon sandwiches. She never married, had no children. She took such an interest in me, divining my Ashkenazi roots, stroking my hand, asking about my studies, saying how proud my parents must be of everything I’d done. When she was discharged, she slipped me her address on the back of a hospital menu. I tacked it up onto the bulletin board in my bedroom, planning to write her in a few weeks. When I finally did, I sent her a funny card, saying I hoped she was doing well and that her heart was behaving itself, hoped I hadn’t missed the window for a visit. A letter showed up in my mailbox a few weeks later from something called National Trust. I didn’t even open it at first, thinking they were a bank wanting to lend me money because I was a medical student. When I finally slit it open, I was surprised to see it was from a lawyer.
We are the executors of the will of Fanny Stein. We are sorry to tell you that Fanny died on November 12th. As such we offer our condolences on the loss of your friend.
I felt a painful lump in my throat. I looked at that word on the paper for a long time: friend. This was around the time a new term was beginning to appear in medicine, professionalism—a word that would fundamentally alter the doctor–patient relationship in both intended and unintended ways.
Was Fanny my friend?
Actually, yes. Yes, she was.
That was my first small act of resistance. I folded the letter away for safekeeping.
* * *
FROM THE TIME we started in clinical rotations as medical students, all of us were basically incarcerated for an average of seven years of training. We spent more time in hospitals than out of them. You might argue with the word incarcerated, but it would be less wrong than you’d think. Medical students, residents and prisoners wear uniforms, eat bland food, have limited contact with the outside world, and inhabit a hierarchical culture. I got paroled the day my fellowship ended, on June 30, 2004. It was Eric’s birthday. I walked out into the sun, squinting, waiting on the curb for him to meet me, so we could take the subway home together and begin our new life.
But I struggled after my training, just as many prisoners struggle to adjust to life after incarceration. Some of them never really adjust and intentionally get themselves sent back to jail, because jail is familiar—awful but contained. Even the worst possible place can engender a feeling of security if it seems easier to navigate than a bigger place with more uncertainty. The outside world has no margins, no structure. We get to know jail so well that we forget what made us want to live in the world outside its walls. Our reference points are permanently altered. We lose the ability to recognize normal.
Over the years, I learned that many of my friends in medicine struggled too. We never exactly got used to life on the outside. It became another channel, a dual track, a world that was always quietly summoning us back to a place where the people around us could understand our words, our humour, our rituals. It was easier to be in that place. It started to seem like the only real world. In a patient, we would have recognized that kind of confusion as a symptom of mental illness. In medicine, without a trace of irony, we called it being committed.
* * *
JUST AS THINGS were starting to get unpalatable for me as an associate dean, but before they became intolerable and I quit, I was passing through Toronto, where I had done my residency. A colleague asked if I would come give a talk to the internal medicine residents. I said sure. The chief resident, Nikki, met me at the elevator.
She takes me to set up in the rounds room. Residents straggle in. Some of the young men have a fidgety, cocky energy. The girls are mostly impossibly thin, wearing gauzy pants and shirts.
I fiddle with the laptop, set up my PowerPoints. The city is fourteen stories below. Nikki introduces me while the students are descending on plates of sandwiches. I have to compete with tuna salad.
“Thanks, Nikki. It’s such a strange feeling to be back here. Exhilarating too. But when I was here, I was suffering. I feel like nobody talks about that.”
I tell them a bit about my training. Then I talk about burnout. I show them some comics by doctors, including one I wrote.
“This is another medium for us to tell stories, and it’s super-efficient. It’s hard to believe, but we actually process images 60,000 times faster than words.”
I take stock of the room. Every single person in the room is looking at their phones.
I pause for a minute. “Speaking of images, I’m noticing that you guys are all on your phones.”
Startled, they look up in unison.
“I’m live-tweeting this,” says a girl. “What’s your handle?”
“I don’t tweet.”
A hand shoots up in the corner. “Don’t you feel like you need an online presence?”
“I prefer actual presence.”
I see a few smiles, people exchanging looks of comprehension.
Nikki puts up her hand. “You do kind of have an online presence, though, right? You write that column, ‘Midlife with Dr. Horton’?”
“It’s called ‘Med Life’!” I correct her quickly. Everybody is laughing. I feel myself blushing. “Don’t you guys feel like online presence is crap?”
“How do you build a career, then?”
“You do that in person! At meetings and talking to people!”
The room is uncomfortable. I’m Grandpa Simpson yelling at a cloud, explaining how things used to be in my day. I’m just over forty, for God’s sake. How can the gulf between me and these kids be so vast as to be impassable?
“No offence,” says a curly-haired resident in the corner. “I think things are different now, and it’s hard for older people to understand.”
“I’m not old! I’m just over forty!” They all laugh again. Was that a joke? Did I intend for it to be funny? “My point is, presence means being present. An online presence is an oxymoron. It’s like virtual love.”
He shrugs. “Virtual love is a thing.”
Somebody quips from the back of the room, “Dave means porn.” Everyone laughs again.
“Okay, I’m going to ignore that. But it’s superficial, right? It’s not real love. And aren’t you just counting who tweets and re-tweets what you say, trying to amplify your own voice?”
The live-tweeter explains it to me patiently. “We totally are, Dr. Horton, because then everybody gets to have their say.”
“But if everybody’s having their say at the same time . . . how do you hear anybody else?”
“Everybody has a right to their say.”
“But is what everyone has to say equally valid?”
“It’s how we do things now.”
“Well, I liked the old way.”
“But you said you were suffering when you were here.”
Dave, the resident with curly hair, puts up his hand again. “Is it possible you’re just idealizing now? Because when we read your column, ‘Midlife’ or whatever, it doesn’t sound like you liked the old normal.”
I’m silent for a minute. Nobody speaks. Maybe they’re wondering if I’m going to do something adorable, like pull out a Walkman.
“You know what?” I tell them after several more seconds have passed. “You’re completely right.”
They’re quiet, watching me. Maybe they think I’m being sarcastic. Nobody is looking at their phones.
“When I was a resident, it’s like I said at the start, nobody talked about burnout. Or suicide, or addiction, or any of that stuff. The staff doctors didn’t say anything to us about their lives. So we felt like the problem was us. Now that we’re talking about it, we’ve stripped you of an illusion. You thought the problem was med school, or residency, right?” Several of them nod vigorously. “But now you’re seeing it doesn’t end there. We took a silent film and added a soundtrack, and it turned out to be a horror show.” I let out a long, slow breath. “I don’t think I would have gotten through residency if I didn’t think it would get better once it was over. And plus, you guys have the added challenge of technology. It’s made some things better, but it’s made other things a lot worse.”
“But doesn’t it get better?” a young woman asks. “I mean, you have more control over things when you’re staff, right?”
“Yes, but . . . by then you have kids, and aging parents, and families and patients complaining about things, and huge problems with gender imbalance and harassment in leadership if you’re a woman or a person of colour, and tenure, and research, and maybe health problems yourself, and huge administrative burdens if you take on roles where you want to try to change the culture. It’s a lot. I mean, residency was harder in some ways, but afterwards is . . . really hard too.”
I look around at the group. Sandwiches are pushed aside. A few have turned back to their phones, but most are waiting for me to say something reassuring, words that will make it all okay.
“I hope it’ll get better,” I tell them. “But the truth is that finishing residency is just changing coal mines.”
“Well,” says Dave, after a long pause, “thanks for being so candid with us.”
Nikki stands up. She thanks me on behalf of the group. The students go back to the wards. I apologize to Nikki, feeling sheepish for sounding so negative. Nikki says no, it was really important, and she’s grateful for my time, although it’s just as plausible
she thinks this was a disaster and is thrilled to get rid of me. She steers me towards the elevator the way you dutifully take your grandma to the washroom at a restaurant, shouting in her ear, “It’s right here, Grandma. The bathroom is right here.” She even pushes the button for me, in case I’ve forgotten if the street exit is at Ground or Lobby.
When I’ve reached the right floor and stepped out of the elevator, I pause for a minute in the atrium, watching the long stream of patients trying to find their way, some frail, some apparently well, their bodies hiding secret pathologies, like ticking time bombs. I’m putting my coat on when my phone vibrates with a new email notification. I fish it out of my pocket, read the screen:
Dr. Horton, thanks for your talk just now. Normally I’d have found you on Twitter ☺, but I got your email from Nikki. I really appreciate your honesty. I just wanted to let you know that I’ve been struggling with depression, and your talk right now gave me hope.
Holy shit. How did I give this person hope? That was the most depressing talk I’ve ever given.
I guess it’s like when you make an elusive diagnosis in a patient who hasn’t been feeling well for months. Even if the disease is untreatable, sometimes it’s just a relief to hear the truth.
I walk to the lakeshore, a place I used to go on weekends, sometimes with my friend Todd but usually by myself. I settle on a bench among rows of seating near the ferry to Toronto Island. I used to watch the mangy, over-fed gulls and the whitecaps on the water, ferries gliding ghostlike in and out of the terminal, the streetcars in the distance emerging and disappearing into tunnels beneath the ground, everything always in motion, while I sat absolutely still, clinging to the certainty that at least after residency, things were going to get better.
We Are All Perfectly Fine Page 3