Introduction
When Steve Hyman, MD, from Nashville, Tennessee, looks back, he doesn't like the person he used to be."I was a lot meaner then," says Hyman, an anesthesiologist. "I was a lot less tolerant. I had a chronic depression and I didn't know what the problem was." Attributing his malaise to his workplace, he switched practices. It didn't help.
Today Dr. Hyman happily splits his time between medicine and music. Three days a week he is in the operating room. The rest of the time he is a concert pianist performing recitals and playing with regional orchestras.
Dr. Hyman wasn't able to avoid burnout, but he was fortunate to find a way out of the abyss. It's something that other doctors can do as well.
Burnout: "A Loss of Ideals and Hope"
Stress and burnout are often lumped together, but they are distinct processes.
Unlike stress, which is associated with overengagement, burnout is characterized by disengagement, blunted emotions, depression, exhaustion that affects motivation and drive, and demoralization.
Stress produces a sense of urgency and hyperactivity.
Burnout produces a sense of helplessness and hopelessness.
Archibald Hart, PhD, psychologist, author, and Dean Emeritus of the Fuller Theological Seminary School of Psychology in Pasadena, California, noted that "Burnout can best be understood as a loss of ideals and hope."
Stress is omnipresent. Underwater mortgages, the economy, job losses, and the mundane stressors of daily living affect many people. Every industry has its own cache of challenges. Doctors may have to contend with healthcare reform, EMRs, reduced rates, medical school loans, and pressure to see more patients.
What puts physicians at greater risk for burnout isn't necessarily the work-a-day stresses they face but the nature of their role as caregivers, says Neelum Aggarwal, MD, a Chicago neurologist who frequently lectures on stress and burnout. "We have to interact with many people many times a day," she says, "and the element of having to provide care for someone -- the personal responsibility for someone else's health -- that's an unconscious element that feeds into everything."
It's a role that many physicians -- unlike professionals in most other fields -- internalize, notes John-Henry Pfifferling, PhD, director of the Center for Professional Well-Being in Durham, North Carolina. "The greatest risk for burnout comes when the doctor identifies being a doctor as who they are."
"Delayed Gratification" Puts Doctors at Risk
Part of the problem, Dr. Aggarwal says, is that doctors are in constant motion. They're also very purposeful and, thanks to their protracted medical training, masters when it comes to delayed gratification.Those qualities, especially if they're mixed with characteristics such as perfectionism, conscientiousness, a need to be in control, and difficulty relaxing, can put physicians at risk, she says.
"When you are always doing, you can't step back and see the big picture," she says. "Often people know something is wrong. They sense it. But the way they try to work through it is, 'Maybe I'm not productive enough or efficient enough' and they go back and try to do more. Figuring out what's wrong really requires stepping back."
The workplace often exacerbates the problem. It's not just long work hours, demanding post call schedules, and administrative demands, notes Pfifferling.
Physicians aren't taught how to work in teams and support each other, and there's a stigma associated with reaching out for help.
What's more, although they're very good about preaching self-care to their patients, they often don't internalize those messages.
"When I talk about burnout I used to start with the medical aspects -- diet and exercise -- for preventing it," says Dr. Aggarwal. "But I realized that just put them back into 'doing' mode.
Now I start with, 'You have to learn to sit and be at peace with yourself.' That hits home with people because most doctors can't just sit quietly."
Dr. Aggarwal herself spends an hour in quiet each morning. Quiet sitting might involve meditation, inspirational reading, listening to relaxing music, or just doing nothing, she says, and it's a skill that doctors need to master before they can move on to more active tactics for combating burnout, such as breathing exercises, walking, improving their diet and -- most important -- adding joyful pursuits back into their lives.
The Importance of Meaningful Pursuits
In February 2008 LocumTenens.com asked 1200 physicians how they avoid burnout.The answer: They aren't couch potatoes. Respondents listed participating in sports, travel, and outdoor activities as their top 3 burnout busters .
Many mentioned volunteer and humanitarian commitments as well.
A recent posting on the Medscape discussion board posed the same question. "Exercise every day," advised one physician. "I'm not a gym rat or fitness freak. I'm just talking about a 20-minute walk. Leave the cell phone at home." Another advised, "Buy a small vacation house in Sarasota and go there for 5 days every 4-6 weeks. I did, starting 4 years ago before I sold my practice, and I came back refreshed and recharged."
Diet, exercise, and rest are important components to health, but wellness is a holistic pursuit with physical, emotional, psychological, and spiritual components.
Physicians need to remember -- or discover -- what brings them joy and fulfillment. It might be making dinner with family or friends, listening to music, bowling, traveling, volunteering, or participating in spiritual or religious activities. Whatever pastime they find fulfilling, Dr. Aggarwal says, doctors need to purposefully reintroduce it into their lives.
As easy as it sounds, it can be very difficult to break out of the cycle of perpetual motion, Dr. Hyman says.
"When you have a really strong work ethic and take time off for yourself, you feel guilty about the free time. It takes you a while to get over that," he says. It was only when he brought music back into his life that he was able to accept and embrace the difference between "what I want to be doing and what I do for a living."
Although it definitely falls in the "doing" category, finding a long-term way to deal with burnout means addressing workplace issues as well, says Gabriela Cora, MD, a psychiatrist and author of Leading Under Pressure: Strategies to Avoid Burnout, Increase Energy, and Improve Your Well-Being. That means finding a way to take control over your environment and workload and learning to say "no."
"Don't just look at yourself," she advises, "Look at your practice. Is your nurse practitioner or your office manager stressed out? Look at your turnover. What's the mood? Burnout often happens when there is a lack of processes but also a lack of lifestyle balance. You need a combination of organizational skills and lifestyle strategy to tackle it."
The Cost of Stoicism
Finally, Dr. Hyman says, doctors need to understand that in ignoring the symptoms of burnout, they aren't being stoic; rather, they are doing a disservice to themselves, to the people around them, and to their patients."In the field of medicine, particularly for people who trained 20 or 30 years ago, the mindset was that you really needed to forego everything to practice medicine. But when you feel so bad about yourself and your workplace, to go there and be cheerful and give 100% is very difficult," he says.
Fortunately, he says, that's not a problem for him anymore.
"Now when I go to work I'm ready to be there. I like my work and I do a really good job. I don't think the fact that I have other interests and that I don't love my work makes me a bad physician. It doesn't make me less empathetic to my patients. You have to take care of yourself."
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