Read an Excerpt
CHAPTER 1
IN THE BEGINNING
"In the middle of the road of my life I awoke in the dark wood where the true way was wholly lost."
Dante, The Divine Comedy
"I hate my job," I said. Sitting in the doctor's lounge across from my friend, I could hardly face him. "I just can't do it anymore. I can't go back."
"Isn't there anything you like about your job?"
I shook my head. "No," I replied, my voice breaking. "Nothing at all." I couldn't find the right words to tell him how bad things had gotten, how hopeless I felt. I no longer had the energy for my work. Cynicism had taken over my thinking.
Admitting it out loud showed me just how far I'd fallen into the dark crevasse of professional burnout. Though I had served the Puyallup Tribal Health Authority for nearly twenty years, first as a physician and more recently as medical director, I felt completely lost. I'd even begun to consider leaving medicine and giving up on the profession I loved. Could I ever escape the unending disappointment and frustration of my work? It seemed I'd been swallowed up by hopelessness.
But I hadn't always felt like that.
Twenty years before this surprising confession, I'd taken my fi rst post-residency job as a family practice physician serving Native Americans in Tacoma, Washington. I'd begun that work full of passion, determined to make a significant difference for this underserved population. In my youthful exuberance, I expected to heal every patient and to be loved and appreciated by everyone. Instead, I encountered a population struggling with all the disadvantages of poverty and marginalization. Many suffered from the physical, social, and emotional consequences of addictive disease. Making matters worse, the staff at our medical clinic seemed to arrive and depart via some invisible merry-go-round.
In my first ten years at the clinic, I had seventeen different fellow medical providers in our two physician operation.
Early on, I discovered that a tribal medical clinic is a bit like a small town. Tribal politics frequently affected organizational and clinical decisions. Supervising the medical staff required that I correct or dismiss nonperforming employees — something outside of my training and comfort zone. The work in our clinic was both emotionally and physically demanding. During those difficult years, I remember one month when I delivered eighteen babies. Early mornings, late nights, and frequent all-nighters left me chronically exhausted. But what I felt was more than physical exhaustion.
This situation of political and staff upheaval, combined with demanding and difficult patients, left me feeling fed up and frustrated. At the same time, I was exhausted, used up, empty, and hollow. I'd lost all sense of joy in my work. I had no resiliency, and I was no longer able to cope with unexpected challenges or difficulties. I had become so cynical that I no longer approached most problems in a productive way.
And then, quite suddenly, I realized that I'd begun resenting certain patients. Though I didn't feel this way about all of them, whenever a particularly difficult patient appeared on my appointment schedule, I dreaded the encounter, feeling resentful of my patient's chronic complaints, dissatisfaction, and manipulative behavior.
I just didn't want to take care of those people anymore.
Recognizing my own antipathy somehow shook me awake. It was as if by feeling this way toward my own patients, I'd crossed some invisible and unforgivable moral line. After all, I'd studied medicine in the hope that I might help suffering people. How could I have sunk so far? Overwhelmed with guilt about my attitude, my frustration mounted. At the end of the day, I had no sense of accomplishment and no job satisfaction. After a day of watching the clock, it was everything I could do to crawl back into my car and drive home.
Desperate, I tried to reverse the situation myself. Believing I suffered from fatigue, I took time off. I planned longer vacations. On weekends, I played hard — as if by wild activity I might recover my lost sense of joy and purpose. I used my time off as a way of recovering lost opportunity and lost exuberance. I coached basketball, went skiing, and spent time with my kids. I kayaked, hiked, and went camping. Those efforts, frantic as they were, made no real difference. Every Monday, I returned to work in the same condition I'd left — dreading every minute of the day ahead.
One afternoon while sitting at my desk in a common work area, a premed student came in to interview our medical staff. He approached my colleague's desk first, asking a simple question: "If you had to do it over again, would you choose to become a doctor?"
Without hesitation, the other physician replied, "No. I'd become a high school teacher and coach basketball."
Eavesdropping, I wondered how I would answer the same question. If I could go back and do it all again, would I choose medicine? What other career appealed to me?
In an instant, I knew I would choose medicine — regardless of how deeply disillusioned I'd become. When I am at my best, there is nothing quite like the work I do. When I connect with my patients, solve problems, and make a difference in outcomes, my profession provides enormous joy. Even at my lowest point, I recognized that no other work would ever satisfy me in quite the same way. At one time I'd loved my vocation, though somewhere I'd lost that sense of fulfillment. Listening to the student interview my colleague, I realized I had to find some way to turn myself around.
In the many years since that low point, my life has radically changed. I have recovered my youthful enthusiasm for the practice of medicine. But before I share the details of my recovery process, it might be helpful to explore some characteristics of burnout. See if you identify yourself in any of the symptoms or emotions described below. Have you lost your sense of professional balance or compassion? Do you find yourself with symptoms similar to depression? Has your professional malaise begun to creep into your personal life? As we explore burnout, you may feel as if you are wallowing in symptoms with which you are already far too familiar. I understand. If you need to, skip ahead to the section in chapter two titled "The End of the Beginning." There you will find the beginning of my journey beyond the misery of burnout.
CHARACTERISTICS OF BURNOUT
Burnout is often characterized by a profound loss of joy. In that way, it can be similar to depression. For some, it feels like all energy, resiliency, and satisfaction are gone from work. For others, burnout has the potential to become all-encompassing — to follow its victim home, affecting his home life, his intimate relationships, and even his physical body. For many, the symptoms of burnout remain confined to the workplace.
The medical field is especially prone to burnout, with some sources reporting burnout in one out of three health-care providers. Physicians are even more susceptible. According to Bloomberg News (August 20, 2013), one in two doctors report being burned out, showing signs of emotional exhaustion and little interest in work. According to the Archives of Internal Medicine, doctors working in emergency, family, and internal medicine are the most likely to report burnout. Though research indicates that nearly 40 percent of physicians work more than sixty hours per week, burnout is more than physical exhaustion. Burnout involves mental and emotional struggles as well. The disillusionment of burnout is so prevalent that one survey discovered that nine out of ten doctors would not recommend their profession to young people considering medicine as a career.
Of course, burnout is not limited to those in the health care professions. If you are experiencing burnout, you are not alone. As early as 1969, researchers began investigating burnout in a variety of human service professions, including health care, social work, education, and public safety. Not surprising they found that members of all these groups also struggle with the reality of burnout.
But what actually constitutes burnout?
Burnout is more than a stress-filled day. Rather, burnout is caused by experiencing persistent work-related stress day after day after day. Over time, the effects of this strain may cause a whole collection of symptoms that, when taken together, create the syndrome we describe as burnout. The severity of these symptoms varies widely. Not everyone is completely incapacitated by them. Most professionals experiencing burnout continue to have good days and bad days. However, as difficult experiences and stressors accumulate, people may find themselves spending more and more time battling burnout's unpleasant effects. Following are some of the common characteristics:
Exhaustion. Though burnout is frequently considered simple physical exhaustion, it is also characterized by persistent mental and emotional depletion. These symptoms, including sadness, depression, negativism, and cynicism, may coexist as well. More subtle symptoms include the loss of creativity, which inhibits innovative problem-solving. The burned-out professional is less able to cope with difficult situations because mental and emotional exhaustion inhibit the creative thinking that helps one discover solutions to presenting difficulties. By itself, exhaustion has the power to magnify the symptoms of burnout, creating a kind of downward spiral of negative emotions and hopelessness.
Detachment. One important emotional symptom of burnout is the loss of empathy. Put simply, providers of all kinds — police officers, social workers, medical providers, and teachers — simply stop being able to connect deeply and care about the people they serve. Without that concern, the burned-out employee frequently pulls away from the very relationships that make for a rewarding work life. In the case of medical workers, this includes retreating from patient interactions, which undermines the most important aspect of the doctor-patient relationship — the ability to listen to and understand the patient's difficulty. Some experts believe that by pulling away, the medical provider actually loses a key tool in patient care.
Dr. Gregory Fricchione (author of Compassion and Healing in Medicine and Society and former chief of psychiatry at Massachusetts General) explains the idea this way: "Empathy is like a powerful drug. It has the ability to change a patient's neurochemical ecology. If you do nothing more for your patient than to listen and care for them, though it seems small, that empathy can begin the healing process."
Though we may not admit it, medical providers frequently consider it naïve or unprofessional to be compassionate toward those we treat. Instructors and mentors in the medical professions still encourage students not to become too close to their patients. This so-called healthy distance is believed to create an objective perspective for the medical professional. However, the loss of compassion and empathy can be costly both to the patient (in terms of quality of care) and to the provider (in terms of fulfillment).
Cynicism. In the academic world, where research is dissected and critiqued with great enthusiasm, it is considered suave and sophisticated to be highly skeptical. Because medical training involves a strong focus on science and research, we approach all treatment options with a healthy dose of cynicism. We believe in and practice evidence-based medicine. Our mantra, "prove it," helps us to separate folk medicine from effective and reproducible science-based treatment. We drum scientific doubt into our medical students, elevating the attribute of skepticism to heroic proportions. As medical training progresses, professional cynicism frequently grows along with it.
Unfortunately, in the burned-out physician, that same cynicism becomes an all-consuming sentiment, pervading the doctor-patient relationship. Eventually, the burned-out provider begins to doubt or mistrust his patient's reports of pain, the history of symptoms, or his assessment of treatment results. Filtering all patient communication through the eye of detachment, cynicism and disbelief has another important, though subtle effect. These emotions and accompanying cynicism have the potential to leave the physician angry and defensive. Rather than solving problems, the burned-out physician is simply angry about having problems. When cynicism replaces trust, we can no longer provide adequate care.
During my worst days of burnout, one patient interaction stands out in my memory. I was with a woman whose adult son had recently died of a drug overdose. As this heartbroken mother sobbed through our interaction, I thought to myself, I've gotta get out of here. I have two rooms full of waiting patients.
As she cried, I found myself wondering, What on earth did she think would happen? The kid was shooting heroin! Instead of identifying with her grief, expressing my concern, and helping her move forward, I felt angry that she had come to me at all. My self-centered response and lack of compassion shocked me.
Loss of job satisfaction. Dr. Ray Baker, associate clinical professor at the University of British Columbia Medical School in Vancouver, Canada, and a specialist in addiction medicine, suffered his own severe burnout. As he tells it, one cool autumn afternoon, with his waiting room packed and his exam rooms full, he quietly slipped out the back door of his clinic! He had begun self-medicating his burnout with alcohol.
Dr. Baker isn't alone. Burnout is a prime factor in employee absenteeism and turnover. After a huge financial investment and many years of training, burnout has the power to put successful careers at risk. It may also contribute to the prevalent overuse of narcotics (leading to drug addiction) and alcoholism. Burnout may even contribute to suicide. According to the Association of American Medical Colleges, Sept. 2016, physician suicide may be anywhere from 40 to 70 percent higher in males and as much as 300 percent higher in females compared to the suicide rates of those in nonmedical professions.
The news about burnout can be discouraging, even dismal, but there is hope. Burnout can actually trigger revitalization.
It gives us an opportunity to take a closer look at how we choose to live life. Thanks to burnout, some choose another way to pursue the careers they once loved. Burnout led Dr. Baker to his passion for occupational addiction medicine. Burnout led me to the most fruitful and rewarding work of my life.
It still surprises me that the answers I discovered during my journey have changed the lives of so many. Burnout may do the same for you. Your path to recovery may reward you with new direction, renewing your old joy and passion for the very work you had come to dread.
OTHER WAYS TO DESCRIBE BURNOUT
Most experts agree that burnout is characterized by exhaustion, detachment, cynicism, and loss of satisfaction. But are there other ways of viewing the burnout experience? Do other views clarify issues which demand our attention? The following descriptions of burnout may help us recognize other factors present in our condition:
Burnout as a grief syndrome. Like me, many in the helping professions — medicine, social work, public safety, and teaching — begin their careers with a profoundly idealistic viewpoint. As they prepare for these professions, many students begin with a strong vision of their professional futures. They believe they will successfully help the people they serve, that they will be effective, and that they will make a significant difference in the world. However, once they begin their careers, the real world, full of human frailty and error, frustration and failure, leaves them disappointed at best and despairing at worst. The discrepancy between expectation and reality leaves many professionals with a deep sense of loss. According to the grief syndrome viewpoint, grief — or sadness and disappointment — arises from the death of those treasured expectations.
At one of my presentations, I was privileged to meet a young pediatrician experiencing this kind of grief. After my talk, she introduced herself with this dramatic statement: "I hate my job." She explained that the intense pressure of rushing through multiple patient interactions was nothing like the work she had visualized during her training. Her current frustration was complicated by the obligations created by her medical education.
"I can't quit," she explained. "I'm trapped. I've invested years of my life in training. I still have student loans. My family sacrificed so much for my education. There's no way out."
(Continues…)
Excerpted from "Life Beyond Burnout"
by .
Copyright © 2018 Alan Shelton, M.D., M.P.H. with Bette Nordberg, BSPT, RPT.
Excerpted by permission of Balboa Press.
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