My Struggle with Depression in Fellowship Training

When I started my fellowship in Pediatric Hematology/Oncology, I was already on maintenance depression medication.  Once you have your second episode of depression, as I did in residency, there is a higher chance of your depression coming back.  As a result, medications are usually not weaned off in between episodes.  

I moved to Denver, Colorado for my fellowship, which was a long way from home.  My co-fellows were very supportive and fun to be around, which was super helpful.  Although I was used to the long hours of residency, fellowship brought new challenges.  Working in oncology was much more emotionally exhausting than general pediatrics.  It is difficult to be on call and be kept awake all night by requests for orders or admitting sick kids.  It is even more difficult to have to tell a family in the middle of the night that their child has cancer.

As a resident, you have more senior residents to teach you about how things work on the inpatient units.  As a fellow, you basically are the senior instructor and have to figure things out for yourself.  The patients I was caring for were sicker and more challenging than most of those I had cared for as a resident.  I was usually exhausted when I got home from work each day.  And I was still on call every fourth night, but I did get to do call from home.  Unless of course someone at the hospital needed me.

Depression Returns

Despite these new challenges, I really enjoyed the work I was doing.  The care was very interesting and there was so much new to learn.  I really loved my patients and learning how to treat their myriad illnesses.  But the high emotional costs took their toll, and by the end of my first year of fellowship I was feeling pretty low.  I had hopes that things would get better in second year, as we transitioned into our research years.  I found a research mentor and started my two years of basic science research.

Even though I knew that I was physically and mentally exhausted, my depression still managed to creep up on me again.  I guess I wasn’t really paying attention to my own thoughts and feelings, being so busy at work.  I remember sitting at home one night and watching TV, when I suddenly had a vision of me trying to kill myself.  It was brief but vivid, and I saw myself slitting my wrists.  It was like a jolt; obviously this kind of thought is not normal under any circumstance.  I realized that I must be slipping into depression, and for the first time in a while started to take stock of where I was personally.

Shortly after this, I was at work one day when one of my senior fellows talked to us about the Colorado Physician Health Program.  This is a confidential service where physicians can go to get mental health support and services.  The evaluation and referral services are free.  I knew that I needed help and copied down the information we were given.  A few days later, I called the CPHP and referred myself.  I had an initial visit at the CPHP offices about a week later, where I filled out a survey about my symptoms.  It reminded me a little bit of campus mental health services in college.  I then met with one of the staff members who went over my answers with me and provided me with a list of psychiatrists in the area that I could contact.

starting therapy again

I was able to get an appointment with a psychiatrist on the list that took my insurance fairly quickly.  This psychiatrist was also trained to do psychotherapy, so she would be the doctor to diagnose me, write my medication and participate in my weekly counseling.  This was a great setup for me, and something I have not experienced since then.  She took my persistent suicidal ideations very seriously, and the first step was to change my medication.  I was already on the highest dose of my current medication, so we needed to transition to something new.  The next medication we tried gave me heart palpitations.  That meant another change in medication.  During these changes I was seeing my psychiatrist very regularly to monitor my safety and continue with counseling.

It took several weeks to hit upon the right combination of medication and counseling.  This time it took a little bit longer for me to start feeling better.  It was hard as I was still trying to function in my training, but my research mentor was very understanding.  I ended up having to reduce my hours in the lab for a short time.  My physical health was also suffering, as I had continued to slowly gain weight in fellowship.  I was diagnosed with binge eating disorder in addition to depression, and my psychiatrist also felt like I had issues with co-dependency.  Needless to say, I had a lot of work to do on myself.

My major depression did slowly start to lift, and the suicidal ideations stopped as well.  But instead of starting to feel good, like I had in the past, the low mood persisted.  It wasn’t nearly as bad as it had been, but enough to keep me feeling blah.  I was also plagued with insomnia.  I had always had periods where I didn’t sleep well.  But now it was getting to the point that it interfered with my daily functioning.  I had to try multiple different sleep aids to try and force myself to get some sleep.  This was challenging, as I am very sensitive to medications and did not respond well to the first few.  I finally found something that worked just enough to get me over the hump.

stress of Fellowship

Looking back, I think it was the continued stress of fellowship that kept me feeling low.  As we got closer to finishing, trying to find a job became an added strain.  There was a nation-wide job shortage in our field that we would now be contending with.  My interest in Palliative Care had grown during my fellowship, and started looking into doing this as a second fellowship (only one year this time).  I had missed the match again and started contacting programs across the country to see if they had a spot available.  I was lucky enough to find one in Michigan that was willing to create a Pediatric track for me if I joined their program.

Finishing up my Heme/Onc Fellowship was extremely stressful.  My insomnia came raging back, and when I did sleep, I started having nightmares about friends and family.  I was also trying to coordinate another cross-country move.  The idea of being so much closer to family and friends was exciting, many of whom had also moved back to Michigan.  I would also need to find a new psychiatrist in my new town.  Everything eventually fell into place, but I started my final year of Palliative Care fellowship in a whirlwind.

I really enjoyed finally getting to learn more about Palliative Care and Hospice.  It was something I had been interested in for so long.  It was a good change of pace from my first fellowship, but still very emotionally demanding.  I had really great mentors in palliative care and found that I also really enjoyed hospice work as well.  I did experience another episode of major depression, which I had to work on with my new psychiatrist.  This meant that my episodes were coming closer together, something that worried me.  I was scared of potentially having an episode of depression that I could not get out of.  Each subsequent episode also brought with it more suicidal ideation than the time before.  This was a difficult aspect of my depression to handle.  

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Burning out

By the time I finished my second fellowship, I was so burned out that I could no longer work.  I was supposed to be looking for a job, but instead I just stopped working for months.  The plan was to take 3 months completely off, but this quickly stretched to 6 months.  I just couldn’t bring myself to even start thinking about my first real job.  To be honest, I wasn’t even sure I wanted to be a doctor any more.  If I had absolutely any other marketable skills, I would have considered switching careers.  Physician burnout is extremely hard to deal with.  It was hard to imagine myself continuing on as a doctor, let alone visualizing myself in a long term job.  I put off the job search for months.

When I really needed money, I went back to doing Locum Tenens work, or being a traveling doctor.  After some time and serious soul-searching, I decided that the most important thing to me in a job was location.  I wanted to be back in my home town where my support system was.  My close friends were around here, as well as my family.  My siblings had started having children and I loved being an aunt.  

I knew that I would be limiting my job opportunities, but location became my top priority.  This was best for my mental health.  After a long job search, I realized that I would likely have to return to general pediatrics work if I wanted to stay in my primary location.  After so much specialty training, this was a hard pill to swallow.  But I knew that location was more important to me than specialty.  So, I again became a general Pediatrician.