Travels via food (8): Burnout via Bagels

In June 2016, I moved to Toronto for a year long critical care fellowship at the University of Toronto. I was drawn to the program because it seemed to be an amazing opportunity to experience living and working in another country. I was particularly impressed by how half of the fellowship cohort would be local, and the other half would be international. My colleagues came from all over the world - UK, US, Argentina, Mexico, Singapore, Japan, Germany, Qatar, Iraq... a very impressive United Nations of Critical Care. I was excited by this kind of collaboration - where I trained in Sydney was an ivory tower, reputing itself as the "very best" but in reality quite isolated from other ICUs even within the same city. 

So much happened during my time in Toronto. A lot of it was wonderful - I made some incredible friends and we made some incredible memories together; I fell in love with chamber music; I learned about this thing called "sourdough" from my friend who was experimenting with her new starter we christened Priscilla (a la Fig Jam & Lime Cordial)... so much of what my life is now is influenced by the short time I spent there. 

But the most profound thing that happened during my critical care fellowship was my burnout, from which I learned that I am human. 

I cannot tell you exactly how my burnout started, but I can tell you about some of the factors that contributed to my burnout. 

First, I had already finished training in Australia and had been working for 10 years out of medical school. The North American system is vastly different and doctors speed through a compressed residency and fellowship. Thus many of my colleagues were just 4 or 5 years out of medical school and a significant proportion of my bosses were less experienced than I was in intensive care. I didn't think this would be a big deal, but it became frustrating when we had disagreements about patient care. The hierarchy in the hospital was stronger than anything I had ever experienced, and I found it disempowering that my clinical experience was less regarded because of my job title. 

One night, I called the attending about a patient that I was worried about. I thought the patient had an unusual procedural complication and was deteriorating rapidly. The boss disagreed with my assessment and dismissed my concerns. Unable to reach an agreement over the phone, I asked her to come in urgently and she refused. Half an hour later, I made a second phone call when the patient appeared to be dying. Soon after that second call and before the boss arrived at the hospital, the patient died. I wanted to inform the family about the procedural complication, but was told to keep quiet. I wanted to refer the patient to the coroner for investigation, and I was told to keep in line and write an alternative diagnosis on the death certificate. In hindsight, this disconnection from what I felt was morally acceptable was the first blow in the development of my burnout. 

Second, I found the medicolegal context of my work extremely challenging. There have been a number of challenging cases in Canada with regard to withdrawal of life support, and this was in full swing when I arrived in 2016. We would frequently be referred patients who were elderly and frail with multiple comorbidities, patients who had lost the ability to advocate for a peaceful natural death for themselves - these were the people we had to admit to ICU because the family insisted that we do "everything". Often, I would scream silently in my head that we ought to do "everything that is reasonable that would be of benefit to the patient". Instead, we were forced to put them on machines and do multiple painful procedures. I felt like I was participating in robbing them of their dignity at the end of their lives. 

One evening, I was called to the Emergency Department to see an elderly lady in her 90s who lived in a nursing home and had advanced dementia. She had had a "Do Not Resuscitate" order in place for several years, but the family decided that it should be rescinded on this particular occasion. She had severe pneumonia and her blood pressure was low. I rang the attending because I felt conflicted about the ethics of this case, but the attending told me to "not make trouble" and "do the usual". The fact that there is an expression of "do a slow code" (ie. you have to resuscitate technically, but don't try to resuscitate too hard) was astounding to me. 

I took this lady up to the ICU - she was clearly dying but I had been given instructions to put her on the ventilator. Her blood pressure was plummeting fast and the oxygen trace was abysmal. To get her blood pressure up before I put her on the ventilator, I had to put a central line in her neck. She was nearly unconscious but cried with pain when I poked her with needles. As I inserted the line, the alarms on the monitor went off. Her nurse had gone on her tea break and the nurse covering was busy elsewhere. No one else was in the room as this lady took her last breath, just as I finished inserting the central line. I took the drape off the patient and felt deeply ashamed that I had participated in this. Her last moment on this earth was one of pain and suffocation under a drape, robbed of the dignity she deserved in death. By then, the alarms had gone crazy because her heart had stopped and a bunch of nurses ran in with the crash cart. The patient looked peaceful, grey and inert. One of the nurses ran to do CPR on her, and the other attached her to the machine to give her electric shocks. The peace was broken by the hubble, and no one believed me when I said she had already died, because she was "full code".  

The crazy hours didn't help either with my burnout. Some weeks were "heavy weeks" -  24.5 hour shifts on Monday, Friday and Sunday, and a normal work day (7am to 5pm) on Wednesday and Thursday, a total of 93 hours in one week. I was told to be grateful to be given so much time off in between the long shifts. With the safe working hours regulations in Australia, I was not used to these hours but they were very much the "norm" in Canada. I was often run off my feet and too overwhelmed to sleep after the long shifts. Sometimes I would queue at the coffee shop and wonder if the lady at the coffee shop got paid more than $1000 for 93 hours. I had never been into money or materialism, but being paid below minimum wage was a demoralising addition to my burnout. 

I thought burnout was something that happened to old doctors - men in their 50s having their mid life crisis. But finally I realised that it can happen to anyone, and particularly young women are at risk. I had protective factors like supportive colleagues, a close group of friends, hobbies outside of work... but at that point in time, the pro-burnout factors were winning. I was far away from my family and my then-partner. Winter was descending, the days were short and I felt deprived of sun.

The final straw that broke the camel's back came in December, when I had a stretch of 17 days of continuous work. I was allocated to do six 24 hour shifts during the 17 days. These were some of the darkest days of my life. Though I remember some moments of joy like a friend dropping by treats she had saved from a party she went to, most of that time was a numb amorphous mass. I felt disengaged and unmotivated. I was embarrassed when I missed things at work, and afraid that others would look at me like I was incompetent. I was not aware that my state of burnout was responsible for these near-misses and misses. I felt like I could not say anything to anyone - how would anyone understand the state I was in? What if I got kicked out of the program? 

The fifth of the six 24-hour shifts started like any other. To look after the 30 bed ICU, I was paired with a disinterested PGY1 orthopaedic resident. I missed home like no other day because disinterested PGY1 orthopaedic residents would never be responsible for the care of critically ill patients in Australia. He was surly, and I was in an even surlier mood. I knew things were unravelling when one of the nurses asked me if I was OK, after I yelled at her for asking me about a blood test result. My heart was racing and I did not know why. 

Shortly after midnight, I was called to the transplant HDU where a patient with a recent lung transplant was deteriorating. As I was about to intubate the patient, another patient had a cardiac arrest and I had to run from the first patient to the second patient. By the time the second patient was stabilised, the first patient had deteriorated and no one had informed me. I ran between the two patients, feeling like I was losing control of the situation and it was all my fault. The first patient improved a little, but the second patient was dying despite all my efforts. As the night dragged on and both patients accumulated more machines by their bedside, I became convinced that a more competent doctor would be doing a better job. 

At 5am, I had the most surreal experience of my life. I was suddenly overwhelmed with an extreme anger that I had never felt before. My body was flooded with a red hot fury that was totally foreign to me. I was so angry at the second patient for being alive - clearly they were going to die anyway, why wouldn't they just die so I can get five minutes sleep? When I witnessed the emergence of this thought from the depths of my mind, I wondered who I had become. Who was this person who had this thought? I went to the on call room and cried. I called my boyfriend in Australia but he did not answer because he was at work. 

Just before the sun rose, the second patient died. The morning doctors arrived for rounds and unanimously shrugged - he was extremely ill so no one was surprised by his death. Nevertheless, I felt responsible for his death, I was scared I had somehow wished it upon him because I wanted to sleep. How could a doctor be so selfish as to wish death upon a patient? I was determined then that I should lose my medical licence, that I was not cut out for medicine. 

After the shift finished, I went to my supervisor and told her about the night. She was nonchalant and said that everyone wishes that sort of thing once in a while, so don't worry about it. I told her that I could not do the sixth on call shift, and she asked me incredulously - who was going to do it then? I told her that it didn't matter who was going to do it, but it wasn't going to be me. Then I walked out and went home. 

That was the beginning of the journey out of the darkness. It was the first time I acknowledged my burnout and the first step towards getting external help and helping myself. I needed to rest and ultimately, I needed to leave the environment that I was in. Everyone always talks about work life balance, but it is so much easier said than done. 

In late January, I had my mid-year assessment with the director of the critical care fellowship program. I tried to tell her about my burnout experience, and she responded with a request for me to consider and remember why I had come to Toronto. I went home and contemplated this - what was I trying to prove by being there? Did I just want the experience 'for my CV'? was it worth sacrificing my physical and mental well being? 

That night, I decided to look for a job back in Australia. Shortly after, I found one and quit the program. Fast forward to now, I have excellent work life balance and work 70% of the time. The rest of the time I play music, bake bread, go for walks, read and write. I have a job that I love and a life that I love - and a greater than ever awareness of self care. 

And so it is that I make these bagels, often the feature of brunches in Toronto. Is there anything better than fresh bagels? 

Bagels.. in Newcastle

(Adapted from the Emilie Raffa sourdough book, the best one there is...) 

120g sourdough starter 

250g water 

500g flour

20g sugar 

8g salt 

Mix into a dough and knead until smooth. This will take about 10 minutes. 

I did this in several bursts allowing the gluten to relax for about 5 minutes in between, it's much easier to bring the dough together this way (or you can use a stand mixer but I don't have one). 

Rise until doubled in size, approx 6 hours in Oz spring temperature. 

I then refridgerated the dough till the next day, but you can proceed on the same day. 

Divide the dough into 8 - 10 balls (depending on how large you want your bagels), shape into a ball shape by tucking the edges in and relax for 10 minutes. 

Poke a hole in the dough and gently stretch it out to a bagel shape (it will start to shrink inwards, so make the hole larger than you think)

Rest covered for 20 minutes 

Meanwhile, bring water to boil in a large pot and add 20g maple syrup to it

Boil 2 or 3 bagels at a time for 30 seconds each side, remove with a slotted spoon onto prepared baking sheets 

Once slightly cooled enough to touch, dip the still moist bagels into preferred seed mixture

Bake at 220 degrees for 25 minutes, flipping the pan half way 

Fresh out of the oven, these were incredibly soft and chewy with a blistery crust.

 

Rather handsome too!