No Wonder I’m Burned Out!

Once again, I ask my friends:  How are you? 

I am not great!!  Neck, back and head pain, insomnia, low mood, and the worst case of stress eating in a couple years—GRRRRRRRR!  *deep breath*  …So, like a good primary care doctor (she says with tongue in cheek), I evaluate and treat myself.

I ask patients to rate the stress and meaning of their work and then compare:  Is work overall more stressful than meaningful, or the other way around?  It helps me assess the sustainability of their work life, and gives me insight into their values and priorities.  In recent years when I’ve asked myself, the answer is consistent: moderate stress, HIGH meaning.  Today it’s high stress, less high meaning.  For the first time in a long while, work is not necessarily more meaningful than stressful.  Yikes.

Stress:  It’s COVID. 

Meaning:  I ask patients how they derive personal fulfillment and meaning from work.   I recently asked myself again.  It’s twofold:   Relationships and Efficacy.

Relationships: I am your primary care doctor. Sometimes I’m your therapist, your cheerleader, your drill sergeant, and your accountability buddy. I have always loved this, even on the hardest days. But this year, I am also a resolute public health advocate. Sometimes that rubs you the wrong way, because I tell you things you don’t like. I recommend against flying. Don’t eat at restaurants. Don’t gather with your family for the holidays. Don’t go to church. Stay home for 14 days after an exposure. I interrogate your COVID precaution practices. Then I dissect and judge them (not you), thank you on behalf of humanity, and admonish you to persist, longer and longer, for all our sakes. It kinda puts a damper on our relationship.

Efficacy:  I. Help. People.  It’s my calling!  Hemorrhoids?  No problem.  Back pain?  I’ got this (yer back, that is).  Viral gastro?  Migraine? Core instability, palpitations, paresthesia, GERD, thyroid nodule—even  depression and anxiety—I can make a good plan for all of these things.  I can walk you through it, reassure you, and help you feel better, even when I can’t fix the problem. 

Not so with COVID.  How did you get it, when you were so careful?  If the test is negative there’s still a 20-30% chance you’re infected if the scenario is high risk, but I can’t say for sure.  If you’re sick, how long will it last?  Will it get worse before it gets better?  How much worse?  Will you have lasting symptoms or long term health problems?  How long does immunity from illness or vaccine last?  I cannot lie:  I. Don’t. Know.  I will stay with you through it, but I can’t even satisfy your most basic questions, while you sit alone at home coughing, short of breath, unable to see or touch your loved ones, sipping ginger ale because you throw up anything else.  I can’t help.  And it kills me.

On top of that, I’m not doing any good as a public health champion, either!  Have I changed any of your behaviors?  Have I made even an iota of difference in my community to stop the spread?  All signs say NO.  I’m failing left and right.  No wonder I’m eating so much.

Burnout

Burnout is widely understood to have three key components: 1. Emotional Exhaustion, 2. Cynicism/Depersonalization, and 3. Reduced Personal Efficacy. Studies of physicians generally show that while we often score high on the first two, we do better with the third. I think not anymore. Burnout affected about half of all physicians in all specialties a few years ago, but had improved due to widespread research, awareness, and advocacy for systemic change led by professional societies such as the American College of Physicians and the American Academy of Family Practice. But think about 2020: Whatever emotional exhaustion my emergency medicine and critical care colleagues felt before, caring for the sickest of the sick, likely pales in comparison to the horrors of this pandemic. When their health systems ignored their pleas for PPE and then laid them off, making remaining docs work that much harder, and when they saw people partying and spreading virus all over the place, could you blame them for getting cynical? And though we’ve learned so much and fatality rates are lower now than in March, imagine going to work every day to watch patient after patient suffer and die alone, despite your and your team’s best efforts. We can no longer count on efficacy to save our morale.

Re-ignition

So how do we hold it together? Well DUH, it’s about connection! I had not felt this bad in a long time, but I’m better now, thanks to my peeps. They’re everywhere, and we hold each other up. Texting a meme here, venting (a lot) over there, and generally being present for one another, sharing, even embracing, the deep suck of the morass. Because this too shall pass… Like a kidney stone, as they say.

The only way out is through.  The best way through is together. 

I haven’t thought, said, or written that in a while.  It’s not that I forgot.  I got overwhelmed.  Happens to the best of us. 

Pandemic Lesson #1: Flexibility

NaBloPoMo 2020 – Today’s Lesson

What have you had to be flexible about this year?  What has this taught you?

It’s not that we cannot make plans anymore.  It’s that we must be willing and able to change them, quickly and effectively, if we want to actually get anything done.  Move all primary care and primary/secondary education online?  Done.  Stop flying?  Okay.  Come back to work and school?  Sure.  Wait no, outbreak, go home again, please?  Fine.  Postpone big vacation 3…6 months… indefinitely…  *sigh*…we can deal.

Many of my patients are actually thriving in the new work from home normal.  Without the constant travel, jetlag, business dinners (the quadruple threat to acid reflux:  late, fatty, large, and full of alcohol), and long commutes, they sleep more and better, spend more time with family, exercise more, and eat healthier.  If all goes well, my executive health job may be obsolete in the next decade, hallelujah! 

Not everybody’s doing well, of course.  60% of the workforce still shows up in person; risk, stress, and burnout are very real, and escalating.  The people who are well are those with choice.  They are the privileged ones.

Most of us still don’t know how the new work life balance will look in the coming years, but we hope to retain and expand the flexibility that has given us some sense of agency and control.  Check out this episode of Hidden Brain to hear a Stanford work from home researcher on implications of this augmented world for all of us. 

What flexibility do you wish for in 2021?

Agency and control in the midst of a global pandemic—how ironic!  Pandemic lesson #2 may be Paradox and Polarities… The last 2020 NaBlo…  Wait for it…

Death Comes Closer

NaBloPoMo 2020 – Today’s Lesson

How many more before it’s over?

This weekend I felt the Reaper’s cold breath over my shoulder again.  It came last 20 years ago, when I left residency for a week and flew to Taiwan, where my grandmother was dying.  The ICU at the teaching hospital in her city was positively rudimentary compared to where I was training.  She was intubated but fully awake, and rolled over before the doctor even had to ask, so he could listen to her failing lungs.  That was Po-Po, always making life easier for others, even at the end of her own. 

Imminent death agitates and disorients like nothing else.  In training I learned to detach just enough to be objective.  My elders modeled the compassion and empathy required to shepherd both patients and families through the passage.  In the emergency department and ICU, and on the cancer floor, we observed a calm, professional reverence for the end of life.  But only a few patients might die on any given month-long rotation.  Today my friends in these specialties witness death, sometimes multiple, often gruesome, on a daily basis.  They risk their own lives, and serve also as intimate messengers and chaplains, in service of helping soul after soul ascend in peace, if that’s even possible. 

When it was my Po-Po, I was beside myself.  I cried non-stop the whole 15 hour flight stateside.  And then I went back to work. 

Tonight I pray for all of us, especially our healthcare heroes.  Death will likely claim someone in each of our circles before this pandemic is over, if it hasn’t already.  I wish I could do more to halt the unyielding march.  But how many times can I say mask and distance?  It’s futile.