Physician burnout is a hot topic right now. Some don’t agree with the term and choose to use “moral injury.” Regardless of the term you want to use, the problem is real. Christina Maslach describes burnout as “an erosion of the soul caused by a deterioration of one’s values, dignity, spirit, and will.” I think that sums it up nicely. And while we’ve identified this as a major issue amongst physicians and have highlighted its prevalence and causes, have we really addressed preventing it?
Being a physician, I have attended many leadership classes. I’ve learned valuable skills that will help me daily in my job. I learned about conflict resolution, empathy, selflessness, flexibility, listening, humility … I could go on and on. All of these are great tools that will help strengthen my leadership skills so that I can lead and serve others. All skills that have served me significantly, thus far in my practice. Yet, in all the classes that I have attended over the years, no one has spoken about taking care of yourself so that you can be a great leader and servant to others.
Some of the best advice that I have given to weary family members that have spent countless hours by a loved one’s side is: “Go home. Get some rest. Get a shower. Have a good meal. You are not going to be any help to your loved one when needed if you have not taken care of yourself.” And as many times as I have told family members this, I have so rarely heeded my own advice.
There is an often forgotten skill in leadership training. I would dare to say that it is the most important skill in leadership training. This skill is self-help. Self-help is a self-guided improvement.
And you may be thinking, “But if I am to be a leader, I am to help others. It just seems selfish to put focus on me.” But if you yourself are not well taken care of, then you will not be able to lead or take care of others effectively.
But to know when to implement self-help, you must also use another leadership skill which is often taught in leadership classes, and that is self-awareness — being self-aware means having a clear perception of your personality, including strengths and weaknesses, thoughts, beliefs, and emotions. There is a strong psychological component to self-awareness. Being self-aware is looking inward and asking yourself “who am I, how do I feel about myself, who do I want to be in this world, and most importantly have I become the person I wanted to be.” Ask yourself, “Am I happy.”
Accurate self-awareness is essential for optimal daily living. It allows us to know what our limitations are and will enable us to make choices based on our capabilities.
When we decide to become leaders in the community, we feel that we must be strong. We feel we cannot have weakness. We internalize our stressors. We don’t talk about our feelings for fear we will be viewed as weak or not good enough. We have an image to protect. But eventually, this takes a toll.
These internal stressors begin to manifest both mentally and physically. We start isolating, retreating from friends and families. Sleep and appetite are affected. Coping skills are strained, and we become anxious and depressed. Sometimes there is even physical pain. We become burnt out.
Sadly, I have been there. I became that burnt out physician. I was a second-year resident. Arguably, the hardest year in my residency and on the hardest two months of that year: The dreaded night float. When your days are literally turned upside down, you take care of the hospital all night and return home during the day to sleep.
For some physicians, it is an easy adjustment, for others a nightmare. It was an impossible adjustment for me. I could never get my sleep cycle to switch. I could not adapt. I worked nonstop throughout the night and was awake throughout the day looking at my clock, counting how many hours of sleep I could get if I were able to fall asleep at that very moment. With each passing hour awake, I got more and more anxious.
Exercise has always been an outlet for me, but I had no energy to exercise. I was so exhausted on the weekends I did not want to do anything social. I had no appetite and was, in fact, horribly nauseated because to complicate things even more, I was eight weeks pregnant.
So, I continued to forge on thinking, “Everyone goes through this. I am no different. This is part of it.”
Well, mid-way through the first month, I suffered a miscarriage. I told no one other than my husband. My OB gave me the pills to help complete the miscarriage and encouraged me to take time off. Well, I surely wasn’t going to do that. So, I loaded up on Advil and heavy-duty pads and continued to work. After three days, I went in for my ultrasound and still needed a D&C. I was warned there would be cramping and still more bleeding. My OB told me that I would need to take the rest of the day off. But I did not listen. I demanded to have the procedure Friday morning, thinking, “I’ll go to work that night and then have Saturday and Sunday to recover.” I never listened to the advice of my OB who warned that the emotional toll would soon catch up to the physical. I had no self-awareness, and thus there was no self-help.
At the beginning of my second month of night float, I experienced another great loss. My grandfather died. He was essentially another father. He was my “Pop Pop.” He was my world. I loved calling him and telling him all my stories of being a physician. He was so proud of me. I continued to try to forge on putting on a fake face. I certainly could not take time off to go home to the funeral. What resident would take time off? Again, I wasn’t eating. I could not talk without crying. I could not sleep. I was so sleep deprived that I was having hypnagogic hallucinations. We know these are often brought on by exhaustion.
When I finally started dozing off, I would hallucinate. It was having hallucinations of people standing over me. They were often hallucinations of psychiatric patients. It would startle me so that I could not go back to sleep. One day, my husband came home to find me in a fetal position on the floor rocking and crying. I don’t remember much.
Thankfully, although I had zero self-awareness at the time, my husband was fully aware of the decompensation that was happening. One of my fellow residents stepped up and got night float covered for me for a week. I do not know that he remembers me or even covering that week, but I will never forget him. I was told to go home to my family, go to the funeral. I was able to be with my family. I was able to rest. I was loved on and cared for immensely. Being from the Mississippi Delta, I was fed and fed and fed some more. I took runs around the neighborhood that I had so many times before as a teen. I returned much healthier after just one week. And because of the self-help, I finished out the month with no issues. But I became so much more self-aware.
So why do we wait so long to implement self-help? We know that suicide rates are on the rise. They have been on the rise since 1999. The overall rise is 25%. And it increased in all sexes, ages, races, and ethnic groups. In 2016, nearly 45,000 Americans took their own life. Sadly, this is lower than the actual numbers because of the stigma associated with mental health; most are not reported.
We know that anxiety, depression, and stress are factors that increase risk of suicide. Suicide is on the rise in physicians. Physicians are suffering. Physicians are experiencing burnout. We need to shift our focus of self-help being preventative of physician burnout, not just part of the solution.
Establishing good self-help skills now is something that will come in handy through the course of your life. Stressors will come and go. Stressors will change. Leadership roles will change. Self-help skills are adaptable to each situation and stressor. There are multiple pathways to self-care: Sensory, pleasure, mental, spiritual, emotional and physical. We, as physicians, must recognize the importance of self-help and truly engage in it. It is essential in preventing burnout. As a psychiatrist, I counsel my patients on the importance of self-help daily.
We must heed our own advice.
But as a psychiatrist and fierce mental health advocate I would warn that self-help may not always be enough. Know when to ask for help. Know when to reach out to a therapist, counselor or psychiatrist.
Knowing when to seek professional help and doing it is, in fact, the strongest thing you can do. We know that mental health care is essential for total health, and treatment is effective. So, if needed, seek it.
Katherine Gantz Pannel is a psychiatrist.
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