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Tuesday Aug 20, 2019

Bouncing Back From Burnout in Residency

It was my 739th day of residency when it hit me. I knew it the moment the nurse told me there was a multiparous woman who had just rolled into Labor and Delivery "looking uncomfortable," and I got a knot in the pit of my stomach. It was 2 a.m., and I was wrapping up notes from the past 18 hours of work, inching myself closer to those elusive bits of sleep rarely encountered on a 24-hour call.  

Michelle Byrne, M.D., M.P.H., gesturing toward a river

One of the steps I took to overcome burnout was to take a break from technology and spend more time outdoors.

"Ok, I'll be right there to see her," I said.

I began examining the patient's cervix.

"Closed, thick and high," I pleaded with the universe. "Closed, thick and high."

Nope.

"You're at 7 centimeters!" I said. "Hang in there; let's get you over to a delivery room."

I dug deep within myself and delivered a beautiful baby with competence and enthusiasm. It was my 86th time helping bring a new life into this world, but it was the first time I would rather have been sleeping.

Post-call, I didn't pop up out of bed to run or get going on my usual activities. I felt absolutely exhausted. "Am I just tired, or is this burnout?" I asked myself.

The thought of checking my clinic inbox or dealing with emails overwhelmed me.

I reviewed a list I made for myself before starting residency(twitter.com) of truths to remember when things got tough. This seemed like that time.

I shared this list on social media with a note about burnout and how I was feeling. Immediately after I posted it, I began to feel guilty. It is such an immense privilege to be a resident, to be a family physician. Who am I to complain?

A few friends who were starting residency reached out, but my guilt worsened. What kind of role model am I for people who are so excited to begin?

The fact that it is a privilege to be a family physician has not changed. And the fact that I am thrilled to be one hasn't either. Residency is a job that includes tasks I don't enjoy, like any job does. Indeed, many people have jobs made up entirely of tasks they don't enjoy, and they do those things to provide for their family or support their life in some other way. But when we begin to dread things that normally give us joy, it's important to dig into what is going on.

I'm now a few weeks removed from this experience, with more space to reflect on what contributed to my period of burnout.

A few months before this experience, one of my faculty members asked me how my class was doing, mentioning that we "looked tired."

An intern chimed in, "But not Michelle, she's fine!"

I laughed it off, but I thought about her comment for a while. Was I fine? Was I somehow cruising through residency, making it look effortless to her?

A few hours later, I observed a poor obstetrical outcome, which eventually led to the death of a newborn. Although the logical part of my brain knows I couldn't have done anything differently, the case continues to haunt me. Was this the start of my burnout?

The trauma we witness piles up on us. Some of this trauma is unavoidable, including tragedies like newborn deaths that happen for reasons we will never understand. Accompanying patients through this, no matter how meaningful that may be, takes an emotional toll on us.

Yet it is the tragedies resulting from our broken health care system -- the ones that are avoidable -- that hit me the hardest.

It's the patients who can't afford their medications despite working multiple jobs.

It's the moms who know their kids need more exercise but don't feel safe walking to the park because of gun violence.

It's the families undergoing unfathomable stress because there are Immigration and Customs Enforcement raids happening on their block.

It's the monthslong wait for physical therapy for uninsured patients with work injuries.

It's the letters and forms and phone calls to insurance companies we pursue to make things happen for patients without resources.

Because in these situations, it's not only the suffering and sadness that weighs on me, but also the frustration (and sometimes rage) that this is the reality our patients are facing.

On top of this, our country continues to demonstrate a gross neglect of primary care, placing family physicians in an impossible position. We simply cannot provide the care that patients truly deserve with the limited resources and time we're allotted. When your one-liner is: "This is a 55M with a pmhx of HTN, HL, CAD (3V dz with 2 stents in Feb 2019, on DAPT), insulin-dependent DM coming in with sob," I think it's safe to say you're not going to finish the visit in 15 minutes.

Documentation piles up. Meaningless tasks suck up our time and energy, leaving us less of both for our patients. As my visits per day ticked up throughout residency, I began to feel the crunch. I now recognize that I'm often unable to provide the care I believe chronically ill patients with complex social situations deserve in the time I have available for them. When clinic begins, it often feels like I'm at the starting line of a race, trying desperately to get everything done without getting behind. By this metric, I fail more often than not.

Yes, being a doctor is a privilege.

Yes, I am grateful to do this work.

Yes, it is a gift to share in some of the most important moments of my patients' lives and partner with them in their pursuit of a healthy life.

I came into medicine ready to get in the trenches and learn to provide primary care to complex patients in vulnerable populations. I am still that person, and that is still my plan. I also recognize that after two years I am already tired because providing the care I dreamed of is currently an impossible task.

Many things contributed to my burnout: I had come off a stretch of service months, covered more 24-hour calls than usual in a short span and neglected some of the things I know keep me grounded. When I realized burnout had hit, I took swift measures to take care of myself. I leaned into my community, spent extra time outdoors and took a few days away from technology.

I also attended the AAFP's National Conference of Family Medicine Residents and Medical Students, where I reconnected with family physicians doing incredible work across the globe and continued to work on policy changes in a number of arenas that promise to alleviate some of the strain family physicians currently feel.

Finally, I recalled times I was inspired by the opportunity to be a part of this beautiful mess we call doctoring.

I am feeling reenergized and reinvigorated. I'm also sure those negative feelings will come again. This post is a reflection, not a game plan, and I don't intend to solve anyone's problems today. (It's worth noting, though, that the AAFP offers a multitude of resources related to burnout and well-being as part of its Physician Health First initiative.) But I am choosing not to feel guilty about acknowledging burnout, even to excited interns, because if they don't realize this work is difficult yet, they soon will.

We need to be honest about periods of struggle so we can support each other in immediate ways while also continuing to push against this broken system together. I'm looking forward to delivering babies again this week, just as I look forward to collaborating with any burned-out family doctor who is working to rebuild the health care system into one that works better for both patients and physicians.

Michelle Byrne, M.D., M.P.H., is the resident member of the AAFP Board of Directors.

Posted at 05:15PM Aug 20, 2019 by Michelle Byrne, M.D., M.P.H.

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