I had an amazing conversation with a wonderful friend tonight. The conversation was about life, mental health and the all round messiness that often surrounds both those things.
She said "I wish people talked about this more".
I couldn't help but agree.
For a long time I didn't talk about it openly.
I certainly helped my patients with their mental health and I think I was good at it. But I honestly didn't see my own impending burnout. I couldn't see the looming storm clouds heralded by 3am wake ups and unfulfilling sleepless nights, by constant worry about making a mistake, by bone aching empathy fatigue.
I couldn't see it, because I was so blinded by my compulsion to help others.
A noble compulsion for sure, but a blinding one none the less.
I also couldn't see it, because so many of my friends and colleagues were exactly the same as I was.
There are obviously individual factors at play here as most of my colleagues haven't (officially) burnt out despite my observation that so many of them were and still are feeling similarly.
Is that a marker of resilience? Perhaps.
Or is it a marker that my path was just going to be a different one?
That the barrier between me and change was thinner?
My yoga teacher training introduced me to the concept of ahimsa, of doing no harm to other living beings.
But here I was unwittingly harming myself everyday by my inability to place caring for myself high enough on my own agenda to protect my own mental health.
So when it all came crashing down, I crumbled into a series of debilitating panic attacks. The first one lasting almost 48 hours. An entire weekend of sheer internal panic that left my aching body depleted and empty.
I thought to myself in that moment "OK, I'll take a week off work".
One week off work, booked in 2 weeks ahead of that date because I was already booked up with patients for those two weeks.
Looking back now I can't believe that I was still unable to see the storm that was now gathering ominously overhead.
I still didn't know I was burnt out. I just thought I was stressed. That I needed a holiday.
The second panic attack put an end to my plans to see out the two weeks of patients that were booked in.
I was dressed and ready for work, the kids all ready for school.
I went to walk out the front door of my house, when all of a sudden I was gripped with completely unmitigated fear.
The vice around my chest and throat told me that this wasn't going to be like that first panic attack that I could quietly implode inward with.
This one literally brought me to my knees. My 3 and 5 year old children worriedly watching on while I burst into panicked tears at simply the thought of being outside my house. The thought of leaving it's safety, even though I had rapidly come to realise that even my home didn't provide me sanctuary from my thoughts.
The rising heat in my chest, the crushing feelings of suffocation.
I had this unrelenting sense that I needed to run away, yet no where to run and an acute awareness that this feeling would follow me wherever I went.
To remember that feeling now still brings tears to my eyes.
The upshot of burning out is that I'm not afraid to talk about these things now. There is something very reassuring about knowing where the bottom is because I know I won't ever let myself get there again.
So I gave in.
What choice did I have? I was no longer functional and certainly not able to work.
I saw my GP, spoke to my psychologist.
I rested. A lot.
I wrote. My thoughts and feelings cascading out of me faster than I could get them onto paper. Notes popping up everywhere, like emotional mushrooms, sprouting from the fertile ground of my distress.
I even reflected here on the huge wide expanse that now seemingly lay in front of me. I didn't really go into the true details of my immense distress at that stage, fearful of the potential for repercussions it might hold for me. The mask obviously slipping, but not yet completely off.
Eventually, some months into my surprise sabbatical, I began to sleep through the night for the first time in many years.
Sleep now became my yard stick of wellbeing. Whenever I again noticed my 3am wakefulness, I knew there was something wrong, something that I must change.
I spent 6 glorious months immersing myself in my kids. Grateful everyday that I was still able to love and enjoy every minute of motherhood.
Burnout for me was the 'doctor' light globe going out, but the rest of the fuse box relatively unharmed.
Since that time, I've been re-building myself. I've been immensely fortunate to have a supportive family, colleagues and friends in this time.
I have talked very openly about my struggles.
Burning out and even more than that, my process of active decision making as to the path I take forward since then has formed such an integral part of the person I have become that I do feel grateful in a sense that it happened to me.
I now know where my 'peak operating point' is. Perhaps it's lower than other peoples? That's OK.
Because ultimately, I know what happens when I go beyond it.
The path back from burn out is no easier than the path there. Both fraught with uncertainty and fear.
But one is more active. The dark clouds begin to gather overhead again and you ease back the throttle, mindful that it was lack of self awareness that contributed to me arriving there in the first place.
The compassionate voice in my head now reminding me to slow down, to notice the physical warning signs of stress and allow them to complete their journey through my body rather than carrying them with me, unheeded, forever held and accumulated.
I am more mindful. Content.
We are all on a different path in life. My goal is no longer to 'keep up'.
The 'doorway of change' that I sensed when I burnt out is now wide open, with the expanse that lies in front of me both exhilarating and unnerving.
My hope now is that I can continue to speak my truth and to walk beside others who find themselves on this path to burn out and back again.
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.
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.