We were walking out of the building to lunch when she described my job back to me, and I realized I'd never once looked at it that way.

Once a month the two of us left at the same time and went somewhere our badges didn't work. We protected that hour, because it was the only place either of us said anything true.

"How do you do it?" she said. "Your department and budget are way bigger than mine. Your needs are so much more complex than mine. And you're constantly denied what you need. I'm getting tired of plugging the gaps in staffing and still trying to get my own job done. The doctors are furious, and even their advocacy doesn't get us very far. You guys don't even have a medical director."

I had nothing to say.

She'd just described the conditions I'd been working in for nine years, and it landed like new information. I knew every fact in it. I'd lived all of them. I had somehow never put them together into a picture of the place.

That's the thing about an environment.

You can't see the one you're standing in.

EVERY 'NO' HAD A GOOD REASON

I told this story wrong to myself for a long time, so let me be careful with it.

It wasn't ten years of the same denial. If it had been, I'd have caught it. It was ten years of different ones, each with a reason that was true.

A year we had new leadership that didn't know the division yet. A year the economy did what the economy does. A year of restructuring. A year when something else really was more urgent, and I agreed. (Throw in a year or two of pandemic and it's pandemonium.) Yet, I sat in those meetings and understood the logic every time.

That's what makes it so hard to see. Each piece arrives with its own explanation attached, and the explanations are good ones. So there's never a year where the answer looks like a pattern. There's just this year, and this reason.

Underneath all of it was one reason nobody said out loud. We were asking for money to keep things from going wrong, and when you do that well, nothing happens. There's nothing to point at. So every year we held it together became more evidence that we could keep doing it without the funds.

If you've had the same request turned down three years running, each time for a different and perfectly reasonable reason, you know this feeling.

THE PROMISE THAT KEPT ME THERE

Why was I there in the first place?

I came back from leave to a department with nobody at the top. We'd had an interim for nine months, I was doing all the operational work anyway, and there was no one steering the ship, so I figured it was time to take the helm. And one thing needed doing more than anything else. We had to get out of that location and into a new space. I told my team I'd get them there.

I did. It took ten years.

I was also the stable half of the equation at home. When somebody in a household is building a business, somebody else is carrying the health insurance and the deposit that shows up on the same day every two weeks. That was mine to carry and I was glad to carry it, but it did mean every other option I looked at stayed theoretical.

You can reframe a story. You can't reframe a mortgage.

And every year the move didn't happen was a year I couldn't go. Nobody was holding me there. The promise was still open, and the closer we got, the more expensive leaving became. Walking out in year eight doesn't only cost you eight years. It costs you the thing the eight years were for.

Maybe yours is a merger or reorganization that's nearly through, or a year that's finally going to be better than this one was.

WHAT YOU'RE STANDING IN GETS INTO YOU

There's a word I'd never heard of back then.

Environmental health researchers use exposome for the whole set of exposures a person picks up over a lifetime. It was proposed in 2005 as a companion to the human genome, on the reasoning that we'd mapped what people are made of and had never mapped what they're standing in.

It has three parts, and the third one is what got me.

• The specific external: what you eat, what you breathe, what you come into contact with.

• The internal: what your body does in response.

• And then there's the general external: your social and economic environment. Your resources. Your neighborhood. The conditions you work under.

Your working conditions are on that list. Not as a comparison to a real exposure, but as ONE of them, sitting alongside what you breathe and what you eat, because your body doesn't sort them into separate piles.

In functional medicine, there's a less polite analogy. Your genetics load the gun, and your environment pulls the trigger. We say it about food and chemicals all the time. I've never once heard anybody say it about the place you spend 50-60+ hours a week.

When I look at that general external category now, for the people I work with, it's the same short list every time.

Calendars built with no recovery in them.
Standards that assume resources nobody gave you.
Being the person everything routes to.
Composure expected and never once mentioned out loud.

None of those are “events.” That's exactly what makes them exposures.

And you already know what accumulation feels like even if you've never called it that. It's the day you held it together through all of it, and then something small at home got the entire reaction. The thing at home wasn't the reason. It was the tenth thing.

You weren't overreacting. You were reacting to ALL of it.

WHAT IT COST ME TO FIND OUT

Our building was old and it leaked, and we worked around it the way you work around anything that's been true long enough. I stopped noticing years before I stopped working there.

Then it was December 21st, 2023. The final flood in the department

That was also the day my body started bleeding and didn't stop. Three weeks. By the third week I was having palpitations and I'd gone pale enough that people were asking me about it.

I got in to see my prescriber. She wrote me a prescription for an antidepressant, for... anxiety. She didn't address the bleeding. She could authorize one week off, and if I needed more than that, I'd have to go find a psychiatrist to sign for it.

I'm not telling you that to indict her. She was working inside her own constraints, in a system built the same way mine was. That's actually the point.

For ten years, I took every no on its own terms and never once added them up. Then I walked into an exam room with a body that had done the adding for me, and got told it was anxiety.

If you've ever said you were at capacity and been asked what you could delegate, you know this feeling. Nobody's being unkind. That's what makes it so hard to argue with.

That was when I knew I couldn't stay.
And then I got a bit angry.
Why did it have to get to this point?
Why did it have to become an illness for me to wake up and do differently?

I know the answer now, and I don't love it.

Nobody sends you a note in year four telling you this is the year it starts costing something. Every piece arrives with its own reason, the reasons are fair, you agree with them, and you keep going. That's how accumulation works. Quietly, and with your full cooperation.

The only thing that ever added it up for me was my body.

And it waited until it had my FULL attention.

The place you're standing in isn't going to change. It's going to keep asking for exactly what you've been giving it, because you've been giving it, and it's been working.

So I don't think the question is whether you can or should leave.

I think it's whether you've ever really looked at the ground. And I'll be straight with you, I still don't know what made me different from her that year.

We both assumed it was character.

That assumption is what I want to take apart next.

THIS WEEK

Two things, right now, before anything else gets your attention.

First, write down every no you've gotten in the last three years and the reason you were given for each one. Don't argue with any of them. Most were probably fair. Put them on one page and look at what they add up to.

Then ask somebody who works beside you to describe your working conditions back to you. Not how you're doing. The conditions. What they'd tell somebody who was thinking about taking your job.

You'll hear and see things you've been standing in for years.