3 BURNOUT STRATEGIES TO IMPLEMENT TODAY

Perhaps with a few months of practicing medicine in this “pandemic-era” under your belt, you are feeling like you are taking on water and sinking fast, aka BURNOUT? Or, perhaps you’ve been managing to keep your head above water, but feel the current workload and stressors are unsustainable, and that you could use something to help stay afloat? Or, perhaps you are thriving and just want to add a tool in your resiliency toolbox? Wherever you are along the “Surviving –> Thriving Spectrum“, I’m here to help, by meeting you where you are RIGHT NOW. Here are three pragmatic tips, to lighten the workload and stress levels for you, as well as for your future self:

  1. CREATE AN EHR SHORTCUT. TIME IS YOUR MOST VALUABLE RESOURCE. It is estimated that clinicians spend 2 hours of documentation time per 1 hour of patient care1. In addition to that frustration, clerical tasks and EHR use are frequently cited as top causes of the burnout pandemic2. We all need to decrease our EHR burden, and improving proficiency (optimized usage) and efficiency (time spent) are ways to save time both within and outside of working hours. Set a goal for today of creating at least one EHR “shortcut”, “speed button”, “dot phrase”, “macro”, “smart phrase”, or whatever your EHR refers to it as: The investment will likely only take a few seconds out of your day, but the time saved will be exponential. Think of it this way: Creating the EHR shortcut will likely take you less than 60 seconds, but let’s use 60 seconds anyways. Invest 60 seconds into creating your shortcut, preferably on one of your most frequently used orders, reply messages, E+M or CPT codes, or physical exam templates, and you will likely save about 5 seconds each time you use it (along with the invaluable mental bandwidth and decision fatigue savings). If you use that shortcut 10 times per day, you have now saved 50 seconds per day, the equivalent of 4-5 minutes per week, or 4 hours per year, just with a single EHR shortcut!

    <60 SECOND INVESTMENT –> 4 HOURS PER YEAR SAVED!

    An example is creating a “QuickAction” item in Epic for the “FYI” telephone encounters you may get each day, with the shortcut adding in your rapid response (“Noted, thanks” is mine), while also signing it off and closing the message…all with just 1 click. If you are unsure how to do this, contact your IT department, locate a Super User/Speciality Champion or someone who geeks out on this stuff like myself. This tip alone just saved you 4 hours within the next year, so now you can start planning on how to reallocate this time towards something else to move yourself away from survival mode and towards thriving.
  2. CREATE A MANTRA. I’ll start by giving you the mantra that I use: “What kind of day have I decided to have?” This is the question to myself, from me, that I post on a sticky-note on my computer screen. Implied within this question is that I have control over my thoughts and feelings, regardless of what my day may bring. It serves as a reminder to focus on what I can control, not the variables outside of my influence, and this approach is rooted in Stoicism. I’ll also argue that there is a comfort to this sense of control, especially during these uncertain times, and that may appease many of us who have Type A personality traits. When our workdays become particularly challenging, and threaten to overwhelm us, a mantra can serve to comfort us and ground the negative thought patterns that may be spiraling, and even compounding. Simply thinking or speaking your mantra will stop the mental/emotional rollercoaster you are on, one that, as it turns out, you are actually the operator of, and then give you an opportunity to hop off and change course. From there, choose wisely.
    So, “What kind of day have I decided to have”? I choose to have a joyful and fulfilling day where I welcome the challenges that may come my way; a day that reconnects me with the reasons I enjoy my career as a PA.

  3. TAKE A COLD SHOWER. Wait…what??!! The purpose of this exercise is to overcome something that gives you hesitation. Former FLOTUS Eleanor Roosevelt said “You gain strength, courage and confidence by every experience in which you really stop to look fear in the face.” Although I wouldn’t classify the hesitation one might have with cold water immersion (CWI) as a “fight-or-flight” level of fear, it still elicits a natural response to consider other options, making CWI a perfect and convenient way to shock you into improved willpower, decreased stress, decreased inflammation and many other physical and mental benefits3. Your primitive brain is risk-averse, and CWI is one method to bypass some innate fear, as you get to choose the comfortable (warm and cozy) or less comfortable (CWI) path for the day ahead.
    I’ve found this useful as a desensitization strategy, which seems to reign in whatever nervous energy that I may be harboring (TIP: most notably on days with presentations or any “performance” activity on the schedule). I usually end my morning shower with 30-60 seconds of cold water immersion, mostly focused on my face, neck, head and shoulders, while focusing on deep, rhythmic breaths (the natural instinct is to breath hold or take a giant gasping breath). Consider trying to progressively lower the water temperature over time, as opposed to just going to the extreme from day one. I challenge you to try it today, and don’t be surprised if you come out feeling exhilarated, and that you find the rest of your day’s stressors might seem a little more trivial and easily overcome.

1 https://www.mayoclinicproceedings.org/article/S0025-6196(19)30836-5/abstract
2 https://www.medscape.com/slideshow/2020-lifestyle-burnout-6012460#5
3 https://www.tonyrobbins.com/health-vitality/the-power-of-cold-water/

DISCLAIMERS: 1) The views expressed here are my own and do not necessarily represent the views of my employer. 2) There are no conflicts of interest to report. 3) I don’t know what I don’t know, so feel free to message me if you don’t agree with something that you read. 4) I am not recommending you do anything foolish or extreme with cold water immersion, and I do not take responsibility for anyone who decides to do anything beyond my basic recommendations.

TREADING WATER

Photo by Arun Kr on Pexels.com

“AIN’T NOBODY GOT TIME FOR THAT” VERSION:

  1. Working in medicine, pre-pandemic, felt like treading water: Dynamic, exhausting and with dire consequences of not being able to keep up with demands.
  2. Approximately 50% of clinicians were “drowning”, aka burnt out, prior to the pandemic, and we should assume that number has increased with COVID-19.
  3. Stressors from this pandemic-era are unprecedented, and it feels like we are treading water in rough seas with a lead vest on, which is unsustainable for many.
  4. Clinicians who are “drowning” need to be thrown a lifeline, NOT just validation, mindfulness tips or anything that doesn’t help get their heads back above water ASAP.
  5. This blog, and any content born from it, will serve to help clinicians go from surviving to thriving in their clinical practice and personal lives, focusing on: 1) Pragmatic solutions, 2) Education (knowledge is power, as well as leverage), and 3) Thought-provoking discussion.

THE FULL STORY

After a steamy bike ride the other day, I decided to cool off and clean up by taking a quick dip in the lake. Normally, I’ll just jump in, float around for a few minutes, maybe take some jumps off one of the many rock formations. This time, I decided to swim for a few minutes, and once I got away from shore and started to just tread water, I found my groove and was thinking how grateful I am to be able to recreate outdoors during this pandemic…some semblance of normalcy for me. As nature’s serenity engulfed me, I began to become a passenger of my train of thoughts. But within a few minutes, my conscious mind started to remind me that treading water requires constant effort, and that I was starting to get tired and not so close to solid ground. It was precisely at that moment that I had this revelation: Treading water is a perfect metaphor for working in medicine, especially as a clinician!

Stop and think about it for a minute: As with working in medicine, treading water requires constant efforts to keep up with the demands. Many professions demand a continuous mental and physical output, but for those of us working as clinicians, the consequences of not being able to keep up can be dire, even deadly (for patients and ourselves1). Even though it may appear to take less effort for some clinicians, we are all working to keep our heads above water, with varying degrees of effort needed to accomplish this. And like with treading water, our jobs as medical practitioners are at best draining, and at worst are enough to exhaust us to the point of drowning, metaphorically speaking, and this state of “drowning” already has a name: BURNOUT.

PRIOR to this pandemic, it was estimated that between 40-55% of clinicians1,2 were demonstrating at least one symptom of burnout. Let that sink in: Before COVID-19 began to uproot our personal and professional lives around March 2020, about half of all clinicians were already burnt out. I’m not sure how everyone else is feeling, but my impression is that these last few months have been unprecedented in regards to stressors, from rapid changes in work protocols to massive changes in personal affairs to possibilities of furloughs/layoffs to the general gloom of the news. It feels to me that, for all of us treading water through our work as clinicians, we are now doing so in rough seas from a tropical storm. Perhaps if it suits your image with this analogy better, it’s like treading water with an anchor tied to our ankles. No matter how you slice it, we’re all having to put more efforts in just to keep our heads above water!

With all of that said, how high are burnout rates now? I’d bet a small fortune that many of you reading this have been experiencing burnout as this pandemic has rolled on, and I will admit that it got the best of me about two months ago. I found myself in a constant “WTF?” state: feeling angry, breathing shallowly, sleeping poorly and attempting to compartmentalize the stress in what at first felt like a “call to duty”, but emerged as a test of stress endurance. Everything about working as a medical professional during this pandemic has felt like a marathon of resilience, one that doesn’t yet seem to have an end in sight.

So, if so many of us feel like we are drowning right now, while many others are somehow managing to keep their heads above water through unsustainable efforts, is there even anything we can even do to help ourselves? YES! Please, read on.

“If not me, who? If not now, when?” This maxim has become my pandemic battle-cry, and also served as my mantra as I emerged from my pandemic-associated burnout a few months ago. Wherein I first applied this to welcoming the patient-related challenges and dangers to come with the pandemic (eg patient surge), I subsequently realized that I can apply this mantra to guide me to helping another population that may be struggling during this pandemic: my fellow clinicians and other medical professionals.

So, how can I help you, my fellow clinicians? For one, here is this blog, written by a medical practitioner (me) with 25 years and over 40,000 hours of wellness experience (see my bio for more details). I, like many of you, am putting in the increasing efforts to keep my head above water as a full-time clinician, trying to provide the best medical care that I can, all the while attempting to be the best version of myself outside of work. With my breadth of experiences, both personal and professional, I’ve reached a point where I can confidently and passionately go from someone treading water, to a swim (burnout) coach and lifeguard. I appreciate that some of the time we may feel that we are at a place to work on our form, and other times we just need someone to throw us a lifeline to keep us from sinking further. Whichever you need, and whenever you need it, I’m here to help.

The aim of this blog, and anything else that is born from it, is to help coach my fellow clinicians, and other medical professionals, by giving them the tools to go from drowning victims to synchronized swimmers, or even future swim (burnout) coaches themselves. From here on out, I want to help future you to become more resilient, even pandemic-proof, and here is what I will focus on:
SOLUTIONS. Pragmatic. Easy. Immediately-applied. Results-focused.
EDUCATION. Evidence-based. Knowledge is power, and I’ll help you to wield this knowledge as leverage to meet your personal and professional goals.
DISCUSSION. Wide-ranging. Pulled from medical and non-medical sources and meant to be perspective-changing, thought-stimulating, action-oriented. Not just an airing of grievances.

My mission is simple: Do whatever I can, with the tools and resources that I have (and will continue to acquire), to help my fellow clinicians and other medical professionals be the best version of themselves. We cannot give to our patients and loved ones what we do not have ourselves, and as Randy Pausch advises in the Last Lecture: “If things get really tough, grab your own oxygen mask first.” I hope you allow me to help you, and in doing so we learn to help ourselves as clinicians and individuals, which will then have an exponentially-positive and sustainable ripple-effect to those that we care for. I am genuinely looking forward to our journey together.

If you have comments, questions, concerns or anything else you’d like to offer, email me at efficientclinician@gmail.com.

1Studies have shown that clinicians have a high rate of suicide as compared to other professions, and also that clinicians with burnout are more likely to make medical errors.
https://www.mayoclinicproceedings.org/article/S0025-6196(16)30625-5/abstract
https://www.mayoclinicproceedings.org/article/S0025-6196(17)30690-0/fulltext
2(NOTE: More studies have been done on physicians, but given that APPs also work within the same medical system and whose job responsibilities have significant overlap, I am choosing to use the term “clinicians” to include doctors, PAs and NPs collectively).

DISCLAIMERS: 1) The views expressed here are my own and do not necessarily represent the views of my employer. 2) There are no conflicts of interest to report. 3) I don’t know what I don’t know, so feel free to message me if you don’t agree with something that you read.

PANDEMIC-FRIED SOUL: My (latest) Burnout Story

WTF??!!” — This was how my pandemic burnout was manifesting. It seemed like every new email, organization-wide protocol change, “red zone” area, COVID-19 related symptom, or essentially anything outside of my control, had me in a perpetual “WTF” state of mind. I had reached a point of where the reinvigoration of, and “call to duty” towards, this worldwide medical emergency started to give way to mental and physical exhaustion in trying to keep up with it all. I was BURNED OUT by it all, but I did not recognize it until one precise moment.

The precise moment when the gravity of my BURNOUT state hit me: During an off-hours, socially-distanced gathering with the other clinicians in my office, my medical director asked me: “How are YOU feeling with all of this?” It was at that moment, with that basic inquiry, when I felt like someone was finally and genuinely checking in with my state of mind, that my anger completely melted away and it took all that I had not to just cry. That one question cut so deeply and quickly through the layers of armor that I was carrying around that I was shocked by my own reaction.

Me?” I said. “I’m fine.” Nothing could have been further from the truth, but I almost felt guilty in stating otherwise, given what was going on in “hot spots” across the U.S. and the rest of the world. I had been telling myself that I should be feeling lucky to be where I was, where COVID-19 cases have yet to manifest in large numbers. There was no surge here, despite our extensive preparations, and in watching what some of our medical peers around the country were going through, how could I be feeling burnt out? Was there any validity to me feeling that way? In hindsight, the answer is 100% YES.

Although it was looking different up here in Vermont, as compared to other places across the country and the world, the near future was looking gloomy, and it felt like the we were bracing for an impending viral-tsunami. It was decided, after both of the doctors valiantly volunteered to take inpatient shifts for the possible “surge”, that I, along with a nurse practitioner from another practice, would take over all responsibilities in our clinic. I was suddenly thrust into a de-facto Medical Director role, with thousands of patients, many of them unfamiliar to us, under our care. There was not time for a transition period, as things were evolving so rapidly, and as with all medical facilities, we were reacting to the daily, and often hourly, changes.

As part of the de-facto Medical Director role, I was now responsible for holding the three-times-a-week staff meetings, keeping the staff safe (in the face of sickening PPE shortages), coordinating with organizational leadership and keeping abreast of news from the CDC, Vermont Department of Health, New York Times and other sources. I somehow was sleeping less and had more energy, but in hindsight, this was probably a constant source of draining my batteries. Despite my time-tested resiliency strategies, I don’t think I was winning the battle, or more appropriately the war, but I can confidently say that I was doing all that I could to project that I was.

Still within my provider role, I was triaging, doing visits with (although we were almost exclusively telemedicine in the early phases, along with some parking-lot medicine visits), and treating some folks sight-unseen. Practicing rapid-decision-medicine wasn’t new to me, as I’ve worked in multiple busy Express Care settings, but I, more than some, appreciate the unsustainable nature of such practice. Doing all of this for three patient panels, in addition to the new medical director duties, was admittedly A LOT.

So how could I, without being surrounded by a hospital full of COVID-19 positive patients, patients on ventilators struggling to be kept alive, or having to even make any life-or-death decisions, be feeling burnt out? Was I just not as resilient as I thought? These thoughts led to some serious guilt and shame.

It all started off well, as I embraced how I was needed most: running our clinic. My PA friend said that he felt invigorated by it all, and I agreed that I felt the same way. The feeling of a “call to duty” sure beat routine hypertension and hyperlipidemia follow-up appointments, and there was a feeling of responsibility to do whatever we could to keep our community informed and safe. It was in these early days of the pandemic that I saw some of the best of humanity on display, and I like to think we, at our clinic, were a part of that.

As we now know and continue to feel the effects from it, this pandemic has shaped up to be more of a marathon than a sprint, although it feels like we started fast and furious out of the gate and continue to try to keep a brisk pace. The bottom line is that much of the medical community continues to run on fumes after such an effort to meet the demands of a pandemic, because those efforts were just not sustainable.

As someone who once made the 5k rookie-mistake of sprinting out of the gate, and subsequently paying the price for the other 80% of the race, I should’ve known better than to not pace myself appropriately. I dove in head-first, embraced my new role, exercised more to “keep up” with mental demands, became a checklist maestro, and thought I had hit my stride and finally felt a “calling” with my medical career. Little did I know that, as we were starting to figure out that the “surge” wasn’t coming to Vermont, and as we began to reintegrate ourselves back to some semblance of normalcy, another tidal wave of stress was heading our way: budget shortfalls and possible furloughs/layoffs. My mental mantra went from “I got this” right back to “WTF?”

Photo by Andrea Piacquadio on Pexels.com

How did we, in what seemed like an overnight shift, go from “Healthcare Heroes” to possibly losing our jobs? Wasn’t this STILL a medical emergency that was STILL happening? The threats to our jobs were real and they were imminent…it was do whatever it takes to make up for these budget shortfalls associated with the pandemic, or there would be cuts. Our benefits and salaries were the first to feel the cuts, and it was uncertain if we would retain our jobs. This felt a little too polarized from where we just had been, and I felt like I was on a rollercoaster with a blindfold on.

I, admittedly, did not see this one coming, and I think that the surprise nature of this new stressor contributed to my inability to deal with it well. I was somehow fine with potentially getting COVID-19 and possibly not having a good outcome (I even spoke with my wife about how she felt about me heading to NYC to try to help), but the thought of losing my “essential” job shook me to my core. And, on top of being shell-shocked by this latest development, pressures were now being put on us to increase our outputs, all still within the dangers and confines of practicing “pandemic medicine”.

This second tidal wave of massive changes came at a time when my batteries were already running a little low, and it was soul-crushing (or consistent with the title of this post, my soul was now officially Pandemic-fried). From invigorated and feeling pulled towards the fight to feeling like a powerless pawn, worse than ever, and all within the span of a few weeks. I didn’t need a pat on the back at this point, but what I really needed was time to process what we had just worked through. It felt like we went from one enormous stressor to another, like jumping from the fire into the frying pan. There was no time in between to rest, recharge and rejuvenate. Without this time to do so, I felt beat down and was now totally burnt out. Returning back to more of the pre-pandemic same, but this time with higher demands and consequences, felt like a huge slap in the face. “WTF?

It was around this time that we had our off-site provider meeting, the one where I almost broke down and cried in front of my colleagues, when I realized exactly how low and “crispy” I had gotten. If I was employing all of my resilience strategies, and was still “losing the war”, then I needed help. My first step was to apologize to my colleagues for being as “crispy” as I had been for the few weeks before my burnout recognition, then I immediately contacted my Employee Assistance Program (EAP*) to get some help via counseling.

As I waited to connect with a counselor, I doubled down on mindfulness activities and discussing my feelings more openly. As a patient of mine recently said: “There’s a [emotional] debt that you’re going to have to pay at some point, so you might as well pay it as soon as possible.” Well, as it turns out, I never did connect with a counselor, but by giving some much-needed attention to how I was feeling, I was able to “pay my debt” and start the road to burnout recovery.

Within two weeks of my near “breakdown”, I felt like I was back on solid ground and my batteries were recharged, all while continuing to work full-time within this new pandemic landscape. I credit myself with having many strategies from pre-pandemic days to call upon, so recharging my batteries happened faster than I anticipated, thankfully. It was on the other side of my (latest) burnout that I started to think and worry about my fellow medical professionals, some of whom had an even more stressful experience with the pandemic, and also many of whom don’t have good resiliency tools in their toolboxes to call upon, that may still be suffering. I understood, better than ever, that their experiences were valid.

Back to a big part of my existential crisis: Was my burnout legitimate and valid, such as compared to the medical professionals in New York City or Northern Italy? YES, YES and YES. Here’s why:
1) We should not judge how we are feeling. Shaming ourselves for our feelings is not productive and will only lead to feeling worse. It is better to just observe and own how you are feeling, without judgment. The energy spent on shaming ourselves should be put towards trying to figure out the reasons why you feel that way, or better yet, on finding solutions on how to feel better.
2) It comes down to a simple concept: If the stressors that are draining your batteries are more than what you are (and can be) doing to recharge them, then you are in a net-negative energy state. This is not sustainable. You need to decrease the energy drain, increase the recharging, or better yet: BOTH! Although my experiences differed from the medical professionals experiencing a “surge”, my energy was being depleted faster than it could be replenished, which is a path that always leads to burnout.

My heart goes out to all of those people, maybe even you reading this, who are in a perpetual burnout state. I hope that in reading my story, you not only can relate, but can also be inspired to try to get yourself out of this unsustainable and joyless state of being. As it appears at the time of this writing, the pandemic stressors aren’t going anywhere for quite a while, so now is as good of a time as any to acknowledge your burnout, without judgment, and ask for help. If you think that I can help you in any way, reach out and let’s start the process of turning it around. I hope that together we can become “pandemic-proof” from here on out.

*Many larger organization have an EAP in place, and usually employees can get counseling free-of-charge, at least up to a certain amount of sessions. Contact your Human Resources (HR) department to see if you are unsure if your employer offers such a valuable resource.

DISCLAIMERS: 1) The views expressed here are my own and do not necessarily represent the views of my employer. 2) There are no conflicts of interest to report. 3) I don’t know what I don’t know, so feel free to message me if you don’t agree with something that you read.

KEYWORDS: #burnout #doctor #APP #nurse #pandemic #medicine