“We’re encouraged to mentally rehearse life-saving procedures for conditions that occur so rarely we might go our entire career without performing them. And the reality is that I could spend every minute of my free time this way and still have an unexpected situation arise during my next shift. So, is there a way, as experts in disaster preparedness, to accept what we cannot control?

Thankfully time, medication, and therapy helped me out of a very dark place, and the journey has prompted me to reconsider my priorities. Tessa and I only meet about once a month now. With her continued help, I’m hoping to find a way forward in the specialty I love, but with the understanding that I’m no longer willing to sacrifice my own mental wellness.”

Adrienne Van Curen is an emergency physician.

She shares her story and discusses her KevinMD article, “Are my coping skills a result of my emergency medicine training?”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Rate and review the show at KevinMD.com/rate. Subscribe at KevinMD.com/follow. Today on the show, we have Adrienne Van Curen. She is an emergency physician. She wrote the KevinMD article “Are my coping skills a result of my emergency medicine training?” Adrienne, welcome to the show.

Adrienne Van Curen: Thanks so much for having me.

Kevin Pho: We’re getting to the article in a little bit, but first off, can you share your story and journey to where we are today?

Adrienne Van Curen: Sure. I currently am an emergency medicine physician in Atlanta, Georgia. I grew up in Georgia and went to undergrad and med school here, and then I moved up to Massachusetts for my residency. Right out of residency, I worked in a community hospital, which was kind of perfect for me then. It was a lot of bread-and-butter emergency medicine. I saw a lot of patients and a lot of procedures and gained confidence as an attending, but it was clear to me pretty quickly that that was not going to be a good long-term fit for me.

My husband is a computer engineer and wanted to move back to Atlanta for a startup, so when we came here, I took an academic position, just because I knew it would afford me some more opportunities with my career. I’ve been with Emory now for about six years. In August of last year, I decreased my clinical time. For the first time since residency, I went down from full time to half time, and I enrolled in the MPH program here, so I’m currently doing that. I’m married and have three school-age daughters who I’m also pretty involved with. So, busy, busy.

Kevin Pho: I’m sure. I have two school-age daughters, so I can certainly relate to what you’re saying. You mentioned that you practice in both a community and an academic setting. When it comes to emergency medicine, what are some of the major differences between those two settings?

Adrienne Van Curen: Well, I think one thing that’s kind of interesting about emergency medicine, and it’s probably true for all medicine, is that the hospital and the location change the whole job. In the community hospital where I was working, there were some residents, but they were not emergency medicine; they were internal medicine. So there was a little teaching, but definitely not as much teaching. Also, where I was, I worked near Boston, and of course there are some big tertiary care centers there, so I didn’t see a lot of the really specialized patients that I take care of now. It was a lot more of the straightforward pathology.

There’s also a huge opioid problem there, so that was a really big part of my practice there, which was also part of what I think was a little discouraging to me. I know in Atlanta there is still the opioid problem, but I don’t think it’s as robust, maybe, as in New England. The patients I take care of here are much more complicated, so I like it because I feel like I see something new every day, something that I’ve never even heard of. I feel like I’m constantly learning, and I felt a little stagnant in the community role.

Kevin Pho: All right, so let’s talk more about your KevinMD article. It’s titled “Are my coping skills a result of my emergency medicine training?” Now, for those who didn’t get a chance to read your article, can you just walk my audience through it and share the story of why you decided to write it?

Adrienne Van Curen: Yeah. The article is based on my experiences over the past year, really. In February of 2021, as a full-time emergency medicine physician, as far as work, I was feeling pretty stressed out to the max. I would say I was burned out with the pandemic. I was working a shift one day and got an email from one of my brother’s close friends that he had become really sick and was hospitalized, not at the hospital I work at, but a little bit north of me. He had a diarrheal illness and just really severe fatigue and was pretty quickly diagnosed with widely metastatic colon cancer.

His hospitalization and ultimately his death were very difficult. The first week that he was in the hospital, we couldn’t visit, because that was still when the COVID precautions were pretty strict. Then we transitioned to hospice, and ultimately, I did feel like, under those circumstances, it was a nice death. We got to have a lot of conversations about how he was feeling, and I know he was comfortable. He was lucid and able to be involved in all the decision-making. So I think, under that circumstance, things went as well as they could have.

Afterward, I don’t feel like I dealt with his death in a very healthy way. I internalized a lot of my feelings, and I didn’t really talk to anyone, maybe my husband, because I think I was this person who has always been trying to project this mentally strong persona. Maybe we all do that as physicians. I think we learn in med school that you have all sorts of things thrown at you, and you just take it and move on. So anyway, I dealt with that by myself, and six months later, I felt like I was doing much better. I was very sad about his death, but I had gotten to a much better place.

Then I got a phone call from my stepfather that my mom had died. She was on Eliquis because of AFib, and she had had some kind of injury to her leg when she was at home alone. He had been out running errands, and she hadn’t met him where they were supposed to, and he came home and found her. With her death, I don’t know if it was that our relationship was very different or just the circumstances of the death, but it had a much different impact on my mental health than my brother’s death and even COVID. I had felt stressed about COVID, but I really began to have uncontrollable anxiety. I was perseverating on the circumstances of her death and spending so much of my time thinking about how she was at the end of her life.

Then, I think, when my mind ran out of possibilities to worry about with that, I then started worrying about my own family. My daughter would cough, and I was convinced that she was going to die, because I was thinking I was this person that terrible things were just going to happen to now. At work, it was interesting, because I really felt like the stress of work was not different for me. I felt like I was doing fine there. It was really in my daily life that tiny things that normally wouldn’t have given me pause were really sending me spiraling.

I mentioned this to one of my colleague friends, and she really encouraged me to take advantage of the therapy services that Emory offers to staff. I was very reluctant to do that, and that may also be something that other people can relate to. I think I felt like it was an elite privilege, and I felt like my life wasn’t that bad compared to other people’s, and I also wasn’t sure how it could help me. But I was in such a bad place at that time. I was really physically not feeling well every day, and I was just not enjoying my life and worrying so much. So I did it, and now it’s been about six months since all that. I did also take some medication for a few months. I don’t know if it was time or medicine or therapy or what, but I’m in a much better space. I think the therapy was a big part of it. I think we’re all pretty evidence-based, so obviously, this is anecdotal, but I learned, I think, some better coping skills.

This article resulted from, one, me returning to writing a little bit more. That was something I hadn’t really done for pleasure since high school, and my therapist, Tessa, recommended that I lean into that and maybe journal, so this was based on some reflections I had during that time. Another thing is that during my sessions with Tessa, we just kept coming back to the fact that I would worry about these scenarios and then try to go through all the possibilities and try to figure out the way that I could perfectly manage all those possibilities. She pointed out that a lot of the time, there were an infinite number of possibilities, and also, I could not solve any of them. A lot of the problems that I was bringing up with her were things that were really out of my control, and she pointed out that I was expending so much energy this way and really not accomplishing anything.

What I thought was interesting about that is that I feel like it flies in the face of emergency medicine training. I think we are taught in emergency medicine to train a lot, especially for these very high-risk but also very low-probability events, because you may see them once in a career or never, like a perimortem C-section or having to do an emergency cric or an emergency thoracotomy for a trauma. But they’re things that we’re expected to be able to do. So I think we’re encouraged to do sim labs and cadaver labs and mentally rehearse these scenarios, but you could spend every minute of your free time doing that and still, tomorrow, walk into a shift with a condition that you didn’t think of.

So trying to figure out how to move forward with emergency medicine while still maintaining that mentality of accepting the things that are out of my control has been a challenge, and it’s something I’m still working on with her. I don’t know the solution, but I just thought it was kind of interesting, and I started to wonder if that was common, if other emergency medicine physicians were the same. I know we have a very high rate of burnout, and I wonder if some of that has to do with just all that pressure.

Kevin Pho: You mentioned that if it wasn’t for the nudge of your colleague or friend, you probably wouldn’t have pursued therapy. Do you think, had you continued on that path, it’s something that you eventually would have come around to, or did you need that nudge to take that next step?

Adrienne Van Curen: I really think I needed the nudge from her. Honestly, this came from a person that I really respect and that I think of as very mentally strong and tough. Of course, I had thought about therapy at other points in my life, going through things, and like I said, I just think I had too many reservations. I don’t think I would have done it if it hadn’t been for that nudge, and probably also from this specific person.

Kevin Pho: You mentioned this earlier, but specifically, what were the reservations that you had that prevented you from going to therapy? Was it the proverbial medical school and residency mindset of not showing any vulnerability or weakness? You mentioned something about privilege, but specifically, for you, what were some of those biggest reservations?

Adrienne Van Curen: Yeah, I mean, I think, yes, there’s the medical school mentality of going through that hazing that we all go through and being expected to not show any kind of emotion, or to just be able to cope with every single thing that you’re dealt with and move on and get things done. I also grew up in a family that certainly would not have encouraged or been open to therapy and probably would not have supported me in that, so I think that was probably a big part of it.

Then, yeah, of course, with the privilege piece, I think whenever I thought about it, part of me was like, “Well, my life is so good compared to so many people’s,” and it felt kind of silly. It’s hard to describe, but I just have guilt about having access to those services when there are people who have so much worse life conditions and situations and aren’t able to do that. So I think those were the main things.

I also do think finding the right therapist is so important. I was lucky, because Emory has a system where you can read the bios of the various therapists that they offer. I met with one of them, and she actually referred me to someone in the community that she felt would be a good match for me, so I was very lucky in that, too. I think the other part of it was that I had heard that you need the right person, and I knew, too, that if I didn’t have the right person to talk to, it wouldn’t really work well. The idea of spending my time trying to find that connection, and also sharing my story so many times, just seemed exhausting and overwhelming.

Kevin Pho: Now, you mentioned coping mechanisms that you learned and are still working on. I’m sure a lot of emergency physicians are in a similar position to yours, dealing with a whole host of issues. What would you say are some of the biggest coping mechanisms that worked for you?

Adrienne Van Curen: Well, I think before this, getting regular exercise, trying to take time for my family, and setting boundaries with work, those are things that have helped me. When I had these two deaths, that wasn’t really enough. So I think it’s the things that Tessa taught me. She practices ACT therapy, which is acceptance and commitment, and a big part of that is, when you’re feeling anxious about something, to first acknowledge it, which is something that I think a lot of us don’t do. We just try to ignore it and move on, even though you’re like, “Why am I feeling this way?” Then you think about the reason that you feel the way that you do, and what values that reflects. The third part of that is to act.

For me, she pointed out that my act piece was actually just sitting with that a lot of the time, because so many of the things that I was worrying about were, again, beyond my control. I think a lot of the things that I worry about that I can control, I have controlled. But with the things that I was worrying about, like, “How is this death going to impact my relationship with so-and-so?” That’s not something that I can fix. I can show up and be whoever, but I can’t fix all those things.

So I think I’ve gotten much better about that. When I can feel that I’m anxious about something, I just work through that process, and then when you get there and you realize, “I don’t have control over this situation. I can’t fix it,” you just let it go and move on. It took a lot of practice for me to do that, because I think it’s easy to say those words but then not actually do it. But I do feel like I’ve gotten to a place where I can do that a lot better. I think that’s the main thing that helped me through this: just working through that process of accepting that a lot of things are out of my control, and I can just do what I can, and it’s OK.

Kevin Pho: We’re talking to Adrienne Van Curen. She is an emergency physician, and she wrote the KevinMD article “Are my coping skills a result of my emergency medicine training?” Adrienne, as you reflect on the past few years and everything that you’ve learned, what are some pieces of advice or wisdom that you could share with other clinicians with whom your story may resonate?

Adrienne Van Curen: Yeah, I think there are a few things. Another thing that I touched on in my article is that there are, I think, a lot of nuisances of the job that are not just emergency medicine, that we all feel: the pressure to see more patients, the charting. Specifically in emergency medicine, we have patients who are angry about the wait, and sometimes we have consultants who are not understanding of the environment of the emergency department. I think one kind of beautiful thing that I saw come out of COVID was these groups of people joining together and saying, “I’m not willing to work in this kind of environment anymore,” whether that was, “I’m not going to come back to the office when I don’t need to,” or, “I’m not going to work for this amount of money.”

I think physicians are so smart, but I wish that we could come together a little bit more and maybe say, “We also are not going to.” Because I think, as a group of people, we also tend to just take whatever people throw at us, like, “Oh, I need you to see five more patients a day.” “OK, I’ll do that.” So I think that’s one thing that would be nice, if physicians started saying, like the rest of the world has, “I’m not going to do this.”

Then, for me specifically, with my mental health situation, I think therapy is probably good for all of us. I wish that we could remove all the stigma around it, and I think if people could find the right therapist, we would probably all benefit from it. So I would encourage anyone who has access to those services, and I think a lot of physicians do, even if their particular hospital or group doesn’t provide them. I know ACEP, which is an emergency medicine organization, has some, and I think there are probably other organizations that people could access that through.

Then, I think, also specifically for physicians: allowing yourself to be vulnerable. With my brother’s death, I think I was sad later that certain people hadn’t shown up for me. But then Tessa, my therapist, pointed out the fact that if you make yourself seem invincible, like nothing bothers you and you’re doing fine, people don’t know that you need help. So I think it’s OK to say, “I’m really sad. I’m really overwhelmed. I’m exhausted,” to people that you trust. Obviously, you don’t have to share that with everyone. And just ask for help when you need it. I think that’s been really hard for me, too, and obviously, writing this article was me practicing that.

It’s been nice, because I have heard from people that I don’t know who said that article really resonated with them. So I think we all feel isolated, and maybe if we were all a little more vulnerable, we’d realize that we all feel the same way. I think we’re all stressed out, and this has been a really hard two years, and I think people want to help you if you’ve done that.

Kevin Pho: And my final question: What are some of your take-home messages that you want to leave with the KevinMD audience?

Adrienne Van Curen: Yeah, I think focusing on your mental health is important. That would probably be my main message. I think we as physicians are trained to take care of other people, and we want to. I think that’s probably what brought a lot of us to medicine. I wanted to help the suffering of other people, and you really can’t do that if you are not mentally well. You also can’t show up for your family, and you can’t enjoy life, if you are ignoring your mental health issues. So I think that would be my main takeaway: When you’re struggling, acknowledge it, and then try to figure out what it is that would help you, and focus on that, because nothing else matters. Nothing else is going to be fulfilling if you don’t fix that part first. So I think that’s the main takeaway I would have.

Kevin Pho: Well, thank you so much for sharing your story, time, and insight. Thanks again for being on the show.

Adrienne Van Curen: Thank you so much for having me. I really enjoyed it.