Why are doctors burning out and what can we do about it?
First and foremost I need to preface this with the fact that the reasons that anyone burns out are nuanced and personal. But there are also some widely accepted (source) general precipitants to occupational burn out such as:
Now let’s look at these specifically in relation to both hospital and community medicine.
1. Dysfunctional workplace dynamics
At last count there were 101 841 doctors in Australia, of those just over 95% work mainly in clinical medicine (source). Clinical medicine consists of a variety of inpatient, outpatient, hospital and community settings. Clinical medicine is the interface between doctor and patient. The one thing that these doctors have in common is that within all of these clinical settings, they are largely beholden to the assorted guidelines, procedures and pathways that each health service implements.
In a resource limited system like the Australian public health system, these guidelines and policies ensure as fair and as equitable access to finite beds and care as is humanly possible. As doctors, our heart often breaks having to watch our patients suffer from extended wait times or difficulties accessing care. Us not being able to change it, doesn’t mean we don’t care. Any of us who have worked in clinical medicine (whether doctor, nurse, allied health or even patient administration) know how heartbreaking it is to not be able to do any more than we are doing. This constant stretching of resources and people to their limits can inevitably lead to fractures or animosity between colleagues or patients. We’re all doing our best, but sometimes it can feel like bailing water out of the Titanic.
2. A lack of job control
Of the over 100 000 registered doctors in Australia, 16 500 of these doctors are in a specialty training program (source). These training programs range in duration from 3-7+ years depending on speciality. While on these training programs, Registrars (as these trainee specialist doctors are known) are required to move across a wide variety of placements, ranging from within a specified state area to all over Australia and in the case of post graduate Fellowship training, sometimes the world, in order to meet their training requirements. Quite simply, they will go where ever their speciality college says they must go.
For many of our specialists-in-training, things like starting a family are put on hold due in large part to the transient and demanding nature of these training programs. And while the rigour of the Australian speciality colleges is to be commended, it must also be appreciated that as more of our doctors come through graduate entry medical programs, many more of our specialists-in-training will desire to be starting a family during their training programs. Our speciality colleges must move with these changes and adapt to afford our trainees a greater degree of autonomy in their training pathways.
Gaining fellowship of your chosen college does change this point enormously, however it is important not to negate the distress caused by this point on the lives of trainees.
3. Lack of social support
From the above point, you can appreciate that during this time of frequent moving and renewing of contracts, it is often difficult to put down roots. From having social supports, to gym memberships, to knowing where the best take away food is- moving every few months makes it very difficult to build a network of support around our specialists-in-training.
4. Unclear job expectations
I have learnt the hard way that this point does become easier with time. Statistics show that older doctors are less prone to burn out (source). Some postulate that this is because more experienced doctors are better able to appreciate what is within our control in medicine and what is outside of it. That the wisdom of years allows us to separate the ‘wheat from the chaff’ better and learn how to focus our energy more productively on that which we can control or change.
I would offer a secondary thought to this concept though and add that this is also partly due to the fact that medicine is such a hugely dynamic field. Things that I learnt at medical school are now completely redundant, medications are superseded at an alarming rate and there are diseases that I was taught were life long and incurable during my medical training that we can not only now manage but even cure. The sheer level of information needed to be kept up to date with in clinical medicine is astonishing. Couple this with the ever changing digital health landscape, keeping up with the advances of modern medicine is a tough task. Google X’s Astro Teller is quoted as saying to author Thomas Friedman that the rate of human adaptability is being superseded by technology and that we must “learn(ing) faster and govern(ing) smarter” in an attempt to catch up and keep up (source). Medicine is the perfect example of this.
5. Extremes of activity
It will come as no surprise to anyone that the working life of a doctor involves long and often unpredictable working hours. The allure of General Practice is often quoted as being “family friendly” or “better work hours” than other speciality training pathways and post fellowship lives. But the reality of private practice is that medicine involves many, many hours of work outside our ‘work hours’ regardless of what speciality you choose because often it is simply not practical (not possible) to ‘hand over a patient’ to someone else. In the hospitals, this shouldn’t be occurring however. The ability to hand over a patient and leave a shift on time in a hospital that is staffed 24hrs a day 7 days a week is something that we must protect for the juniors that come after us.
Unfortunately, this seems to not be a sentiment shared by many medical administration departments as shown by a current class action admirably launched by a collective of junior doctors fighting to be paid their fair overtime (source). This is something that as doctors we must all call out and enforce in order to protect our junior workforce from burn out when it is obvious from the previous and above points, that our trainees are shouldering the lions share of these known ‘burn out precipitant factors’ (most notable of which is the lack of job control and limited social support).
6. Work life imbalance
For most doctors, we have taken a path of 10-15 years of education post high school. For those years, education, work and other aligned commitments have been front and centre in our lives. We’ve literally conditioned ourselves to place work above all else.
Medicine is often spoken of as ‘not just a career but a calling’. As noble as this sounds, doctors are people just like the rest of us. There was not course at medical school that took the fleshy vulnerability of humanity away from us. We too need to strike a balance between taking care of others and taking care of ourselves. These two things however are not the dichotomy that they may initially appear to be. One of the fundamental concepts around my model of Basic Life Support Self Care™ is that in the same way we first check for danger in our clinical BLS algorithm, we must take care of ourselves in order to take the best care of our patients. Learning how to integrate authentic and holistic self care practices into our lives as clinicians is not self indulgent but is in fact paramount to being a good doctor.
Clearly there are huge systemic issues that contribute towards physician burnout. No doubt there are also individual factors at play, after all, despite the fact that I burned out, not everyone one of my colleagues will. I’m not offering an ‘either/or’ solution here. What I am suggesting is that there are a variety of things that each of us can do to mitigate feelings of burnout for ourselves as well as systemic issues and structures that as a collective we can begin to shine a light on.
Most importantly however, I want to say to others in my profession who are feeling burnt out or overwhelmed that I see you. I know what that feels like and that is exactly the reason that I started The Healers Health Collective. That right now I am just one person, but that my hope and dream is that this resource will grow and flourish and that one day I will be able to “be the change that I wish to see in the world” (Gandhi).
Blogging for me has been an interesting thing. It’s so easy to think that the thoughts I have and the problems I encounter are mine alone. To identify myself with them and define myself by them. To think that no one else in the world has these thoughts or problems.
Blogging has opened my eyes to the fact that this really isn’t true.
We share so much of our humanity with those around us, yet often we feel like we must keep those ‘uncomfortable human bits’ to ourselves. To project our best self forward only.
Thinking back on when I burnt out, I remember how I felt then.
Tired. So tired.
Depended on. Suffocated.
Yet, I was still functioning.
Outwardly at least, I was ‘good’. Perhaps slightly ‘stressed’, but ‘good’.
When in fact I didn’t even know how ‘not good’ I was.
I remember saying at the time that I felt like my “doctor light globe had gone out”.
I was still happy at home as a wife and mother, but my fuse was shorter.
I wasn’t depressed, but my sleep was affected. I would wake most nights in the early hours and lie there, unable to get back to sleep. But I was productive in those early morning hours. Ever the lark, I got work done to maximise my bodies inability to hold onto the fitful slumber of those cold moments pre-dawn before my household and the world awoke.
I had started a new business. I had done all the branding and marketing myself. The website a shining example of my early morning exploits.
My body’s subtle calls to slow down and find balance were duly noted.
I threw the full force of over a decade of personal mindfulness practice to bringing mindful awareness to myself and what in hindsight was my impending burn out.
I practiced gratitude and self compassion.
I practiced my beloved yoga. In fact, ever the Type A person I was, I was in the process of undertaking a full 200hr Yoga Teacher Training. So yoga too had become a ‘job’ to me.
I ate well, I went to bed early (to counteract the 3am wakefulness).
I saw a psychologist.
I did everything that I told my patients to do when they found themselves in these difficult times.
But I still burnt out.
In the time since then, I’ve been blessed to be able to spend a lot of time in reflection on this. I’ve also been graciously supported through an intense period of personal growth and discovery by my husband and family. I feel like I have a better understanding of the stones that paved the path towards burn out for me.
This is of course only my path.
Perhaps others may find a stone or two common with their own and find these reflections helpful?
But here are some of the things that I have learned by walking this path to burn out and back again.
That a step back is often infinitely harder to make than a step forward in life.
Life has a certain inertia to it. Each day rolls around, as the seasons change, the world keeps turning. Life keeps moving on.
Even in the most untenable situations there is still momentum to time alone.
In choosing to take a step back from work, socialising, the online world, what ever it is we are considering taking a step back from, we are innately aware that these ‘worlds’ keep going without us. Nothing is on pause.
Stepping forward, in whatever capacity we can, continues to indulge us in the idea that we are ‘keeping up’.
Stepping back (or even sideways) involves the reality of falling behind.
Now I know that this isn’t a bad thing. Logically, we ALL know that this isn’t a bad thing. But I want you to think about the last time you turned down an opportunity or opted to take a leave of absence. How did you feel?
For most of us, the FOMO is strong!
And when we inevitably return to our own forward path in life, we are acutely aware of the momentum we feel we’ve missed.
Again, this is not a bad thing. Simply my own observation as to how I felt pre ‘stepping back’. That sometimes continuing to do something, even if we know it is bad for us, seems easier than making a change.
There is a threshold at which my brain functions optimally.
When I stress my operating system above that threshold, all functions tend to suffer. I and I alone am the one who knows where that limit is and therefore I and I alone am the one who must honour that limit.
That flattery of the Ego will often cause us to go beyond what we know we are capable of.
Is this a good thing or a bad thing? I guess it depends how much point 2) affects you or not?
That the thing that hooks our Ego in the first place, often begins to harm our Ego when we use it as an excuse to go beyond our optimal functioning limits.
For example, for me as a doctor it was helping people, a noble cause for sure. But when it became something that I allowed myself to make excuses for continuing to cause stress to my body as I watched it crumble around me, it was in fact merely a ‘hook’ that kept my Ego in the game. Helping people isn’t something you do as you’re drowning, that’s ‘saving’ people. And when your Ego is in the game, it becomes less about helping and more about saving and being a saviour.
Think about it, there’s got to be something valuable on the table to keep playing as you watch your world falling apart around you.
Now this was an uncomfortable truth for me to learn. My Ego story made it very easy for me to talk myself out of this fact. The praise and adulation of those around me made it even easier. But the more I made friends with my own Ego, seeing it not as a ‘bad’ thing but simply a construct that I had built around me over time. A reflection of the stories the world had told me and that I had absorbed about myself.
I was a ‘good person’.
I was smart.
I was a helper.
I could put aside my own needs for the needs of others.
As I began to see my own Ego as a small child in want and need of protection and affection. I saw that this steadfast push beyond even what I knew I was capable of at the time was not in fact ‘personal growth’, it was survival. Survival of an Ego and a person simply doing their best.
And this brings me to my final point.
No amount of mindfulness or yoga can outweigh a lack of self awareness.
Self awareness is about knowing when to say ‘no’ more than it is about knowing when to say ‘yes’.
It is about learning where that ‘optimal functioning point’ is for your brain and respecting it. Not about never going beyond it (after all that is where we are able to grow) but more about bringing mindful awareness to when you are existing at your growth edges. Being in control of that time. Knowing when to pull the throttle and when to hit the brakes.
It is about making friends with your Ego. I mean true, laugh until you wet your pants kind of friends with your Ego. About seeing your Ego with the most compassionate of eyes and thanking it for always being there to protect you when the chips were down. About loving it and then carefully strapping it into the back seat so your True Self can take over from now on.
Awareness of the Self is about knowing that we are beautiful, dynamic and complex creatures who need to commit to a daily practice of exploration and compassion as we move and grow over time.
Like I said, this story is not all burn out stories. It is just mine.
It is however, a road I walk with many other travellers and I’m sure there is a step or two we may walk together on.
This post was also published on Whole Hearted Medicine, an organisation run by doctors and offering self care retreats specifically for doctors.
Call it 'Imposter Syndrome', call it self doubt. It doesn't really matter what name you give it, most of us feel it to some extent at some point in our lives.
Medicine is full of high achieving individuals often with perfectionistic traits. Why wouldn't it be? People's lives fall into our hands every day. This sort of precious cargo demands as close to perfection as possible.
As a patient, I completely get it. I want a 'perfect' doctor. Who doesn't??
As a patient, I also benefit from this collective of immense knowledge and dedication.
As a doctor, I demand 'perfection' from myself.
Yet, as a human being, I understand that no one is perfect.
How can I reconcile these facts?
This tends to be where self doubt creeps in.
We set the bar at perfection and berate ourselves if we ever fall even a millimetre short.
We see our colleagues with more compassionate eyes than we see ourselves.
We put ourselves or our family members in our patients shoes and understand the need for attention to detail, for the constant striving for perfection.
Imposter Syndrome or pervasive self doubt is the natural consequence of this constant self flagellation.
Mindfulness teaches us that we can be an observer to our thoughts.
That we can watch that stream of berating thoughts and self doubt as they come to us just as we might watch a train pulling into a station. That we can choose to step back and not engage, to not 'hop on' the train as it takes us on a journey to Imposter Syndrome Station.
Self compassion comes when we gain this ability to disengage with our thoughts.
Mindful self awareness is a state of mind in which the default mode of the brain is set to compassion. Compassion for ourselves and compassion for others. This comes from practice. Whether it be a daily meditation practice, regular prayer or even informal mindfulness cultivation. The key is consistency.
When we begin to see the goal of perfection not as some unattainable star, always seemingly out of our reach but rather the balance to our own practice of self compassion- we can see that striving for perfection isn't in fact a linear path along a spectrum but rather a constant state of being.
Sustainable, but only when in balance with our practice of self compassion.
by Dr Emily Amos
This is an excerpt from a blog post that was originally published on my website about 18 months ago.
I am a good doctor, an empathetic doctor. The sort who listens intently to you and tries to reflect back what I've heard you say with a mixture of comprehension and gentle advice. I've spent the last 15 years either training towards or being a doctor. But right now, I am a doctor who feels jaded and empty. Like the 'doctor' light globe inside me has gone out. The weighty responsibility of trying to help people in their darkest hours finally causing my legs to buckle under me. An unfamiliar mixture of panic and despair stopping my whole being from even getting out the door to go into work. To a job I am good at. A job that helps people. A job that (outwardly at least) appears so fulfilling. So why do I feel like this?
This was only a few short weeks after I had stopped work. Little did I know it then, but there was an immense journey ahead of me. A journey that in some ways I think I'll always be on. This path of life that we all walk, I now walk more intentionally. No longer swept just onto the 'treadmill'.
Some people are fortunate to have the self awareness to have always been on this intentional path. Yet for many of us, this path is in fact a treadmill. A moving conveyer belt on which we feel sometimes passively shifted along. The 'Medical Treadmill' has such inertia from school, to medical school, to internship, residency, unaccredited positions, being a junior reg, senior registrar, fellowship and eventually consultant. Don't get me wrong, there are huge life decisions to be made in that time.
"Which college do I want to join?"
"Will I have any say into where I go?"
"When will I have time to have a family?"
Ultimately however, this process does tend to move along in a fairly linear pattern. Unless we are forced to or choose to step off.
What do we say to our colleagues who express a desire to 'step off' the treadmill at any point? Whether for a short break or even forever?
I experienced a lot of well intentioned encouragement not to do that.
That I would have to work too hard to "get back". Or that I would "miss opportunities". That it would be a "waste of my skills".
The dialogue here is really important I think.
As it turned out, I ended up needing to 'step off' for a while anyway. Perhaps I could have done this in a more intentional way sooner? Perhaps not.
For me personally, I am immensely grateful for the journey I have been on as a result of the last couple of years and my 'burning out'. That doorway I felt myself standing in all that time ago was in fact this doorway into working to support the wellness of the healthcare workforce. Healing the healers. Caring for the carers.
I am excited and hopeful for the future.
If you are feeling swept up on the medical treadmill, passively shuttled through your professional life towards some seemingly far off goal, I'd encourage you to try and familiarise yourself with the concepts of mindfulness.
Of self compassion.
Self awareness comes as we take our consciousness inwards to become more familiar with our own internal environment rather than only focussing on those things outside of ourselves and our control.
Sometimes it involves some time "off the treadmill" for self reflection. And that is OK.
Sometimes it involves staying "on the treadmill" but building a support structure around you so that you can lean on that and just lift your feet up every now and again.
Sometimes it involves the speed and incline being turned up so far that eventually you end up flying off the end of the treadmill, unable to keep up anymore (like I did...). Look, it's not ideal- but that too is manageable.
The most important thing to realise is that ultimately, you control the treadmill.
Even at the times when you feel like you don't, you always have the choice to step off for a while.
Yet, I was still a square peg.
These are blog posts submitted by those in the healing and healthcare professions who are reflecting on their lives, their roles and themselves.