Anxiety about the unknown

January 3, 2016 10:33 PM

I am interested in hearing about how other professionals entrusted with the lives of others deal with the anxiety that comes with this responsibility...

I became an inpatient psychiatrist about a month ago. I love my work and I feel like my training has me well prepared to take on this role, however when I come home from work I am plagued with anxiety about the decisions that I have made and their possible ramifications. I worry about catastrophic things happening to my patients: deathly drug interactions and side effects, suicide on the ward etc. It keeps me up at night. There is always a remote possibility of these things happening, so how do I deal with this?

I find that reading about the things I'm worried about helps, but I could read forever and still not be prepared for every possibility.

I do have a history of bipolar disorder and anxiety myself, so that is contributing. SSRIs and SNRIs tend to make me manic, so I'm looking more for non-drug ways of dealing with this. I have a therapist and have done a course of CBT yet this persists. The input of healthcare workers would be especially valuable, but I'm happy to hear ideas all around. Thanks!

posted by chemgirl to Health & Fitness (13 answers total)

I think this is really common among young doctors and therapists, and most that I know turn to a mentor, a friend in a similar position, or a therapist with experience working with professionals. The anxiety will fade as you develop confidence in your decisions, and as you experience the negative outcomes that will sometimes occur, get through them, and survive them. It definitely helps to have someone who knows the terrain to talk to and to reassure you that your anxiety is normal and your standard of care is appropriate.
posted by Eyebrows McGee at 11:01 PM on January 3, 2016 [3 favorites]

I don't work in healthcare (though I have had a bit of OT training), but I work with young kids (kindergarten age) so understand completely how my work has a direct and palpable impact on fragile lives and how that could be (ok, is) anxiety-inducing.

A few thoughts on things to remind yourself of: Trust yourself. Believe (and make sure, which I bet you do) that the decisions you make are the best you know to do as a professional. Accept that there are things that might happen that are out of your control. The people you work with are all squishy humans and so are you, and not everything's going to lock perfectly into place. But think about where they'd be if they didn't have you to do this work.
posted by transient at 2:08 AM on January 4, 2016 [1 favorite]

I have an acquaintance who works as an inpatient psychiatrist who says the thing she loves about working in inpatient is that she is able to "leave work at work" and not worry about her patients excessively when she's not at the hospital. A large part of this reassurance comes from personally knowing the physicians who are there when she's not and trusting that they provide great care. Have you been able to get to know those people at your institution and develop those relationships? I believe that would help.
posted by telegraph at 5:26 AM on January 4, 2016 [3 favorites]

I will second the concept of having a peer to talk to when things get tough...and, there will be events that you'll need to discuss, it is the nature of the work you do. Whenever I've experienced a client event that I feel I should have been able to foresee or prevent (including client suicide), it has helped to discuss the details with a peer for feedback. Doing so can be both reassuring and a learning opportunity.

Also, as you continue in your profession you will acclimate to some of this and have a different, more balanced perspective, a month in is a very short time.
posted by HuronBob at 6:47 AM on January 4, 2016 [1 favorite]

I'm a PA and before I started in my current field (sleep medicine) I worked in geriatrics and urgent care. Especially when I was working in urgent care I would go home and have panic attacks. What if that horse was actually a zebra? What if I missed something serious? In geriatric IM it was more panic about polypharmacy. What if the [necessary] medication I prescribed caused a fall and a broken hip? It was terrible so I can relate to your experience.

What helped me:

1. I had a spouse who, even though he knew nothing about medicine, listened to me panic and was extremely supportive. Do you have someone similar in your life?

2. I would talk about my anxiety with my old schoolmates. They were also new PAs and also were scared on a daily basis. Are there old classmates of yours that you could contact?

3. I had a very good supervising SP (he acted as my mentor in the company as well) in geriatrics so I was able to remind myself that he was always there for me to talk to. I actually quit the urgent care fairly quickly because there wasn't this type of person there for me. Is there another MD there who has been working for longer than you and with whom you'd feel comfortable talking to?

4. I had a hobby to escape to when things got really bad. I would spend an hour or so not thinking about anything related to medicine. For me it was/is editing photos. Do you have a hobby? You should if you don't.

For me it was six months before I wasn't terrified to go into work and a year before I became totally comfortable. I know that sounds like a long time but it will go by fast.

It is seldom now that I leave work in a panic about one of my patients. It still happens on occasion though. It is usually related to the thought that I may have missed a zebra. I don't think that will ever go away. But it becomes manageable. You will get there. Just keep reminding yourself that these things you're feeling are not permanent and are actually evidence that you are an empathetic and good doctor.

Good luck. You'll be great.
posted by teamnap at 6:50 AM on January 4, 2016 [4 favorites]

Outpatient therapist here. I focus on the fact that my clients are autonomous adults, and they're going to make decisions I don't agree with, including possibly suicide, and I have to understand that I'm not powerful enough to control them fully, nor would it be healthy for me to do so. I also (as pointed out above) take comfort in knowing that there are other professionals available to them 24 hours a day (I work at an agency, so we don't take the after-hours calls ourselves) if there is a crisis; I worry much less about my clients who are in hospitals, as they're getting a much higher level of supervision and care.

I don't have to deal with the medication mistake/interaction questions, and I specifically do not work with children because they're not autonomous adults and so my own cognitive coping mechanisms don't work with them and I can't stop worrying, so I realize my techniques don't address your entire question. But I hope they help a little!
posted by jaguar at 7:32 AM on January 4, 2016 [3 favorites]

Great question. I do case management with homeless folks, some of whom are mentally ill. My work leaves me with a fair amount of moral and ethical distress. Even though, given the limited resources of my community, I have relatively little ability to impact and improve their lives, I still feel this enormous weight of the fact that I do have an impact, and at times my small actions could have very intense impacts for them, and even when the impact is on the surface positive, that could also have a long-term problematic impact. This stuff does keep me up at night at times.

In terms of whether I am offering the right advice to my clients though – I don’t feel a lot of anxiety – and I think the key to this is that my practice is rooted and grounded in using Motivational Interviewing. What makes Motivational Interviewing go beyond just a counseling technique, but is also a philosophy of work for me, is that I am putting the decisions back in the hands of my clients (who have systematically had choice removed from them their entire lives).

MI is this great balance of directing the conversation (I’m a nurse, I’m not here to support a client’s choice to deal drugs or beat up his girlfriend or whatnot) with empowering the client to make choice. I say a lot of things like, “If you were going to make a change in your health right now, what would it be?” and then help people make specific action plans about how to make those changes. People tend to know what actions are healthy. They know they would feel better if they stopped taking drugs, or quit smoking, or started sleeping inside. Providing directed support that truly respects and priorities the client’s own goals is a really satisfying way to work, and takes the burden of responsibility off my shoulders.

I understand that acutely mentally ill patients may have a limited ability to make thoughtful decisions, but they still have the ability to make choices, and they must ultimately decide things for themselves. So a conversation where you explore medication adherence, but give the client agency in that conversation, well it takes the burden off you as the provider, and feels inspiring to know your supporting the client to make their own choices.

Maybe I sound like an ad, but MI isn't really a product being sold, it's a helpful strategy and as I say, a philosophy, that is protecting me from burnout and helping my clients be treated with respect.
posted by latkes at 8:50 AM on January 4, 2016 [7 favorites]

Internist here--This is super common in new attending physicians and I would actually be concerned if you were NOT having those feelings. Do you have colleagues you can check in with periodically? During my first month as an attending doing hospital medicine I had lunch every. single. day. with a friend from residency who was doing the same thing and we would talk about the patients who we were worried about and just make sure we weren't missing anything. Having someone you can bounce things off of is a huge help. As you gain experience and confidence this will get better. (Recall how you felt during the first couple of months of internship--I distinctly remember being called to see someone who was going downhill in the middle of the night and thinking "Somebody better get this guy a doctor!--Oh. That would be me." But a few months later it was like "OK, we got this."). But even now, almost a decade after finishing residency, I ask colleagues to weigh in on stuff at least once a week, and they do the same for me.
posted by The Elusive Architeuthis at 9:04 AM on January 4, 2016 [4 favorites]

Family medicine doc here, 4 months into practice. I want to reassure you that everyone goes through this to some extent. As those above have said, having a mentor to bounce ideas off of, as well as someone to vent with is important. My boyfriend and I are both in medicine, so we understand eachother's work frustrations very well. All the regular anxiety management stuff- exercise, mindfulness, therapy, is important. You probably know this.

However, as someone who also works with high risk populations (the uninsured, low income, undocumented, mentally ill, substance using/abusing) I also have to remind myself that I personally can only do what I can do. It took a whole system to get these people into the terrible place they're in, I can be a part of getting them out but I can't fix everything. You do your best, use what's available to you, and for some people it will help and for some it won't. Statistically speaking someone is going to have a bad outcome, even if you did everything in your power to help. Doing what you can has to be enough.
posted by genmonster at 9:57 AM on January 4, 2016 [3 favorites]

You can always check for DDIs with your hospital pharmacy team. The pressure is not all yours to bear alone.

I also think it's very important to put yourself first. You can't take care of others in the best way if you aren't taking good care of yourself and meeting your needs, and that means making your health and welfare and ability to cultivate peace of mind (and putting time into developing this) as priority in your life.

Make peace with doing the best you can. And keep things in perspective. You are one person. Be on your team and on your side.

And make friends with colleagues, collaborate/share knowledge with them, etc. part of doing hard work that matters right is having the feeling that you have support at work, someone to consult with, etc. treat everyone with respect and make friends with everyone who works with you and treat them like you'd like to be treated, and I think you'll find you won't feel solely responsible for everything anymore. Clinicians need to make sure their at work support network is strong because this work is anxiety inducing. It is especially so when you have a big heart and are already anxious.
posted by discopolo at 10:09 AM on January 4, 2016 [2 favorites]

Something else that might help is thinking about your (smaller) role in the (larger) overall treatment trajectory for your clients. In my experience (and your experience/philosophy/institution may differ), inpatient psychiatric care is mostly about keeping the client safe and getting the client to a place where they can keep themselves safe for more than a day or two. The client's outpatient team would then take over from there. So it may be helpful to find out how your institution connects with the client's outpatient team by talking with the social workers and discharge planners at your institution, and maybe advocating for better discharge planning if you think it's necessary. Knowing that your client is set up well after they leave -- including making sure they have prescriptions and medication instructions, therapists/psychiatrists/case-managers set up, appropriate housing, etc. -- may help you feel better about knowing you're not entirely responsible for fixing the client.

I have also found a weird unwillingness for some inpatient psychiatrists to talk with clients' outpatient psychiatrists; I realize there are time constraints, and that some outpatient psychiatrists may be hard to reach, but connecting with the client's outpatient treatment team may also help you feel part of a larger treatment team, rather than feeling like the entirety of this client's life is on your shoulders.
posted by jaguar at 10:15 AM on January 4, 2016 [3 favorites]

Just wanted to share this bit of research I came across while doing some reading around suicide risk assessment. (I think it's likely the same kinds of insights are reached over time with clinical experience, and through knowledge-sharing with experienced colleagues (from all disciplines) and supervisors, but data-driven efforts seem useful [to me]. That research used data from health records at a VA hospital, so I guess it's unclear how widely results might generalize outside of that context, but more is being done in that vein.)

And following jaguar, would add to that list of team priorities educating patients' family members in suicide risk assessment. (I think there's a chance it could have made a difference in outcomes for a close friend of mine. But there's always something that could have been done differently.)
posted by cotton dress sock at 6:55 PM on January 4, 2016

Response by poster: Thank you everyone for your answers, I am just getting to them now as I've been off at work, surprise surprise! I appreciate you taking the time to answer my question and I'll be reading through them all carefully.
posted by chemgirl at 9:43 PM on January 7, 2016