Some thoughts on C/L, performance vs. growth, and “pager anxiety”

At the start of October I switched from my three-month Consultation/Liaison (C/L) rotation to the Adult Inpatient Program rotation, which will run through the end of December.  I found the C/L rotation challenging in multiple ways.  There was so much interesting psychiatry that I got to see and learn, with many clinical situations I hadn’t encountered previously, and I admit that there was a certain level of excitement that came with the pace of the service.  At the same time, I had to come to terms with the fact that I really don’t like to work at the behest of a typically-busy and always-unpredictable pager, and I very much don’t like to feel rushed.  

As an example of unpredictable and rushed: one afternoon the service pager stopped working without us realizing it.  Fortunately there was a workaround that involved forwarding the pager number to a personal pager.  But after the service pager got reactivated the next day I simultaneously fielded pages—including a couple of “We tried to consult yesterday but never heard back” calls—while exchanging emails with IT to figure out why the pager had stopped working in the first place.  Put another way: I found this work quite stressful.  There were more than a handful of nights where I woke from a vivid dream that I hadn’t finished a note or clearly signed out a to-do, and would have to convince myself that it had simply been my anxious subconscious and not an actual daytime lapse.  

It’s not that I didn’t have enough support or encouragement during this rotation; in fact, I was grateful to receive feedback that I was adapting to and handling the work well enough, and I discussed my qualms with both faculty and older residents.  But on a deeper level, my anxiety in trying to adapt to this workflow still made me question my own competence.  I intellectually understood that it was ok if this particular style of work wasn’t “my thing,” and that it was ok if I didn’t feel a sense of equanimity (to say nothing of mastery) when holding the consult pager.  Realistically, how could a resident at the start of their PGY-2 year be expected to have or feel mastery over anything in their specialty?  But I was afraid—and when on a call shift, especially, I am still afraid—that if I were to become overwhelmed, I would make a mistake that would affect patient care, or would not get everything done during my shift and would need to sign too much out to the next resident, or would need to stay far too late to finish my work.  What this all adds up to, in my head, is that I might be insufficiently efficient or effective, that I might be the weak link on my team.  I think that at the root of my “pager anxiety,” a fear of being overwhelmed connects with a fear of failure.

At some point in the past I read that residents go through several stages of growth which I loosely recall as 1) not knowing how much they don’t know; 2) knowing more than they did at the start but also realizing how much more there is to know, and so feeling discouraged and less confident than they should feel; 3) thinking they know more than they actually do; and thus feeling overconfident in their knowledge/abilities; and 4) realizing that they know a certain significant amount, but balancing that with the need for ongoing learning, and therefore calibrating confidence more appropriately.  Recently I joked to my therapist that stage 3 sounded nice because I was definitely still in stage 2, and very much worried about how much I have yet to learn.  Six months of psychiatry during intern year and three months on the C/L service felt like a mere scratch on the surface of this enormous field.  

In thinking about my “pager anxiety,” I’ve been thinking about the difference between a “performance mindset” and a “growth mindset,” which was a contrast drawn for us at the start of residency by one of our program directors.  As medical students, it’s impossible to avoid the performance mindset, as we are in fact constantly being evaluated and our future trajectory (i.e. residency prospects) depend in large part on those evaluations.  As new residents, we were encouraged to shift into a “growth mindset,” since we now have the opportunity to focus on patient care and our professional and personal development as clinicians / scholars / scientists / public servants / teachers / etc, without the same pressure of performance evaluations every couple of weeks.  

At this stage of residency, I can certainly look back on the start of intern year and recognize the considerable growth that has occurred, and anticipate much more to come.  I know I am still susceptible to the performance mindset, and on some level I don’t know that I will ever be able to entirely set it aside.  It does matter to me to feel like I am delivering “good” or even “excellent” clinical care, and also that I am meeting or exceeding expectations for my role as a trainee.

But what does it mean to be “excellent” in this work?  Hospital quality metrics aside, I’m starting to realize that on a personal level there is a risk to chasing the feeling of “excellence” if it is tied to a sense of surety, mastery, or ideal patient outcomes, when the very nature of residency training is that we are learning how to do this job, and especially when the nature of psychiatry is that our patients’ presentations and trajectories are multifactorial and often unpredictable.  On top of that, even without the COVID-19 pandemic, the system simply doesn’t allow me (or anyone else) to deliver perfect care.  There are too many patients and not enough providers, and so I simply can’t spend as much time talking with each of my patients, poring over their histories, or pondering their formulations as I would like.  To do so, I would need to routinely work until 10pm or later every night (not even taking into account those call shifts!).  

As such, I have to balance my own high expectations with what is realistic and sustainable.  I have to continue to ask for help when I need it, and to believe that I will continue to become more knowledgeable, efficient, and effective as my training progresses.  I need to keep working to build my internal locus of control and confidence, while keeping faith that my threshold for feeling overwhelmed will continue to rise.

And, if all else fails, the beauty of shift work is that each shift eventually comes to an end, and then comes a time to rest, reflect, and prepare for the next.

Anti-racism check-in

A case vignette I wrote back in the spring, “A Racial Enactment Amid COVID-Focused Anxiety and Mania,” was published this month in Psychoanalytic Dialogues.  The vignette focused on some racially charged interactions and I and a colleague (who is also of Chinese descent) had with a Black patient, “Iris,” in the inpatient setting. The full vignette is behind the journal paywall, but below is the closing paragraph:

Also present was another internal object that is both insidious and impossible to ignore: the reality that we psychiatrists, no matter our own ethnicities, are part of a mental health system with a long history of pathologizing and criminalizing Black anger as a symptom of mental illness (rather than a reaction to centuries of oppression and intergenerational trauma), supporting the shattering of Black families, and over-diagnosing Black individuals with learning disabilities or schizophrenia while underdiagnosing them with depression. This institutional racism continues to haunt our present systems of care, and has understandably wrought mistrust of psychiatry. I may be a well-meaning and even idealistic resident psychiatrist who sought to connect with and understand Iris. However, within the setting of involuntary hospitalization, I represent an institution of racial and social power, eliciting caution, deference, and fear. I am discomfited by two coexisting truths: I am a physician of color whose own ethnicity, especially during the present pandemic, leaves me vulnerable to racial enactments; and at the same time, I occupy a position of privilege and power within a system that can retraumatize patients, even as I seek to treat their illnesses.

One of the [long-overdue] changes I’ve made in my practice over the past few months is that I’m trying to be intentional about naming and validating structural racism (particularly structural anti-Black racism) as a factor in my patients’ experiences, whether longitudinally in their lives, during the past few months in context of national events, or as it affects their relationship with the mental health system.  Some of my patients have brought up race and racism of their own accord, which has led to some unexpected conversations and interactions that were deeply meaningful for me. Sometimes, I have tried to name race and structural racism as being present in the room with me and my patient, and to openly acknowledge my own role within the power structure of the mental health system.

These interactions haven’t always been graceful or effective. The stumbles are real. But, stumbles and all, it feels necessary to continue learning from my patients’ perspectives, and for me to be able to broach the topics of race and the pain of racism as determinants of health. The work continues.

Staying put, for a change

Being on the Consultation-Liaison service feels like everything is in constant flux: a patient list that is different every morning, walking all over the hospital, encountering different clinical questions, and seeing patients with different attendings. Over the course of a day I put on hats ranging from psychopharmacology non-expert (who is nonetheless trying to offer some semblance of expertise or authority), to therapist (for the patient) to therapist (for the patient’s family member) to therapist (for the primary team), to amateur ethicist, to legal hold writer, to student, to teacher, to note-writer, to team manager.  At any given moment, I’m probably trying to wear more than one of these hats.  None is comfortable yet.  One thing that is unchanging is the constant reminder that inherent to residency, and to being a physician, means never getting completely comfortable.  I read once that if I stop feeling all fear or uncertainty, then I need to change something about my job.  Right now there’s plenty of both.

This past week I was on vacation, i.e., staycation.  It started off with several days of sleeping poorly and feeling generally anxious and grumpy, which made me feel upset about being anxious and grumpy, which made me additionally upset about how I wasn’t enjoying my vacation the way I wanted to and the precious days were just ticking by, poorly spent.  Then I felt even worse that I was feeling bad at all, when so much of the state is literally on fire and so many people have lost their homes, are afraid of losing their homes, have lost loved ones or are afraid of losing loved ones due to COVID or structural racism or both, and/or don’t even have the option of taking time off because of financial insecurity.  In short: I have so, so much to be grateful for, so who am I to complain?

When I’m at work, certain core elements of that work have remained relatively unchanged from pre-pandemic, and that too is a blessing.  I’ve been consistently working in inpatient settings since February, and so I’ve acclimated to the masks, face-shields, and Zoom teaching sessions.  When I have time off, it’s much harder for me to ignore how disrupted our world has become (first by a pandemic, and now by fires and air pollution), that this is our new reality, and that we cannot predict a return to “normalcy.”

What ultimately unfolded this past week was that I let myself mope, to some extent.  I watched “Indian Matchmaking” and the latest season of “Selling Sunset,” ate some pastries, and drank some wine.  I also had regular meals with protein and vegetables; talked with my therapist, who helped me put words to the negative emotions I was feeling; and talked with one of the chief residents, who helped me come up with different ways to approach some of the challenges I have been encountering in my current clinical rotation.  I did some online exercise classes, and even went on an outside jog with friends.  I chatted in person with some of my residency classmates, and felt slightly (but tangibly!) less weighed-down afterward. My husband and I went to Ocean Beach and found some intact sand dollars, watched a seagull battle with a crab (the seagull won), and stared in horror at the apocalyptic ridge of smoke stretching from the North Bay to the horizon.

I finished Isabel Wilkerson’s “The Warmth of Other Sons” (in a word, awe-inspiring) and Frances Cha’s “If I Had Your Face,” and started and finished Molly Wizenberg’s “The Fixed Stars.” I started Jonathan Metzl’s “The Protest Psychosis” and Kara Cooney’s “When Women Ruled the World: Six Queens of Egypt,” and started listening to the audiobook of Isabel Wilkerson’s “Caste.”  Last night Andrew and I finally watched “Parasite,” during which I alternately laughed and squirmed, and nearly cried at the end.

Tomorrow morning I head back to work. I’m trying to keep in mind that it is simply impossible to be confident and excellent in everything that I do, that being resilient does not mean being emotionally impervious or without anxiety, and that a certain degree of emotional permeability allows for empathy. Accepting uncertainty and constant change has never been a strong suit of mine, but it’s an area of ongoing growth.


Other update: A little while ago I was honored to work with the expert storytellers heading up Stories Behind The Mask, which is a fantastic project focused on highlighting perspectives from healthcare workers on the fight against COVID-19 and racism. My video is here: https://twitter.com/MaskStories/status/1294303196240850945

PGY-2 so far

Part of my houseplant collection, with the most recent additions being the feathery fern and the large dracaena on the right side.

First day on the Consultation-Liaison (“C/L” or “Consult” for short) service last week: a surprisingly manageable easing-in for me and my co-resident, with our chief resident and multiple attending physicians (i.e. our supervising physicians, “attendings” for short) orienting us to the service.  Started getting familiar with the long patient list.  Spent significant time getting lost in this hospital, where I’ve only worked for a week in the past.

Second day: Long and overwhelming. This was in part because I was still getting physically lost and didn’t know my patients well yet, but also because I hadn’t yet learned to titrate the number of follow-ups seen in the morning before getting some of their corresponding progress notes done (this is key so I’m not super behind come mid-afternoon).

Thanks to the July 4 holiday I had some time to recover before my third day, a weekend call shift, during which I was covering the Consult pager (albeit at the very familiar hospital where I worked the prior four months), as well as supporting new interns who were getting used to covering the inpatient psychiatry pager.  It was a packed day but ultimately felt manageable, and made me appreciate the growth that happens over the course of one year of residency.  Knowing I needed to periodically check in with an intern and review some how-tos with them actually helped me stay focused on my tasks and try to be as efficient as possible.  As a bonus, it was wonderful to watch the interns give a clear and organized sign-out to each other at 8:00pm.

4th through 8th days: Varying degrees of “busy” ranging from comfortably busy to “we just got six new consults in two hours, yikes!!” but ultimately doable with the support of our attendings, senior residents, fourth-year medical student, and nurse practitioner.  We were getting lost far less frequently, and managed to eat lunch more days than not.  As the cognitive load of finding the right room numbers and simply keeping track of my to-dos lessened just a tiny bit, I found myself again able to recognize some moments of satisfaction and even joy in the work. My co-resident and I are alternating weeks of holding the pager, and he did a great job this past week.  It is also heartening that when one of our consult patients gets admitted to inpatient psychiatry, one of our residency classmates often becomes the primary physician.

Looking ahead at the coming weeks, in addition to my work-related goals and psychiatry learning goals, my secondary goals include:

  • staying hydrated as much as possible
  • remembering to pack a snack every day
  • aiming for 10+ minutes of strength- or mobility-targeted exercise most days, in addition to my 12-min daily walking commutes
  • continue to keep my houseplants alive
  • continuing with music and non-psychiatry reading, even if sporadic.

Currently reading/listening:

  • Isabel Wilkerson’s “The Warmth of Other Suns”: I started this while on vacation three weeks ago and it is such a gorgeously written and overall epic book. It also feels particularly timely and thought-provoking now.
  • Ibram Kendi’s “How to Be an Antiracist”: Almost finished listening to the audiobook (read by the author), though I expect to return to it later as well. Part of my self-assigned educational curriculum as it is for many others.
  • Anna Solomon’s “The Book of V”: audiobook, I’m 30% of the way into it, but I think it might be better read in a couple longer sittings instead of listening in short spurts.
  • Kevin Kwan’s “Sex and Vanity”: fluffy fun, though unsurprisingly, not as good as the “Crazy Rich Asian” series.

From intern to resident

I took this photo at the end of a night shift in early April 2020. From the seventh floor I could see the long line of socially-distanced hospital staff waiting in line for pre-work infection screening.

As of a few days ago, I am officially a second-year psychiatry resident, or PGY-2 (see end of post for a quick primer on the quirks of residency year naming). When I began my intern year in June 2019 I was excited to practice medicine, but was also apprehensive about whether I would find the work fulfilling, or whether I would experience burnout.  Both turned out to be true: it was an incredible year wherein I’ve truly enjoyed [finally] getting to be a doctor, and I’ve also learned invaluable and sometimes unexpected lessons that include how to choose and adjust antipsychotic doses, but also how to more accurately recognize and then mitigate burnout.  I’ve had the enormous privilege of learning from patients, fellow interns, senior residents, attendings, nurses, technicians, social workers, nutritionists, psychologists, and occupational therapists at the VA, at San Francisco General, and at Benioff Children’s Hospital; in different specialties (psychiatry, medicine, neurology, pediatric neurology, and adolescent medicine); and in a variety of different clinical settings.

At the start of residency I had hoped, but certainly hadn’t expected, that my fellow residents might become close friends.  My fear that I would be terribly unsuccessful in making new friends turned out to be unfounded; in fact, some of the senior residents have described our residency class as notably cohesive, which bodes well for the coming years.  Our camaraderie certainly helped when, two thirds of the way through the year, we unexpectedly faced the specific challenge of working in healthcare during a pandemic with various unknowns.  From February through June I worked on the same psychiatric units at the General, and it was at turns fascinating, stressful, and educational to watch the city, our institution, and our department adapt to this public health crisis.  Amid bouts of uncertainty over whether the curve would be flattened or if we would end up with a terrible outbreak on our units (which, thankfully, did not happen), the overall consistency of my schedule during these past months gave my life structure.  Together with my colleagues I settled into the new normal of daily pre-work screening questionnaires and surgical masks all day.

Then, toward the end of the year, we all found ourselves grappling with the role of structural racism and police brutality in our communities and our medical fields, and the impacts (both acute and chronic) on our patients, colleagues, and friends.   As part of this long-overdue collective reckoning, we have had to rethink what it means to be supportive of each other, to hold each other accountable as allies, and to advocate for each other and for the patients we serve.

During orientation for the incoming interns, a classmate and I each shared a couple sentences about our cultural backgrounds and how they affected the start of our residency.  I shared that I am a Chinese-American immigrant who grew up in a relatively liberal and well-educated college town, and that while during medical school I was involved in some equity-focused advocacy efforts, it was during intern year that I finally began unpacking my intersectionality and privilege in earnest.  I believe a necessary step in becoming an anti-racist physician is understanding one’s own cultural intersectionality, that we are each at a different stage in this process, and that wherever we are is a fine place to start.  Just as this chosen career path requires that we hold space for our patients’ emotions and inner conflicts, so too do we need to hold space for our own uncomfortable truths.  And so, I am reading, listening, writing, and thinking.  

My second residency year (PGY-2, or post-graduate-year 2) will start next week with three months on consultation-liaison psychiatry at UCSF, followed by three months on adult inpatient psychiatry at UCSF, and then six months of outpatient psychiatry at the VA.  Throughout the year we take call shifts at the General, VA, and UCSF.  Each residency year brings new expectations and challenges, and just as I did a year ago, I again find myself feeling both apprehensive and excited.

***Summary of residency year naming schemes: each year, or title for a resident in that year, is often named as “Post-Graduate Year” followed by the number: PGY-1, PGY-2, etc. Another informal shorthand for residency years or residents is R1, R2. Thus, a second-year resident could be referred to as “a PGY-2” or “an R2,” and is in their PGY-2 or R2 year. The first year of residency (PGY-1) is colloquially called “intern year” because some medical specialties, such as radiology or neurology, require that their residents first complete a general medical internship (which may or may not be at the same institution) before starting specialty training in PGY-2. Psychiatry residency is one that begins in the PGY-1 year. Regardless of these differences, across specialties, the completion of the PGY-1 year is thought of as the transition from internship to residency.