Struggling Through Burnout Toward Wellness

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Struggling through burnout toward wellness

Wow, medicine can be so tiring at times, I’m exhausted. Did I make the right specialty choice? The right career choice? How many more clicks until I’m done? How many notes do I have to bring home from work again? That huge queue of messages, am I the only one struggling with all this? If you’ve thought any of these things or heard them from your colleagues, please know you are in the right place, and you are not alone.

Starting out

My story begins as I graduated pediatrics residency in 2016. Fresh out of residency, I take off 3 weeks and go on an amazing vacation with my wife. We traveled through Utah, hitting Arches, Canyonlands, Zion, Bryce, Grand Canyon, a night in Vegas, back through Colorado to Rocky Mountain National Park, saw some family before finally getting home and jumping right in to my first clinic job as a general pediatrician.

It was the same clinical system as my residency continuity clinic, so I already knew a lot of the processes. I had great mentors, prior faculty that were now colleagues. I was excited, more than a little nervous, and yet, things started pretty well. I ramped up my clinical volumes pretty quickly, pushing myself to full clinical volumes within about 4 months of starting. I passed my boards, transitioned medical records systems with my system, and even exceeded my RVU goal for the first 6 months. Wait, they incentivize exceeding expectations, sweet! I’m full time, 9 sessions per week with 1 session of admin time, I’ve got this, things are going great!

Margin Declines As Volumes Increase

And yet, as I got into that first winter, things began to catch up with me. Being so early in my career, I was still developing many of my scripts for both interviewing and counseling on particular problems and diagnoses. I was still figuring out charting in real time, how I could get my notes done efficiently and yet keep the clinical flow going, patient orders and paperwork done in the course of the day. I found the flow to be very different than residency. There I would come in, pre-round on my patients, work on notes while waiting for the attending, round, go to noon conference and get educational time, see my colleagues, get lunch at the same time, and even on busy months, there was often still a little down time in the afternoon.

Outpatient attending life, though, was a whole different ballgame. Though I didn’t have in house call or 28 hour call overnight, the pressure of 15 minute appointments all day long, different languages, complicated situations that just didn’t fit in the 15 minute slots, I barely had time to eat lunch before starting an afternoon of the same, and barely any of my notes done at the end of a session either. So more and more notes coming home, charting in the evening, the next day, on the weekend. The margin was rapidly eroding, and my ability to adequately recharge was clearly being overwhelmed.

I am an introvert at heart, love my patients, love the diversity of my clinic, but especially speaking another language, using phone and video interpreters, the complexity of the problems, quality metrics, urging from leadership to go faster, keep it moving, all the things, it is a cognitive load, and then the extra notes to bring home, documentation, finish them in 48–72 hours, sooner even same day if you can.

Burnout Arrives

I was asked to cover a week of newborn nursery in February of that first year and decided to go for it. So naïve was I, however, that I worked Monday through Wednesday, covered 7 days of nursery and then worked Thursday, Friday, no comp day off, no nothing. I know, it’s no trauma call, not q4 call in Peds ICU like I did in residency, but it was the final straw for me. Finally my wife and I were sitting on the couch one evening a few weeks later, and I was so exhausted, it was an ongoing thing this exhaustion, and she said “something has to change”, we knew that our faith and our marriage were more important than my job, I think I had taken a standardized burnout questionnaire by that point, confirming what I already knew, I was burned out.

Charting a Path Forward

Great, so NOW that I was burned out, what had to change…enter my annual review. One of the leaders in my department was doing my review, and upon finding out what I was going through, she said, we’ll talk about the academic stuff later, we need to figure out a plan for you, you need to physically not be in clinic one day a week. I had wanted to decrease multiple afternoons by a few patients each day, but she convinced me that the time would just get filled up even if I had fewer patients.

This turned out to be such wise advice, and I am so thankful. I was fortunate to have physician leadership in our large medical group and they were supportive of me cutting back my clinical time due to my burnout. Around that time, I also went and did specific training with my electronic medical record to get an additional certification. It would allow me to help build things in that environment as a physician and offer more specific input. It was something that was intriguing to me, clinically relevant but another opportunity to diversify my skills and my time. That first year, I cut to 8 sessions then and eventually 7 sessions as I eventually got some protected time to help with system initiatives around the electronic medical record, having received that certification during my two offsite trainings.

Current state

Now, my admin time is paired with my half day reduction in FTE, and I ended up 0.85 FTE, still full time for benefits and student loan eligibility, and I still work about 40 hours per week. My wife and I had maintained the financial flexibility to do that by “living like a resident” as Jim Dahle over at the White Coat Investor would say. We had not maxed out our budget and still had some financial margin to make that change, which regardless of income meant evaluating our needs and wants against our priorities. More to come in future episodes about things I have learned along the way that have been helpful with the financial wellness piece, but this was part of me being able to make the professional changes that needed to happen for my personal wellness.

The days I have in clinic are still long and stressful sometimes, but 3 consecutive days not in clinic, including the weekend, has made a big difference. All of my clinical time now consolidated at one clinic has been helpful also, but that is only within the last month at the time of recording, so we will see how the benefits or challenges from that transition play out over time. A story for a later episode. And yet, I still struggle with managing my time and energy at work, when to spend a few extra minutes in the room, when to add on that sibling rather than making them come back another day, getting more of my notes or paperwork done vs. connecting with colleagues and hearing about their day, how their own family is doing. There is always tension in balancing competing priorities, caring for others at work, caring for my family, for friends and others in the community, and caring for myself.

Work and priorities

Overall, I still love pediatrics, I love my patients and families, the opportunity to make a difference in their lives. It is an intellectually stimulating profession, and I am thankful for this privilege. And yet, work is hard. Each profession and job have their own challenges, but part of life is acknowledging that. And then saying, ok what capacity do I have to do my work? My capacity doesn’t have to look like that of a particular colleague that may have specific reasons for picking up all those extra shifts. I am an introvert, so after a day of talking to patients, coming home and engaging with my family and spending time with them, at some point, I try to get a little down time, read a book, listen to music, play the piano, maybe watch some sports. But then, when do I have to push beyond my typical limits? It may be when you are short-staffed at work, when there is an illness in your family, or you are a parent and your child needs more of you in this season. And then what restorative, rejuvenating habits do I need to cultivate, either continuing current activities or practices or developing new ones? Is this exercise, reading a book, mindfulness, spiritual practices, regular connecting with friends?

Mindset and priorities in wellness

So that begins to scratch the surface of the inputs and outputs of energy, effort, and time facing each of us in the same 24 hours we are given to invest. Looking at your core priorities will definitely affect your personal, professional, and financial wellness, how you respond to things that come up and how you proactively plan and make decisions. Certainly personal mindset affects wellness and how you respond to some of the things that you may or may not THINK you are able to change. Previously, I would have only said, may or may not be able to change, but after doing some mindset work myself, I saw that it often comes down to priorities and whether you say I can’t leave this job or I can’t try ask for that change at work because “what if they say no?” Maybe, my priority on family says location matters, so I think that I am stuck in this job, when maybe I could apply with another group across town, even if that takes 6–12 months. So again, personal mindset and priorities matter, a lot.

Systems issues and wellness

And yet, there are systems issues at play that greatly affect wellness as well. Just because some physicians actually like their electronic medical record, and I am one of them, physician researcher Tait Shanafelt and his team found that those same physicians who use an EMR that they like are still more likely to experience burnout because of the use of computers and the complexity and increase in time using them. Then there is also the feelings of being unable to do what you know needs to happen for your patient because of policies, prior authorizations, lack of staff, lack of PPE, any number of things can be systems issues, and they are not remedied by just using personal wellness strategies, mindfulness, nor resiliency training. These difficult experiences can lead to moral injury as you aren’t able to do what you know should be doing or you are stuck doing things, such as making life and death triage decisions, that you otherwise wouldn’t if resources weren’t as limited. Or making decisions about appropriate clinical care that you know will decrease patient satisfaction scores even though it may be the right thing to do. Many of these things may need to be addressed at the level of institutions, health departments, or nationally and involve many of us coming together to advocate for and be a part of the change that is needed.

Listen to your colleagues

In the midst of these difficult times with both individual and system stressors, each of us would benefit from a colleague coming alongside us, really asking “How are you doing?” and then taking the time to really listen. It may mean that you help connect one of them with your Employee Assistance Program or make debriefing as a team more of a thing, whether after a difficult event or also at regular team meetings.

Take Action Now!

As you’ve heard a bit of my story and interacting with wellness, I want you to take a step back and look at your own life today.

• What are the core priorities that drive you? that motivate you to go to work and live your life?
• How do you feel about your current work situation? Do you think you might be a little burned out? or a lot? Don’t stay in the shame and the negative self-talk, reach out and ask for help, whether that is making a change in your schedule, seeing a counselor through your EAP program?
• What is one thing you could change today in your mindset and how could that improve your wellness at work in the next month?

Again, take a moment and reflect on your CORE PRIORITIES, where are you with your wellness, and what small change are you going to make to impact your wellness, starting today?