Stress junkies: A single surgeon account on how we crash and burn by Dr. Jarin Noronha

A heart that’s full up like a landfill,

A job that slowly kills you, bruises that won’t heal.

You look so tired unhappy.

I’ll take a quiet life,

A handshake of carbon monoxide.

– Lyrics of a Radiohead song that somehow over dramatically apply to burnout in some surgeons

2017, Friday afternoon. Elective head and neck oncology Operating Theatre.

That day, I was assigned to operate a patient with a large, angry tumour swallowing half his jaw. As expected, it bled. And bled and then bled some more. But through the blood bath, one must march on with the aim of safely removing at least 1 centimetre of normal tissue around the tumour to prevent local recurrence. This requires nerves of steel, comprehensive knowledge of the local anatomy, physical endurance and a virtual 3-D model of the patient’s cancer to continue the now routine 7 hour procedure. The harsh years of surgical training permitted me to do a thorough job and once the surgery was successfully over, I scrubbed down to proceed with ward rounds and a quick 4PM working lunch.

However, lunch was interrupted by an emergency ward page and I rushed bedside to witness the horrible sight of one of my patients lying in a pool of his own blood. This is what most of us refer to as a surgical “Oh f**k!” moment.

When presented with such a scenario, the years of training kick in. Take a deep breath, focus, multitask and act like how you were trained to respond in an emergency – Call for help, assign someone to intravenous access, another one to monitor the vitals, get a good spotlight and demand surgical instruments with one hand still on the goddamn bloody vessel (excuse the pun) and the other free to proceed with a tracheotomy, if needed.

In such a situation, the responsibility falls on the team leader to guide the team’s next critical steps. At this point, I was not sure whether the bleeding was from the largest artery in the neck supplying the brain or the largest vein in the neck draining from the brain.

“Trolley! ICU! Wound pressure! Shift!” I screamed out the orders, applied pressure on the bleeding site and we all reached the ICU a bit ruffled. In the controlled environment of the ICU and under better illumination, my team caught the rascal artery which was bleeding like a fountain due to a spike in the man’s blood pressure and we secured the bleeding. I unclenched my sphincter, thanked everyone for their rapid response, updated the patient’s eager relatives and proceeded to scrub in to finish the rest of the cases assigned to me that day.

Although the above story ended off well, not all stories have a colloquial ‘happy ending’. I use this episode to highlight the daily drama and stress that accompanies routine surgical practice. Let’s multiply that stress by a factor of seven (or infinity, take your pick), compound the problem by a strong bully culture in the surgical field, throw in multiple sleepless nights and countless skipped meals to reach the state of mind harboured by most young surgeons in the country.

A few years into my training, I realised that something didn’t feel right. So, at my introspective best, I asked myself, why am I happy most of the time and find my work very fulfilling but also have a constant struggle with physical and mental fatigue accompanied with intermittent self-quizzing about whether such a lifestyle is sustainable or even worth it.

My initial reaction was anger. Over the last five and half years of surgical residency, I have not had a fixed day of the week off. ‘Keeping the Sabbath holy’ certainly does not exist in the surgeon’s bible. 100 hour work weeks are more the norm than the exception. Life comprises of occult sleep hours, questionable nutrition, doubtful hygiene, unsettled emotions and hypothetical vacation plans.

The emotional exhaustion (which risks sounding like something quoted in Cosmopolitan) has only been compounded over the last few years. Constantly swimming in a pool of hungry overachieving surgical sharks, one internalizes the unspoken norm that any publicly perceived faltering displayed on the job is an unequivocal sign of weakness and incompetence. We have been conditioned to feel repulsed by any form of self-pity without understanding the basic difference between sulking and calling out for help publicly when it is needed. The job is to fix things and being broken doesn’t feature in the description. In addition, the many number of years spent in training and lack of an immediate reward system compared to my peers in other fields fosters a belief in delayed gratification. Unfortunately, a surgeons life isn’t a Disney movie and the abundant “me-time” which one hopes to have someday never arrives which only encourages internal friction. This sentiment is echoed by a newsfeed filled with angry rants by doctors on a regular basis triggered by the weekly ritual of public doctor thrashing, medical facility destruction and popular sensational media doctor bashing.

I realised I was part of the disenchanted bunch, blaming my profession and the world around me for all my troubles. But what if the problem lay within me? It was now time for identifying the real culprit. So, I did what most people would do in my situation, I turned to Dr Google. After ignoring the initial diagnosis thrown up by Google (which is brain cancer), it was obvious I had classical Burnout symptoms. I accepted that I was on the road to crash and burn if my present lifestyle continued and choose to fight this new battle.

Most surgeons join the profession to help others and through the practice of wielding the knife, they begin to understand themselves. The time comes when one begins to accept the reality of not always living up to one’s ideals. The realisation dawns that a chronic shortage of time is predictable and only finite battles can be fought, even by the stress junkies, the self-proclaimed enthusiastic megalomaniacs. Some of this valuable time must be allocated to the preservation of sanity and mending what’s wrong with one’s own life. When we are swamped with work, taking a step back from it all may initially seem counterproductive initially but when viewed as an investment, it stands to reap sustainable dividends making the mind sharper, enabling the hand to move deftly and facilitate the cool, calm demeanour that is demanded the next time there is a challenging tumour, a difficult patient or an emergency situation presented. It’s a gamble with the intent of playing the long game.

The Japanese concept of “Kintsugi” comes to mind –to repair broken ceramics with a special lacquer laced with gold. The wisdom in this act is we recognize the beauty in broken things and incorporate repair into the broken pieces rather than disguising it (the gold lacquer makes the cracks conspicuous). A practice of mindfulness and meditation (Thich Nhat Hanh recommended), regular vacations (Japan is particularly enchanting), actively nurturing my work-life balance and maintaining a positive outlook to the war on cancer have been small measures in my armament to combat burnout. I personally believe that it is time to revisit the old proverb “Medice, cur ate ipsum.” (Physician, heal thyself). This would be possible by first accepting burnout as a disease and only then can there be cure.