Richard Gunderman, MD PhD and William G. Tilbury
Burnout is characterized by emotional exhaustion (emotional overextension and exhaustion), depersonalization (negative, callous, and detached responses to others), and reduced personal accomplishment (feelings of competence and achievement in one's work).
Burnout is surprisingly prevalent among physicians in training, far exceeding the estimates of program directors. In a 2014 survey of 504 medical residents at University of North Carolina, 70% met criteria for burnout based on the Maslach Burnout Inventory, a common tool used to assess burnout.
A Mayo Clinic study showed a strong correlation between burnout and depression, with 31% of resi-dents with burnout screening positive for depression and 51% reporting a history of depression during residency.
Of course, burnout and depression are linked to a number of other psychological and medical problems, including alcoholism, other forms of substance abuse, and suicidal ideation and attempted suicide, all of which tend to take a toll on the quality of patient care.
Kyle is a 30-year-old internal medicine resident who has emerged into the light on the far side of a very dark time. Was it burnout, or perhaps depression? We can’t say for sure, but Kyle’s is the kind of story that every physician – and everyone who cares for a physician – should know.
Kyle was working harder than ever and had never been so productive. His evaluations were very good. In just about every observable sense, he was firing on all cylinders, and his future in medicine appeared bright.
Inside, however, the situation was different. Despite the more-than-respectable volume and quality of work he was completing each day, he felt far from the top of his game. In fact, deep down inside, his life as a physician felt more and more hollow.
Despite duty hours regulations that should have enabled him to get plenty of rest each week, he felt increasingly run down. He felt he didn’t have time to take care of himself, and his diet, sleep, and exercise habits gradually deteriorated.
Kyle went into medicine with genuine enthusiasm to make a difference for his patients, but it was taking more and more effort just to get up in the morning and report to work. Each day felt like more and more of a grind, with less and less to look forward to.
It was becoming increasingly clear to him that his efforts were not really making a difference. The same patients kept showing up in the emergency department and clinic, with the same problems that, despite his best efforts, didn’t seem to be getting any better. At first he felt frustrated. Why wouldn’t patients follow his advice? What good could the best medicine do if patients lacked the will to collaborate in their own care?
Gradually, a film of cynicism descended over everything. He began to feel as though he was nothing more than a gopher, a record keeper, a box ticker – definitely not the physician he imagined he would be on the first day of medical school, even though he looked the part. He sported a white coat and a stethoscope around his neck, and both MD and physician appeared on his badge. But inside, it felt more like a costume than a uniform, more like a part he was playing rather than an identity he embodied.
Work began to seem so futile and meaningless. Would anyone really notice if he didn’t show up on Monday? Sure, they would have to adjust the clinic and call schedules, but before long they would replace him with another white coat and all would be forgotten.
Although he spent virtually every day in the company of others, he began to feel alone. His pain was invisible to everyone else, but was looming larger and larger inside, to the point that he sometimes couldn’t see or think about anything else.
The sense of guilt became increasingly oppressive. He was living the dream of countless premedical students, including a younger version of himself, but instead of thanking his lucking stars, he was sinking deeper and deeper into misery.
Weekends and time off provided no relief. Instead of refreshing him, they merely provided more alone time, additional opportunities to obsess over the mess he was making of his career and his life. He began drinking more. The pain lost its edge and he was able to forget, if only for too brief a time.
Kyle explained: “It is hard to put into words, but medicine, my career, and my life began to seem like an island from which an unseen current was pulling me further and further away. Trying to swim back accomplished nothing, only sinking me more deeply into exhaustion.”
Unfortunately, Kyle’s story is all too common. Nearly everyone feels blue from time to time, and there is no reason that physicians should be exempt. But there are steps physicians can take, for themselves and for one another, that can prevent the anxieties and frustrations of training and practice from sucking the joy out of medicine.
One of the most effective ways to help a resident like Kyle is to encourage him to invest in building a relationship. Burned-out and depressed physicians often express a sense of isolation. They feel alone and lonely in their struggles. Everyone needs someone to talk with, and while many burnt-out and depressed individuals benefit from talking with a mental health professional, every-one needs other people to count on and share life with.
An important part of the ongoing orientation to demanding professions such as medicine should be explicit encouragement to build relationships. Friends and loved ones don’t just share the burden. They make life itself more meaningful. Having someone to talk with can make all the difference.
Find reasons to celebrate being a doctor: Venting off steam is important, but so is searching out daily experiences that evoke a sense of gratitude, wonder, and joy — an opportunity vital for every physician. Just as dwelling on anger, fear, and doubts can become self-perpetuating, sending a physician into an ever swifter downward spiral, so can developing a habit of looking for moments to celebrate have an elevating effect.
Pay attention to diet, exercise, and sleep
Eating right, exercising, and getting adequate rest are all important, but they do not address the underlying significance of a physician’s work, and wellness in the most superficial sense should never be mistaken for meaning in work and life.
Share and learn from other physicians
Residency programs can help build a sense of meaning and resilience among physicians by creating opportunities for residents to talk about their work and their lives with one another and with other physicians who have experience in these matters.
Which physicians are most fulfilled by the work they do every day? How do they think, feel, and live out their professional callings? How do they handle fear and failure? What do they feel most grateful for and inclined to celebrate about being a doctor?
It is especially important to foster conversations between residents and physicians who have managed to move beyond burnout, depression, and substance abuse. What or who do they credit for their improvement and what insights can they share with others in similar straits?
Fortunately, Kyle found a friend. In fact, Kyle found a small circle of friends who meet regularly to talk about their experiences in medicine. When they meet, they not only vent their frustrations but talk about experiences they are thankful for.
Sometimes they tell stories about their work. Sometimes they talk about books they have read or events in their personal lives. Whatever they talk about, they make a point of reaching out to one another, deepening their network of mutual concern and support.
Kyle still worries about medicine. But that anxiety is no longer a solo burden. Instead it is a shared experience, a means of discovering opportunities to make medicine and the physicians who practice it even better.
When bad days come, as they inevitably do, Kyle makes a point of seeking out things to be thankful for, whether from that day, prior days, or days to come, and tries to do the same for others. Instead of burning out, Kyle has become a source of warmth and illumination for others.
Richard Gunderman, MD PhD is Chancellor’s Professor, Radiology, Pediatrics, Medical Education, Philosophy, Liberal Arts, Philanthropy and Medical Humanities and Health Studies at Indiana University.
William G. Tilbury is a fourth-year medical student at Indiana University School of Medicine.