“Ask yourself”, my ninth-grade football coach called through the evening roar of early autumn secadas, “Have I emptied the tank today?”
He’d ask the question with one “gasser” left in the conditioning portion of practice; sun already set, us already spent. The whistle would shrill, and I’d give it everything I had for the next thirty seconds, almost blacking out upon crossing the finish sideline, scared to death at not emptying the tank. Why? Our coach would always ask us afterward, not punitively but curiously, “So, did you really empty the tank today?” I always knew. Some days I had, and the peace was amazing. Other days I hadn’t, and it haunted me, until I vanquished it at the next chance to empty the tank.
It was regret.
I’d lost the analogy to nostalgia when it reappeared during residency.
Psychiatry, like other specialties, tries to minimize negative outcomes. In surgical fields, you aim to reduce post-op infection rate. In the ICU, you aim to reduce central line infections. In psychiatry, you aim to reduce suicide. It’s our negative outcome.
We were taught risk assessments for suicidality. We knew the red flags. We asked all patients about the presence of thoughts, through several different questioning tools. We watched behaviors. And, we hospitalized patients against their will for fear of their suicide risk, but the majority of patients with reported suicidal thoughts we did not hospitalize, after careful evaluation.
The field has worked to make the subjective objective, but judgment calls remained a part of a very human decision-making process. Ambiguity reigns. There aren’t many clean fixes, no appendixes to remove.
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As an intern, I had not this hindsight, so I leaned on the risk assessments and did the best I could, supported by my attendings. Even still, there were many nights where I drove home from the hospital in turmoil. Did I do the right thing? Should I have hospitalized that patient? Should I have let that patient go home? Did I do enough? Will something bad happen to this person because of what I did or didn’t do? It seemed an unwinnable game—the win or loss outside my will.
Second year passed, third year concluded, and as I finally arrived at fourth year of residency, I began trusting the assessments paired against my clinical experience. I wavered less. There were less tortured drives home. Still, once a month or so, there’d be a patient situation that would land just right, with enough uncertainty and doubt, that I’d spend a weekend ruminating.
Thankfully, I noticed a pattern.
When I was fully present, not consumed with the stress of the clinic schedule, and committed to whatever it took in that individual session, oftentimes taking the most difficult path forward, I went home in peace. I could sleep at night. Because I was there.
That’s when, from the memory bank, Did I empty the tank today? returned as a guiding compass. There in my car driving home one day after clinic, dominion swung back within reach as a simple path cleared; all I could do was my best in each session and release the results. How present could I possibly be with each patient? If I did my best, I could live with that.
Difficult and uncertain decisions remained just that, difficult and uncertain, but as fourth year ended and I graduated, emptying the tank with effort and presence became my compass. Though I left the field and decided to pursue another life outside medicine, there was peace inside those last few months of residency. I was there doing my best and releasing the rest.
A game I’ll continue to play (without it).
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