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Coping with Anxiety


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Hi there, I’m a new PA. I recently graduated school and have been working my first job in emergency medicine for the past 6 months. I’m getting great feedback and all my docs and coworkers say I’m doing well, however I’m really struggling with anxiety. I’ve had some anxiety prior to starting work but never anything severe or debilitating. I’m a pretty down to earth person and didn’t stress too much in school. However with work I find myself being super anxious after I leave my shift. I worry I missed something, did something I shouldn’t have, etc. Sometimes I even lie awake in bed at night unable to sleep constantly worrying about patients from that day, unable to sleep or have horrible work nightmares. I’ve talked to some older PAs and Docs about this and they say it’s pretty normal and gets better with time as you become more comfortable in your job, but the stress is just really bothering me as I’m not used to having anxiety like this. Does anyone have any tips for coping? How to leave your work at work and enjoy your time off? Strategies for distraction when you start to worry too much? I know some anxiety is good and it keeps us on our toes as practitioners, but I just feel like this is more than just productive anxiety. I look forward to your tips and advice!

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I would get into counseling, I did it myself due to the same think as well as PTSD from some situations. I did EMDR with a PsyD and it has helped a lot. I still have my bad days and good days, but my anxiety/stress/crazy thoughts went from a 7/10 to a 3/10 with therapy. I did try an SSRI which did not work for me and I have not tried another one yet, I do have Wellbutrin in the cabinet but have not even started it. It has been up there for about 4 months. Do not wait to get into counseling, just trust me and get in. I have 4 years out from graduation and work in a RHC, family medicine. Good luck and PM me if you need to! I will disclose more if you need more guidance. Keep us updated. 

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Unfortunately, I've heard of this quite often for new grads and it usually hits at the 6-month mark, almost without fail. A lot of this will improve with time, confidence, and experience, but I do second the counseling recommendation.

With that said, keep reading, and always be reading and learning. Review things, ask questions to senior partners, etc. Exercise is always a good addition, whether it's yoga/meditation, running, sports, weights, etc. Breathing techniques work for some: take a breath, focus on your breath as it comes in through your nose for 4 counts and then breathe it out your mouth for 4 counts. They teach this in yoga and Pilates, and it's really helpful for stressful situations. Also, think through and try to understand why you're feeling the way you are. Is it because you didn't check a ROS? Didn't examine the other side? Or is it just because you're growing as a provider and establishing your own practice style, which can make some uneasy, especially those who aren't used to the unknown? Learn from these thoughts and that may help frame your understanding of how to "treat" or improve.

I hope this helps. Trust in your training and gain confidence in yourself. 

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Honestly, nothing wrong with some meds and therapy, in that order...we're all on them.

Get a consult for low dose antidepressant for anxiety control...to take the edge off, then therapy to work on calming techniques so you can get off the meds in a little while.  Just my two cents.  Maybe a little bit of Klonipin or Ativan to help sleep with acute episodes.

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I have struggled with anxiety at times, and have found mindfulness helpful. Those anxious thoughts will always bubble up, but mindfulness gives you the tools to recognize when you are lost in harmful thoughts, and to let them go. I recommend Dan Harris' app (it is called 10% happier) for beginners. Try doing a few minutes each day, along with the suggestions that others have recommended here.

Best, LK

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Guest ERCat

I have been a PA for 2.5 years and struggle with this. In fact last night I was tossing and turning and worrying about this old man with constipation and no vomiting or abdominal pain, whose CT showed a really funky gallbladder that my attending basically said to ignore because he had no abdominal tenderness. I did send him home but regretted it. I literally called the night doc at 1 AM to get their opinion and ease my fears!

One piece of advice - especially when it comes to high risk populations like this old man - if you think about ordering the test just order it. Don’t let anyone talk you out of ordering something if you have a heeby jeeby feeling. In the beginning YOU WILL OVERTEST! 

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My go to is vigorous exercise - helps blow the steam off.  I live only a couple km from work, so I ruck to/from, which gives me some lead time to settle and time to decompress on the way back as well.  Have a BowFlex in the basement and a humanoid punching bag, which often has a new "face of the day".  My dog is very understanding as well ?.

 

SK

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11 hours ago, lemurcatta said:

I have struggled with anxiety at times, and have found mindfulness helpful. Those anxious thoughts will always bubble up, but mindfulness gives you the tools to recognize when you are lost in harmful thoughts, and to let them go. I recommend Dan Harris' app (it is called 10% happier) for beginners. Try doing a few minutes each day, along with the suggestions that others have recommended here.

Best, LK

Mindfulness: that's the word I was thinking of. They also try to teach that in yoga, which I've found to be a great addition to lifting.

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Thanks for the feedback everyone! I’ve gone to counseling but only 2 appointments in my 6 months but I think going frequently would be beneficial. What exactly do you talk about? It’s hard because I work and get so anxious and can’t sleep or worry but then on the day I go to counseling I’m not really anxious about anything at all. So what is helpful to talk about? I’m definitely going to work on mindfulness in the setting of yoga as well. 

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3 hours ago, NewPa2017 said:

Thanks for the feedback everyone! I’ve gone to counseling but only 2 appointments in my 6 months but I think going frequently would be beneficial. What exactly do you talk about? It’s hard because I work and get so anxious and can’t sleep or worry but then on the day I go to counseling I’m not really anxious about anything at all. So what is helpful to talk about? I’m definitely going to work on mindfulness in the setting of yoga as well. 

Psychotherapy, why you're there, vent session, guidance, coping skills, homework assignments... you name it. Some may guide the session while others let you guide it and then give feedback. Consider making an appointment with your PCP to get started on meds to help get a hold of things, and then consider weaning off once things settle down as others suggested. 

Think of the etiology for your anxiety (missed dx, patient worries, etc) and the aftermath (racing thoughts, sleeplessness, anxiety, worry, etc). Write it down. Bring your notes with you to help you during the session. 

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I have practiced for the past forty/six years and spent sixteen years in Emergency Medicine. I had the same anxiety because I had a reputation to live up to and I wanted an excellent outcome on everything. I experienced the same situation of going over my patients while lying in bed instead of counting sheep. Sometimes, as I thought about patients, I would have done differently. It’s all normal and is your best mentor. Do not, I repeat, do not go on Canax which only turns off the computer but is highly addictive. Some words from My Mentor, Dr. Loch. When answering my questions he stated; Bob, I have never done a perfect case but when I do, it is time for me to retire. Great advice from a great surgeon.

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Here are 2 self help books that I like with just this in mind:

https://www.amazon.com/Unfu-Yourself-Your-Head-into/dp/0062803832?SubscriptionId=AKIAILSHYYTFIVPWUY6Q&tag=duckduckgo-d-20&linkCode=xm2&camp=2025&creative=165953&creativeASIN=0062803832

https://www.amazon.com/Thoughts-Feelings-Harbinger-Self-Help-Workbook/dp/1608822087/ref=sr_1_1?s=books&ie=UTF8&qid=1527123895&sr=1-1&keywords=thoughts+and+feelings+taking+control+of+your+moods+and+your+life

 

I have them both, used and still use them both and the second one has work for you to do so if you aren't willing to do the work...it may not help much. It was recommended by a psychologist I saw for anger that was actually anxiety.

Use multiple modalities. Self help, therapy, meds when appropriate. Mostly make sure you are taking care of yourself mentally and physically and get enough sleep and exercise. Not enough of the first can make your whole life suck. I hate exercise for exercise's sake but  enjoy heavy work that accomplishes something. So find what works for you and get busy making it happen.

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What was it the wacked out cardiologist from "The House Of God" used to say?  "I have two hobbies - running for health and fishing for calm" or words to that effect.  Hobbies are a good thing too - they distract.  Classically trained samurai were taught to do poetry or calligraphy or other things as ways of focussing and distracting their minds from the horrors of battle - we aren't a lot different, though as a rule, we're not supposed to kill people (unless you're doing MAID).  As a guy dealing with a hard to scrape off layer of charcoal presently, outside of work distractions are important.  I also refuse to do OT anymore - my downtime is valuable to me and tell people as much.  Blogging or journaling are great ways of getting things off your chest - I used to do that when I was on deployment at the end of each day - helped a lot.  

$0.02 CAD

SK

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I recommend Mindfulness Therapy - a form of CBT that works directly on emotions - for learning how to overcome anxiety and depression without using medications. Medications only treat symptoms; they do nothing to change the underlying psychological cause of anxiety or depression. To make a real change, you need to change the underlying psychological cause of your anxiety or depression rather than just treating symptoms.

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I think some form of therapy is a good idea several mentioned in above posts most I never heard of.  After 32 years of practice in Family Medicine MOST evenings/nights  I review in my head what I did during the day.  That is normal (I hope).  No one prepares us for the fact that people put their lives in our hands, same for docs.  I think the anxiety thing is more common in the young PA's.  Need life experience in everything to take the edge off the anxiety.  It should get better as time goes on. ED medicine is stressful just by the nature of the first word "Emergency".  All the above is my personal opinion.

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It may be your personal opinion, Tom, but it is a shared opinion by those of us over sixty. I was out of Emergency Medicine by sixty as I loved it and loved the stress but knew this was a younger PAs job and was happy to teach them and exit stage left. As I had previously mentioned, I did the same review every night even after becoming an excellent provider. I too have not heard of mindfulness therapy as this is for the modern, academic PA who has lifted herself from the swamp that we were in when we were told to reach down and pick ourselves up with our bootstraps and keep on keepin" on. Regardless, you will get through this without Xanax.

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