Podcast Episode 13 | How to Manage Your Stress During Medical Training

With Neela Rao, MD

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The Prosperous Doc® podcast by Spaugh Dameron Tenny highlights real-life stories from doctors and dentist to encourage and inspire listeners through discussions of professional successes and failures in addition to personal stories and financial wellness advice.

Shane Tenny, CFP® is our podcast host and Partner at SDT. He has lectured numerous times for hospitals and physician groups and, most importantly, helped hundreds of clients develop strategies to navigate through turbulent times toward their financial goals.

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Neela Rao: 00:00 The one word that jumps out to me is guilt. I felt so much guilt that I could not be a better girlfriend because it would detract from me being a better doctor or surgeon.

Intro: 00:14 From Spaugh Dameron Tenny, it's White Coat Wellness, a show for doctors who are ready to improve their financial wellness. We know you work hard to help your patients, but you can't be at your best if you don't have your own finances in order. In White Coat Wellness, we highlight real life stories from physicians and dentists to educate, encourage, and inspire you to personal, professional, and financial wellness. Now, from Spaugh Dameron Tenny, please welcome your host, Shane Tenny.

Shane Tenny: 00:42 Welcome to today's episode of White Coat Wellness. I'm Shane Tenny and glad to be with you today and grateful for the chance to be invited into your car or your workout or your hike or whatever you're doing while you're listening to this. Today, we're going to be talking about medical training and stress and managing relationships.

Shane Tenny: 01:05 Last fall, the Journal of the American Medical Association published the Mayo Clinic's study, which showed nearly half of all residents today report some feelings of burnout, exhaustion, stress, anxiety, depression, depersonalization. And fortunately it's a topic that is no longer being ignored and more and more training programs and medical schools are opening the dialogue and shining a light on the issue. To talk about the issue with us today is Dr. Neela Rao. Dr. Rao just completed her fellowship in facial plastic and reconstructive surgery at the University of Texas Health Science Center. She completed medical school in Michigan and residency at the University of Illinois in Chicago and is now knee-deep in building her practice in Fort Mill, South Carolina with Charlotte Eye, Ear, Nose, and Throat Associates. Neela, thanks so much for making time for us today.

Neela Rao: 02:05 Thank you, Shane for having me on the podcast.

Shane Tenny: 02:07 Absolutely. Well, I think we've got a lot of really great things to talk about and maybe I'll just ask you to start us off with just a little bit of background about yourself and your journey into medicine.

Neela Rao: 02:22 So I have actually kind of an uninteresting story of my journey into medicine. Both of my parents were physicians. They were also both immigrants and they had a very different experience than I did in my medical journey. Looking up to them growing up, I just saw how hard they worked. They were so dedicated and earned their success from the ground up, and I really respected their intelligence and compassion. Their patients always came first, but they certainly worked a lot. They weren't the type of parents that were home for after school practices or activities, and that is something now that I'm in my shoes of becoming a doctor, now I'm realizing, well, is that the kind of doctor I want to be? Is that only what defines a doctor? Do doctors just work nonstop?

Neela Rao: 03:18 So, growing up I always thought being a physician was a very glamorous and honorable profession and without a doubt I'm so honored to be a physician and have this opportunity and have my parents as mentors to really encourage and make me familiar with the field. But I'm also realizing that it's maybe not as glamorous as I thought it was and it's been a journey to get here though and it's still, it's very exciting.

Shane Tenny: 03:46 The process is a long one to become a physician and to move to another state and to start practice. What have been the... What has met your expectations through the process thus far and what has been more challenging than you were expecting?

Neela Rao: 04:02 Certainly things that have met my expectations are just the complete sense of fulfillment and gratitude for the opportunity to take care of patients and to have people trust me to take care of them. Nothing can ever replace that. And I think in the purest sense of medicine, that is what being a doctor is. And certainly the training and education has had rigorous hours, which I expected. I knew what I was signing up for. I knew there would be a lot of tests and I knew there would be a lot of late nights at the libraries.

Neela Rao: 04:41 Things that surprised me were certainly the fact that I made the best friends I could have ever expected during medical school and training. It's really a bond you don't create anywhere else unless you're struggling side by side by other people, and certainly the friends that I've made in medical school and residency are going to be friends for life.

Neela Rao: 05:01 But there are other things certainly with the day-to-day barriers of practicing medicine. I had no idea going into it that there were issues with burnout or self-doubt or dealing with student loans or fighting insurance companies to authorize necessary treatments, lots of documentation at the end of each day, certainly fear of litigation even and strain on personal relationships. And again, going back to medicine being a very honorable profession, at the end of the day it wasn't as glamorous as maybe TV made it out to be.

Shane Tenny: 05:42 Yeah, no free lunch. A lot of balancing there. Now, through the process and I want to explore what you were referencing there, just about the strain on relationships and some of those things that I know have been really impactful for you, but help connect the dots for me just one step further. You've gone through training, you've chosen a subspecialty with arguably the hardest pronunciation possible of any subspecialty as an otolaryngologist. In medical school, what attracted you to that career path? How'd you find yourself in the facial plastic world?

Neela Rao: 06:22 Certainly in medical school, I think most people will counsel you when you're making that life-altering decision of what specialty am I going to practice for the rest of my life. The first divergence is always, do you feel that you're going to be a medical doctor or a surgeon? And for me, I knew right away that I loved working with my hands, and part of it is that instant gratification of knowing I can go into an operating room and do something, do some type of procedure, and end that day knowing that was taken care of, that cancer was removed or that nose was fixed and that person can breathe better, and that is such an uplifting feeling at the end of each day. I have so much respect for my colleagues who went the medical route, who have chronically ill patients and see things that can really endure months, and it takes a certain type of person to deal with those types of issues certainly.

Shane Tenny: 07:21 And through the process as I was reading at the top of the show here, you trained in Michigan, Illinois, Texas. You're now in Charlotte. Moving, alone, is not quite for the faint of heart. In fact, it causes me dry heaves and hives every time I have to undertake it. So I can't imagine what it's like to move every couple of years. How'd you manage that process? What was the impact on your marriage? Just that element of the training process.

Neela Rao: 07:49 Absolutely. I was fortunate to have a lot of family support, but to be really honest, the most difficult move for me was for fellowship. And that was to Texas for a year and it was only a one-year fellowship, so it didn't make sense to uproot my significant other at that time. He had a great job and he had already moved once for me and so I couldn't move him again. And it was one of those times where I moved somewhere where I knew no one. I had no friends, no family. I actually signed up to have a roommate. I found a roommate because I was worried about being so lonely.

Neela Rao: 08:27 And that was actually a very uncomfortable moment for me because I felt like I was progressing as an adult and as a physician, but then I suddenly realized I was kind of regressing. It was like I need support. I need to be with someone. That was a time where I really had to be honest with myself that maybe I am insecure or afraid to be alone in this challenging time and even being with a stranger would be better than being alone. I think we've all had roommates so that always raises a little anxiety.

Shane Tenny: 09:06 Right, right. You use the word regressing. Like here I'm advancing in my career and then I end up in Texas and I'm afraid of being alone. Was the process of acknowledging... I realize in the moment it felt like regressing. As you look back on it, were you regressing or were you progressing in your own self-awareness?

Neela Rao: 09:25 That's a great way to view that, and it's not something I really realized until the other end, until I was out on the other end of the fellowship that I felt so vulnerable and that was okay and I learned something about that, and yeah, it made me stronger.

Shane Tenny: 09:44 Yeah. And I always say, I mean the fact is we are all interdependent and dependent on one another and thinking that we're not is almost the regressive approach, you know?

Neela Rao: 09:56 Yeah.

Shane Tenny: 09:57 I mean that's kind of what I think as you go through that. And so moving and you've been married for how many years?

Neela Rao: 10:04 Actually I just got married three months ago.

Shane Tenny: 10:07 Okay, recently married, but long time together. And so what was the move like on your relationship?

Neela Rao: 10:14 That was incredibly challenging because we had actually just with my medical journey and moving for new jobs, we actually did almost four years of long distance out of a seve- year relationship, so that certainly was difficult. But I'm fortunate to have had the most supportive partner, but I have to be honest, the training was not easy on our relationship. I actually broke up with him a couple times during my training and looking back, the only reason I can really understand why I did that, the one word that jumps out to me is guilt. I felt so much guilt that I could not be a better girlfriend because it would detract from me being a better doctor or surgeon.

Neela Rao: 11:02 I felt guilty that I was too tired to go out on date nights or would fall asleep during date nights or wasn't the girlfriend that would come home and cook dinner. I was pretty much eating cereal for dinner most nights of the week. Or just being the girlfriend that could give and not just take constantly. I have, again, I think the most supportive significant other who's just given me so much and I'm so ready to be in this position now where I can give to him.

Shane Tenny: 11:34 But it wasn't easy.

Neela Rao: 11:35 It wasn't easy, absolutely. And he stuck with me even though I tried to run away from him a couple of times.

Shane Tenny: 11:41 Yeah. Yeah. Now I know you brought up as we were kind of planning our conversation and talking through some different things, just this concept of burnout, so I want to talk with you a little bit about that and ask you some questions right after we get back from this break.

Will Koster: 11:59 I'm Will Koster. On this episode White Coat Wisdom, I'd like to talk about your emergency fund and specifically where you keep it. Hopefully you have designated cash reserves that are strictly used to cover things like an unexpected medical bill, replacing an air conditioning unit, or other big ticket expenses. The money in your emergency fund is not meant to be dipped into each month for ordinary expenses. While it is not advisable to have too much cash sitting idle, not working for you, it is definitely better to have cash reserves than not having enough liquidity and having to pull from your investment accounts or use credit cards anytime you have a large unexpected expense.

Will Koster: 12:41 There are a few characteristics that we like to see from an emergency fund. As I mentioned before, the first and foremost is being fully liquid. The second is that the money is easy to access, meaning the money can be transferred without penalty or restriction. Sometimes this results in people having their emergency fund as their primary bank sitting in a very low interest savings account. While this is not a bad option, and your emergency fund is not meant for longterm growth, with a rise of online banking, there are options to get more interest out of your cash reserves. High yield savings accounts at online banks such as Ally, Discover Bank among others can typically yield much higher amounts than brick and mortar banks like Wells Fargo or Bank Of America.

Will Koster: 13:27 In summary, having emergency cash reserves with the sole purpose of covering unexpected expenses is the foundation of a solid financial plan. While you won't get rich off of this money, the takeaway from this segment is that there are options to squeeze a little bit more interest out of that bucket than keeping it in a traditional checking or savings account. For this episode's White Coat Wisdom, I'm Will Koster.

Shane Tenny: 13:54 So if I wrote it down correctly, Neela, when we were talking about burnout, you said, "I didn't realize how burned out I was during training until I got out." Talk a little bit about that.

Neela Rao: 14:07 So once I finally finished my fellowship, it was like... I felt like I could finally breathe again and I didn't realize I was running on endorphins for the six years of training. It was always about the next step. As soon as I got into residency, it was what would it take to get me into fellowship? As soon as I finished fellowship, it was what would it take to find the job of my dreams and to pass all my board exams? And all of that finally came into place. I finally again feel like I'm an adult. I'm a physician. I'm a grownup, and it took a little bit of time to get there.

Shane Tenny: 14:54 And so what, as you look back, what were the attributes of the stress that you were going through? Or I guess maybe you'd say just the endorphins, the adrenaline kind of keeping you going and working late days and grinding through? As you look back, what was happening in you that you now recognize and say I think I was on the verge of burning out?

Neela Rao: 15:18 What made me finally realize that I was burnt out was having time to breathe and finally saying, I finished my fellowship and I thought, "Where the heck did my 20s go? I don't even know what happened the past six years." I felt like it was a blink of an eye. I guess they say time flies when you're having fun, and it was fun, but it was also a lot of work and a lot of emotion. It was such a roller coaster day-to-day that every... It was baby steps every day. It was waking up, making it through the next day and trying to make it through the next day. And it wasn't until I could step back and I finished my fellowship and I realized, wow, this past year I actually lost 15 pounds and I feel like I haven't slept a single night without waking up in the middle and worrying about were my patients okay, or am I ready for surgery the next day? Did I forget anything?

Neela Rao: 16:19 It was this constant state of living in checklists, which it's important to have organization in life, but it can't be to the point where you are so micromanaged, you forget to live your life, you're just going through the motions of each day. And I realized I was getting to that point of not really enjoying each day and that really got me interested in this concept of mindfulness, of really being present. I'm present when I'm treating my patients, but when I'm home I forget to appreciate what's in front of me.

Shane Tenny: 16:59 Given the pace and the checklist that you say was kind of constantly running through your mind, as you look back, do you feel like I was just... there were days I was just a robot or I just wasn't connected or I guess mindful, kind of your word? Is that kind of what you see as you look back on yourself, but it was hard to recognize in the moment?

Neela Rao: 17:22 Absolutely. It was hard to recognize in the moment because sometimes I felt like I was doing things because that was on the checklist that day. But was I really... Life is full of ups and downs, there's successes and victories, or victories and things that disappoint us. We have successes and failures, and I realized that throughout residency and fellowship, the successes were always glossed over. There was no pat on the back or 'atta boy'. It was the failures that really ate away, and that really lingered. And that can make it really difficult and I think that's part of what contributes to burnout in general.

Neela Rao: 18:12 I think just if I had taken a step back and just given myself credit and felt okay with saying, "Hey Neela, you did a good job today. That case went well. You're getting faster and you're connecting with your patients better and you know your material. You're doing great." And I think a lot of doctors forget to give themselves some credit once in awhile. We're so hard on ourselves. Most people are. We want to just work on being better and stronger, but we forget that we are growing and we are getting better and stronger each day, and that's okay.

Shane Tenny: 18:51 Does the constant critique that is inherent in the training process, at least historically inherent, maybe the trends are shifting there, but is that kind of what contributes to the self doubt that I sometimes hear docs talk about, or the imposter syndrome of those sorts of things? Is that at all a little bit of what you're alluding to?

Neela Rao: 19:14 Absolutely. I, as most young doctors and aspiring doctors, realized that this is... It's a tremendous responsibility to take care of other people. I treat all of my patients like family and I realize each one of my patients is someone's mother or brother or child, and it's almost an overwhelming responsibility that's beyond any one human. And the fact that each day you walk into the hospital or clinic and you say, "I'm going to take care of this patient to the best of my ability and knowledge," and show up to work each day realizing you have that pressure. It's on me to make sure I've honed my skills to the best of my ability. I can keep my patients safe. And every time I see a patient I'm going to be thinking, "Did I miss something? Did I ask all the questions? Did we do everything according to our protocol?" And that's my job. That's my responsibility. I accept that, I signed up for that.

Neela Rao: 20:19 But it's also, it can be overwhelming. I think it's a good thing for doctors to always want to be checking and asking twice, three times, is it right? Did I miss anything? But it can also be overwhelming. It can be all-consuming too, and it's also, it becomes who I am. I do that with a lot of things outside of my life.

Shane Tenny: 20:44 Being in a position where you have such close proximity to your training, what words do you have for your colleagues around the country who may be listening and are in training right now to help them just be self-aware, to help them with their stress or their burnout or their mindfulness? What would you wish you knew that maybe you can say to others?

Neela Rao: 21:09 It's waking up each day during your training or during your medical school and remembering to be thankful of having that opportunity to take care of other people, and also trying to remember why you started this journey. It's really easy to lose sight of that with the day-to-day grind, but remembering that it's all about taking care of other people and making sure that you're as well trained as possible, that you know your material, you have your skills to provide that service to others, and unfortunately just with overbooked appointments or being pulled in multiple directions, it's so easy to forget that each day, and it is a gift.

Shane Tenny: 21:56 Do you find, is this topic of physician burnout or resident burnout or the mindfulness, the stress, the anxiety, is that a topic that you found open discussions about when you were in Illinois, or when you were in Texas? Is it growing in I guess the receptivity among the program directors and things like that? Is the stigma being broken?

Neela Rao: 22:20 It absolutely is and I'm very happy to see that. We first started openly talking about burnout about midway through my residency and we were actually given books on educating ourselves about burnout. And most residency programs do have resources available for trainees that are feeling overwhelmed or stressed or doubt, but at the end of the day, the trainees are actually almost too busy to even think about going to those resources or missing work. So the issue is not necessarily maybe having those resources available, but finding time or finding ways for trainees to incorporate it into their lifestyle, and I hope we can get to a point where we can actually maybe set aside time for each resident to meet with a counselor regardless, maybe once a year or just to check in.

Shane Tenny: 23:16 Right, or just finding the space to reflect and really take your own temperature and how am I doing? Have there been circumstances where you've come out of a procedure or something maybe hasn't gone as ideally as you would've hoped and you've had to just kind of take the step of courage to grab a colleague and debrief on it and just kind of, I don't know, lament the reality of what's happened?

Neela Rao: 23:42 Absolutely, and I think that's necessary to do and too often we fear that it makes us appear weak to say, "Hey, I'm having a hard time with this," or, "This was really difficult." And to be honest, I think a lot of doctors don't realize that we can sometimes be the second victim when things go awry or not to plan and that it's okay to ask for help and to feel something real when it comes to your patients. You don't have to be that robot that can handle everything. You are a person at the end of the day.

Shane Tenny: 24:20 Neela, I want to follow that one up by just asking your opinion as a female physician and one who has the self-awareness to think about your own emotional IQ and your authenticity. Do you think it's... is it harder for men or women in medicine and in training to raise their hand and say, "Hey, I think I'm struggling with burnout?"

Neela Rao: 24:45 You know, Shane, I went into my medical journey thinking that men and women were always on the same playing field and the opportunities were equal for both of us and we would be treated the same way. But a moment sticks out very clearly in my mind where I had just graduated from medical school actually. I had just finished my fourth year and I went on a mission trip to Peru to volunteer in ENT, in otolaryngology. And a couple of days into the program, one of the senior surgeons just turned to me and said, "Why are you even here in Peru and why are you pursuing a surgical specialty? You're just going to work part-time anyways." And that just threw me back. I had no idea that he was thinking that in his head the whole time. He thought I couldn't handle it and I wasn't dedicated to the field, and that he said something like, you're just going to be a stay-at-home mom or work part-time anyways.

Neela Rao: 25:49 That, honestly Shane, it lit a fire under my butt. I was going to say, "I'm going to prove this guy wrong. I can handle this as much as the next guy next to me." And certainly moving forward there were difficult days, but in the back of my mind, I always remember that day and even on the hardest day I say, "I know I can handle this, I can get through it." There are going to be good days and bad days and that's something that will always stick out with me in my mind forever.

Shane Tenny: 26:19 Yeah. I mean it's that sort of environment that I guess through the whole conversation we're having contributes, or can contribute, to a reluctance on the part of a resident or a fellow to say, "Hey, this has been a really tough week," or "I'm struggling," because you don't want somebody like that looking down the hall and saying, "Yeah, I figured you were going to flake out anyway." Yeah, that's astounding. So the journey is not easy, but now that you have come through the gauntlet, I want to ask what, as you look back on it, what was one of the most gratifying days that you got to have?

Neela Rao: 26:56 Probably one of the most gratifying days was a mission trip I took to Kenya on my last year of residency and that was really one of those days where I felt all of my training had culminated. I was in my final year of training and I had my own operating room and was able to help patients who actually walked for days just to find our clinic and they slept outside through pouring rain and thunderstorms just for the opportunity to have surgery while we were in town and able to offer our services.

Neela Rao: 27:37 I had one patient in particular who I was able to operate on her and we had a very successful surgery, and I saw her the next day. She just slept outside overnight. There were no hospital beds, just a little awning to cover our patients. She and her family were just crying and hugging me and we didn't speak the same language, but it didn't matter. And that to me was the purest sense of being a surgeon and being a doctor. And it really made me feel like this is what I want the rest of my life to be like. This is why I do what I do, and it was a very proud and happy moment for me.

Shane Tenny: 28:23 This is what it's all about. Yep. The good news in all this is that you've made it through. I'm not sure if you've made it to the finish line or you've made it to the starting line, but you're here now and setting up your practice as part of a large group. I'm curious, how's it going so far? What have you encountered in trying to build your practice?

Neela Rao: 28:45 It has been fantastic. I have honestly found my dream job. I've only been here about three weeks, but I have the most supportive group with the best partners and I feel fortunate that they have experience and they have all taken me under their wing to give me guidance and I have a team that's just ready to help me hit the ground running and help me do what I enjoy best, which is taking care of patients.

Shane Tenny: 29:17 That sounds great. Although you do know the best two weeks of any new job are the first two weeks when you get to say, "Oh, that's not my responsibility yet, right?"

Neela Rao: 29:27 You got that right.

Shane Tenny: 29:28 Absolutely. Well, Neela, I just want to thank you so much for being with us today, sharing a little bit of your story and just your authenticity on making it through and making it through well.

Neela Rao: 29:39 Thank you so much for having me, Shane.

Will Koster: 29:45 I'm Will Koster bringing you this episode's White Coat Achievements, a segment where we highlight noteworthy achievements by your friends and colleagues. Did you know that more than one in three physicians have had a medical liability lawsuit filed against them at some point in their careers by the age of 55? This statistic shows that facing malpractice litigation is extremely common, yet it's often taboo to talk about within the physician community.

Will Koster: 30:10 Today's White Coat Achievement is highlighting Dr. Stacia Dearmin, the Thrive Physician who has experienced her own difficult situation due to an unexpected patient outcome and professional litigation. Dr. Dearmin is a pediatric emergency medicine doctor who has made it her mission to support physicians facing malpractice litigation. These cases can be damaging to doctor's careers and personal lives, bringing an immense amount of stress on doctors who already report high burnout and suicide rates. Dr. Dearmin founded The Thrive Physician because she felt like doctors were not talking about the litigation they were going through because they were ashamed, and she wanted to provide resources to her fellow colleagues.

Will Koster: 30:54 She wished the resources on Thrive Physician were available when she went through her long malpractice battle. In her blog, Breaking Our Silence Around Malpractice Litigation, she says, "Just like cancer, our silence around such a tough experience has the potential to take physicians' and other healers' personal and professional lives from them, their families, and their patients figuratively and literally." The experience of adverse or near adverse outcomes and litigation is widely known to result in PTSD in practice.

Will Koster: 31:28 We commend Dr. Stacia Dearmin for sharing her insights from winning her case and helping doctors who are struggling with this taboo topic. We also look forward to having her on the show in a couple of months. If you'd like to learn more before that episode airs, feel free to visit the links in the show notes. As always, if you know someone who is wearing a white coat and is achieving something noteworthy, please drop us a line. We'd love to hear about it. We might even feature them on a future episode. But again, this episode's White Coat Achievement goes to Dr. Stacia Dearmin.

Shane Tenny: 32:01 Well thanks so much for joining us today. We've got more great episodes queued up for you in the coming weeks, so make sure and subscribe through Google Play or Apple podcasts so you make sure you get notification of those. If you'd like to be part of the conversation around White Coat Wellness, check out our private closed Facebook group called White Coat Wellness. You can apply to be part of that and just be part of the dialogue. We've also got posts on Instagram and Twitter and Facebook, LinkedIn. And of course if you have any suggestions for either topics to cover or people that you'd love to hear interviewed, you can drop me an email directly, shane@whitecoatwell. Thanks so much for spending time with us today. We'll see you back here next time.

Outro: 32:47 This episode of White Coat Wellness is over, but you're not alone on your journey toward financial wellness. Spaugh Dameron Tenny has been helping physicians and dentists with their financial planning for over 60 years, and we'd love to answer any questions that would be of help to you. Visit SDTplanning.com today and take your financial wellness to new levels. Once again, that's SDTplanning.com and we'll see you on the next episode of White Coat Wellness.