Episode 451: WDx #41: Burnout, Existential Dread, and Everything in Between

[MUSIC] Welcome back clinical problem solvers, Maddie and Yusuf here. At CP Solvers, our mission is to make clinical reasoning accessible to learners worldwide. We invite you to join us for our live virtual morning reports, where we break down cases and sharpen our diagnostic reasoning together. Now over to you Yusuf. Thanks Maddie. Just a quick reminder, this podcast is for educational purposes only. And is not a substitute for medical advice. Patient details haven't modified to protect their privacy. And the views express your own, not those of our employers. Now let's dive into the case. Enjoy the show. [MUSIC] Remember when we thought burnout? Just meant we needed a long weekend? Yeah, like have you tried yoga? Turns out it wasn't a downward dog deficiency. It was just a bit of existential dread. Well, with that, welcome back to WDX, woman and diagnosis series. Today, your hosts are three former medical students who survived training and like to process their failings very publicly. Wait, did you guys bring me to a podcast or just delayed therapy? This is an intervention. It's both today we're talking about burnout or that feeling when your soul quietly leaves your body on overnight cross-cover. Too real, too real. We are going to delve deeper into all things we refer to as burnout. And yes, you guessed it, there's more to the story than just eating better exercising and sleeping. But before we get started, a killin' and I are joined by the one and only Dr. Alice Mal. And Alice, I meant though, in our world, you need no introduction. Do you want to introduce yourself to the audience? Sure. Hi, everyone. I'm Alice Mal. I'm a practicing internist and geriatrician. And mostly importantly, I am a proud member of the friend group of Kaelin and Sharmeen, where I receive both doses of medical wisdom as well as delay their peaks. Our faith, it's our faith, right? With a touch of sarcasm. Of course. So getting into our topic, I can't think of two better people to walk up through this. So, when did you first realize that medicine wasn't just stressful? But I like something else was lingering on. AKA, when did you realize burnout wasn't just being stressed and tired? Yeah. Good question, Sharme. I felt like in residency, my program director was always telling us, you know, you should go and take some personal time off, do some yoga. But I felt like at a certain point, it just wasn't, it just wasn't cutting it for me. And more specifically, I guess, in the middle of my second year of internal medicine residency, there are just a lot of things going on. I was a word senior for the first time. I was rotating the MQ. I was leading the charge in the ER. But also, personally in life, there's just a lot of things going on. I had just come off of a big breakup with the person I had been dating for a good chunk of time that I thought, you know, we were possibly going to get married. And obviously that didn't happen. And I also just felt pretty disconnected, honestly, from my residency community and community at large. So it was just like a perfect storm of things where I felt like, man, you know, like even if I took more time off or, you know, did more mindful breathing exercises, it wasn't getting better. And I just felt like, huh, like, is this burnout or is this something else? Yeah. I agree. I feel like similarly when I really started to reflect on this was probably somewhere around second and third year. I feel like going into intern year, I kind of had the expectation that it wasn't going to be very busy. I was going to live in the hospital. I wasn't going to have much time. But I think when I think about intern year, I think I was tired, but I was like happy. I was like getting to do medicine. I was getting to work with my friends. And there was a very defined finish line. You know, it's like it's one year you'll get through it. And then I got to second year and third year. And then I just, even though I was not in the hospital as much, I wasn't working as many long hours. There just was this more kind of like lingering angst. It just felt different. And it didn't feel, I just didn't expect it. You know, I think kind of compared to intern year where you kind of know you're going into and there's a defined end point. I think there was something much more nebulous about how I was feeling in second and third year. And luckily, I was able to do a well-being elective where I got a chance to really reflect on this and delve into the literature, what we know and have some more time to think about this. And it ended with like a presentation where I was able to kind of talk through this with the residency. So I'm really excited to kind of talk through kind of the things that I've learned from the experience. And how it's like refrained in shift, I thought about burnout with you guys today. Yeah. We have gotten that presentation in multiple different chunks over the years. The house was like when we were living together. And I was pretty burned out and K brought out her presentation who teach me about one of my all-time favorite books. Yeah. Big benefit with it together. You know, just cross-steak me. Our feelings and having delayed their peace together from Kaelin's well-being elective. Yeah. Yeah. It's generally a good idea when your friends are feeling burned out to tell them what they're feeling and how to live their lives. It's good. It's good to micromanage your friends. I see what you're feeling and I have a presentation to you. Yeah. Yeah. I did a well-being elective on this. And also, have you invested in your Roth IRA? I also have a presentation for that. Yeah. A future episode coming down. Okay, Lauren. Okay. I'm lovely dad. But you know what you also like resonate so deeply? I don't know a single person that I've talked to is Edison who has a burnout at one point or the other. And one thing that I've kind of noticed that we call everything burnout is, my, it's obviously because not all these the same thing. Yeah. So Alice, how do you think about burnout? It's how do you unpack this like really umbrella term? Yeah. You know, I think I agree. Burnout is such a generalized term. And maybe what would be helpful is if we take a step back and just unpack a couple of terms that lead to burnout and are relevant to burnout and just to find them for our audience. So we know what we're talking about. And this comes from various pieces of literature that we've looked at. So one term is stress or double-bind which can lead to additional stressors and burnout. And so this is like when you're, you know, busy in clinic or on-rounds and you want to spend more time with your patient, you feel like that's the right thing to do. But then you're also struggling to finish your notes and that's really stressful. And the next term is moral distress. So this is kind of like a higher order type of stress where you have a troubling event or stressor paired with some kind of moral trespass that some value of yours has been trespassed against. So, you know, that could be like over time you're continuously feeling the sense of oh, I can't spend time with my patients, which is something I value, compassion, connection because of the thing I have to do to get my notes finished in service to the system. And then long term moral distress can lead to moral residue, which is this lingering discomfort after repeated compromising of your values. And then long term residue can lead to moral injury where, you know, the system really forces this repeated violation of your values and you feel like you cannot deliver the type of care that you want to deliver that's in line with your values or kind of live the way that you want to live. And then all of that can lead to burnout. A burnout can also look differently, not just as a result of moral injury. Yeah, yeah. Thank you so much for framing that. I think it's really helpful, because I feel like we throw around the word burnout all the time. And but there's so much more that goes into it. And so kind of thinking about the different things that led to burnout or this kind of maybe end point of all these different triggers that have led to it. And so I think for me, one of the concepts that was super helpful in thinking about burnout was this idea about circumstantial versus existential burnout. And so during my residency as I was thinking about well-being and during this elective, I found this article from Nazly Ebidini who was at the University of Washington. I think it just as many great physicians are. And she published in 2018 in Journal of Graduate Medical Education, this article, which will link where she and colleagues did a qualitative study looking at burnout amongst internal medicine residents. and recognizing that the burnout rates for internal medicine residents were among the highest of the specialties. They interviewed a sample of PGY2's, threes and recent graduates who had experience and recovered from burnout. And using qualitative methods, they found that there were two different categories of burnout. So, circumstantial and existential. So, circumstantial meaning situations that are associated with the environment. So, whether that's the work environment or personal challenges. And so, the recover from that are they found were three main themes. So, one, resolving these workplace challenges. So, you know, some of these challenges could be things like high case load, long hours, be a cutie, the medical record, and dealing with that. And so, the things that helped with that are moving on to different rotation, making changes to the rotation, things like that. Two was personal stressors. The recovery from that was, you know, doing what it took to nurture the personal lives. So, spending time with family and friends, and so on, and the third was taking time off. And so, prioritizing sleep, rest, etc. So, in contrast to circumstantial burnout, there was this existential burnout. And existential burnout stems more from a loss of meaning, essentially, an uncertainty about their professional role. And it describes more of this internal dilemma of how the residents were viewing themselves in their developing ruralist positions. And that really resonated with me because I think in turn year I felt really the circumstantial burnout. And that was kind of my understanding of what burnout is. It's like you work long hours, so you need a day off. You have a stressful situation at work. And so, you know, you need to kind of recover from that. But what I was starting to feel a lot of in second and third year was this bigger existential question of kind of like, what is my role? And also starting to recognize these bigger issues in medicine where there wasn't a quick fix. So, hopefully in this article, they also categorized the themes that they found that helped with recovery from existential burnout. And so, one was recognizing the burnout and getting validation. And importantly, they said that, you know, for some, there's this self-imposed stigma about burnout and, you know, needing to overcome the stigma to recover. Two is connecting with patients and colleagues. So, just, you know, connection with our community. Three was finding meaning in medicine. And that of course looks different for everyone. So, we'll talk about that. And then four is redefining the professional identity and role. And so, I just thought that was so helpful and really shifted how I thought about it. And I think the existential burnout really helps me reframe and understand kind of what I was feeling the second and third year resident compared to what I had known it to be and what I had felt. As an intern. Yeah, okay. I think I really resonate with that too. You know, I think in the example I gave, there was a piece where I felt like, oh, it's not just because I'm working long hours or this is hard or like I know myself to be able to overcome hard things. And so, you know, what's going on? And I think that's kind of like what you're talking about the circumstantial versus existential burnout. And I do also want us to just kind of also talk about what burnout is not because I think there is a lot of shame wrapped up in sort of feeling depleted, feeling like, oh, I can't do the things that I know I can do. Yeah, so a burnout is not weakness. Burnout is not lack of resiliency. It's not just sleep deprivation and just not solved by, you know, pizzas and yoga's. I have to say, though, we love yoga. We love mindfulness. But it's not just the only self-care tool as, you know, you all are teaching us like burnout is either start from social or existential and circumstantial is like, you know, situation related. And if that situation, you remove yourself or that issue is resolved, you're good. Whereas it's existential burnout is like a lot more complicated and is like behavioral end points is like emotional exhaustion, the personalization and reduced sense of accomplishment. And that many things from like moral injury, distress, repeated circumstantial burnout, any of these things can lead to existential burnout. One thing that we just want to mention as well that like sometimes like burnout is does not burn out and it could be like depression. So I think one of the most important thing when it comes to existential burnout is to seek help from anyone that you feel comfortable seeking help from. And you know, in our world of medicine, medicine can be perfect. A setup for burnout. Yeah, exactly. I want to highlight one more article or resource that I came across as I was looking into this. I think really helped me and reframing it. So it's an article by Simon Talbot and Wendy Dean. It's called physicians aren't burning out. They're suffering from moral injury. And I just want to share a couple of lines from this article because I think they say it better than I could. But essentially they describe the idea of moral injury and healthcare. And essentially they say that quote perpetuating failing to prevent bearing witness to or learning about acts that transgress deeply held moral beliefs and expectations and quote are that's moral injury and healthcare. And they use it to illustrate that burnout is not a failure of physician resilience or inefficiency. But rather it's working in a system where physicians have to act against their deeply held moral belief. And I think that really helps me because as we alluded to earlier, I think there can be a lot of stigma about burnout like, oh, you know, like I can't do the job. I'm not working. I can't keep up with these hours. I'm not efficient enough. And just kind of recognizing that no, you're working in a field where there's a lot of moral injury. And I'll share a couple of other things that were helpful for me from the article. One quote was quote physicians are smart, tough, durable, resourceful people. If there was a way to make out for themselves out of the situation by working harder, smarter or differently, they would have done it already. And quote, and so I think just reminding ourselves that we're smart, capable, hardworking people. And that's not to say that, you know, we don't take ownership for our own well-being. But also to say that it's not a personal failure to feel burnout. It's we're part of a larger system. And there's a lot of really difficult things that we have to encounter and grapple with. Yeah. And I think like that, my guy, ring ourselves out of it is like something that I even see on daily basis. One of the most common things I hear when I'm like, you know, sitting down and like, kind of doing like expectations with the wonderful residents and interns. I have the privilege of working with is this need to like one of their goals. Like I want to be more efficient. And like any time that question gets that answer, I always like come back. I'm on my reflecting of like, you know, we are just like, we are trying to make ourself out of, you know, the system pressure is like, DD hours like all this like more data that we have to consolidate more things we need to do. And a lot of the solution in our brains is to be more efficient. So I always like to ask like, okay, what is efficiency to you? Why why like we focus on that word a lot. And I think so much of it is like a double line that, you know, we mentioned earlier. But yeah, we are tough, durable. We do a lot for sure. Yeah. And I think there are a lot of things about medicine, you know, that makes us a perfect storm in terms of, you know, like medicine is very structurally hierarchical. There's a culture of perfectionism and like resiliency at all costs. We, you know, as physicians and physician trainees are like really good at delayed personal gratification, like word the kids that did not eat the marshmallow, you know, like for years in hopes that there will be more marshmallows later. And yeah, and I think we're really good at, you know, like abiding by sort of stated or un-stated rules to figure out what we need to do to succeed. And so sometimes when I think about, you know, like wanting to be efficient or wanting to be better, it's like, who's asking of that is that like the system we're in, like are we meant to be robots or am I being sort of like the best physician as defined by me. And what does that mean and how do I like make that workable within the system that I mean. I just want to echo that I think one big realization for me is similar to what you're saying Alice is I think a lot of us are used to being like what's the goal post will need it or will exceed it. and then I think at one point just looking around and looking at it. recognizing that the expectations that are given to us are not reasonable. Like they're meant for burnout, right? Like you cannot expect anyone to go through residency and continue to operate at that level forever or even talking to young attendings and realizing that a lot of young attendings burnout because they, you know, they're working at a certain level and they're, and they burn out after a couple of years. But then when you look around, you kind of see everyone working at a certain level and that's the level that you think you need to be performing at, but that's a false threshold. That's a false standard because the level that people are working at is not sustainable. So I think that was really important for me because I was like, wow, these people are able to work so hard and not sleep and do all these things. But just recognizing that, you know, ignore the person who publishes 10 articles in nature during residency, ignore those people. But for most of us, like this is not a sustainable level and it shouldn't be, it's an artificial standard. I guess it's my point. It's, it's an artificial standard. It's like you cannot operate at a certain level and do that forever and the people that burn out leave and you don't see those people. So it's a very skewed sample size that you're comparing yourself to often. Mm-hmm. Yeah. Now very true. I will like now that, you know, you're all our attendings. How have your perspective shifts thinking about this topic, like looking back? Mm-hmm. One thing that I've like come to realize more is that I think one of the big challenges in residency and in training is that you just don't have enough time to reflect and they just, everything that happens. Sometimes a single day in medicine feels like 10 years, the words of like craziness that happens. So from every single interaction and then there's just no time to process that and to reflect that and the reason why I think that is not good and do us at the service is because so much of us getting to know ourselves and our values better is depending upon our ability to be able to reflect on what is important, what is, like, what is the, uh, the distress here that I'm feeling, what is it, underlying, what is the value there? And I think the more time, however you can spend understanding what your values are, like, what is important to your medicine? What in medicine brings you joy? What in medicine you value? What in medicine drives you insane? And I think like having ways of like understanding that over time helps you set yourself up about like the job that you want to take and everyone's different and the better you know yourself, the better chance you are setting up yourself for success doesn't mean burnout won't happen. It will. I think you will be more equipped to recognize it and more equipped to kind of better navigate the next steps. The more you spend time examining your values and what is important to me. And I feel like that was one of the biggest realization I had like towards the end of like my chief year when I was like looking for that's what's a beginning of chief year when I was like looking for jobs about like as I was like talking to everyone, that was like the first moment that I was like, what is it actually that is important to me? Like what to me makes a good doctor or a good educator? Why didn't this work for us make you want to like get up in the morning and do the job and what aspects of it like able to destroy me if I keep doing it that way. So those things like really helped. As you all know, I still bright down afterwards. It's fun. I do think I was about to add my camera so you guys are navigating it. Yeah, I mean, I was really leading to it's an ongoing process. There's no one solution or quick fix, but it's just something to think about. And as we go through training in our careers to continue to come back to and build skills in. Yeah. Yeah, well said, Charm, I do you think that the promised land of post training attending life is that you do get more time in space to hire like rehuman a little bit or pick up some hobbies. You like neglected or maybe like just sleep more and eat better. And I think that really does help to create some space to clarify who you are and what your values are. And I think some of the additional one additional challenge of post training life that one of my mentors highlighted for me really well is that she said, imagine training and residency like climbing a steep mountain. It's hard, but you know where you're going and so and you know where the mountain top is and when you're going to get there. But after training, you're kind of like an uncharted terrain. It's pretty nebulous terrain. Sometimes you're going to have hills. Sometimes it's just grassy plains and you're not totally sure how long the journey is going to be or it's sometimes exactly where you're going. And that type of burnout can be even more hard and confusing. And so it's even more important, at least for me, to have a compass and a road map built by your values because the more that we spend time and resources clarifying what's important to us, the more we'll know how to find sharp buzz and co travelers along this uncharted terrain and we'll know which direction we want to go to and what actually gives us meaning and what challenges we're going to overcome through what means. So it is a little bit of a different type of burnout, I think in post-training life in the sense that it can be less defined. It's more of a marathon than a sprint for sure. But you also get more time and space, hopefully to just build your own road map around your values. Thanks Alice. I agree. I think even the idea of building your own road map can be very daunting. I remember when I was finishing my fellowship and I was starting to apply for jobs and I felt very much what you're saying, this uncharted territory and people would ask me what I was looking for a job, what my ideal job is. And I was like, I don't know. I don't know. I've never had a job. I don't know. I was feeling very burned out and I was like, is this what I'm going to do for the rest of my life? Just take calls about tripotan elevations. And I remember one of the recent graduates when he was asking me about jobs, I was like, how do you know what kind of job you want? He was like, you know, Kaelin, you live in a Bay area. It's really beautiful out there. It's going to hike, some soul searching. And I remember at the time, I was like, that's not helpful. In some ways, it's not because you're just like, you just want someone to tell you the answer. But ultimately, there's no shortcuts to this. You do have to be really honest with yourself about what brings you meaning and defining your own personal identity and role because no one's going to be able to do that for you. And the other thing I'll say, another thing that's been really helpful for me is when I was talking to one of my residents. And I remember this, you know, even those years ago, he was saying that he was suffering from a lot of burnout and he really just sat down, wrote down what values he had, what values he didn't have. And then also what values he had that he wished he didn't have. And I think there can be a lot of judgment, you know, because maybe the values that you have feel different than the values that medicine has or you feel you should have. Or maybe you have certain values that you feel you shouldn't have. And there can be judgment around that. But I think, you know, it's your life. And I would just encourage you to be really honest with yourself and to be empowered to kind of have to just, you know, it's your life just. Yeah, live your life and just just recognize in what ways you might be kind of downplaying your priorities because you don't feel like, yeah, they're what is expected of you. Yeah. And I think like the challenge of like training and residency is you are these metrics that you need to hit, right? Like if you want to go to a competitive specialty, you have to do certain things. And unfortunately, like we don't have control over changing the system. We have to operate on. So sometimes, you know, the best you can do is the best you can do. And the good news is that it's just a bigger world on the other side of it. It's not easy navigating it. However, like knowing yourself, being yourself, it allows you the right tools to help create a life in medicine that is closest to your values or like what you want. And if, you know, if it's not all medicine, it's okay to you. Yeah. I really resonate with that. that actually I think with the story that I told earlier in this episode, when I felt really disconnected from community and burnt out and tired, I felt like what helped me was really coming to this space of understanding, oh, actually the thing that I feel most missing is connection to community, which is something that's really important to me. I felt like acutely not alone, but lonely in that. And so, yeah, it wasn't about working harder, smarter, more efficient, or eating better, but it was about how do I better find and shepherd community. And so I got involved in some endeavors that were really important to me, like some of the DEI stuff that our residency was doing. And really getting to build relationships with those folks. And so that even, you know, I couldn't change systems at large, it was being able to find co-conspirators who valued what I valued and being able to find energy, meaning, and community and that. And that's kind of helped me bring me out of the slump, if you will. Yeah, and I will say for me, there was a lot of angst around the next step in career. And so I think my advice for anyone that's feeling existential angst or worry about the next step is similar to what we're saying in terms of values, but being really honest with yourself about what is a non-negotiable for you and what you're willing to make your trade off and what you're not willing to make your trade off is really helpful because there is no perfect job. And I was very clear with myself when I took my job, what the trade-offs were, but also the reasons I was making those trade-offs, because there were all these other things that were in line with my values. And so on days where I'm really frustrated about certain things, it really helps to kind of come back to like, yeah, this is really frustrating. But this is something I can deal with because I took this job because it gives me x, y, and z opportunities. And that really helps me to not get bogged down by some of these systems issues. And even though they're frustrating, I'm not trying to negate that. I think as we're saying, when you are really clear with yourself about what your values are and the trade-offs that you are and are not willing to make, when you run it to some of these systemic issues and to some of these things that cause you to make you so frustrated, it is very grounding. Yeah. And just a quick word, I felt a lot of pressure trying to thread the needle on the perfect job after training. And just to say that it's okay, we're probably not going to nail it out of the game. And it's okay to spend some time in your first job and realize, oh my gosh, actually, there's not enough pieces here that align with my values. And sometimes when you're in a system where your values are not aligned, it's time to leave. It's time to leave a system, find your job, find a new group of people, and that's okay. And so, again, this uncharted terrain that can feel sometimes like a morass is a journey. And will sometimes get it right, will sometimes get it wrong, but just continuously clarifying what's important to you along this journey is how you'll get to places that make you feel more meaning in who you are and what you're doing. Beautifully said, life is just about finding your people. You know, you need to get people finding your tribe. Go through all this like craziness with them. Bonus points if they can give you a wellness lecture. You got to have their lovely and elective too. I like to process externally with everyone around me, whether or not they would like to be involved or not. Okay, we get a second hand therapy from that. You found people who are very much in love to be involved. Hence, just find your people and find your tribe. That makes life infinitely better. Even when you're birthed out, they will help carry you through this crazy thing we get to do every day. Mm-hmm. Yeah. I feel like that could take home message from every episode of the podcast. Exactly. Hang on to them and it will be okay. (laughing) All right, well, I guess maybe to take a home, do we want to share just like one piece about burnout that we're gonna take home? Alice, you get to wrap this up as well. Go for it, but. Well, I think for me, there are a lot of roles we talked about, but just recognizing that burnout is not our fault. Oftentimes it's emblematic of greater systemic issues that are not aligned with our values. And sometimes circumstantial burnout, it is about taking some time off, spending time with people you love and just recuperating from whatever acute stressors are happening in that season. And then there's existential burnout where we really do need to spend a little bit more time figuring out what our values are, that are being repeatedly transgressed against and how to better remore ourselves to meaning and personalization in our profession and maybe even kind of our personal lives. And so, to me, I think at the end of the day, it's about just really, again, being clear about what your values are and finding people who are gonna be your tribe to shepherd for those values, continually clarifying as you move along your journey, what those values are even as they evolve and then being honest with yourself as you figure out what works and doesn't. All right, well, there you go. - That's how you have to say about that. So, and that we're gonna cut these. - Yeah, we're gonna cut these some yoga now, because absolutely, I read your love. - We, yeah, we, we weren't trying to hate on yoga. - We do. - Yeah, yeah, we're all gonna go. - We're all gonna do some mindful breathing yoga. - Eat some marshmallows now. - Yes. - All right. - All right. - Bye. - Bye. (upbeat music) - That's a wrap, everyone. Thanks for tuning in. - If you enjoyed this episode and wanna be part of our community, join us for our live virtual morning report where we can present the case or discuss with us. Visit our website for details. You would love to have you. - Free audio post production. - By Alphonic.com.