This Armor of Mine

By Justin L. Bullock, MD, MPH, with Cary Paine, MD
June 14, 2024 | VOLUME 2, ISSUE 3

When I received my diagnosis of bipolar disorder as a second-year medical student, a lot of my life suddenly made sense.

I have always said, “I feel more than most people do.” With a diagnosis, I had medical words to describe my emotional state which, at the time, was a blend of tearful and hopeless insomnia combined with self-harm behaviors.

I wanted my physical pain to match my emotional suffering. I was in a mixed episode, an amalgamation of the worst of depression and hypomania. Bipolar battles can end in very dark places: I have come incredibly close to losing the fight for my life through my three suicide attempts.

I am not unique in this. Every human knows someone battling mental illness; sometimes, we are the person in the fight. I experience the essence of what it means to be human through my euphoric highs and devastating lows. Now at the end of my medical training, I look back and see that surviving medical training as a bipolar doctor is much like navigating a battlefield. I have learned that I need to suit up with my armor every single day to be successful.

I’d like to share some of my armor with you.

Helmet of clarity: I believe that the single most important thing for me as a human with bipolar disorder is to build strong relationships with people who will serve as my anchors in times when I am unwell. For me, these people include a therapist, a psychiatrist, and my partner. These people hold my clarity of mind in times where I may struggle to, and they accompany me to help make decisions about my psychiatric treatment and my work as a clinician. The helmet of clarity demands transparency and forethought between myself and my advocates. When I am well, I plan with my advocates what to do if I were to get sick—things like who will make the call to determine if I need to be hospitalized.

Breastplate of introspection: I continue a lifelong journey of challenging my internalized ableism. Ableism is the belief that some bodyminds are superior to other bodyminds.¹ Challenging my own ableism forces me to question my deeply held beliefs. For instance, nights are often a contentious point for doctors with bipolar disorder and training programs due to the tension between the risks to our health and a program’s staffing needs. I struggled with the belief that if I did not do every grueling aspect of medical training like my nondisabled colleagues did, then I would be a subpar doctor. Reflection allows me to see that there are doctors in every single specialty who do not work at night; they are not subpar doctors simply because of the shifts they work. Furthermore, introspection has let me see that my experiences as a bipolar doctor make me a better and more relatable doctor. These days, I often wear a Docs with Disabilities jacket at work. Once, I was consenting a patient with their own history of mental illness for a kidney biopsy, and the patient asked me about my disability. I told them I had bipolar disorder. “Will you do my biopsy?” they asked. “If you’d like me to,” I responded. They nodded yes.

Belt of accommodation: The Americans with Disabilities Act legally requires employers to offer “reasonable accommodations” once individuals request them. In both my large residency program and my small fellowship program, my accommodations were deemed “reasonable,” yet this term has always felt intimidating to me and is often legally contentious. Effective accommodations processes allow for trainees to seek accommodations without disclosing their specific diagnosis. My accommodations include: 1) protection to go to weekly therapy/psychiatry appointments, 2) adjustments to my night schedule to minimize flipping between days and nights, and 3) flexibility around my work schedule when I am in a mood episode. I work with my therapist to schedule therapy at the end of the day or at a time when someone can cover my pager. I do Zoom therapy on particularly busy days. Most mental health professionals would recommend that doctors with bipolar disorder work no night shifts at all, as there is clear evidence of the harms of sleep disruption.^2,3 I worked night shifts and night home call during medical training, in large part because I struggled with my internalized ableism. I felt I would be less of a doctor if I did not do them. I am not a good model for others in this way; I knew working nights was bad for my health, and I still did it. I attempted to mitigate the harms by implementing harm reduction methods by working with my psychiatrist to adjust my medications upward around times of sleep cycle dysregulation.

Shoes of peace: It is hard to admit that, at times, I must step away from clinical medicine to prioritize my well-being. In these times, it is safer for myself and my patients if I work on nonclinical tasks, like research. It is tempting but unwise to use my patient care competence as my internal metric to keep working. I have been deeply unwell in the past and justified continuing to work because I was still doing a good job at doctoring. I must use my own two feet to walk toward things that will lead me to my internal peace.

Shield of proactive defense: Before I started fellowship, I had a discussion with my program director about my bipolar disorder. I was worried about repeating bad experiences. My program director wrote to me, “I want to acknowledge how much we can learn from [you], while simultaneously recognizing that the burden for educating us does not fall squarely on you.”

I invited him to share his perspective as a program director on some of the specific ways a program can support a trainee with serious mental illness through the battle of training:

Sword of intervention: Sometimes, despite my best efforts, mood symptoms come. Attacking with the sword is my last line of protection during times when my mood is going to a dark or sped-up place. At baseline, I take medications, exercise, and attend therapy. When things heat up internally, with the guidance of my providers, I increase my frequency of therapy, change my medications, cut back on night shifts, or take time away from work. Giving my mind time to heal is often the best thing I can do for myself.

As doctors, we are witness to the strength of humans in the toughest of battles. Many of us exist in our own battles, too. This armor of mine is a tool that enables me—the human inside the armor—to find my internal strength and to head powerfully into battle.