When a Thought Won’t Let You Go

We’ve all been there (yes, all of us). Something happens and we can’t stop thinking about it. It can be a complication, a misdiagnosis, something that happened in a toxic work environment, a failed exam, a harsh word. Not being able to let go of these thoughts means you are a normal person who cares… but it is not comfortable.

It will stop. At the time you are caught in the spiral of rumination, it seems unending. But it can’t and won’t last forever.

You are not your thoughts. There are your thoughts (and this annoying thought in particular)  and then there is “you”. Hold that thought (then see below).

Don’t make it worse by yelling. It’s human nature to try to push an uncomfortable thought or image out of your mind. But it doesn’t work. Yelling at yourself (in your mind) because you are not able to move past the thought/event makes it even worse.  

Get curious. Berating yourself makes it worse, but there is a way to disarm the thought and even make it go away:  

When the thought arises, just notice it. 

Wait….if “you” are noticing it, then the thought isn’t  “you”.


Every single time the thought arises, say to yourself “I’m thinking about it again.”  But – and this is the most important thing – when you notice that the painful thought is back, you have to notice it without judgment.  Not… “I can’t believe I can’t let go of this thought.”…or “Something must be wrong with me.”… Just “There it is again.” 

Image from multiple internet sties

Mindfulness. The practice of noticing without judgment is called mindfulness. There are good data that an informal practice of mindfulness helps when we find ourselves with a thought that won’t let go. A daily practice helps even more. Set aside just 10 minutes and sit still. Just notice everything that comes up, acknowledge it, and don’t judge. Ditto for the next thought, and the next, and the next…

Here are some links if you’d like to learn more about mindfulness:

If you only read one thing about mindfulness, make it this book: The Miracle of Mindfulness: An Introduction to the Practice of Meditation by Thich Nhat Hanh

Headspace is a fantastic app to help you learn mindfulness

Mindfulness for Beginners from Psychology Today

National Suicide Prevention Lifeline 800-273-8255. You are precious. You matter. Call if you need someone to talk to.

If you are starting the think you might be depressed, or that your brain is out to kill you, here’s what you do…

The following is an “unrolled” Twitter feed from Mark Reid, MD on depression.  It’s solid, important advice that I thought should be shared. Dr. Reid  is an internist from Denver, who is very active on Twitter as @medicalaxioms. He is also the author of Medical Axioms, a delightful book of medical wisdom

Interview with Dr. Reid about @medicalaxioms

If you are starting the think you might be depressed, or that your brain is out to kill you, here’s what you do:

1. Find or call your primary care IM of family MD. When you call for an appointment and they ask what for, say “depression.” Notice how the scheduler doesn’t flinch. They get this call 4 times a day!

2. When you get to the doctor, and they ask what’s wrong, just say, “I want you to do those screening tools on me to see if I’m depressed.” Let them do their thing. If they say you’ve got it, let them tell you how meds and counseling work. Let them tell you what they know about pills and which one might help you. Decide together if pills are worth a shot. Tablets really work for some people.

3. You also need a counselor. Ask the MD for a referral. That might work. If not,

4. Go to your insurance and find out their preferred providers for counseling. I suggest you pick someone your same gender. Counterintuitive for some but works better for many.

5.  If that doesn’t work, go in the internet and type in counselor or therapist and the name of your town or city. Read ratings and reviews. Cross reference them with yelp. Look for someone nearby who writes a bio that sounds okay. Figure you’ll see them once a week and it will cost $100. Give them 4 tries. If you don’t feel like you are getting anywhere, ditch them and try again. I’ve seen 3 people in the last 10 years and in retrospect I can rank them.

6. With tablets and shrinks, the trick is resolve. If they aren’t working or give side effects, don’t just quit. Try again. Different shrink. Go back and try a different tablet with your MD.

You can feel better and you are worth it. You deserve it.

There’s lots of other stuff that helps some people: support groups, sobriety, exercise, sleep hygiene, self help books, spiritual practice, ALANON. If your shrink is any good they will recommend this stuff and know something about it.

Photo credit

To add a few more comments to Dr. Reid’s advice….

  • Depression is a disease, not a failing. You wouldn’t judge yourself for a sprained ankle.  This is the same…. except for one thing.  The disease of depression includes not being able to objectively see what’s going on.  That’s why it’s so important to get started on treatment.
  • If you are a medical student or resident, counseling is available for you and it’s free. The same rules hold, though.  If the first person you see isn’t helping after 3 or 4 visits, it’s ok to make an appointment with someone else.  This is not personal and you don’t have to worry about “hurting their feelings” any other consequences.
  • The National Suicide hotline is 1-800-273-8255. You are loved.  You matter.  This is a disease not a failure.  Please seek help.

Photo credit



Alcohol and Physicians

Alcohol has been a drug for millennia… for a reason.  Alcohol works as an anxiolytic and induces euphoria, mostly likely through endorphin release.  Unfortunately for some physicians, the combination of a stressful job with a drug that is so effective can lead to problems.  A recent study showed that up to 15% of surgeons may have a problem with alcohol abuse or dependence.  This is similar to previous reports that somewhere around 8-12% of physicians experience alcohol dependency at some point during their career.  Tragically, often as a result of suicide, the mortality rate of alcohol dependency in physicians is as high as 17%.

The following is written by a colleague who is now in practice and has been for several years. It is a heartfelt account of discovery, action and recovery… one that I thought was well worth sharing.


 During the third year of my general surgery residency I navigated to a website and read the following:

Answer YES or NO to the following questions.

1 – Have you ever decided to stop drinking for a week or so, but only lasted for a couple of days?
2 – Do you wish people would mind their own business about your drinking– stop telling you what to do?
3 – Have you ever switched from one kind of drink to another in the hope that this would keep you from getting drunk?

4 – Have you had to have an eye-opener upon awakening during the past year?

5 – Do you envy people who can drink without getting into trouble?

6 – Have you had problems connected with drinking during the past year?

7 – Has your drinking caused trouble at home?

8 – Do you ever try to get “extra” drinks at a party because you do not get enough?

9 – Do you tell yourself you can stop drinking any time you want to, even though you keep getting drunk when you don’t mean to?

10 – Have you missed days of work or school because of drinking?

11 – Do you have “blackouts”?

12 – Have you ever felt that your life would be better if you did not drink?

The website was Alcoholics Anonymous, www.aa.org. The website defines a score of four or higher as representative of someone who likely has a problem with alcohol. I answered “yes” to all twelve.

Although upsetting at the time, this information did little to create lasting change in my life. I was still in a profoundly stressful work environment, buried deep in a culture where using alcohol to displace anxiety, anger, frustration, and chronic fatigue, was commonplace.

Why alcohol? I never drank in high school. I never drank in college. I never drank in medical school.  I was 28 year of age when I took my first drink, three months into my intern year. I had avoided alcohol for many years because of a family history marred with alcoholism. Why now? The backdrop is a spiritual valley that I had slowly descended into over several years. My former childlike faith seemed like that alone, childlike. There were too many unanswered questions, too many competing world-views. I disengaged from the conversation. I was able to limp through medical school in this state but residency would soon take me to rock bottom. This was a painful world of crushing fatigue, heart-wrenching grief, and endless performance pressure. The anxiety was unbearable. I became infatuated with alcohol because it worked. I felt less anxious. I was able to relax. I was able to commiserate with fellow residents, laugh, complain, and forget…..at least, temporarily. I justified my behavior by telling myself it was a short-term coping mechanism. I only needed to drink to survive residency, it would be a fleeting crutch. Then I started giving a more honest account of my habits: when I was excited and wanted to celebrate – I drank, when I was angry and frustrated – I drank, when I was dejected and depressed – I drank, and when I was bored – I drank. There was no occasion where alcohol wasn’t indicated. It became more than a crutch. Just walking through the basics of life were reason enough to have a drink, not to treat anxiety, but to prevent it.

Admitting you have a problem is always the first step but still miles away from sobriety. I was on vacation abroad when I saw a figurative fork in the road. I knew that if I continued to drink I would either lose my job, permanently damage relationships, or risk my life. I had already managed to avoid paying full price for my behavior to that point and it was clear to me there would be no more opportunities to move on without deep wounds. How could I risk all that I had worked so hard to achieve and all the wonderful GIFTS in my life? The gifts of family, health, and a fortuitous background that enabled success. I went back to the basics. My family, my faith – the very things that had served me so well, for so long. I found peace. I found self-confidence. I realized that showing emotion over the loss of a stranger’s son in the trauma bay was a caring thing to do, not something to fight and hold back. I realized that late-night drinking only made my fatigue worse, adding to my stress level. I realized that a poor speaking performance in front of an attending would soon be forgiven and forgotten, and made up for another time. When anxiety would overwhelm me, I would pray.  And that worked too, with the benefit of no hangover.

If you or someone you know is struggling with substance abuse, don’t wait for a tragedy to act.

  • Find someone you trust and confide in them. Talk to someone in your house of worship, or sit down with your favorite uncle, your high school chemistry teacher. Go to a meeting of Alcoholics Anonymous, or tap into numerous other resources.
  • This is a problem that medical schools and residency programs are familiar with.  If you are a medical student, talk to your Dean of Student Affairs.  If you are a resident, talk to your Program Director.  If you are too worried to do that, at least find someone who is familiar with addiction in your community and talk to them.
  • It’s normal that you might be worried about asking for help, but realize that asking for help will not lead to problems with your medical license … but being arrested for a DUI will.
  • If you’d like to reach me, you can contact me through Dr. Brandt by clicking on the “Contact” button on the bar at the top of this page.  Needless to say, it will be completely confidential.

Physician Suicide

What a hard topic to write about.

Like most physicians, I knew a colleague who committed suicide.  Also, like most physicians, I didn’t see any warning signals.  I recently came across a review article on the subject of physician suicide on emedicine that made me decide to post some information.

Every year in the United States, we lose the equivalent of at least an entire medical school class to physician suicide.  It happens during medical school, residency and once doctors are in practice.  It’s nearly always related to depression – a clinical problem we all learn about, but have trouble recognizing in ourselves or our colleagues.

Depression is a disease, not a personal failing.  It affects 12-18% of practicing physicians and – it’s treatable. It’s often associated with alcohol or substance abuse, which are also treatable.  The good news is that depression, substance abuse and alcoholism are more successfully treated in physicians (and trainees) than the general public – probably because of the personality traits that lead us to become physicians in the first place.

All medical schools have confidential and free support for students and residents.  If you are worried about the effect on your career – don’t.  Seeking treatment is a sign of strength, not weakness.  If you are struggling, please know that there is help and you are not alone.

Here are some important resources (you don’t have to be suicidal to ask any of these sites for information or help)

National Suicide Prevention Hotline 1-800-273-TALK (8255).

http://www.doctorswithdepression.org/ an outreach program from  The American Foundation for Suicide Prevention

Burnout and medical errors among American surgeons. Shanafelt et.al. Ann Surg. 2010 Jun;251(6):995-1000

Ann Surg. 2010 Jun;251(6):995-1000.

Burnout and medical errors among American surgeons.

Shanafelt TD, Balch CM, Bechamps G, Russell T, Dyrbye L, Satele D, Collicott P, Novotny PJ, Sloan J, Freischlag J.

Department of Internal Medicine, Division of Hematology, Mayo Clinic, Rochester, MN 55905, USA. shanafelt.tait@mayo.edu


OBJECTIVE: To evaluate the relationship between burnout and perceived major medical errors among American surgeons. BACKGROUND: Despite efforts to improve patient safety, medical errors by physicians remain a common cause of morbidity and mortality. METHODS: Members of the American College of Surgeons were sent an anonymous, cross-sectional survey in June 2008. The survey included self-assessment of major medical errors, a validated depression screening tool, and standardized assessments of burnout and quality of life (QOL). RESULTS: Of 7905 participating surgeons, 700 (8.9%) reported concern they had made a major medical error in the last 3 months. Over 70% of surgeons attributed the error to individual rather than system level factors. Reporting an error during the last 3 months had a large, statistically significant adverse relationship with mental QOL, all 3 domains of burnout (emotional exhaustion, depersonalization, and personal accomplishment) and symptoms of depression. Each one point increase in depersonalization (scale range, 0-33) was associated with an 11% increase in the likelihood of reporting an error while each one point increase in emotional exhaustion (scale range, 0-54) was associated with a 5% increase. Burnout and depression remained independent predictors of reporting a recent major medical error on multivariate analysis that controlled for other personal and professional factors. The frequency of overnight call, practice setting, method of compensation, and number of hours worked were not associated with errors on multivariate analysis. CONCLUSIONS: Major medical errors reported by surgeons are strongly related to a surgeon’s degree of burnout and their mental QOL. Studies are needed to determine how to reduce surgeon distress and how to support surgeons when medical errors occur.

PMID: 19934755 [PubMed – indexed for MEDLINE]

Why You Should Run and How to Get Started

I hate running.  Whew.. that’s out of the way.  BUT – I have been a runner in the past, I live with a runner, and it’s absolutely clear to me that running is the ideal cardio exercise for medical students and residents.  So, I’m going to try to convince you that you should incorporate running – even in a very small amount – into your daily routine .

Why Running is Perfect for Medical Students and Residents

  • It’s cheap.  Other than an good pair of running shoes (and don’t buy less than good ones), there is no expense.
  • It’s portable.  A bag with your shoes, shirt and shorts can stay in the trunk of your car.
  • It’s social.  Once you identify a friend or two who agree it’s a good idea to run, you can do it together.
  • It’s efficient.  Short runs are still a great workout.  Unlike other workouts which require planning, travel and time to complete, you can walk out the front door and run.
  • It’s empowering.  You can set goals and easily accomplish them.  There are a lot of times during your training that you will feel things are out of your control. Setting a goal (I’m going to run a mile) and then doing it (Yeah!) is empowering.
  • It does more than just get you fit.  There are good data that show that exercise in general (and running in particular) decreases stress, improves depression, helps sleep, etc. etc.

How to get started

Here is a great guide for beginners from the New York Times that I recommend you read. Another qreat source is the most recent online Runner’s World guide on how to start running.  It’s hard to find now, but here are some tips from the Runner’s World May 2010 Special Beginner’s Guide:

  1. Don’t do too much to start with.  Start with walking and add in small amounts of running.  “Every able-bodied person can be a runner,” says Gordon Bakoulis, a running coach based in New York City, :Just start slowly and build up gradually.”
  2. Be consistent.  Your goal is to exercise every day. Cardio is an important part of your exercise, but not all of it.  You can run every day, but you’ll have to find  time to do resistance and flexibility training as well.  Alternatively, you can view resistance days as “recovery” from running i.e. alternate the days. Commit to some kind of exercise everyday.  Plan your week to make sure you get at least 3-4 cardio sessions/week – and then cut yourself some slack if something happens that pushes you off track.  It’s human nature – if you say you are going to run every day, you’ll probably run 4 or 5 times.  But, if you say you’ll run 3 times a week, it will probably end up being only once.
  3. Read, ask questions, learn about this skill.  Every city has a “runner’s store” (which is different from a store than sells running shoes).  Ask the runner’s in your class where they go to buy their shoes.  The store will have shoes, but it will also have very knowledgeable people who will be delighted to help you learn about running.

How to fit it in and how to stay motivated

  • I know you don’t want to hear this, but early morning is the best time to run.  It’s an energizing way to start the day, you “get it out of the way”, and you don’t have to fight the siren song of the couch at the end of a long day.  If you do choose to run at the end of the day, change into your clothes before you leave school or the hospital and run before you get home.  If you have willpower of iron you might be able to lace up the shoes and run before you go to sleep … if it works for you, great!  (but it won’t for most people) .
  • Think about signing up for a fund raising group.  Running for kids with cancer makes you feel pretty silly about whining….
  • Register for a 5K race – having a goal to finish  (and getting your first time) will be motivating
  • “Gratitude is contagious.”  Kristen Armstrong suggests that instead of feeling like you “have” to run that you think about what a gift it is that you “get” to run.  “If you view your run as an opportunity, your attitude will get an adjustment”.

Book Recomendation: Iron Doc by Mamta Gautam, MD

I became aware of this book last week through one of the anesthesia residents at work (whose chairman made this book required reading for all residents in his department).  Dr. Gautam is a psychiatrist who has specialized in caring for physicians and is an expert in physician wellness.  She uses training for an Ironman triathalon as an analogy.  Physicians have to “train” for different roles (personal and professional) if we want to prevent burnout.  She proposes a training program that helps keep balance in the complicated life of a doctor. The book primarily addresses physicians already in practice, but the information is very applicable to trainees, as well.

Here’s her website if you are interested:  http://www.drgautam.com/gautam/books.htm