Nobody told me about the guilt!

I had no idea just how much guilt comes with chronic disease. This may not be true for everyone, but it is definitely true for me. I just can’t seem to balance the whole “just concentrate on getting better” side of me with the side that is worried about everybody else, my business, other people’s schedules, my patients, and just generally letting people down with all of my limitations. Sometimes I think it takes me more time and energy to process all the guilt and worrying than it would just to be sick. I get it. That sounds ridiculous, but it is the truth for me. It is just a tough balance for me.

You know what I think would be a good idea? We should sit patient’s down, after they have had a chance to digest the news of their new diagnosis, and hook them up with a mentor or counsellor to sit them down and help them start to wade through and plan for all the other complications and stuff that comes with any chronic illness. It might make it less overwhelming than just having everything smack you in the face as it comes, while you are busy trying to “just concentrate on getting better.” I get that some cancer patients have patient navigators, but the main role of these individuals is to keep the patient on track in terms of appointments, tests, and treatments. This is useful to be sure, but the real trick is managing all the outside life stuff that is on top of the tests, etc. I say we start offering life navigators too because, in most cases, the damage that is done with all the life fails, failed relationships, missed work, and unpaid bills far exceeds whatever damage the cancer inflicted.

Dr. Katz

We are all tired.

Hey everybody. Show of hands…who seems to be tired all the time lately? I bet there is a ton of you. No matter how much sleep you get, no matter how well you eat, no matter how much caffeine you drink, that thick blanket of fatigue just never leaves lately. But why? My guess is that this persistent exhaustion isn’t actually just physical, it’s emotional as well. I mean sure, I am one of the believers that constant mask wearing puts you at risk for CO2 retention and respiratory acidosis, which can cause fatigue, but I know that is not the whole story.

So, why are we so exhausted? There are ten basic causes for fatigue that are the most common. Some of them we do to ourselves and some of them we have no control over. Let’s review.

The first one is poor diet. If you eat a diet full of refined sugars and carbs, you will be totally wiped out because all you get from that is short energy bursts followed by crashes. Likewise, if you are trying to diet and you are not actually getting enough calories to keep your body going, you will simultaneously just drain your own energy reserves throughout the day. On the other hand, if you eat a well balanced diet with no meal skipping, you will stay fueled the whole day!

The second one is using electronics before bed. I am totally guilty of this one. I mean, who is not filling their heads with the latest anxiety-causing social media right before they want to go to sleep? Sometimes it is the only time that we feel like we can “catch up” on the world right? Did you know that using electronics before bed turns up your fight or flight response which increases your pulse and blood pressure for several hours? It also decreases your melatonin levels. Both of those things are sure to keep you up longer. Ideally, you should aim to “unplug” at least three hours before bed time to give yourself a fighting chance.

The third one is sleep apnea. Sleep apnea happens when you literally stop breathing multiple times during the night, even if you don’t know that you’re doing it. This happens because your airways close while you are sleeping because of extra soft tissue. Not sure if this applies to you? Ask your bed buddy, if you have one, if you are keeping them up at night with your intense snoring. If the answer is yes, talk to your doctor about it and get treated.

The fourth one is anemia. If you are anemic with low hemoglobin, your red blood cell count is low and they are not getting enough oxygen and therefore you are tired all the time. The most common cause of anemia for women would be iron deficiency from menstrual blood loss. Some symptoms of anemia might be skin pallor, elevated pulse, fatigue or weakness. If you think you are anemic, talk to your doctor before self treating.

The fifth one is diabetes that is undiagnosed or poorly controlled. Diabetes causes excess sugars to stay in the bloodstream instead of going into the muscle where they can be used for fuel. As a result, you stay fatigued all the time. Some symptoms of diabetes could be frequent urination, excess hunger, excess thirst, and fatigue. If you think you might have diabetes talk to your doctor.

The sixth one is dehydration. We are all racing around lately without stopping just to try and keep up with the world around us. One sign of dehydration could be darkening of your urine when you go to the bathroom. If you notice, start increasing your fluids and see if it changes. We need to take the time to drink water frequently throughout the day. Experts say that we should aim for at least 3.7 liters(15.5 cups) a day for men and 2.7 liters( 11.5 cups) per day for women. How many of us are even close to that? I better get drinkin!

The seventh one is too much caffeine intake. I think that the world in general is guilty of this nowadays. There is no dietary recommendation for caffeine. It can be found in some medications, chocolate, caffeinated teas and sodas, and energy drinks. While caffeine can give you a temporary boost, it doesn’t last. How much caffeine is too much depends on the person. The effects of too much caffeine include increased blood pressure, elevated heart rate, premature heart contractions, and headaches. With caffeine, it really is a vicious cycle. You start drinking caffeine because you are tired. The caffeine then makes your body race and you get more fatigued. Then you find yourself “needing” more caffeine. Then when you try to wean yourself off of caffeine, you can get ridiculous headaches as it washes out of your system. In an ideal world, I would say don’t even try it in the first place. Mind you, I am saying this as I am sipping my dollar sized McDonald’s coffee.

The eight one is a chronic infection of some kind, most commonly a bladder infection. If you have been recently treated for a bladder infection and have no other symptoms except a lingering fatigue, go back to your doctor and get rechecked. You could have some infection left over.

The ninth one is thyroid issues. The thyroid is that little gland in your neck that literally has it’s fingers in multiple body functions, not the least of which, your metabolism. If your thyroid is underactive(hypothyroid), that could slow your metabolism and make you feel really sluggish. It could also affect your skin and make it difficult for you to lose weight. If your thyroid is really underactive, you might even notice a bulge in your neck and have trouble swallowing. If you think you have thyroid issues, call your doctor and get checked.

Last, but definitely not least, depression and stress are a major cause of fatigue. At least 25% of people suffering from depression report fatigue and a loss of appetite, in addition to the classic depressed mood that we think of. This is the one that I think is really affecting all of us right now with the the state of the world like it is. Depression causes feelings of sadness, anxiety or hopelessness for an extended period of time. People who are depressed often have sleep problems, which only add to the fatigue. Stress stimulates our flight or fight response which overtaxes our metabolism and can leave us feeling worn out and tired. Who doesn’t feel all of those things right now? The world is just not the same. We feel out of control. We feel like the joy has been sapped out of all our favorite things. We are spending a lot of energy looking for someone to blame for how things are instead of using our energy to deal with it. In my practice alone, the percentage of patients that I am helping with depression has risen 75%. This is a real problem and we need help.

So, we have talked about the causes. For the first nine, the strategy is fairly obvious: treat the underlying condition and the symptoms should resolve. Correct the lifestyle slip ups and the symptoms should get better. The last one, depression and stress, is a much harder mountain to climb. There is no one strategy that works for everyone because it is not a straightforward issue. You know what my first suggestion is going to be: talk to your doctor! Clue them in to what is going on with you and maybe they can help. Talk to your family and your friends. Maybe they are feeling the same way! Support each other the best we can! Seek counselling and therapy. I know that I personally have a list of counsellors ready to help at my office at any one time. Don’t try to tackle it all on your own! There is no harm, no foul, and no defeat in seeking help. The real battle is lost when you don’t take advantage of the resources around you and something terrible happens. Then the consequences spread like ripples on a pond, not only affecting you, but everyone you care about as well. Make sure you take the time to realize your own importance, especially now. No one can do that for you. I will make you a promise right now, we doctors are here for you.. We understand and we are tired too, but we will always be here.

Physician Burnout

Being a good doctor has been especially tough lately. It seems like there are so many obstacles to being able to provide quality care without completely sacrificing your own mental and physical health. Fortunately for me, I consider myself to be very strong of mind and body and my love for my patients and my job still far outweighs all the negative impact of the obstacles. I am very grateful for that, but, some are not so lucky.

You ask yourself, what kind of obstacles could doctors really have? Don’t they have it made? I mean, don’t they just make a ton of money off of the rest of us and live these amazing extravagant lives? Don’t they just get to direct us like sheep with all of their recommendations, procedures, and prescriptions etc? I hate to burst your bubble, but it is not like that at all, at least not for me.

Did you know that the rate of physician burnout is set to hit and all time high this year? The final numbers are not in yet, but it doesn’t look good. On top of that, Ob Gyn as a specialty has the fourth highest rate of burnout among all the specialties. 46% of Ob Gyn physicians report feeling burnout. So, what is burnout anyway? Physician burnout is classified as a psychological syndrome that is a prolonged response to chronic occupational stressors. Heh? What? It means that the stresses of the job potentially get so overwhelming and so stressful that you kind of break down and just don’t want to do it anymore. Yikes! Sounds awful doesn’t it? I mean anything with the word burn in it can’t be good right?

So, what are the symptoms of burnout? 1) Feeling tired and drained all the time is one of them. 2) Fatigue that does not budge no matter how much sleep you get is another. 3) Feeling sick all the time is yet another. 4) Changes in appetite or sleeping habits 5) Drop in libido or sexual desire 6) frequent back pain, muscle aches, headaches with no other apparent cause.

What do physicians have to be so stressed out about you ask? There are a ton of potential stressors. Let’s start off with the fact that your incredibly high medical school loans offset by the lower average salaries for most physicians means that your debt is not paid off until you are nearing 50. How about the fact that reimbursements for physicians, particularly in my specialty continue to drop, regardless of manhours spent or level of difficulty to the point that I find myself wondering if I am going to be the one paying to do procedures on patients instead of the patients…lol. Let’s think about the hours for a minute. For me, a solo practicing obgyn, I am essentially on call 24 hours a day and 7 days a week. My ability to do anything with my family completely depends on what is happening with patients. I find myself getting coverage if I decide to go to the bathroom in a town that’s greater than 30 miles away, much less if I am going on an actual vacation. I just can’t risk missing a call. For those of you with 9 to 5 jobs, most of you get to be done when you go home. I am never really done. I am always responsible for my patients. I am not complaining. I chose this life and this specialty. I am just clarifying.

Another stressor is the fact that there has been a huge breakdown in the concept of the doctor patient team relationship. Patients are now viewed as consumers rather than patients and as such, this wave of consumer-oriented thinking has brought a wave of bossy, entitled, demanding behavior that is often hard to stomach. I am extremely fortunate that I do not have a lot of these patients, but when I do, it is very exhausting. I have spent too much time invested in my education and have worked too hard and too long to have patients shake their finger at me, dictating their own care without listening as if I am their secretary or sales rep, rather than their doctor. It’s just not right.

One of the biggest stressors is the fact that doctors, even with all of their training and medical knowledge, do not really have the final say in what they can recommend for patients. The insurance companies do. The expenses do. The patient’s ability to pay does. I cannot tell you how many thousands of times in the last 25 years that I have had to change the optimum management, prescription, procedure, etc for a patient because of insurance and cost. Most of the time, my poor patients have to go through multiple treatment failures, medication side effects, extra office visits, etc before I am allowed to finally do the right thing for them because of some insurance criteria. To make it worse, most of them do not understand that I am not the one dictating these delays. They are under the impression that I am just “nickel and diming” them. Nothing could be further from the truth, yet I bear the brunt of their frustration and mine anyway.

Last but not least, let’s touch on the impact of COVID 19 for a minute. Wow talk about a stressor! Now we have to worry about exposure, like the rest of the world. We can’t hug our patients, hold their hand or comfort them in any way except with words, which is just not enough for some patients. If you thought insurance companies were bad about dictating care, they have nothing on COVID. We are being told when we can do procedures. I didn’t operate for months. We are being told what care is essential and what care isn’t. (Apparently vaginas fell in the isn’t category for awhile, unless a baby was coming out.) Our businesses are shut down and employees are sent home because there weren’t enough patients to keep them. Employees are afraid to come to work even when we have enough patients. We are told to do virtual consults instead of bringing patients to the office. How exactly are you supposed to do that with ObGyn patients? Hold their vaginas up to the screen? Generalization and conformity rules over sense and applicability. Even now when we are allowed to see patients, fear keeps most of them home anyway, crippling my ability to adequately care for them. I can say 100 times that it has never been safer to go to the office with all the precautions and prescreening, but I cannot force them to come in.

Long story short, physician burnout is a real thing. It affects nearly half the physicians in a lot of different specialties, and obgyn is no exception. I just want everyone to keep in mind that we doctors realize that everyone is struggling right now, but we need you to realize that we are right there with you.

Have a thoughtful day.

Dr. Katz