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Tara Riddell MD, Marc Legault MD
Image courtesy: Ana Hategan
Amanda was an obstetrics/gynecology resident nearing the end of her third year of training. (See section Know Yourself, topic Recognizing Burnout, for more details on the case scenario as this is a case continuation.) She was burned out, depressed, and her work and relationships were suffering as a result. She knew something needed to change, but had no idea where to start or where to go for help. Amanda thought about speaking to her program director, but worried about confidentiality and the potential repercussions this could have on both her residency and her ability to secure a job down the road.
Even in considering outside supports, such as seeking a counsellor or psychiatrist herself, Amanda was not sure how she would be able to carve out time for such an appointment, when there already were not enough hours in the day to accomplish what she needed to. She had been hoping to see her family physician for several months now, but between her doctor’s limited and busy schedule, and her own, this continually was put off.
To make matters worse, Amanda felt alone in her program. Whenever spending time with her co-residents, they all spoke of their many accomplishments and extracurriculars, and appeared to be happy and handling the various stresses of residency without difficulty. No one spoke of their challenges as no one wanted to be perceived as weak or vulnerable; however, this meant that Amanda perpetually felt as if there something was wrong with her and that she was the runt of the group.
As we have come to learn, the problem of physician burnout is often multifactorial, involving a mix of environmental stressors, biological vulnerabilities, and coping styles unique to each of us (Wiederhold et al, 2018). Many of these factors are seemingly out of an individual’s control (Dyrbye et al, 2016). This is particularly true for residents, who often have even less input with regards to their schedule, workload, or income, and who face frequent institutional and organizational pressures, such as by being under close supervision, and having to complete various evaluations, exams, and projects all prior to their graduation.
While there is growing awareness of the role that these systems factors play, there is still much work to be done in this arena. We encourage medical students and residents to consider advocating for physician wellness and exploring ways in which they can help be involved in promoting change both within their institutions and with regards to the overall culture of medicine; however, in the meantime, we need to find ways to keep us well.
Though programs and services to aid physicians can vary by institution and region, by building awareness of what does exist and learning what personal wellness practices have been shown to boost wellness and fill up our reserves, we may be better able to fight against burnout. To learn more about some of these strategies and tools available to physicians in Canada and the United States, click on each of the following sections below.
Image courtesy: Ana Hategan
Though medical training can be challenging and stressful in and of itself, how one perceives these stressors and copes with them, is also of importance. Though there are different forms of counselling or psychotherapy, they all generally provide an opportunity for an individual to openly express themselves and their distress, to explore their problems from a different lens, and to learn alternative and perhaps more constructive coping strategies and ways to problem solve (Dyrbye et al, 2016). As such, data supports counselling and psychotherapy as an intervention to address burnout (Ishak et al, 2009).
Most of the evidence for therapy in physician burnout has supported the use of cognitive behavioural therapy (CBT); however, there have also been positive findings with more general and even very brief counselling treatments:
Resources to consider:
As with our case example, Amanda, burnout can be a very lonely experience, both due to the fact that we can find ourselves detached or withdrawn from others, but also likely due to the culture of medicine which tends to instill some sense of competition and leads us to hide our perceived weaknesses and difficulties for fear of negative repercussions and embarrassment.
Despite this, social support is crucial. In fact, in a study of medical residents with burnout, the top two coping strategies that were highlighted as the most essential for managing stress were talking to other residents and talking to one’s significant other or family (Shanafelt et al, 2002). This is not surprising as humans have an innate desire to connect with others, as it provides not only a sense of belonging and community (McKenna et al, 2016), but it can help reduce stress and anxiety (Ishak et al, 2009).
Resources to consider:
With burnout, not only do we lose sight of our purpose and what is important to us, but often the work-life scale becomes unbalanced as we devote more and more of our resources in an effort to stay afloat at work and keep up with our various duties as a resident. The problem, however, is this tends to exacerbate the problem, as our relationships outside of medicine, our leisure pursuits, and basic self-care practices fall to the wayside even though they are vital for our self-identity and in replenishing our reserves and maintaining our satisfaction with our lives.
As such, to foster resilience and combat burnout, we may need to return back to the basics, such as by trying to regain a healthier lifestyle and working to instill a more equitable semblance of balance in our lives. While the right “work-life balance” may be different for each of us, one way that we can work towards this is by reflection to assess what is missing, and setting goals to help get us back to where we want to be (Deb, 2017). Goals in particular help keep us accountable and committed to our action plans, and help us build self-efficacy and confidence by frequently checking-in to evaluate our progress (Turkay, 2014). In considering some of the resources or suggestions below to foster self-care, consider formulating some goals to bring about these changes in your own daily routine.
Resources to consider:
As resident physicians and practicing physicians, our work revolves around caring for others and treating the ill. Given our commitment to our careers and altruistic attitudes, however, it is easy to spend most of our time helping others and prioritizing the wellbeing of our patients over our own. However, physicians are humans too. None of us are immune to the common cold, cardiovascular disease, or even burnout and depression. We tend to forget this, however, and even in the face of illness or suffering, we can become the worst patients. For instance, we work even when we are ill (Penedo et al, 2005), we downplay our symptoms and avoid seeking help (Davidson et al, 2003), and we self-diagnose and medicate (Christie et al, 1998).
These behaviours can be harmful to both our patients and ourselves. Instead, to function optimally and provide the best care, we need to start caring for ourselves and prioritize our own wellbeing. This can be accomplished by building our own healthcare network, seeing our doctors/team regularly (Shanafelt et al, 2017), and knowing when it is time to ask for help (Dyrbye et al, 2016). By doing so, we build resilience by attending to and filling up our physical and emotional reserves.
Resources to consider:
A study of internal medicine residents found that almost 50% had no primary care physician or considered themselves to be their own family doctor (Christie et al, 1998). Those that did not have a primary care physician were more likely to engage in self-treatment, of which over half reported self-prescribing a medication (Christie et al, 1998).
Another study of Australian physicians found that almost three in four physicians downplay their symptoms or feel embarrassed to seek out care from another physician, and 95% are likely to work when sick. Particularly when it comes to depression or other mental health issues, these numbers increase as 87% were reluctant to seek out appropriate consultation (Davidson et al, 2003).
Now that we have had a chance to learn about some of the evidence-based strategies to combat burnout and some of the resources that may exist, it is time to explore what is available where you live. Whether for yourself or a colleague in need, having an understanding of the various tools, programs, and crisis supports that are available through your community or institution can be a good way to stay prepared and can help tackle burnout early on.
To assist with this, consider and explore each of the following areas to see what supports exist for medical learners and physicians in your area:
Given the utility and importance of social support, it may also be worthwhile to consider those around you, whom you would feel comfortable sharing experiences with. Perhaps this may include trusted faculty members, co-residents, or former medical school classmates. Consider whether it may be possible to arrange regular meetings to discuss what is on your mind, any difficulties you are facing, and ways to address and cope with these challenges. You may be surprised who else has had similar experiences or feels the same as you!
Though Amanda was struggling with feeling as though she was an imposter in her program, the one resident who was struggling to keep up and who had lost sight of the purpose and joy of her work, she was surprised one day to discover that she wasn’t alone. At a resident social, a more senior peer opened up to her about their difficulties with processing a patient’s death and struggling to find time for their own self-care, which was necessary for them to maintain their wellness. Through this interaction, Amanda not only felt relieved and reassured, but she felt closer to her peer group, particularly as she and her co-resident began meeting regularly for coffee to discuss their challenges.
Inspired by her peer’s own coping strategies, Amanda decided that in order to create some separation between work and home, she needed to go back to the basics. Though it felt a little silly at first, Amanda began scheduling in outings with her spouse and friends, as well as time to attend yoga and the gym, or go on a hike. She worked to try and limit the hours she spent studying and writing notes, and even picked a day or two a week where she focused only on relaxing or engaging in her hobbies or relationships. In doing so, her mood, self-esteem, and sleep improved, and she found that when working, she was more focused and productive, and she began to enjoy her clinical and academic work more.
Amanda also scheduled a day off to attend her own medical appointments, including with her family physician. After relaying her story and symptoms, her family physician worried that she may be experiencing a depressive episode. Though medications were discussed, Amanda opted to pursue psychotherapy instead. Through her family doctor, Amanda was connected to a social worker who began to engage her regularly in the evenings on both CBT and mindfulness work, which Amanda enjoyed and found helped her in managing her perfectionistic and anxious tendencies. In discussion with her family doctor, Amanda also began to cut down on drinking and began going for massages regularly, often on her post-call days.
While Amanda was slowly starting to feel better, one day she received tragic news that one of her young patients, who had recently had a miscarriage, had died by suicide. This was unexpected and greatly shook Amanda. She felt upset and deeply saddened, and as the news sunk in, guilt began to emerge as she felt that she had let the patient and their family down. She worried excessively that she could have done more. The loneliness and darkness returned with a vengeance; however, as she had been exploring options for resident support, she knew there were help lines for physicians. On one particularly difficult night, Amanda contacted the 24-hour helpline through her residents’ association, which allowed her to express her distress and receive some support and guidance. The next day, Amanda also sought out her supervisor and asked if they could discuss the suicide and debrief. Amanda learned that her supervisor had lost a few patients over the years himself and each time though he had struggled, he had ensured he had others to talk with, which helped him in processing the grief. Her supervisor also recommended that it may be helpful for her to write a story or a narrative to review her experience with that patient and the emotions that arose following the patient’s death. Though it was difficult, Amanda found this exercise to be cathartic and therapeutic, reminding her of what she had done for the patient and what she could learn from this experience moving forward.
Though it took some time and there continued to be ups and downs, by the time fourth year rolled around, Amanda felt stronger, and more capable of handling all that was still to come.
1. To recap, what are the core features of burnout?
2. Which of the following have been associated with untreated burnout?
3. Which of the following learners is experiencing symptoms concerning not just for burnout, but for depression?
4. What are some effective strategies to increase one’s social connectedness and support?
5. If you were becoming increasingly distressed or were in crisis, where could you turn for help?