The quit before the quit: Exit strategies for burned-out doctors

Mid-afternoon in early March, I sit at a neighborhood café, stiffly enrobed in a long down coat zippered up to my chin. The impotent light of late winter offers nothing to sufferers of seasonal affective disorder. Hot tea with honey soothes virus-battered mucus membranes. The café is a fluorescent-lit landmark, close to the hospital and frequented by healthcare workers downing a quick lunch. The menu of the past two decades holds fast to soup (salty) and sandwich (fresh) combos. My gaze floats past the café’s picture window: a frosty pane framing another long tail on another long winter. I keep watch for Erin, my friend and colleague. Heads huddle nearby, urgent conversations about work, the healthcare system, the fatigue. The rhythm, only occasionally punctuated by a staccato of irritability, is predominantly resigned. There are tears. No one supposed we would land here, back when the pandemic could have been a portal. Sipping my minty tea, I encourage my shoulders to relax; press my Sorel-clad feet into the floor, searching for solid ground. There is Erin. Her face is a betrayal, line by line at the mouth and eyes, of worry and bewilderment. Her skin is crinkled in new places. The lines only deepen as she navigates muddy parking-lot slushpiles. Then she sees me and shines a big smile—pretending. She hefts the heavy glass door open in a swirl of snow dust. I feel no less than a surge of love. After a quick hug that still feels covidy, we huddle over a scarred wood table to join in the chorus of despair that surrounds us. Nurses, doctors, social workers and hospital staff, all singing a melancholy tune that sounds like loss. Loss of what? Optimism. Trust. Meaning. In so many cases, our own health. Yesterday, a medical student’s eyes welled up after an encounter with a sweet man deep in suffering. I showed the students how to examine the tired bones of his emaciated wrist. When our patient, homeless, reclad his gaunt body in its many layers of protection, we stood by, silent. Once he had hobbled, clutching his torn shopping bags, out the door to the snowy sidewalk, we talked about tears. And they shed some, but I didn’t. To be present for the patient, I stoically advised the shaken students, put your feelings in a basket. Gently now, tuck them under a blanket. All the feelings: fear, disgust, and horror; grief and disbelief; dejection and despondence; sorrow and despair. Wrap them up in cotton muslin, preferably organic, better for the planet. Then, I counseled, be sure to open the basket and give them air, those feelings, lest they fester like a wound left too long under a ragged dressing. I carried on, imagining the students to be enraptured by my sage advice: Punch those feelings around like bread dough. Run them like restless toddlers after a long car ride. I droned on, inspiring myself to the edge of absurdity, don’t forget to be vulnerable but not too vulnerable while observing yourself with non-attachment. Finally, take 10 deep breaths—focus on the exhale—say 10 hail-Marys, perform a perfect downward dog while listening to a Stoics podcast, meditate in a cross-legged posture that makes your hips scream in pain, then put those mewling feelings back to bed. Presto change-o. Ready to doctor for 24 hours in a row! What, you might wonder, is so absurd about self-care? Well, even if the emotional impact of caring for other humans in deep distress could be processed and baked into something good, the resulting pastry still depends on having the time and space, not to mention the equipment and labour, to do the baking in the first place. I’ll say this: Doctor-parents are not known for their bake sale contributions. Yet without the airing and proofing, all of those stashed-away feelings mould and fossilize in their neat muslin-lined bread baskets, stacking up over the years in the anaerobic basement-pantries of our souls. Erin and I sip our tea. The café sounds like a COVID ward; incessant coughing; mucusy honking and dribbling. “I can do hard stuff,” notes Erin. No kidding, I muse, thinking of a popular cartoon from April of 2020 depicting a meek, white-coated doctor facing a group of superheroes who quip, “Welcome to the Club!” Erin lists her hard things: Three years of COVID hell in a chock-full urban hospital. Also, cholera outbreaks, travel to refugee camps, and staying up all night at least twice a week. I was relieved when she did not say, ‘having coffee with you.’ I point out that all those hard things were for a good cause. Take, for example, grinding fresh coffee beans by hand: very different than the incessant grind of being asked to do things that are not only hard, but well-nigh impossible, for causes we don’t buy into and with zero back up. I’ll take a little forearm burn for a bittersweet psychoactive beverage, but a chronic migraine to appease the clinic manager? No thanks. I’ll take coffee—and patients—anytime over paperwork, passwords, new software, or the latest information technology. Half my day is over by the time I authenticate, duplicate, collaborate, document, sign, send, fax, phone, keep track of, bend, bend some more, and bend some more still. Until, uh-oh, we broke the doctors. Self-care in doctoring is an obsolete notion these days, with zero chance you’ll have time or emotional bandwidth to lift the lid off your bulging basket of feelings and horrors. If, emboldened by a long weekend off, you brave a peek: Yikes! Close it again, quick, before the monsters devour your first weekend off in months. Erin is a deeply compassionate physician, still a decade from when she expected to retire. Having subjected herself to more than 10 years of taxpayer-subsidized post-secondary education to gain unique and specialized skills, knowledge and attitudes, she’s since cared for thousands of patients. So much to offer, even now, if only she could give it to people instead of the insatiable shark that is paperwork, admin-work, grunt-work, and make-work. Since most doctors, Erin included, are blind to shades of grey, part-time work, and love is love, she tells me matter of fact over mint tea with honey in a homey coffee shop, that she’s going to quit. “It’s not the patients,” she apologizes. It never is. The truth is that every doctor I know is looking for a way out of a system that expects more and more for less and less. We are stuck in some ways: doctors are, for obvious reasons, not allowed to strike or enact other job action. Yet, the kind of buckling pressure we bear demands dispersal . . . no, reversal: A system is supposed to support individuals, not the other way around! Yet, that is exactly what doctors have been doing while health ministers, complacent administrators, regulators, and other conspirators wring the living daylights out of us. We are not between a rock and hard place, because that would signal an enjoyable day in nature. Rather, we are crouching behind a gurney sucking our thumbs and whimpering. The doctors, dear friends and neighbours, are not alright. If you find yourself there too, I see you. As someone who still doctors but has de facto (Latin for trying repeatedly to do something that is inane or impossible) left medicine to save her mind and heart, I have some tips for you on how to do the same. Numero Uno: Tell someone you are considering quitting. Do it now. Tell a friend, pillow-talk whisper to a partner, or offhandedly mention to your barista, who not only makes a mean cappuccino but whose soft inquisitiveness cuts through the chafe of your zoom therapist’s psychobabble. Just say the words, “I’m thinking of quitting medicine.” Finito, bandito. Going surfing, traveling, crocheting, whatever blows the wind up your skirt. In my therapist sister’s words (we grew up on the prairies): “Not my pig, not my farm.” Next: Take time off. Not a vacation, which requires executive function you cannot spare. Call in sick for two weeks. Instead of wishing for a nonsurgical lower leg fracture, Call. In. Sick. For a week or two. To sleep, putter around, and get some seeds started for your garden. Swallow some antidepressants while you’re at it. I know, I know. You can’t. There is no one to look after your patients; there are no locums; your colleagues are already over capacity; only a sociopath could possibly dump more on them! I know all those things are true. But do it anyway. Because when you collapse, you won’t be there either. Number three: Count your money. Do you have enough saved to quit? Maybe you thought you didn’t, but after a call to your money person—which you’ve been meaning make for the past 20 or 40 months—it turns out, you do. Or maybe you can (gasp!) work part-time. It wasn’t difficult for me. I simply queried my accountant in a short email that read, “How much do I need to sit beside the river and write sub-par personal essays all day?” Four. Lean out. Quit before you quit. Immediately after returning from your sick time, tell everyone you know you’re taking a sabbatical (See above under “I know, I know.”). After rehearsing an entitled tone in your bathroom mirror, say these words exactly: “I’m taking my sabbatical in the fall. For six months. To do some research.” Don’t tell them it’s to research how to really quit medicine. Particularly if you’re addressing your practice partner who will, understandably, immediately type up a memo to your shared patients advising that she’s taking a sabbatical in the fall, and they should book all their follow-ups with you. “Sabbaticals” are unpaid for most of us unless we are doctor-researchers with loads of academic perks, but during them we also don’t have to do any actual work. If you conclude that you must work to save, to save yourself, then don’t. Cash in some investments instead. Or do some lucrative work stat, maybe botox or laser? Then finish strong with some serious quitting. Your next point of business: Set a Quit Date. We know it works for smokers. Write it on your calendar in flowy pink (not red, that’s angry) calligraphy. Sabbatical. Practice again saying the word ‘sabbatical’ often, because ‘sabbatical’ is more valid than ‘holiday.’ You could even tell some people, like your in-laws, that you’re “doing a program.” Look coy and demure, as though the person should know what that means. Wink for extra effect. Burnout means you are sick and need time to recover from this shit-show of a healthcare system. And to pet the cat. Teach more. Though be aware that this can too be “a system that expects more and more for less and less” (how can you not love an essay that quotes itself?). Teaching reminds us how smart we are and makes us feel important. It also passes hard-earned cynicism to a fresh batch of young doctors. Such as the way in which I coolly advised my students who witnessed the tragedy of homelessness to stuff their emotions into a metaphorical baby basket with a tight-fitting lid. The ways in which one can quit before they quit are endless. Apply for a leadership role that pays actual money and has a short but renewable contract. Negotiate for additional hours. Say, “I am someone who knows my own value,” during the negotiation. Do so only after they offer you the job, not before. See also “a system that expects” above, under “teach more”. The nudge method is next. Start filling a lot of time with other things that you love, which can make you forget even the most anchored habits, like practicing clinical medicine and infinite scrolling on Twitter. Heed the top-shelf science that concludes meandering through mountains and nurturing social connections, including of the most intimate variety, will prolong your life. Allow fun things to edge out incessant emails, Facebook, doom-scrolling and news-watching. If fun starts to encroach on medical work, well that’s kind of the point. Book fewer patients and book each one for longer. Chart less. Chart far, far less. Asked to sit on a committee? Politely decline but recommend a colleague. Someone whose job it is to sit on committees. I lost track of what number this is on the list of tricks and tips for quitting medicine—quitters are plump with wise advice! Nor is math one of my many strengths—you don’t really need it to be a doctor anyways. There are so many choices because, like all things scientific, there is no single right answer. Choose from a glorious array of options; make a collage! Nothing is linear. Go with the flow. Write much less email. You will notice an immediate positive change in that you get less email back. Get a creature or two. Strolling behind a bounding labradoodle on a snowy day bumps endogenous endorphins better than a double dose of duloxetine. Pet the cat some more. Try episodic care! You can bring your best healer-self to each patient for 10 or fewer minutes, without the garish expectation of continuity of care to drag you down into chronic hypertension management. Try virtual care! You can wear your PJ bottoms and slippers with your cat on your lap. Episodic and virtual care both elegantly bump aside clinic, hospital and committee time. That’s good! Unfortunately, they still require gobs of paperwork, passwords and fobs aplenty, and are heavily laden with both glitchy tech and that largest of inconveniences, people. But do not fret, fearless one. You have it in you to be a quality quitter, I promise. As you lovingly arrange your ‘I Quit’ collage, make sure to create the illusion of being very busy. Vary your schedule and activities so much that nobody, including you, grasps that most of your time is spent sitting at your dining room table painting watercolour flowers. Be nimble and keep it under wraps. We can’t have a mass exodus just yet mostly because I need my own family doctor to continue to work at least until I’m through the menopause. By now you’ve surely taken all my clever advice and built your collage, your map to freedom, a pathway to happiness. The dough should be rising. But wait. Your yeast expired and you still can’t find your way out of the soul sucking drudgery of clinical practice? Locked in, head down, shoulders hunched, slogging through 50 or so lab results? At this juncture in what has become a hodgepodge musing of mixed metaphors and home baked bread, I must pause to admit: When I should have, I implemented none of these evidence-based interventions and always felt too guilty to try. I always thought it would just get better tomorrow. I was too tired to buy fresh yeast. My final recommendation, therefore, is that if all else fails, get yourself fired. This tried-and-true method is nothing less than a shortcut to freedom. It’s easy, just say out loud some of the words you think of late at night when you can’t sleep, to the people that haunt you—or at least annoy you a great deal. Say them kindly of course, but with feeling! Then do not worry. People get fired all the time these days. It’s de rigeur in the business world, which is probably the career you regret not having chosen in the first place. Caveat: Do this manoeuvre only after you’ve attempted methods one through whenever this essay, much like my medical career, rapidly decompensated. Or done a thousand laser hair removals, whichever is sooner. Once fired, get a haircut which you probably need by now. Then slip into Birkenstocks, with or without socks, and buy a bookstore/gallery/scotch tavern in a quaint mountain town. Try slipping on your favourite germ-collecting necktie and going back to business school. Whatever brings you joy; I won’t judge. I meditate all the time. If I had one regret, I wish someone had suggested some of the less dramatic exit strategies to me earlier in my career. That way, when I did get fired, I could have enjoyed myself instead of banging on the door to the dungeon, begging to be let back in. Sometimes we fall in love with our oppressor; get addicted to poison. We are human after all. The truth is that there are no lifeguards for doctors. Not to whine, whinge or whimper, but we are expected to tread water not for five minutes for the Bronze cross or whatever, but forever. I therefore anoint myself doctor-lifeguard and grant every physician permission to walk, or swim, away from the impossible tasks you are asked daily to perform. My own daily practice of fake-quitting has, in fact, helped me be a better (non)doctor. To conclude I would like to address exhausted Erin and two tender-hearted medical students in my homeless serving clinic; and, by extension, all doctors both wizened and fresh. I hope you can look up and around for long enough to see your myriad choices beyond “all or none.” You are human beings, after all. I entreat you to see your own value and quickly lean out before you find yourself having to tap out altogether. Paul Simon’s ‘50 Ways to Leave your Lover’ was the soundtrack to the writing of this tale meant to convince you—through baseless fact, bad attitude, and innumerable poor examples—to ponder how you too can leave a “lover” that takes and takes and gives little in return. You might even emerge with a custom-pasted collage that you did on sabbatical, and find you still want to be a doctor. No matter how you land, you will always be a healer. Hopefully of yourself first, and then of many, many others. In the meantime, we can just slip out the back, or make a new plan, while the engineers and elves repair the engine. But no matter what path you choose, Jack, Stan, Jane, or Jo, just get yourselves free. If you are struggling with mental health, thoughts of self-harm, suicide, or premature retirement, please know that you are not alone and there is help available. CMA's Wellness Support Line for Physicians: https://www.cma.ca/supportline Dr. Bonnie Larson is a clinical assistant professor in the Department of Family Medicine at the University of Calgary, a preclerkship educator at the Cumming School of Medicine and lead for the Calgary Street CCRED Collaborative.

The quit before the quit: Exit strategies for burned-out doctors

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