I’m Just So Tired (And My Labs Are Normal): A Physician’s Guide to Burnout Without a Physical Cause
You may have been thinking about your New Year's resolutions over the past few days. Whether you made them or not, if you didn't make them and think you should have, if you're doing really well with them, or if you're not doing really well with them and you're questioning whether to throw it all in or start over. Wherever you are in that process, I bet one of the things you’re thinking is, "OMG, I'm just so tired." "I'm just so tired" is a common refrain among physicians, and especially among women physicians. When someone asks how you're doing, and you’re being polite and don't really want to get into it, you’ll answer, "Good, how are you?" But for the people who really know us, we would answer the same question with, "I am just so tired."
A few months ago, I went down my own rabbit hole of trying to figure out why I was so tired. My vital signs, hemoglobin, and thyroid studies were fine. I was not going through menopause. (Forget anything about peri-menopause. I’ve concluded that peri-menopause is not well-researched enough to have any sort of data-driven diagnostic criteria or management guidelines and has thus become a place where influencers claim to have it figured out and try to sell you hundreds of dollars of direct-to-consumer tests and super shady supplements that are packaged in a super aesthetically pleasing way.) There was no physiological reason for my fatigue. That led me to realize there's “tired” in the physical sense, but there's also “tired” in other senses. Mentally tired. Emotionally tired. Spiritually tired. If I wanted to determine how to address my tiredness, I would need to identify which “flavor” of tired I was experiencing.
As physicians, we know all the reasons for physical fatigue. As above: arrhythmias, anemia, hypothyroidism. Poor sleep hygiene or OSA. Anxiety or depression. Zebras like lupus, tuberculosis, malignancy, and narcolepsy.
Mental, emotional, and spiritual tiredness have a similarly broad differential diagnosis. Ruminating on problems that don't have solutions. Beating myself up, self-flagellation, and telling myself that I'm not good enough. Wishing other people were different or behaved differently. Fretting over the state of the world. Not deciding to decide, allowing decisions that need to be made to linger and stagnate. Arguing with reality. I can't measure the calories burned by these activities, but I intuitively know they are processes that use energy. This is what happens when we feel like we ran all day but can’t pinpoint anything that got done. The days you have so much decision fatigue that you'd rather go to bed starving than decide what to have for dinner. There were no marathons run, life-altering decisions made, holy-unbelievable monkey wrenches encountered, or life-threatening hemorrhages to be managed. But you’re still exhausted. There’s no objective biomarker for mental, emotional, and spiritual fatigue, but if you find yourself reading this and thinking, “This resonates,” you already know how to identify it.
I’d be remiss and a traitor to the medical profession if I didn’t point out that it’d be prudent to rule out physical sources of fatigue before we start working on fixing non-medical sources of fatigue. When been evaluated to the point that you’re satisfied your tiredness does not have a physiologic etiology, it’s time to look for the etiology of non-physical fatigue. Once you become aware that you may be mentally, emotionally, or spiritually tired, your brain is primed to seek reasons for that feeling. You’ll notice previously-unconscious thoughts like, "OMG, I can't believe I'm having this conversation again," or, "Holy crap, you really screwed that up. Everybody's going to figure out you're an idiot now," or, “Ugh, I cannot even start to decide whether to leave my marriage/go no-contact with my sibling/change my kid’s school” or “shoulding” yourself to death (“I should be a better teacher/a more-present parent/further along in my promotion trajectory”).
Want to know what I've been so tired about lately? I've been trying to read my spouse’s mind. If I'm honest, I've been trying to read his mind nearly constantly since April. Despite all that effort and time, I still have no clue what he's thinking. (And I refuse to ask him what he's thinking because I don't want to be "that girl.") So, I’ve been exhausting myself trying to do something that’s impossible, all while deliberately choosing not to do something rational about it. Talk about a complete and total waste of energy.
Now that I’ve diagnosed the etiology of my fatigue, I can get to work correcting it. I can notice when I’m trying to read his mind and then remind myself, “Babe. This doesn’t work and just wears you out.” That little pep talk loosens the habit’s grip and lets it just kind of fall away. We can't expect to undo an unconscious process that has been occurring for months (or even years) in a single instance of a single exercise. But that one exercise, repeated deliberately and gently with curiosity and self-compassion, is where we begin to rebuild our energy. That's when we start to be able to answer the question, "How are you?" with something other than, "I'm just so tired."