Burnout and beyond

In my last letter, I promised a more cheerful update.  H-E-E-R-E it is!  And I include my thanks from the very tips of my toes for your incredible generosity and helpfulness in this part of my journey.  I couldn’t imagine a more caring, loving group of friends than you have been through my years in El Salvador and in the more recent challenges of the unexpected sabbatical in the US. (See also point 4 below). You have repeatedly inspired hope and encouragement.


1)  That “Rest and Recovery 101” is a challenging class indeed and the homework ‘they’ give can be forbidding (despite its occasional enjoyable aspects).    During this time I’ve read books written by fellow-students of this ‘class’ who similarly [and also grudgingly] studied the lessons and have grinned at their woeful sentiments:   “Just let me go back and die in my old level of rushed activity;   this recuperation process is killing me anyway.”  1 My words exactly during my first weeks  back in the US.

I’ve been greatly helped by several  counselors who have themselves  survived missionary burnout and/or have worked extensively with missionaries who have experienced the same.  These wonderful women were particular lifelines during those first months away from El Salvador when I felt like a scuba diver coming up way too fast from deep water and high pressure.  The counselors have been working to help me learn the value of rest [the VALUE of REST—isn’t that an oxymoron??!] in the regular rhythms of life.   One of these counselors grew up in Central America and believes with me that mangos should be a basic food group in themselves; she made the mistake of locating her practice in Indianapolis rather than in Kansas,  so I fly there for several concentrated sessions with her each month.  Along with the figuring out rhythms of rest, work, and health, I’ve been trying to sort out, discard, and redistribute my multiple hats that have accumulated over the years as sole physician and chief administrator of a clinic in a resource-challenged region.

2) That I’m not practicing medicine in the US.   I’m finally figuring out (15 short years later!) that one really cannot transport ideals of a solo practice in the US–with its multiple referral and diagnostic services–to an area devoid of most of these services; it’s particularly unrealistic to expect the same kind of continuity of care if one is the only physician residing in the community, to expect the same continuity of medications and other resources if many of them must be imported from another country, or the same level of outcomes if one has inadequate backup resources in specialty referrals, hospitals, labs, x-ray technology, or economic means (see the story below as an illustration).

3) That’s it’s easier to cross a swamp if there are others traveling with you.  I’ve been so blessed to be helped in these fact-finding times by a support group who meets with me weekly and blends insight with love in looking for the best solutions for the clinic and me.  (When looking for a template of a business plan for the clinic, for instance, we eventually decided we were going to have to create our own template of an Amish non-profit clinic in Latin America; we couldn’t find any ready-made samples of these on the Internet).

4) That I have been blessed with some of the world’s most loving friends and family and that you are a treasure that surpasses description. I want you to know how greatly your prayers, your thoughtful words and letters, and your extraordinary financial generosity have helped me in my recovery process, and I’m eager for the day when I can give to the Salvadoran people from the wealth of love you have given me.  To each of you, THANK YOU!!!!

5) That with recovery come renewed delight and joy; thus, that delight and joy often reflect inner wellness more than they do external variables. Being an aunt to my 6 nieces and nephews brings its particular delights.  Allow me one auntie tale: after a typically rambunctious Christmas with a bunch of Nisly’s in one farmhouse, 5 year old nephew Braden ran out to give good-bye hugs to Uncle Wendell.  The hugs quickly turned into displays of male affection (read ‘tussling’); Uncle Wendell, chuckling, flipped Braden upside down, gave him a fond pat on the bottom, and said, “Are you a squirt, Braden?”  Braden, muffled giggle:  “No, I’m upside-down!”  Life’s OK, if going from hugs to “upside down” is all bundled in affection.

6) That the eternal God who invades each moment with goodness may be best heard in times of silence.


1) Continued patient care:  Marietta, with Karen (NP) and James (new clinic administrator) continue finding ways to better serve our patients.   When Karen calls me periodically to ask advice on a patient, I wince to remember the kind of challenges that frequent our clinic.  Two weeks ago there was the patient with advanced Goodpasture’s syndrome who had just returned from the US and had received initial diagnosis and treatment there.  In her purse she carried an arm-long list of unfilled prescriptions and an equally long list of therapy needs, including dialysis; since we are a US-based clinic in El Salvador, she wanted to transfer her care to us and hoped we would have most of her meds in stock (we didn’t).  Last week it was the woman in her mid-twenties who walked in for her initial visit at our clinic exam with her skirt tightly-stretched over a distended abdomen; sadly, the distension was not due to a healthy pregnancy but, instead, fluid build-up.  To discover where that fluid was coming from Karen had available only  1)the history and physical exam which she would perform and 2) possibly, a sonogram and 3) possibly, a creatinine and BUN; the lab and x-ray exams would happen only if the patient could afford to go elsewhere to private facilities and obtain them.  Realistically, we are not likely to pinpoint her illness with this kind of limited evaluation, but even if we could accurately diagnose her disease, she would be unlikely to find adequate therapy after diagnosis.  In times like this, I inwardly sigh and calculate approximately how long it will be before we attend yet one more funeral of one of our patients, give our sore hearts in companionship to the family’s grieving souls, and hear once again the sad but accepting words, “Well, God willed it so”.

In one of these phone calls with Karen, my ‘consultation voice’ changed to one of mild scolding.  Since she is replacing me due to consequences of overwork, you may understand the rebuke in my voice in my response to her inquiry about the patient who came to her house at 5 am for his daily insulin injection.  “Karen!  At your house?!  At 5 a.m.?!”  Karen also understood my rebuke not as criticism, but as concern.  But my memory understood her explanation far too well.  (The following story is Karen’s and my mixed explanation for why coming to the provider’s house at 5 am for insulin injections was the best option for this patient and for Karen).

Tomás (name changed) lives across the street from our clinic:  a 3 minute walk down a steep hill and across the road.  That short walk and an all-day wait at a clinic for treatment is a small sacrifice for Salvadorans.  Tomás has diabetes and often presents with blood sugars greater than 500 mg/dl (for the non-medical folks reading this, 126 mg/dl is the highest blood sugar reading we wish to see).

Tomás’ story actually begins with his sister.  His house adjoined that of his Margarita’s (name changed).  One day several years after the clinic opened, we discovered that Margarita had diabetes.  Because Margarita had children in the US, she went for diabetic

care to a private doctor in Santa Ana (because, naturally, the very best care is at some distant place with a doctor that charges hefty consultation fees).  Despite the fact that she had already been blind from diabetes for a year, the physician was content to allow her blood sugars to stay above 200 and kept assuring her that the diabetes was being well controlled.  My warnings to the contrary were ignored.  She had a major stroke at age 49 and lay on her cot in her bedroom for the next year until she died.

When Tomás routinely missed his regular check-ups and wandered over to the clinic at about 9 months intervals, I tried reminding him of Margarita’s health outcomes and to gently but urgently reason that poorly controlled diabetes was probably at the root of her early demise and that these can often be prevented with adequate blood sugar control. —-(Insert sigh here) Have you ever tried explaining the route to from Kansas to Kentucky to a caterpillar??  You probably felt more successful than I did after trying to explain diabetes care to Tomás.  The congenial, vacant nodding of the head and the unconvinced eyes.

When Karen called me to tell me that his blood sugars were still greater than 500 and that he had ketonuria, despite the remarkable fact that he had consistently been taking his meds– maximal doses of 3 oral diabetic meds– for two weeks, I suggested hospital admission for initiation of insulin (in this country, that medication is still started only in hospitals).  The closest public hospital is 45 minutes away; Karen wrote the referral note and was pleased to hear that the hospital actually admitted him (admission, as you may recall, depends upon many factors, not the least of which is the grump-titer of the intern who is staffing the Emergency Room at the minute).  He was hospitalized, given insulin for 8 hours and then—blood sugars controlled for the moment—-was sent home with NO medications:  no insulin, no oral meds.

Tomas managed to convince the hospital staff several days later that he needed ongoing insulin therapy.  So they gave him a vial of insulin, and Tomas started coming to Karen’s house twice a day for insulin injections.  His eyesight was so poor he couldn’t see the numbers on the syringes to draw up his own insulin and he trusted Karen’s technique more than he did his wife’s.  So Karen found the option of giving him twice daily injection-giving at her home to be preferable to the otherwise inevitable health decline.  And, she reasoned, generally the morning injections were at 7 a.m. rather than at 5 a.m.

2) CHANGES:  The new clinic administration has persuaded us ‘old-timers’ that a clinic might actually be able to use an appointment book in rural El Salvador, now that many people  have access to cellular

phones.  (In the clinic’s early years, the only way to communicate with us was to  personally come to the clinic or to send crumpled, barely readable notes with a neighbor; in subsequent years only wealthier patients owned cell phones and thus an  appointment system would have favored this subset of patients.  Now, phones are as ubiquitous in these hills as are dust and mosquitos.)  IF the appointment system works, it could actually give us some way to control the quantity of patients we agree to see in a day and to occasionally schedule a day away from the clinic.  (And as all US docs know, appointment books entirely eliminate scheduling headaches, right??!!)


And now as I finish writing this, I am looking at the red-bloomed hibiscus and the roses and ferns outside my back porch in El Salvador (there really is no way to convey the deep content and pleasure of that scene in mere words, is there?!).  My counselors and support group agreed that this was a good time to make a short trip back to El Salvador and give Karen a bit of a lift (and we all knew how selfish this trip really is:  it allows me to ‘get back home’).  So I arranged for a 2-week trip back to El Salvador.

What a homecoming.  Ninety degree weather in March, parched landscape, my Salvadoran ‘mother’ and ‘sister’ and my good roommate all waiting at the end of our drive for my arrival; balloons, roses, cake, and joyous tears from the staff who had stayed late at the clinic to celebrate, and—welcome back!!—no water in our cisterns for my first 12 hours in the country.  But, goodness, it’s nice being back, with or without bath water.  If all goes as planned, I hope to return to El Salvador more permanently sometime in mid-summer.

For all your love, prayers, generosity, and genuine care, thank you.

Very warmly,
Jana Nisly

1Sue Monk Kidd’s book When the Heart Waits (Harper San Fransisco) has many  thoughtful insights she gained when she walked a journey similar to mine.