What Happens When an Expert in Burnout is…Burnt Out?

I haven’t written in two weeks. Until recently, I have written every week for the last 29 months and have written through service weeks, day-to-night and back again shift work, international travel, and the death of a family member. So what could have happened that was so bad to get me out of the habit for two weeks straight? Life as an academic physician. 

In hindsight and by objective measures, the last two weeks don’t look like they should have been all that bad. A bunch of days straight on service, but certainly nothing I hadn’t done before. A few overnights in quick succession, but again, nothing out of the ordinary. Meetings, always meetings, but none that involved life-and-death decisions. I’d ramped up a number of projects outside of my clinical time, but nothing I thought would be a big issue. My home life was clicking away as expected, no monkey wrenches there. I never felt ill outside of the middle-Tennessee “seasonal” allergies that are now, inexplicably, year-round. But as time went on, I felt myself getting more and more just…down. Not pushed down, but pulled down. The more I struggled, the stronger the downward pull became, and the faster I went under. Eventually, I stopped struggling and just focused on keeping my face towards the sky, rationing my mental, physical, and emotional energy while trying to remember to breathe. 

The three core components of burnout are:

• emotional exhaustion (check),

• depersonalization (not towards my patients, but very much towards my colleagues, as I felt myself getting super disconnected and distant from them), and

• reduced professional efficacy (the wins were very few and far between, and aggressively hard-fought before any remote feeling of “winning” occurred).   

Having found them all in myself, I knew it was only a matter of time before I slid into cynicism and victim mentality. Talk about a downward pull; when I’ve been there, it’s been weeks (months?) before I’ve been able to get myself out of it. Having just enough gas left in the tank to swerve, here are the moves I’m making:

1) Put aspirational behavior on the back burner and accept the minimum baseline from myself.

Minimum baselines are different for each of us, but to orient around the task, let’s define it as “the least amount of anything required to function safely, play by the rules, or keep something moving forward.” For me, this means showing up for my shifts, attending meetings that directly and acutely impact me, and completing tasks that put someone else at a significant disadvantage if I don’t. Everything else waits. I review the manuscript a fellow needs to meet their graduation requirements, but I review the literature search for my own project that has no deadlines yet. I make sure my partner’s prescriptions are refilled, but I don’t volunteer to help him make dinner. I round, but I defer doing any complicated bedside teaching. Some people put exercise in their minimum baselines; I do not. Some people put ounces of water to drink or healthy foods to consume, but I don’t really have to. (I’ve always liked drinking water, and my GLP-1 makes it massively easier for me to eat well. A little bit of luck, a little bit of better living through chemistry.) Take a couple of minutes and decide, right now, what your minimum baseline is. Once you know it, you don’t have to flail as much when you find you need to enact it. This is not selfish behavior; it’s self-preservation.

2) “What am I trying to control that is not mine to control?”

When I’m burned out, I get very grippy. I try to control everything because I implicitly believe that if everything is going to my exact specifications, then I won’t burn out. Sounds reasonable, but it does not work in practice. The reality is, other people are simply not controllable. (Not without sedation and neuromuscular blockade, anyway.) I am in systems over which I have no agency to control; forget about the desire and/or bandwidth to do so. It typically comes from a good place, but trying to control things beyond our control is a colossal waste of time and a massive energy suck. Traffic to and from work? I did everything I could to not get stuck, but I am anyway, so lean out of the road rage and into the podcast I’m listening to. Patients’ families having big emotions? Turn on my empathetic listening and turn off my reflex to “fix.” Frustrating general state of healthcare? I’m at my minimum baseline, that’s not mine to figure out right now. Maddening general state of the world? I’m just going to forgo checking the news for a few days. What are you unable to control despite your best efforts? How’s that going for you? Make peace with it, acknowledge that everybody involved is truly doing their best, and move the eff on.

3) Find a break within the next 6 weeks (and if you can’t find one, make one)

I’ve found that 6 weeks is about the limit through which I can white-knuckle my way through something unpleasant, yet close enough on the horizon that I can be excited about something. I’ve also found a weekend to be a completely inadequate break when I’m crispy, but four days can get me back right around if I’m intentional about them. If you have a spot on your calendar that’s already free of obligations, block it off so nothing else sneaks in. That’s your time to decompress, come back to the human being practicing medicine that you know you can be when you’re at your best. If you can’t find those “at least four days within the next 6 weeks,” make them. Move obligations around and delegate tasks that don’t require you specifically (or even offload the early steps so you can set yourself up to finish it sooner/easier/better when you get back to it). Don’t worry about disappointing people: “I’m sorry, I need to move this thing I’ve already agreed to,” is not nearly as big a deal as we make it out to be. Better to do that than show up to the thing you’ve agreed to do even more burnt out, maybe resenting the person you’re meeting with because they’ve “made you” do this thing. (Newsflash, they’re not “making you” do anything, because, again, people are not controllable without sedation and neuromuscular blockade. You don’t actually “have to” do a single solitary thing you don’t want to do. Even if you agreed to do it and then changed your mind. If you do, it’s because you’re “making” yourself do it, not the other way around.) If you’re extremely burnt out, you’ll need a longer break. Don’t fight it (because fighting things is what’s gotten you here in the first place, and look at how well that’s working), just stop arguing with reality and take the time away. Use FMLA if you have to; that’s what it’s there for.

4) Resist the urge for dramatics

I can get very Chicken Little when I’m burned out. Everything is awful. I’m never going to get out of it, and I’ll always feel disconnected, twitchy, and ungrateful. And my favorite thing is when my brain goes, “Your performance is going to suffer, you’ll get fired, Mo will divorce you, and you’re going to end up homeless under a bridge.” I don’t know why my brain always goes to me being homeless and under a bridge, but here we are. When burned out, dramatics, like trying to control the uncontrollable, are a colossal waste of time and a massive energy suck. I think they’re also a way of arguing with reality: “How can I be burned out when I have all this capacity for wailing, gnashing of teeth, and ruminating incessantly?!” The other thing I’ve found about drama is that it typically coincides with avictim mentality. And if there’s a victim, there’s a villain. Be that villain work, patients, patients’ families, your own family, or someone else out in the world, that’s an awful lot of power to give something that you’re so furious with. What’s your go-to drama? “I have to do everything around here,” or “All of this is so unfair.” Catch it, recognize it for what it is, and get to your minimum baseline. Absolutely no one’s minimum baseline has space for dramatics. 

After the reset, I start testing my resilience by adding things back to my routine a few at a time. I start with things that I know will be easy: teaching on rounds, attending didactics, and walking on my treadmill while working from home. Once the easy things are going well, I pick up the things that require more mental energy, more creativity, and a greater commitment. And before I know it, I’m back to myself. 

An amazing colleague who is retiring imminently reflected in a lecture I attended that over her long time in medicine, she’s never been burnt out. That’s remarkable. And very respectable. But I suspect she’s a unicorn, some combination of a career that is deeply aligned with her personal values and a personality that has a level of “steady in a storm” that has allowed her to weather the changes in patients, patient care, and the world at large over the decades of her career. I think she’s on the “good” tail of the bell curve, the physician who retires deeply gratified with her work, and proud of the impact she’s made. I also think there are people on the “bad” tail of the bell curve, those who are burned out from the day they start their careers until the day they end them. Most of us are somewhere on the bell curve. (Because, you know, statistics) I think I’m getting closer to the “good” tail, with my last period of burn out being years ago, and this one being recognized early and dealt with swiftly. It’s not a bad place to be, my spot on the curve. Come, join me.