Dec 01

Burnout is Not Bullshit

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Recently I’ve been stumbling across more and more articles about physician burnout. It is a trendy term to use these days and I think a pretty darn good one. It was first used in the field of psychology in 1974 by Herbert Freudenberger, and the meaning has evolved over time.  Social psychologists Christina Maslach and Susan Jackson developed the widely used tool for assessing burnout, the Maslach Burnout Inventory which describes burnout as a three-dimensional syndrome composed of exhaustion, cynicism, and inefficacy. It is even in the almighty ICD-10 so it must be the real deal. Burnout described what I went through several years ago very accurately, and I found it to be a good intellectual framework to work from.

 

Apparently there are people who don’t believe that burnout is ever an appropriate diagnosis. Some declare that burnout is bullshit.  “Burnout doesn’t happen” they say. “What you are suffering from is abuse!” At the other extreme, some feel burnt out physicians are all a bunch of pampered millennials crying wolf and that these docs are just suffering from not being tough enough.

“I went through the system and made it through just fine and so should everyone else” they proclaim.

 

Everyone is opinionated. Any nuance to the discussion is not tolerated and dissent is quickly destroyed by the angry mob, shaming those that disagree into disgraced silence. “Thou shall not be burned out!”

 

Well, the world is not black and white, and when people make bold absolute statements I am naturally skeptical. I see the world as more of a messy shade of gray. I say both burnout and abuse exist and neither is bullshit.

 

The problem with this ‘burnout does not exist, it is abuse instead’ narrative is that if there is abuse, there must be an abuser. Maybe it’s a person, the system, the government or some international conspiratorial shadow organization that is also fixing the price of gold and using social media to control us like puppets. It could even be the NFL (I mean, they lied to us about concussions so who knows what other kinds of sneaky things they are up to). But, when we declare that all our problems are from abuse then the only logical way to fix them is to find our abuser, leave our abuser, or change the abuser’s behavior and make them treat us better.

 

Not only that, but if you follow this line of thinking to its logical conclusion, then any burnout anywhere is abuse. Are all the burnt out teachers, nurses, lawyers, social workers and telemarketers also being abused? All of these professions have a high rate of ‘burnout’. Is it all bullshit? I think we run the risk of watering down the word abuse here. If everyone is abused, no one is.

 

When I was going through burnout (yes, I am going to unapologetically keep using that term because it is awesome) the last thing I needed was someone telling me I was not going through burnout. It would have been counter-productive. There was no abuser that I could point to, no one magical thing I could fix. It was something much more insidious. It was a combination of all my internal problems made worse by a stressful profession, other complex external events, and the life stage I was in at the time. It was messy. Let’s not kid ourselves; physicians work in a high stress, emotionally exhausting profession.  Each and every day I’m working my brain makes thousands of decisions that have real impact on people’s lives, and often have life or death consequences. This weighs on us. It is the primordial soup of burnout.

 

Taking a step back, I’m not saying for one minute that abuse does not exist in some medical schools, residency programs, and post-training jobs. There are clearly many deranged sociopaths and emotionally broken and abusive people in medicine, and like politicians, they seem to rise to positions of relative power and prestige. Many of these people cannot feel empathy and should clearly not be running medical schools, residencies, and hospitals or training our students and residents. There are countless examples and I don’t want to minimize the horrible emotional and physical abuse many suffer while going through medical training. I’ve seen it up close. There are systemic institutional problems that should be addressed. But I couldn’t find my abuser when I burned out. And there are plenty of good people that care in both medical training and hospital administration. My medical school was awesome and supportive, and despite this a classmate of mine died of suicide in the first two years there. My residency was hard work, but aside from the occasional attending physician acting like an asshole I overall felt pretty supported and listened to. In fact I have mad respect and admiration for the vast majority of people who helped train me and make me the physician I am today. I came out of residency and fellowship optimistic believe it or not.

 

Five years later I was trying to figure out how to quit medicine and retire.

Exhaustion – check

Cynicism – check

Inefficiency – check

Abuse – Sorry, couldn’t find it. There was no smoking gun, I just burned out.

Not all burnout is caused by abuse.

 

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So why does any of this matter? Why do I even care about this? Why am I wasting one of my beautiful days off typing furiously into a computer when I could be out mountain biking, hiking or sitting on my porch drinking a beer?

 

Good question. The answer is because it matters. The words we use matters, and when we say “burnout is bullshit” we marginalize the people who are actually burnt out. We are telling many of them to look in the wrong places for the source of their pain and teaching them the wrong solutions to their problems. There is the subtle message that if they cannot find their source of abuse their symptoms don’t exist. If you can’t find the abuse, and burnout is bullshit where does this leave you?

 

I have seen physicians described as the canary in the coal mine of our medical system, and I love this analogy. For those of you who don’t know, coal miners used canaries in mines because they are very sensitive to carbon monoxide poisoning and will die before the humans when exposed. If the canary stopped singing you knew it was time to get some fresh air. Incidentally, if you were a canary this was a pretty shitty job and your life insurance premiums were probably unaffordable. Anyways, if we want to stop losing canaries we can either:

 

  1. Build a better canary; or
  2. Make the mine less toxic.

 

When burnout is bullshit and there is only abuse, we are implying there is only one solution: clean up the mine or never step foot in it again. Maybe this is the best long term fix, but this is simply not a practical short term solution for everyone. There are simply not enough good mines for all the canaries to work in yet, and some of the canaries aren’t even functioning well in the mines that are perfectly fine. With burnout there is the implication that both solutions could be helpful. We need stronger canaries to go into those mines and help clean them up. When we convince people that building resilience through mindfulness and gratitude, and optimizing our physical health with exercise and diet is pointless (after all you wouldn’t tell an abuse victim to meditate and be grateful), we do them a disservice. When we tell someone the only way to solve their problem is to find and punish their abuser instead of making themselves the best version of themselves to face the very real stresses of being a physician, we teach them to focus their energy on things that they very likely can’t change in the short term. Sometimes you need to become a more badass canary, and then figure out how to deal with the mine. Again, just to be clear, becoming more resilient is not a good solution to put up with more abuse. Real abuse should never be tolerated. We should continuously shape our work environments to minimize it.

 

Resiliency is a word that many hate, but I’m going to use it and I’m not going to apologize. You are working in a stressful, high stakes career and you need to be resilient. The thing is though, how you become resilient changes from medical school to residency to the real world. What worked in residency may not work well for private practice. The stressors and sources of pressure change. Now, just to clarify, resiliency does not mean putting up with abuse. ABUSE DOES EXIST AND SHOULD NEVER BE TOLERATED! I think many bristle at the word resiliency because they feel it shifts the burden from the system to the individual, and to be honest many probably use it that way, but resiliency does not assign blame. It does not look for a cause; it is simply a tool for dealing with the world. The truth is we all need to be more resilient because burnout can come from anywhere, and when it comes it is fast, harsh and quite brutal. It often brings friends like depression, substance abuse, and suicide – all one big dysfunctional family. And it can be fatal. Suicide is much higher in physicians than the general population.* Regarding physician suicide, some of these suicides are due to abuse, no doubt; people being pushed to their psychological limits by the very flawed medical training programs and the medical industrial complex, but some of them would have committed suicide if they became an accountant, office manager, or barista. And some of them would die without being abused in any sense of the word.

 

I want to take a slight tangent here for a moment. There are two kind of people that go into medicine (not really, but go with it for a minute). Some people look at medicine as a calling and could imagine doing nothing else with their lives. They knew from their earliest memories that they were meant to be a healer. It was their destiny. And then there are those that…don’t feel this way. This second group went into medicine because it sounded pretty cool and they didn’t really know what to do with their life, or they wanted to help people and make a difference, or they wanted a stable high paying career, or they were really smart and their parents told them that’s what really smart people do, or they just thought MD looked really prestigious after their name (please don’t become a doctor for this reason). And by the way, it is not socially acceptable for a physician to be in the latter cohort. We all tell ourselves that we went into medicine because it was our calling, even though it wasn’t for some of us. Confusing, maybe even Orwellian, I know.

 

Well, the realmedicine is my calling’ people cannot imagine burning out. It is not in their search pattern. How can you burn out from your calling? The human mind cannot reconcile this craziness. There must be an external reason, hence the need for an external source of abuse, and maybe for some of these people there is. But for others there just isn’t some external, clearly identifiable reason for feeling burned out.

 

Depression, burnout, abuse, problems with identity and ego; all of these things are real, and all of them have different treatments. They can coexist or present in isolation. It’s comforting to reduce the world to binary black and white categories, but it is also simply wrong. The world is a bit much more complex. Let’s not forget this fact. Let us bring all who suffer into the tent and try and help them.

 


*Two of my classmates from medical school have died by suicide, and even in retrospect I do not see anything that resembled abuse contributing to their deaths. If we only focus on abuse we will neglect these people and not find the true reasons for their suffering.

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19 comments

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      • RocDoc on December 1, 2016 at 3:40 pm
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      A great loss of a wonderful person and physician. I can’t believe she’s gone.

      1. Rest in peace Amanda.

  1. I am not a medical professional, but can well attest to burnout being real and not a respecter of anyone’s status, profession, size of their bank account, etc. I know your post maybe felt like it was getting long, so maybe there will be a part II or maybe other posts have addressed some solutions, but what are some solutions, how is resiliency learned/built?

    I have not suffered burnout, yet, but just started a soccer coaching job and it is far more stressful than I imagined. I tend to actually do fairly well with stress, or at least I use to. :O)

    I did suffer with mild panic/anxiety which I hid from my family for about 20-years. To make the story short, healing only came when I first shared the problem (shining light on the darkness) and then allowed friends/family to help. I did not end up taking any medicine and that was just a personal choice, but finding mantras, phrases, and for me, scripture/prayer, have made all of the difference. And for some medicine will be necessary and there should be no shame if it is.

    The fact is we just don’t allow much grace for “mental” issues because we can’t see them like we see a broken bone or physical problem. THEY ARE NO LESS REAL AND SADLY FAR MORE DEADLY!!! A bit of compassion goes a long, long way.

    1. I will work on a post addressing solutions to burnout. Too much to discuss in a reply to a comment and I want to do it justice. You are right that ‘mental issues’ are often not given the attention they deserve. They are unseen and difficult for many to accept. They are hard to measure and often difficult to treat. Having gone through burnout has given me more empathy and understanding of these issues which is one of the silver linings.

    • Ursula Dekle on December 1, 2016 at 11:38 am
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    If you think you’re “burnt out” …. then you are. No rational person could refute that fact.
    YOU are whatever YOU think YOU are. YOU get to decide in a democratic republic. It’s about accountability. Abuse is real and should always be reported to authorities and the abuser prosecuted through due process. If that’s not possible, then change jobs and be happy.
    Less well-paid jobs are more plentiful and easier to leave and also easier to find another such one.Dish-washers, road-workers, store clerks, house cleaners (especially) are some good choices.
    By lowering one’s standard of living one can find peace and a stress-free life with hardly any burn-out.
    Most highly paid jobs are stressful. A stressed out chef should stay out of a kitchen.
    Their mistake could kill me, just as dead, as could the mistake of a stressed out surgeon, a stressed out driver, or a stressed out social worker whose mistake denies one’s medical benefits. A stressed out teacher who neglects to teach a student the research skills to get a job, could also contribute to their demise…..eventually ….or as their choice now by suicide.

    I’m certainly not advocating suicide, or in any way, minimising the horrific impact of a suicide on the family, friends and co-workers, of the person who may choose this option. Basically it’s death now, rather than later on. It appeals to stressed out individuals as a way -out of many years of stress, often unbearable pain and usually miserable mental torture, in a materialistic society that judges success by wealth and values individualistic self-actualization rather than the well-being of the entire group. Many buy into this illusion sans using their critical thinking skills.
    Selfishness and greed can become the norm and job security the driver that runs most people into that awful boring, stressful, ditch. When one’s immersed in the maelstrom of societal fear, greed, selfishness, longing for recognition, competition, winning at any cost, insincerity, back-stabbing, blaming, gossip, cheating, lying ……it’s the rat-race we all recognize….and some love! Sounds negative? Well, it is…..and if you don’t, you’re either in denial or ?

    So , solution….

    A “barter” system of life seems like a feasible choice for stress-free living , within a trusted group of like-minded professionals and skilled artisans and farmers. It frees participants to pursue their creativity and self-actualize in a variety of self-chosen activities….rather than e.g. the imposed sports :
    nascar, golf, football, skiing, yachting, eating out, shopping, cars, clubbing, concerts, media, films, ….ugggh…boring…so boring….why? because it’s expected!

    Live your own dreams …..not the illusions.

    Ursula Dekle

    1. I’m a big fan of self-actualization, but it is easier said than done. I think we are more shaped by our surrounding than we like to admit. Leaving the matrix is not easy, the illusion is comfortable and predictable.

    • RocDoc on December 1, 2016 at 3:37 pm
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    I think it’s not well publicized enough that burn out can occur even in the very early years of practice. New physicians often feel embarrassed to think or admit they’re burned out when they’ve only been working as an attending for a few years. Those first 5 years of practice are very vulnerable ones for physicians. One doesn’t have an attending to run cases by anymore, and it can feel very isolating and stressful to be making all these decisions on one’s own for the first time. Those first five years were my toughest by far and a very burnout prone time.

    1. Good observation. When I look around I see it most commonly around the 10-12 year mark but I burned out earlier.

  2. Great post and analogy. We will wait to learn what happened with DWM, I’m still hoping it had nothing to do with stress or burnout factors.

    1. We may never know. Every time a young doctor dies I tend to assume the worst, not because I am fatalistic but because I have seen it too many times. I hope we can get an answer, even if it isn’t the answer we want to hear. May she rest in peace.

    • Joseph Beckenbach on December 4, 2016 at 9:10 am
    • Reply

    Suggesting a correction in “Five years later” paragraphs: “inefficiency” should be the “inefficacy”, as cited in paragraph one.

    Having burned out myself (in the IT and software fields) and helped others also self-diagnose and self-treat, inefficiency is merely a possible symptom. Becoming increasingly efficient at irrelevant tasks seems a common coping mechanism, as I’ve seen both first-hand and from organizational folklore over the past few generations.

    As well, inefficiency has many other causes besides burnout. That changes one’s approach in dealing or healing.

    1. Good point. There is a big difference between inefficacy and inefficiency, although they often go hand in hand. We can be very efficient at things that don’t matter at all as you mention. In my case I think it was less efficiency. I still had a defined pile of work to do, and it was important I did it well. I could not escape it, I just had to plow through. I found it harder to stay present and focused. It took me longer to get through cases. I think that is what was so scary about burnout from my perspective as a physician. I could not allow myself to become less effective. Not to be all dramatic, but lives depended on me. It was not an option to become less effective because there was no one to pick up the slack. I would burn myself to the ground before I let that happen. Every doc I know is like this. Thanks for the comment.

    • Heather on December 6, 2016 at 12:04 am
    • Reply

    I wonder if part of the burn out phenomenon in medicine is related to the humbling ball busting nature of medicine and the hazing nature of medical training.

    I think lots of physicians are smart, hard working people who start off as big fish in a small pond who are used to their smart, hard working ways really dazzling other people and being pretty special. And those dazzling and pretty special ways are really effective at getting things done the way you want them to be done early on in life for many people who go into medicine.

    But medicine is a super humbling field. Not only do you funnel into a group of other really smart, hard working people where you no longer stand out just be being smart and hard working.You also funnel into a job where you have to heal and calm the sick and those are really, really hard things to do even when you are smart and hard working. There are so many factors in medicine that are beyond the control of just working hard and being smart. I think it’s the first time many of us have to smack up against a problem that our smartness and hard working-ness can’t always solve perfectly.

    And I think it feels exhausting and somewhat pointless and demoralizing to have put in all this effort for so long and realize that at the end of the day, your smartness and hard work only go so far.

    I know some current residences are trying harder to be sensitive to the fact that doctors aren’t robots but are humans with feelings but for those of us who trained 15 or more years ago, we were all trained with a mind set that admitting that you ever felt overwhelmed, or frustrated or sad or even just tired was the same as admitting that you were being a big wuss not cut out for medicine.

    I know that I struggle with listening to current residents complain about their work load. It triggers a Pavlovian response of feeling like they must be “weak” in some way because “in my day” we weren’t even allowed to talk to our attendings about our work load. You just sucked it up and kept working until you felt like a worn out nub. And then you still kept working.

    I guess if I there is any point I’m trying to make, I just feel like being a doctor is hard, demanding work and that many of the people who go into medicine aren’t used to being overwhelmed by something hard or demanding and that the training of most doctors reinforces that any admission of how hard it is is a sign of personal weakness that needs to be overcome instead of acknowledging that the job itself is pretty hard core.

    I think it is a challenge to get the personality type that goes into medicine to openly acknowledge that some things in life are really hard and that it is not personal failure to feel the stress of that hardness.

    1. I agree with your observations. It is a balancing act. I think the big question is how do you make tough, resilient physicians without burning them out and driving 2% or more of them to suicide? I don’t have all the answers (but I do have some of them and I will write a follow up article soon!)

      When I look back, I see so many emotionally unhealthy people in medicine, but it all seemed sort of normal at the time. I think one thing we can all do is to have more empathy. Even without changing the system we can listen to people and give them permission to be burned out. We can normalize it and say ‘what you are experiencing is a normal response to this stress’. If we don’t give people this permission then they become the failure and experience shame. This is a dangerous place to be.

        • Heather on December 6, 2016 at 3:40 pm
        • Reply

        Yeah, I think that medicine tends to attract people who have a difficult time admitting that they might feel overwhelmed or need help. And we’ve created a culture of medicine where it’s really difficult to be able to admit those feelings out loud to anyone without feeling shame or a sense of failure.

        I’m interested to hear what thoughts you have on how physicians might be able to shift those cultural attitudes.

        1. I should write a post about it. Cultural attitudes and institutional traits are difficult to change in ways that we can control. It seems like nothing is changing, then all of a sudden everything is different one day. We start by openly discussing these problems until there is an awareness. No one was writing about this stuff 10 years ago, now it is everywhere. As different generations and cohorts of people make their way through the workforce the cultural attitudes will shift. The way we train and the way we view medicine will shift as a culture. What it changes into I have no idea.

          I recommend starting simple: cultivate empathy towards our colleagues, talk about our own struggles openly and simply be more kind to others day in and day out. We have to embody the change we want to see.

            • Cheryl on December 12, 2016 at 8:06 pm

            I’ve burned after 11 years as an attending. There isn’t an easy way back into practice after a prolonged recovery. There should be physician a way to return to practice.

    • Curt Morrison, MD, FACC, CFA on January 1, 2017 at 9:49 am
    • Reply

    Cheryl:

    I returned after a 13 year absence. I studied for 1 1/2 years while preparing to return, completed over 800 hours of CME, and aced the ABIM re-certification exam. I contacted physicians in my old network and found an employed position.

    Many (most?) states have no written criteria for obtaining a license after a prolonged absence; they evaluate case-by-case. I applied to two states where I held licenses in the past, and both approved. No problems.

    My current job is very stressful (relative to my recent work in financial services), but much less so than the last go-round when I started a solo private practice from scratch and was overwhelmed with work. The advent of hospitalists has helped a great deal as well.

    If I could take a mulligan, I would have taken a few months off to breathe and then found a part-time position that allowed for a life, but either way, you can return.

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