growing through the motions

bringing the magic of ritual back to mundane routine

About a year ago, we had a PA meeting with one of the chief primary care PAs (a very seasoned PA who’s been practicing for over 20 years) and I remember sputtering through a bulge in my throat, read: having a meltdown (…me? crying during a work meeting??? never!), “I’m doing ALL of the things to prevent burnout!! I’m practicing mindfulness, slowing down, prioritizing sleep, taking time off, and I’m still insanely burnt out!!”

The meeting was about burnout in general and I was just so frustrated at the time. When I’m in my lower moments, I sometimes have an internal/external tantrum - that being a PA or working in healthcare in general is unlike what I anticipated. It sometimes feels like I’m working three work weeks in one. There is extremely minimal down time; I’m usually working through lunch and finish well after 5pm. And I acknowledge some of this is my own doing and I need to be a bit less rigid about feeling like I need to ‘finish’ everything before going home because that is frankly impossible.

I’ve stayed afloat by utilizing my morning and evening routines as pillars that keep me going over the last 3 years. Gentle movement in the morning, a breakfast that I enjoy packed with protein/healthy fats/fiber, taking a walk, engaging my senses though pleasant sounds and smells, going to therapy, and creating my apartment into the sanctuary I love coming home to. It’s been the framework that keeps me grounded and has been useful in so many ways.

I’m reminded of Maslow’s hierarchy of needs (finally my college psych degree being put to good use). And I certainly do prioritize getting my physical needs met. This has served me in so many ways - I have shelter, clean drinking water, have access to nutrient dense foods and family/friends nearby for social connection. Acknowledging that there’s so much privilege here, especially in that I have the time and funds to do this.

But what about the next level of needs?

I went through a very bad season of depression/burnout a few months ago. The physical heaviness I felt in my chest was crushing. I had to call out of work because I couldn't stop randomly crying. I’ve had a few of these very low seasons and I’m grateful for the routines I’ve created, as they’ve become automatic, things I do without having to really think about it. During this time, I continued to go through the motions of routine, and it created a semblance of lift and structure despite feeling cloaked in shadows.

Though lately, because it’s so routine, it’s become mundane. When doing my movement class in the morning, my mind has been absolutely racing thinking of my to-do list for the rest of the day. My walks have turned into professional self-development, trying to finish a book while also getting completely wrapped up in the tornado of my thoughts rather than noticing the walk or book. The act of finishing has taken precedent over experiencing the process.

I’ve felt this way for a long time actually. If I just get through the Master’s program, get through PA school, get through the first few years of being a PA, THEN I’ll be able to slow down and relax. I absolutely prioritize just getting through it, finishing it, rather than savoring the process.

So instead of this ‘getting through’ mindset, this week I aimed to bring some mindfulness back to the mundane.

Here’s how the week went:

Monday (clinic day)

Monday started out great. I really challenged myself to name what was going well not just at the end of the day, but throughout the day. Doing so was like a constant reminder that things overall were good, rather than hyper focusing on a single appointment that was challenging and having that feeling override the rest of the day. Saying what is going well or what I’m good at is REALLY hard for me. I value humility and it feels straight up braggy and vain to do this. I’m starting small and just texting my boyfriend at the end of the day. Rather than ‘ugh today was busy and hard’, I said on Monday ‘No, no shows but I think I did a good job and held space for patients during really hard appointments. And I even drank two Owala’s today!”

The temperature and texture of the day was dense. A lot of grief, stress, depression, history of self-harming behavior in back-to-back appointments. When these are all stacked on one day, I feel impossibly heavy by the end of the day, as if you take on a bit of suffering with each subsequent appointment. Today, in the appointments, rather than dissociating (which I’ll sometimes do as a survival mechanism), I tried to stay really present. And I actively left some distance. I repeated to myself ‘I can be here, but I don’t have to take this on.’ This allowed me to continue showing up for patients without feeling like a part of me was crumbling throughout the day.

This type of day usually has me feeling so drained. I come home, rot in front of the TV, and dissociate until I feel tired enough to fall asleep. And I actually did still come home and watch a show. But I was genuinely enjoying it and I was present for it. I didn’t change the actual activity I was doing, though I did shift how I was feeling while doing it.

Tuesday (clinic day)

I had a full day Monday and Tuesday (no no-shows on both days). I also sent two people to the ED in the morning alone - just super medically complex cases this day. By the end of the day the exhaustion had not just crept it, it steamrolled. My last patient of the day was late and it took me about ~90 minutes. There were a lot of things going on and forms to be filled out. The drive home I could feel myself slipping into the negative and then I had to remind myself that while the day was busy, it was actually a great day.

I deeply laughed with patients and truly felt present in the encounters. It’s so easy to let those few super challenging cases take on the face of the entire day, but they’re actually just features; they’re not the whole picture. I came home and watched tv, then took a shower, did a skincare routine, put on perfume just because / to engage more senses, and settled comfortably on to the couch to read.

Wednesday (televisit day)

On Wednesday morning, I was feeling great. My Portuguese lesson was canceled so I had a bit more time in the morning. I went for a walk, the weather was lovely, the disco ball I have in my kitchen was making the light dance on the ceiling, and I lit my favorite candle. Interestingly, I had a few dishes in the sink in the morning and was completely unbothered.

By the afternoon, having another day of no no-shows, sending someone back to the ED, and a 90yo complicated hospital follow-up scheduled inappropriately as a 20 minute visit, I felt like I had worked a full week in 2.5 days.

Furthermore, the person I sent to the ED had a horrifically negative experience the night before and therefore didn’t want to go back. I tried to hold space for this patient, discuss the risks if they didn’t return to the ED, express empathy for what had happened, troubleshoot to find another ED they could go to, call the ED to give the expect, and then file a safety report. This happens often - trying to remedy or listen to the many, many reasons or events that have led to a deep mistrust of the system for so many patients.

And suddenly dishes in the sink were a mountain that I could not tolerate.

I was absolutely spent by the end of my televisit session. I went for a walk, though it was a slow one. Just one foot in front of the other. I left my inbox for the nightmare that it was and instead focused on decompressing so I could show up for my group visit, which is virtual on Wednesday evenings. I did an ‘Othership’ breathing exercise. I read a book out of enjoyment, and reviewed my notes for group. I started repeating to myself, ‘I am attracting ease.’

Group was LOVELY. Oh wow it was so energizing and the conversations were fruitful. It was just amazing to see how members of a group help each other and cheer each other on with health promoting behavior changes. I received the kindest feedback at the end and I was putting all of my energy into magnifying that feeling. It was such a nice reminder of ‘oh yes, THIS is why I do this.’ I didn’t open my inbox for the rest of the night, took a relaxing shower, and read my book.

Thursday (admin day)

I slept well, and woke up to take a juicy hour long pilates class. I was FEELING. GOOD. I was not letting the week get me down!!

It was busy and challenging the last few days but I again felt like I had reset the night and morning before - adding more presence to my pre-existing rituals. And then I opened my computer and signed on to Epic. My inbox this week has been relentless. Oh wow. It’s just a week where you feel like you make a dent and then come back and have 50 new items to attend to. Like being at a restaurant and never having an empty water glass. When this happens, I feel even more pressured to get to everything quickly: to zero out the inbox.

The inbox stuff is in and of itself draining. With patient interactions, there is satisfaction and joy in the work and in the moments. That does not exist with my inbox (for me personally).

I also had to call an insurance company to initiate a prior authorization process and after 40 minutes on the phone, they told me I wasn’t talking to the right person so I had essentially gotten nowhere. (note: yes I know a lot of systems have different processes/workflows in place for prior authorization processes. This particularly case was something I had to do.)

By mid-day, having not yet even gone outside because I felt buried by my inbox, I wanted to crawl out of my skin. I found I was scrolling through social media way more, anything for an easy distraction. I didn’t have the energy to engage in presence because quite honestly I didn’t want to be present.

I realized I needed a change of scenery and ended up going to my parents and my sister and her wonderful friend were there. I laughed with my sister, hugged my mom, wrote out my feelings via this diary entry and spoke with my dad about the rage I feel on a daily basis and how can it be healthy to harbor all this rage and how could you have worked in this field feeling this way for nearly 40 years (my dad is an ER doc). !!!

My boyfriend then came to my parents with Red (his dog). We walked Red, picked up dinner for my family, and ended the night with tea on the rooftop. It was so soothing. I usually isolate in these tough moments/days, and today I didn’t. I felt so much better by the end of the day. I went to bed feeling recharged and ready for Friday.

Friday:

The day started out great, honestly. I had a televisit appointment in the morning and a patient mentioned they were working on body celebration after our last visit and that nearly made me tear up. We then had a staff meeting and it was a fruitful conversation about how sometimes being a provider can feel dehumanizing and demoralizing - how we’re the face of the messed up system and can’t always meet patient expectations, especially if patients have had multiple negative touch-points with the system prior to meeting you. Everyone came together in a really beautiful way and it was a super supportive environment.

And then the day unraveled, and…swiftly. I had another no no-show day meaning it was a no no-show week. I kept hitting the pattern of one patient coming 15 minutes late and the one after that coming 15 minutes early so I was perpetually behind. I had someone added on to my schedule for “ortho concern” and I felt fairly positive it was actually a blood clot. As I was calling the hospital to give the expect, I had two patients waiting, and then a team member approached me letting me know a patient was at the clinic needing assistance despite not having an appointment. The patient missed their appointment earlier in the week and now was showing up an hour before clinic closed because someone had stolen their medications.

And here’s where I shift into talking about shame and guilt because these moments are hard.

You go into this line of work because you genuinely want to help people. And also recognizing there are a ton of factors that make access to care nearly impossible for some - ie finances to afford healthcare, money to pay for childcare in order to go to appointments, the ability to take work off, transportation, etc.

If I were in a slightly different headspace, my reaction may have been different. But I was immediately angry.

“Why did the patient miss their appointment earlier? How did someone steal their medications again when they just got an early refill earlier this week?”

I was short, flippant, and reactive. And this is the scary side of burnout. After this immediate explosion of anger, I felt so incredibly guilty and hated myself for having this reaction.

Because honestly, how amazing that the patient trusts our clinic to come when they really need something. It’s certainly not perfect or ideal to come outside a scheduled appointment, though always better to ask for help when you need it than to simply not come at all.

So rather than coming at myself from a place of compassion, I usually am so ashamed that I have no compassion left to give. In these moments, I start to really, really, REALLY dislike myself. And then spiral into quite a low mood.

But since writing this all week - seeing the physical evidence of an incredibly busy week where I had already been doing so much high intensity emotional regulation, resetting, then going back to work to be overwhelmed all over again - at this point, Friday at 4pm, I had no energy for any additional regulation or compassion.

This is not something any one told me about in school - that you’ll sometimes feel so absolutely terrible about yourself, filled with rage, guilt, shame, sadness, and overwhelm. That your schedule will be packed and busy, that things will be scheduled inappropriately, that your inbox is bursting at the seams, that patients sometimes come in requesting medication refills that you don't feel comfortable refilling, that there’s always someone to call back, a message to respond to, a prior authorization or form to fill out. And that you do your best to reset when you get home from work, but when you get up and the next day is the exact same, it can be nearly impossible to feel the joy.

After getting everything settled and seeing all of the patients, both scheduled and unscheduled, I left clinic feeling oh so defeated. I had a massive headache at the end of the day. But I came home, showered, then went to my boyfriend’s. The weather was gorgeous, the clouds were idyllic, we went for a slow walk, got pizza at Armando’s, and watched Paddington 2. I felt okay despite such a chaotic day (likely because I didn’t have any energy to process any of it so I just repressed it.)

Saturday:

OH. I got my period. Now everything makes sense. And maybe if I didn’t have it, I’d have some more energy for additional emotional regulation, but quite frankly, this week was fucked up.

I never want this newsletter to be toxic optimism, which is why I’m talking about this in more detail. This type of week is not sustainable and yet is often a reality. You do everything you possibly can - accept the overbooks and things that are scheduled improperly, and because you can’t do them FULLY (which is quite frankly impossible), you get caught in a guilt/shame cycle. You feel responsible and start to dislike yourself because of how you reacted and it’s just awful.

Saturday I woke up and felt okay but by the afternoon I had absolutely crashed. I was irritable, sad, guilt-ridden, and was short-tempered. It took me 15 minutes to make a smoothie because I just couldn’t focus or remember what ingredients I had already added. All brain synapses felt disconnected. All I could do was scroll on my phone because everything else required too much brain power.

I’m usually really hard on myself during these weekends. And feel like I’m wasting a weekend and not really recovering before I have to head right back in to the work week. Weekends are for general adulthood maintenance (ie grocery, laundry, cleaning) and content creation. If I can’t get these accomplished, I start the week feeling behind.

And I just can’t do that anymore. I’m done gaslighting myself, wondering why I feel so awful after having a week that was A WEEK. I genuinely believe I did the best I could this week. I worked hard and advocated for patients. I provided good care given the circumstances. I’m allowing myself the grace to rest, whatever that may look like, even if I get absolutely nothing done off the to do list. If I’m not feeling called to create content, I’ll take a week off. I’ll ask for help with laundry or groceries.

On Saturday, I absolutely allowed myself to sit in the sulk for a bit. And then I decided I had two options - I could sink my teeth into the sadness and suffering and let it overshadow the rest of the weekend. Or I could breathe life into ALL that I did this week for patients and myself, taking care off myself and patients moment by moment. It’s hard and often doesn’t feel like a choice. It just feels shit. But given I had made presence a more active practice this week, it felt a bit more easeful to choose moving on.

Takeaways from the week:

Something I’ve noticed more is my tolerance for discomfort and uncertainty and how that shifts throughout the week. The busyness and heaviness of this week just continued to compound. I’d come up for air and then be thrown under a wave again. And when it comes to weeks like this, I’m incredibly short-temperated by the end of the week and have nothing left to give.

For example, by Thursday of this week, I was incredibly bothered by: sitting on the couch with a too tight ponytail, dishes in the sink, cleaning dishes with a sponge that was wilted and decrepit, having on one layer too many and feeling hot. All of these things are absolutely miniscule. And when I'm feeling well, they really don’t bother me at all. Though when stressed, it’s the straw that breaks the camel’s back - and then I feel guilty for not understanding why I’m such an impossible person who’s always sweating the small stuff. I’m not. There’s just a lot of big stuff that’s out of my control, so I overreact to the small stuff that is in my control. And then it really doesn’t seem so small anymore.

This week, I did start making little changes in the moment that created more comfort and ease. I didn’t even notice how irritating these things were in the past. If I saw a sponge that was gross, I just threw it out and got a new one. Or let my hair down the moment I felt it was uncomfortable. Rather than getting caught up in the mindless/automatic routine, I genuinely asked myself what do I want in this moment. I usually don’t have the bandwidth for this on a hard day. But given it was a new thing I was trying, it did create some micro-currents which ended up feeling nurturing.

I also paused in the in between moments. Rather than bombarding through my to-do list, I’d genuinely ask myself ‘okay where would I like to go next here? And how would I like to feel while doing that?’ Then I’d set the scene to feel good while doing that thing.

In the past, I either 1. didn’t notice these little yucks until I’m at a breaking point and screaming about seemingly ‘nothing’ or 2. a silly part of my brain thinks it will just go away if I ignore it long enough.

This actually was a huge shift for me. And this only came with acute awareness of these discomforts, achieved through staying present during my standard routine.

ridiculous photo of me and Red cuddling in the sky LOL.

Other thoughts:

• cuddling a dog after a hard week is magic

• The moment I feel some level of discomfort or if I’m in a transitional period, asking myself ‘okay what do I need in this moment” and acting on that. This is helpful!

• Repeating to myself, “I am not in a rush, I am attracting ease” was actually nice during the “I promise you I really am about to fuck!ng scream” moments.

• Everyone seems to do a mindfulness/breathing practice as part of their morning routine and I find it better for me to do at night, especially after the more challenging days.

• If you have a really hard day, write things down. That way if the hard days continue into a hard week, you can use the words to encourage self-compassion rather than gaslight yourself into thinking ‘why am I feeling like this, I’m just over-reacting and need to set better work boundaries’.

• You cannot do it all in this job. Progress must be measured in ways other than 100% perfection. It is a very imperfect job because of the very imperfect system and you CAN and WILL do good and important work despite it not being exactly perfect.

• Rest can be truly rest. It doesn’t mean still crossing things off the to do list.

• Asking for help is imperative - both in and outside of work.

• Pouring positivity, presence and gratitude into the day does actually help significantly, though to a certain extent. I am, after all, VERY human. A sensitive human at that. I can’t expect to just bounce back and accept a week like this week with a snap of a finger. While this newsletter is absolutely intended to show how I’m finding joy in the day-to-day, this is a systems level problem. It should come as no surprise why so many in healthcare feel such rage on a daily basis. There needs to be massive organizational restructuring in this country in order for healthcare to be sustainable for providers and actually helpful for patients. It is deeply meaningful work AND it is draining and not sustainable.

• Paddington 2 is a wonderful movie to watch after an impossibly tough week.

• Armando’s Pizza (half tray Sicilian) in Cambridge is a wonderful dinner to pair with Paddington 2.

• While some of these hours are sleeping, work hours theoretically comprise ~23% of the week. Sometimes seeing this number is a gentle reminder to not let it overtake 100% of my energy and thought process.

Wow this was a doozy, but I think I really needed to write this. If you made it this far - THANK YOU!

In humility and hopeful happiness,

Katie