Burned out on burnout

“I know how I’m going to die. It’s in a tin can of a plane at an altitude so low that birds will see the whites of my eyes as I go down screaming. Whichever nondescript great lake abuts Toronto and Rochester—okay, Lake Ontario—that’s the lake I’m dying in, today, on this plane.”So begins Dr. Jillian Horton’s 2021 book We are all perfectly fine. A memoir of love, medicine and healing. At the time, she was on her way to Chapin Mill Retreat Center in Batavia, N.Y., halfway between Rochester and Buffalo.Dr. Horton had initially focused her energy on medical education, however over time, she experienced a profound shift in perspective. Inspired by the work of Stanford medical educator Dr. Kelly Skeff, who highlighted the need to care for faculty and practising physicians, Dr. Horton realized there was a significant void in addressing the well-being of those tasked with nurturing the next generation of doctors.This realization prompted the general internist to reflect on her own professional life and the pervasive nature of burnout in medicine. A turning point came when she attended that evidence-based program at the University of Rochester, designed to equip physicians with tools to navigate the complexities of their work environments.Now the best-selling author has started “Conversations with Jillian,” a video and podcast series sponsored by the Royal College of Physicians and Surgeons of Canada.Dr. Horton spoke to the Medical Post via video from her home in Winnipeg, delving into her journey and sharing insights into combating physician burnout.Q: You’ve talked before how the “type A” characteristics of doctors may explain why burnout is more common among physicians. Anything else behind this?Well, also our systems have expanded and changed at a rate that is far more rapid than anything we can process. Medicine has changed so much in the 20 years since I finished my fellowship. So you look at the people, the rapid change, (plus) the decisions that we’ve made in terms of where we’ve put our money in the healthcare system. And you can start to see how all of these things create the circumstance for the most perfect storm for highly conscientious people who are driven to do a lot of good to suddenly say, “I cannot do anything and my personality and the environment that I’m trying to work in are actually the worst possible match.” You know, the most driven people working in the most dysfunctional systems may actually struggle more with acceptance, being able to adapt and being able to change their cognitive or emotional stance in those moments.Q: A physician friend said she’d been through a period of burnout trying to keep her small-town ER going. So it is almost like perfectionism: a high degree of responsibility and not being able to practise medicine the way you feel it should be. There’s this weird, if you can’t do it the best way, it’s hard to “half-ass” it.I totally agree. An analogy I sometimes use is: Imagine that you’re a neurosurgeon trained to put in a drain in a very sophisticated way in a tertiary care centre. And then, suddenly you are asked to go do that same procedure out in the middle of a baseball field with a corkscrew and a bottle of vodka. It sounds absurd, but it’s actually not all that off base. We sometimes talk about it as a moral injury. I do think moral injury is a term that has been so overused—maybe almost like burnout.One other thing I would add is we’ve had a long history of medical exceptionalism: being unwilling to acknowledge the ways in which our physiology is identical to the physiology of most other human beings on Earth. So, failing to acknowledge that profound sleep deprivation also has profound impacts on our performance, profound impacts on our mental health, profound impacts on our mood and our reactivity. And I think that is another shift that I see that is really a long time coming: reframing those types of considerations as occupational safety issues. Medical exceptionalism has long prevented us from being able to say: “You know what? I don’t think I’m safe when I’ve been up for 24 hours.” (You get back:) “What? You’re not safe. Well, nobody else is saying they’re not safe.” So this must (mean), “You’re not strong enough. You’re not good enough, You don’t have what it takes.” And again, I think we’re moving slowly but surely into a more reality-based conversation about what it means to be human, not just physically, but emotionally, in this profession.Q: We have a healthcare system that is struggling, and people lose their mind when they are having a hard time and are told, “Oh, here’s an online wellness exercise.”Totally. And it’s actually an affront, right? I’m really glad you said that. In my book, it talks heavily about my own experience with learning skills related to mindfulness. And I get to do a lot of speaking and work with different groups all over North America, and sometimes when I go, I know for sure there are people who think, “Oh, great! She’s going to tell me that mindfulness is going to fix my life.”I am never going to tell anyone that mindfulness is going to fix their life! And specifically, I’m never going to tell an organization or anyone working within an organization that that organization should (promote mindfulness) as their primary approach to physician wellness and the crisis that we’re facing right now.Mindfulness is important. It’s had a huge impact on me and helped improve my quality of life immeasurably. But it’s a personal decision to engage with that.I get where people start feeling angry. “You’re telling me to make myself more resilient. What? So you can just pile more work onto my back so I can be immune to all the things that are happening around me?” That’s, I think, where some of that tension comes from, and I often relate it back to Maslow’s hierarchy of needs. When we say to people, “It’s Staff Wellness Day: Here’s a hot dog.” People (see) there’s such a mismatch between that and what people are experiencing. This just tells (someone), “You don’t see me. You don’t see what’s happening to me, what my needs are.” (It’s) adding insult to injury.A lot of my work with groups is around when they’re going to roll (programs) out and trying to begin to address where people are at. Then at least, we can contextualize, even if we are going to offer people programs relating to deep breathing, mindfulness, self-regulation, etc. Again, these programs have a high degree of value. (But) we first had better spend time explaining to staff: “We’re not doing this as our only thing that we’re addressing. We’re doing it as one offer as part of a multi-phase component.” The truth is, in healthcare, most organizations are not at that stage of a multi-pronged approach.Q: I hear you. But people may say, “My problems are because our hospital doesn’t have enough staffing.” There are many system issues that are beyond the control of a physician leader.Well, two things come to mind. The first thing is the personal piece for all of us working in this system. One of the best quality of life things we can possibly do for ourselves is learn to manage our own reactivity. If during the course of a day at work, my reaction is a 10 out of 10 every time something goes wrong, every time I have to deal with a frustration, the person who that actually ends up costing the most at the end of the day is me, because I’m going to have nothing left to devote toward the things that I must deal with and get through my life.We have to . . . control what we can control. This means asking ourselves: “Is there anything I can do to better manage my reactions in the clinical environment?” Because if I’m setting the emotional tone for others in a way that’s unhelpful, it’s not serving them or me. Emotional contagion is real, and managing that is just part one—the microcosm.From a systems and strategy perspective, what can we do? We can make things easier by teaching and providing clear approaches. Organizations like the CMA are already working on national initiatives to build this kind of literacy. For example, when healthcare workers voice concerns like “the EMR is (challenging); the leadership in my facility is impersonal and nobody acknowledges me. I don’t even feel respected or cared for,”—well, leaders need to understand how to incorporate these issues into a broader, systems-based approach. They need to connect the dots and see how these problems impact physician health, healthcare worker well-being, and professional fulfillment. A good leader or decision-maker should be able to say, “Here’s where this issue fits, and here’s how it connects to the larger picture.”You know, in medicine, we have schemas for almost everything we do. Whether it’s heart failure or kidney failure, our training provides us with diagrams, flowcharts or models that help us organize and address each patient’s problem systematically. And I would just point out that (we) struggle to have anything like that when it comes to an approach to physician well-being.(So) when a hospital wants to offer resilience training—that is part of personal resilience. But it’s important to recognize that personal resilience may only account for 10% of the (broader) problem.The key is being able to place these concerns into their respective categories, understanding that addressing physician well-being requires a systems-based approach. It’s not just about resilience training or Staff Appreciation Day. It’s about creating a sophisticated, evidence-based strategy grounded in literature—something foundational and actionable, not a series of ad hoc measures.I would note, as others have, that most hospitals, every cohort, every group, now have wellness leads. However, they don’t have a common vocabulary. They don’t have a framework for where to start or how to repeat. So those are some of the problems I see.Q: Reframing can help doctors address burnout?There’s a concept often discussed in work: Is it a job, a career or a calling? When it comes to burnout, people sometimes think, “I don’t feel like it’s a calling anymore, so I’m burnt out.” But I say to people that, throughout the day, this can shift. At 9:30 a.m., what I’m doing might feel like just a job. By 11 a.m., it’s part of my career. By 2 or 4 p.m., it might connect to my sense of calling. We can be (in medicine) pretty rigid in our thinking—and that is OK if that is just right here and now. That’s why mindfulness is such a beautiful complement to working through the reality of doing a really difficult job. “Right now, I feel this way. I love this part. I hate this part.” But I’m going to work with it a bit more non-judgmentally.How can I be more able to tolerate what is sitting on me like a rock? Can I actually be curious about it? Can I start to say, you know what? Maybe I’m labelling and this is not helping. Maybe there’s another way to look at it.This connects to the stories we tell about our work. Behavioural psychologist Adam Grant popularized the concept of task perception: Is a bricklayer merely laying bricks from 9 to 5, or are they building a bridge that will connect communities for generations? Which story is more motivating? That’s great research that shows just talking about something—“I love my dog. I love writing”—illuminates the reward centre of the brain.Ultimately, a multi-pronged approach is essential. Focusing solely on personal resilience or reframing stories isn’t enough—it can even harm if it’s the only strategy. But as part of a broader, evidence-based, systemic approach, it becomes a powerful tool. Mindfulness, I believe, has the power to influence our perceptions and our experience of working in this profession.

Burned out on burnout

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