Since completing my vascular neurology fellowship in 2010 and entering practice in North Carolina, I have had the great privilege of evaluating, caring for, and guiding-through-stroke-aftermath hundreds (perhaps thousands at this point) of young stroke survivors. When I reflect back on the trust that so many young adults whose lives have been forever changed by a disease they never expected to strike have placed in me, it is both humbling and invigorating, and I will forever be grateful for each and every one of these encounters, for I have learned something new from every unique experience.
I made the decision to leave my full-time job last year, and provided a six month notice indicating such in June 2018. Since making the decision to embark on a new career path (more on that in a bit), I have received numerous emails, Facebook messages, calls, and texts from friends who also know young stroke patients I have met – wanting to know why I left and where I went, if I went anywhere at all. I hope I can successfully offer an explanation here.
To start, I will share some of what my professional life looked like prior to my decision to change course. These words will also hopefully convey what the lives of many physicians are like. Our academic calendars in teaching hospitals run from July 1st through June 30th. During the academic year of July 2017 through June 2018, I was on call in some form 24 hours a day, seven days a week, for 26 weeks. Put another way, every minute of my life for half of my life that year I was on call. Overlaying this, patients I had seen in clinic would call with questions, send electronic messages, request that paperwork be completed. Just about every night, after running nonstop all day long while on call, I would get to my “in basket” late at night. I lost count of the number of times I fell asleep sitting upright with my computer in my lap, only to be awakened at 2AM by another page.
During weeks when I was not on call, I evaluated patients in the clinic setting, taught students and residents (both activities that I loved at their cores), carried several administrative titles with responsibilities, attempted to catch up on weeks of email from on call weeks, attended meetings, and if there was time, tried to write. Then, in there somewhere, I also had four young children who craved my time and attention.
Please don’t misunderstand my tone – I am not complaining, but merely describing my existence behind the scenes. While I thrive on caring for patients with strokes, and I cannot imagine any other profession I would rather have, after the years of intense on-call hours consuming 50% of my life each year while also yearning to spend time with my children, trying to maintain relationships with those I love, and fueled by a desire for decent sleep again, I reached a point of recognizing that I needed more balance. For years I could not admit this to myself. After all, I had never had a stroke, so my fatigue could not possibly rival the suffering of my patients. And I had many colleagues in both my field and in other areas of expertise who lived similar existences (or worse – years ago, I had a colleague in a procedural specialty who was on call 100% of the time when he was in town, which was about 46 weeks a year).
Year after year, I kept going, until last year, the year of being on call for half of my waking and sleeping hours. Eighteen of those 26 weeks of that particular year were hospital on call weeks, which meant I was physically in the hospital caring for patients on both weekdays and weekends. Over the years I have missed or been noticeably late for countless rec league basketball games, sports practices, piano and violin lessons, and swim meets. My children used to groan when my pager went off at dinnertime or while I was reading bedtime stories with them, but I knew things had to change when the groans stopped with each pager alert and instead they remained quiet with dejected facial expressions. It was almost like the final stage of their grief – acceptance.
As I detailed in a previous post (if you are interested, click here), one of the wonderful experiences I gained during my time at Duke was becoming familiar with Duke’s telestroke network. Briefly, the idea behind a telestroke network is to place a neurologist at a stroke patient’s bedside in communities where neurologists would not otherwise be available. When I would receive a telestroke page, I would sign onto a computer, securely video conference with the patient in whom stroke was suspected, and partner with the emergency medicine or internal medicine physician at the hospital requesting help on which steps to take to properly and rapidly treat the patient. It has amazed me that so many hospitals across the United States who have never had access to neurological care for stroke patients can now have a neurologist at the bedside within minutes under this model. Patients in these areas are receiving IV t-PA (the “clot-busting” medicine) at much higher rates because of this access, and those who are eligible for thrombectomy (a procedure in which a large blood clot is removed from an artery) are being selected for transfer to hospitals where this service is available.
I have had many a patient encounter in the outpatient clinic setting that has led me to feel sadly remorseful as I ponder why a patient did not receive IV t-PA when it seems from the person’s story and medical chart that it should have been an option, but it was not administered in those first critical hours. Why didn’t an eligible patient receive IV t-PA? Why didn’t an eligible patient undergo thrombectomy when numerous clinical trials have shown how beneficial it can be to long term outcomes? Frequently it is a matter of lacking quick access to neurologists who are comfortable evaluating these patients and backing up emergency medicine providers in implementing these interventions.
As I pondered last spring how to achieve more personal balance while also continuing to treat stroke patients, I began to consider the reality that so many patients are disabled or not disabled based on what happens in those first critical hours, and that I could have a phenomenal impact if I focused my time on working with telestroke networks. I could evaluate hundreds, if not thousands, of patients each year, help emergency providers distinguish between stroke and conditions that mimic stroke, treat eligible stroke patients with IV t-PA, coordinate getting eligible patients to sites to undergo thrombectomy, and so much more.
As I investigated the possibility of performing telestroke work full-time, I found a number of hospital systems seeking vascular neurologists to provide telestroke care. Among them was Sentara, a healthcare system comprised of 12 hospitals and numerous outpatient clinics in Virginia and North Carolina. As soon as I spoke with the medical director of the telestroke program at Sentara, I knew I wanted to be a part of it. I also became aware that my medical school alma mater, the Medical University of South Carolina (MUSC) was seeking to hire more vascular neurologists for its telestroke network. I was already part of the Duke telestroke team, and months after my notice of resignation from my full-time position there, we worked out an agreement for me to continue to provide telestroke coverage.
In addition to having the opportunity to provide a lot of care to a lot of patients under this model, I also knew it would give me flexibility – the ability to work from home, to control my hours such that I could prioritize time with my family, and to limit the stretches during which I was on call so I could sleep regularly. So far, the journey has been beautiful. I have sincerely enjoyed telestroke work thus far, and feel that balance has finally been achieved.
When I find that I have free time now, I am using it to write. I had started writing a book in 2017 on cerebral venous sinus thrombosis, but my work load and rigorous on-call schedule had prevented me from completing it. I’m back on track with it, expecting to publish it by the end of 2019. The Stroke Blog is up and running again. Amanda Anderson (my co-author, former patient, and friend with whom I collaborated on Carotid and Vertebral Artery Dissection: A Guide For Survivors And Their Loved Ones) and I are in the process of outlining another question and answer guide for stroke survivors. Many people have passions that drive them, and writing has always been one of mine. Without writing, I feel that a void develops in my life.
For those of you who were my patients, I wish to communicate the following: First, thank you again for your trust. Please know how much I learned from you, and how deeply I appreciate the encounters we had. I truly loved tracking down the sources of your strokes, working on action plans with you for how we were going to prevent further strokes, and determining how we were going to address symptoms from your stroke aftermath. Caring for stroke patients in a clinic or a hospital grew into my passion for advocacy for stroke survivors because of what you were willing to bravely share with me. Caring for stroke survivors is much more than just a job to me.
At this point, I am not in a new outpatient clinic or an environment to do outpatient work. However, I am very interested in starting an online telemedicine practice to provide this very service for young stroke survivors. I have seen what telemedicine can do in the format of telestroke networks, and can only imagine the possibilities with an online e-medicine practice. We think of medical practices as residing in a bricks-and-mortar building, where patients transport themselves or are transported by others to this building during traditional business hours, wait in a waiting room (sometimes for hours if the office is running behind schedule), and receive a limited amount of time with a specialist provider. I want to change that.
Imagine that you have an appointment with a specialist who is 200 miles away at a big hospital, and all you have to do to physically see and speak with that person is log on to a computer or bring up a phone app. If the physician is running behind, he or she texts you to say he or she is behind, and instead of sitting in a waiting room for minutes or hours, you go about your day at work or in your home. When it’s your turn, he or she texts you, you sign on, and the visit starts. No travel time, no parking hassles (huge deal for stroke patients), no hotel room or airplane flight or additional gas in the car. No taking the day off of work or having to find someone to watch the kids. Does this have potential? I think it does.
To summarize the answer to the question of…where did I go?
The answer is…I am still here, although my path has changed. And I am very much looking forward to what each day brings. You have all taught me that life is precious, time is a gift, and nothing is to be taken for granted. I have witnessed wonderful mothers and fathers who are younger than I am now with their lives abruptly and unexpectedly cut short by stroke. If my life were to suddenly end, my great hope is that my children will know how much I loved them, and will cherish the time we had together.
Despite how much we attempt to keep the risk of stroke for ourselves as low as possible, none of us are immune from having a stroke tomorrow.
Tomorrow is not guaranteed to anyone.
And that includes me.