“Burnout? In rheumatology fellowship? You’re kidding me, right?” That was the response of one of my very good friends from residency who is now a cardiology fellow, when I told him that I was concerned that one of my co-fellows, at another institution, was on the verge of burning out. Stepping back, I could understand his skepticism. After all, as the now-classic The Rheumatologist article (July 2012) by James O’Dell, MD, says, “rheumatology is the happiest specialty.” Looking back, when both my friend and I were residents, we looked forward to our rheumatology electives because they were more educational and less demanding, leading to the nickname “rheumat-oliday.”
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But the more I reflected and the more I researched, the more I recognized that burnout is a danger that all fellows, including those training in rheumatology, are at risk for. Burnout is endemic within our profession, but we scarcely talk about it.
With that in mind, here are six ways to identify and deal with burnout. Know that:
Burnout is a work-related syndrome, not a mental condition: There’s an implicit connotation when talking about burnout that it is somehow linked to depression and anxiety. But even though the outward signs may appear similar, the root cause is completely different. As far as the science of psychiatry can inform us, depression and anxiety are conditions rooted in biochemical imbalances and structural phenomenon in the brain. Burnout, on the other hand, is a work-related syndrome, causing a depressed mood and anxiety, among other symptoms, that resolve when the workplace is removed. Think about burnout as you would work-related asthma or tendinitis due to repetitive mechanical stress. The difference? Burnout involves the mind.
This distinction between burnout and mental illness has incredibly important implications. First, it means that even though counseling and antidepressants may be helpful, they do not get to the root of the problem. Second, we have to remove the stigma behind burnout (along with depression and anxiety). Burnout occurs because of a poor fit between the worker and the workplace, not because there is something inherently weak about the physician.
Burnout is a smoldering fire, not a dramatic explosion: Burnout is an unusual term to describe this phenomenon, because it really depersonalizes physicians as pieces of wood or candles that are ready to be incinerated. But at the same time, it accurately describes that burnout isn’t an event; rather, it’s a slow process that starts almost imperceptibly for both employee and employer alike. We know from studies that burnout starts in medical school, if not earlier, and continues throughout graduate medical education and beyond. With that said, when it is not recognized early enough and is allowed to grow, it can come to a point where it becomes an explosion.
Emotional exhaustion, not excessive work, leads to burnout: Another misconception about burnout is that it is caused by excessive work. That’s simply not true. People can be extraordinarily productive when they are in settings that are supportive and conducive to personal satisfaction. At the same time, when physicians feel stuck in places where they can’t do as much as they would like to do or are performing tasks that they really do not want to do, it leads to emotional exhaustion.
Among physicians, there is an additional danger: moral injury, when we incorporate the pain of others into our own lives. For rheumatologists, who treat chronic disease, this can be debilitating.
Burnout doesn’t just hurt physicians. It hurts patients, too: Physicians who continue to trudge along, burning themselves out in the process, don’t just hurt themselves. They hurt patients, because they are unable to do the things that patients rely on them for. Even the most basic obligations, such as establishing rapport, become so difficult once physicians are burned out. And, in our field, where creativity and thinking outside the guidelines are so vital for successful outcomes, burnout can lead to incredible harm. Therefore, the need to look after ourselves and our colleagues is a vital aspect of professionalism.
Personal satisfaction protects against burnout: Unfortunately, there is no quick-and-easy antidote for burnout. In the quest to keep burnout at bay, physicians have to look at what brings them satisfaction, both at work and at home. Rheumatologists have a built-in advantage in this regard, because we can see the fruits of our labor in decreased joint swelling and less disability, but it requires that we actively observe these successes. Just as important, in order to prevent burnout, or even reverse it, we have to invest our time in doing enjoyable activities far removed from the clinic and the hospital. It may sound like a very technical way to say “get a hobby,” but it is exactly that: an investment in one’s own happiness. The bottom line is that we have to maintain a passion for something, regardless of what it is, in order to stay motivated.
Recognize signs of abuse, and formulate an exit plan: Burnout is serious, and sometimes an environment can be simply so toxic that there is no other option but to get out. Unfortunately, there is no clear line that differentiates an unsupportive environment from a hostile one, but once an environment crosses into overt hostility, and its workers are subject to abuse, there simply is no return. Signs of abuse, including depersonalization, a lack of respect for boundaries, and predatory deprecating practices by supervisors, should not be overlooked. Instead, they should be noted carefully, and strategies should be implemented to counter the abuse. At its extreme, an exit plan may need to be formulated.
Finding a job elsewhere, transferring out of one fellowship to another or leaving medicine altogether are options that may not seem favorable but may become necessary to prevent or reverse burnout. As mentioned earlier, burnout is something that demands a strong defense, and sometimes tactical retreat is the only option.
Burnout is clearly something that most physicians are uncomfortable talking about. There is a connotation of weakness and mental illness that is borne of misconceptions. There’s a medicolegal aspect as well that prevents physicians from speaking out against hostile work environments that lead to burnout. But we have to talk about it. We have to talk about it because letting burnout occur to physicians privately and in isolation leads to tragic consequences for our profession, our specialty and our patients at large.
Bharat Kumar, MD, is a second-year fellow at the University of Iowa pursuing a dual-certification pathway in rheumatology and allergy/immunology. Dr. Kumar has a special interest in medical education, journalism and ethics. Follow him on Twitter @BharatKumarMD and check out his website.