Dx: Burnout

burnout

Author: Brenda Varriano

Guest Author: Jason M White

What is Burnout?

Most of us have experienced some component of Burnout in one shape or another. I know that I myself experienced burnout while preparing for my STEP 1 shelf exam. While I was able to hit my goal, I experienced immense fatigue and mental fogginess for weeks following. Fortunately, I recovered.

For those who are curious if they have experienced Burnout, the AAMC defines and measures it by three indicators: 1) emotional exhaustion associated with work-related stress, 2) feeling of detachment toward patients and 3) a low sense of personal accomplishment. Though I was not in my clinical rotations yet, my feeling of detachment resonated into my personal life and relationships.

Introducing Dr. Jason M White

Dr. Jason M White is an Emergency Medicine physician with over 30 years of clinical experience.  He has almost a decade of experience at the C-suite level as a Chief Medical Officer (CMO). His administrative responsibilities have included Medical Student and Graduate Medical Education, Quality, Physician Relations, Trauma and Emergency Services. His expertise includes Wellness, Patient Safety, Coaching, Leadership Development, and Patient Experience. He is a board certified by the American Board of Emergency Medicine (ABEM) and the Commission of Medical Management. He is a Clinical Assistant Professor in the College of Medicine at Central Michigan University and has over 40 years of experience teaching medical students and residents. It is with great pleasure that I introduce Dr. White to the iEM community to discuss his experience with Burnout.

Figure 2: Dr. Jason White

Q: What is your experience with Burnout?

The relationship between the specially of Emergency Medicine and Burnout goes back for almost half of the century.  When I was in residency 40 years ago, Burnout was already a major topic of discussion.  In fact, we used to joke that our residency program was so advanced that we graduated already “burned out” after just three years of training. 

In addition, you must remember that early in the history of the specialty many practitioners of Emergency Medicine were itinerant Physicians or Physicians from other specialties since there were few accredited Emergency Medicine residency training programs until the late 1970s.

Therefore, much of the longevity and Burnout data at the time was skewed by the presence of Physicians who were transitioning either into or out of their medical careers. I remember seeing data at that time that said that the average emergency physician only practiced for 7 years.

Nonetheless it put the topic of Burnout on the radar screens of the specialty very early on and I believe for this reason became part of the foundation of the curriculum of our specialty and much discussion.

I don’t believe that I personally experienced Burnout during my clinical career.  However, I saw many of my colleagues floundering in the specialty and experiencing Burnout.  In many ways the emergency Physicians are the canaries in the coal mine.  If our work environment is toxic and unhealthy, we may be among the first to demonstrate symptoms.  Much of the emphasis around Burnout has been focused on the individual practitioner which is appropriate.  However, it is an incomplete picture if we don’t also consider the practice environment as a significant component of the problem of Burnout.

Q: What are tactics to avoid Burnout?

I believe that there are several excellent tactics which have had success in helping practitioners to avoid Burnout.  The basics are all about self-care.  We all need to eat healthy, exercise and get an adequate amount of sleep.  However, the specialty of Emergency Medicine, by its very nature, is in direct opposition to those fundamental aspects of self-care.  The hectic, unpredictable pace of the emergency department makes it difficult to eat right or even at all sometimes.  The varied nature of shiftwork and swinging shifts is the enemy of developing good sleep patterns and regular exercise practices.

These foundational factors make it even more important that we understand the factors that contribute to Burnout, the symptoms of Burnout and the ways of preventing, avoiding, and healing from Burnout.

Q: What makes a good Wellness program?

There are as many definitions of Wellness programs as there are Wellness programs. One of the challenges of starting Wellness programs is not everybody has the same definition.  I can’t tell you how many times I would try to discuss developing Wellness programs with hospital administrators, and they would already have their own biases and oversimplifications of what successful programs work.

The conversations would quickly devolve into talks about having New Year’s resolution inspired weight-loss competitions and offering $25.00 gasoline gift cards as incentives.  Or they would quickly default into discussions about yoga classes and barriers to participation and cost. 

Unfortunately, much of the literature around the topic of Wellness has been done in industrial and manufacturing environments where employers may be self-insured and are interested in saving money on their Health Insurance costs by supporting stop-smoking programs or weight-loss programs.

So, the first step is to understand that Health Care providers need a different approach than the manufacturing community. In addition, much of the literature about Burnout in the healthcare environment is anecdotal.  This is what we did, and this is how it worked.  The bias is to report the elements and components of what are perceived as successful programs while never reporting failures.

In addition, the endpoints of success are highly subjective, challenging to reproduce, and often lack sustainability. For these reasons, we need both better design and better execution of the studies about Wellness and it must be focused on the Health Care community.

I believe that a good Wellness Program for Healthcare Providers should include the following elements at a minimum:

  1. Acknowledge that we are all at risk for Burnout.
  2. Educate ourselves about the symptoms of Burnout in ourselves and our colleagues. [see Stages of Burnout]
  3. Preform self-assessments on a regular basis (probably quarterly) to identify at risk areas in our personal lives. [see Gazelle, Wheel of Life]
  4. Educate ourselves on successful strategies to address our at-risk areas and tailor them to our unique situations. [see Being Well in Emergency Medicine: ACEP’s Guide to Investing in Yourself]
  5. Develop a written plan for how we are going to address our at-risk areas.
  6. As leaders, educators, and administrators, we must make the “coal mine” as healthy as possible and create an environment of support and emotional safety. We can also provide resources and advisors to assist practitioners in their self-assessments and creation of their personal Wellness plans.

Q: This last question is for fun. I know the quote below is from your medical school interview. Does it still hold true?

Yes! Absolutely still true! However, I might modify it slightly and change it to: “Because I love medicine, I want to help people, and I want my life’s work to have meaning.

Thank you, Dr. White, for taking to time to share your experiences and research on EM Burnout and physician Wellness. I learnt a lot, and I believe, we are acknowledging what will be a shift in how medicine is practiced over the next few years.

References and Further Reading

Cite this article as: Brenda Varriano, Canada, "Dx: Burnout," in International Emergency Medicine Education Project, January 5, 2022, https://iem-student.org/2022/01/05/dx-burnout/, date accessed: July 4, 2022

Things you should know about wellness and emergency medicine

things you should know about wellness and emergency medicine

In this episode of Coffee Chat With Emergency Medicine Experts, we discussed wellness and emergency medicine for medical students. Dr. Tracy Sanson, Dr. Al’ai Alvarez were the guest speakers of this episode. Dr. Janis Tupesis and Dr. Arif Alper Cevik were the co-hosts of this unique session.

Dr. Sanson and Dr. Alvarez shared their experiences and lessons learned during their career. We believe medical students and junior EM trainees can learn many from this episode.

Want More on Wellness?

burnout
Brenda Varriano, Canada

Author: Brenda Varriano Guest Author: Jason M White What is Burnout? Most of us have experienced some component of Burnout in one shape or another.

Read More »
things you should know about wellness and emergency medicine
iEM Education Project Team

In this episode of Coffee Chat With Emergency Medicine Experts, we discussed wellness and emergency medicine for medical students. Dr. Tracy Sanson, Dr. Al’ai Alvarez

Read More »
Coping with an Emotional Crisis
Sheza Qayyum, Canada

In the ED, we often see patients presenting amid an emotional crisis – whether it’s a panic attack, or a period of extreme anxiety or

Read More »
Who Takes Care of You While You Take Care of Others
Arthur Martins, Brasil

The COVID-19 Pandemic has changed our lives in so many ways that sometimes it is difficult to remember how life was without all these changes.

Read More »
Why Me? The Story of My Burnout - Part 3
Jule Santos, Brasil

The story continues from link (Part 2). I must take a deep breath. I must ask for help. The Self-Knowledge Path I could go away

Read More »
Why Me? The Story of My Burnout - Part 2
Jule Santos, Brasil

The story continues from link (Part 1) I had already been tired and sad. Now, I was also feeling wronged. The Dangers of Burnout It meant

Read More »
Cite this article as: iEM Education Project Team, "Things you should know about wellness and emergency medicine," in International Emergency Medicine Education Project, September 29, 2021, https://iem-student.org/2021/09/29/wellness-and-emergency-medicine/, date accessed: July 4, 2022

Coping with an Emotional Crisis

Coping with an Emotional Crisis

In the ED, we often see patients presenting amid an emotional crisis – whether it’s a panic attack, or a period of extreme anxiety or stress, or a feeling of being overwhelmed. In fact, it is not just patients. We as humans can experience this too, finding ourselves in situations where we feel overwhelmed, unable to deal with our emotions, and not knowing what to do next. For this reason, I wanted to provide some tips on coping with an emotional crisis, that I learned during my psychiatry rotation. In psychiatry, we called these “distress tolerance skills”, which is a component of Dialectical Behavioural Therapy. 

One distress tolerance skill is TIPP – which stands for Temperature, Intense exercise, Paced breathing, and Paired muscle relaxation. 

  1. Temperature: During a crisis, our body may feel hot. So, it can be helpful to come into contact with something COLD. This can include eating/drinking something cold, tapping a cool cloth on yourself, splashing cold water on your skin, standing out in the cold or front of an air conditioner, or holding an ice cube. Whatever is convenient! This will “cool” you down both literally and emotionally.
  2. Intense Exercise: At times, feelings become overwhelming, and you may become full of anxious energy. Performing intense exercise on a daily basis can act as an outlet to release negative emotions and energy and can decrease stress levels. This can be any form of intense exercise, including jogging on the spot, doing jumping jacks, going on a run, or going to the gym. 
  3. Paced Breathing: This is a technique of taking slow, deep breaths. It can heighten performance and concentration while also being a powerful stress reliever with a soothing effect. One way of doing this is box breathing, which actually has evidence for regulating the autonomic nervous system. Here are the steps for box breathing:
    1. Close your eyes. Inhale through your nose while slowly counting to four.
    2. Now, hold your breath inside while counting slowly to four again. Try not to clamp your mouth or nose shut. 
    3. Begin to slowly exhale for 4 seconds.
    4. Now, hold your breath there while counting slowly to four again. 
    5. Repeat these steps multiple times daily, for 5 minutes at a time. 
  4. Progressive Muscle Relaxation: This is a technique that helps to slow down your heart rate and breathing, while also releasing the muscle tension that often accompanies anxious feelings. To perform this, you first tense particular muscle groups in your body, such as clenching your fist, while you slowly inhale. Next, you release this tension, e.g. slowly unclench your fist, while you slowly exhale. 

Focus on what helps you, and encourage patients to focus on what helps them. This may involve identifying problematic ways of coping with anxiety that end up exacerbating anxiety in the long term, such as resorting to alcohol. Other daily things that may be helpful include meditation, yoga, exercise, and getting adequate sleep. Maintaining a routine can be beneficial. Any relaxation exercise of your preference, that helps you be more present in the moment and slow down your thoughts, will help in times of an emotional crisis. Many people find it helpful to keep a journal on a daily basis to collect their thoughts, and to keep up hobbies they enjoy such as sports, hiking, walking, spending time with loved ones, cooking, and so on. I hope you found this blog post helpful, not just for ways to help patients going through an emotional crisis, but yourself too. Feel free to leave a comment below with additional strategies you have found helpful to cope with an emotional crisis!

References and Further Reading

  1. Dialectical Behavior Therapy. (2021). T10: TIPP. Retrieved April 9, 2021, from https://dialecticalbehaviortherapy.com/distress-tolerance/tipp/
  2. GET.gg. (2015). Distress Tolerance. Retrieved April 9, 2021, from https://www.getselfhelp.co.uk/distresstolerance.htm
  3. Scott E & Snyder C. (2019). Tips on How to Cope With a Crisis or Trauma. Verywellmind. Retrieved April 9, 2021, from https://www.verywellmind.com/cope-with-a-crisis-or-trauma-3144525
Cite this article as: Sheza Qayyum, Canada, "Coping with an Emotional Crisis," in International Emergency Medicine Education Project, May 24, 2021, https://iem-student.org/2021/05/24/coping-with-an-emotional-crisis/, date accessed: July 4, 2022

Recent Blog Posts By Sheza Qayyum

Who Takes Care of You While You Take Care of Others?

Who Takes Care of You While You Take Care of Others

The COVID-19 Pandemic has changed our lives in so many ways that sometimes it is difficult to remember how life was without all these changes. We got used to the “new normal”, which includes a constant concern about contamination, economic crisis, and isolation. When we consider emergency physicians and other healthcare professionals, technical and scientific challenges regarding the pandemic response are also added to the equation.

Recently we completed three months since the first case of COVID-19 in Brazil and, since then, more than 300.000 have been infected and at least 23.000 people have died. These astonishing numbers could be 8 to 10 times higher if it wasn’t for under-notification¹ in countryside areas. The psychological effect of these numbers can be seen every day while people try to cope with the situation, and it may be even more intense in those who are in the frontline of the healthcare system. With this in mind, the question emerges: Who takes care of you while you take care of others?

What are the major psychological symptoms we can expect in healthcare providers three months into the COVID-19 pandemic?

After 3 months of COVID-19, we are not dealing with acute and immediate psychological response anymore; this next phase can be called assimilation, where we already understand better the new workflows, protocols and forms of living. However, we are still in a context of insecurity, fear, and loss of control over things we used to know how to deal with. The major psychological symptoms that are expected and considered to be normal in this context are:2

  • Fear (of getting sick and dying, losing people, being socially stigmatized, being separated from people you care about and transmitting the virus to other people);
  • Stress reactions such as anger, anxiety, confusional states, apathy
  • The recurrent feeling of impotence, irritability, anguish, and sadness;
  • Behavioral changes: changes in appetite and sleep habits, and interpersonal conflicts

Which strategies we can use to minimize these effects?

It’s very important to understand these reactions as being normal reactions in the context we currently live in. However, that doesn’t mean there is nothing we can do to ease them. It’s very important to intervene as early as possible as a way to prevent the chronification of those symptoms and progression to psychological disorders. Here are some strategies that can help2:

  • Recognize these feelings and accept them as real and valid; try to talk about them with people you trust
  • Think back to the strategies and tools you used in moments of crisis in the past. When it comes to dealing with difficulties, everybody has some preferred methods, which were tried and worked. Resume those actions that have worked for you and try to find ways of applying them to this new context
  • Keep your social network active by establishing -even if virtual- contact with family, friends, and colleagues,
  • Avoid watching, reading or listening to news that makes you feel anxious or distressed; look for information only from reliable sources
  • Avoid using alcohol and drugs as coping mechanisms
  • Ask for help if you find your strategies inefficient

There are lots of health professionals who are self-isolating from their families to prevent “bringing the enemy home”. How can self-isolation affect our mental health?

Isolating from family and friends means physically isolating from your support network. It’s relevant, in this context, to understand that physical isolation doesn’t mean affective and emotional isolation. As said before, it’s important to find new ways to be present in people’s lives and keep the social network active. Maintaining these contacts is also a way to ensure that when you leave the hospital and arrive at your rest place, you can actually disconnect from the routine and difficult times by talking to family members and listening about their day, their stories, and so on. In this moment of isolation and fear, we also witness the stigmatization of healthcare professionals3. People can direct their feelings of fear and uncertainty at health professionals, potentially causing behaviors of avoidance, rejection, aggressiveness and violence. If you find yourself in this situation, it’s key to understand that these reactions are not directed towards you personally, but to the global state of insecurity and fear, we are currently living.

Have you seen any changes in the problem-solving and decision-making capabilities of the physicians in the ED due to the stressed environment?

Interpersonal conflict, due to constant changes in protocols and workflows is expected in times of crisis and might be affecting problem-solving and decision-making processes. Here are some strategies to prevent it:

  • Try to maintain a supportive work environment, including designated spaces to eat and rest
  • Have moments to let the team talk about their mental state to help to develop a sense of community
  • Alternate workers between activities of high and low attention and tension, if possible,
  • Recognize effort made and encourage mutual respect among professionals
  • Map and disseminate mental health care actions. Even if most workers will not need individual assistance, knowing that there are services that they can rely on when needed makes them feel supported

Finally, do you have any special tips for emergency physicians who are in the frontline against COVID-19 at this moment?

It’s important to know and to understand when the frequency and intensity of the normal symptoms indicate that you should see a specialized mental health professional.2

  • Persistent symptoms
  • Intense suffering
  • Risk of complications, especially suicidal ideation and substance abuse
  • Significant impairment of social and daily functioning
  • Significant difficulties in family, social or work life
  • Major depression, psychosis, and PTSD are conditions that require specialized attention

We know that healthcare workers bear considerable suffering and symptoms, but usually, this group of people refuses to seek or receive help. Among others, the main reason is that having difficulties to deal with all the emotional demands is -wrongly- seen as a sign of weakness or incompetence. At this moment, it’s more important than ever to understand that we can only take care of others if we, first, take care of ourselves. And taking care of our mental health is as important as our physical health to be at the front lines of COVID-19 response.

Gabriele H. Gomes

Psychologist, current Critical Care & Emergency Psychology Resident at Hospital de Clínicas de Porto Alegre (HCPA)

References and Further Reading (Portuguese only)

Cite this article as: Arthur Martins, Brasil, "Who Takes Care of You While You Take Care of Others?," in International Emergency Medicine Education Project, August 5, 2020, https://iem-student.org/2020/08/05/who-takes-care-of-you-while-you-take-care-of-others/, date accessed: July 4, 2022

Why Me? The Story of My Burnout – Part 3

Why Me? The Story of My Burnout - Part 3

The story continues from link (Part 2).

I must take a deep breath. I must ask for help.

The Self-Knowledge Path

I could go away and work in another hospital. We have many good hospitals in Brazil. Some even employ emergency physicians who are local graduates. I really could. In truth, there would be no shame if I left the hospital. But I decided to give it one more try.

I just want to make clear that there is no single route back from burnout. It is a multifactorial treatment. You need emotional power. Some you may already have, or you can develop with a mental health specialist’s help. Some you will gather alone, or family and friends will help you to recover if you are lucky enough. Read, talk, discuss, and share with your community. You will never be alone because it is the system that is inflicting moral injury and burning you, and everybody, out.

Each person needs different means and tools to recover. We have to acknowledge that not everybody can afford all of them. Not everybody can pay for a therapist or even leave their work. I was one of the lucky ones. I could.

I promised myself and others that I would get better, and I wouldn’t give up. I felt obliged to improve the system that had harmed me. The system that made me afraid; afraid that I would fail.

It was not easy! It wasn’t “just not thinking about it.” It wasn’t “just a phase.” It wasn’t “just yoga.” It wasn’t “just wanting.” It was more than all the above. It took a long journey of self-knowledge: Who was I? What did I want? How could I achieve that?

Gradually, intertwined with relapses,​ the healing process began. I returned to therapy. Thanks to all support from my amazing friends, -virtual friends, present friends, distant friends- mentors, mentees, students, residents, followers, I was overwhelmed with affection and understanding. There were messages of encouragement everywhere I looked and listened. I did not plan this. It happened organically from across our community, and sometimes unintentionally, as I reached out to others, who always found time to help me.

Kindness can save a life! If you feel so, just go around saying how important people are in your life. I assure you that the kindness and positive comments of these people saved me.

I improved gradually in small steps. With empathy and determination, I took one step after another. Each step led me to find new perspectives. With each small victory​, I felt a small but important​ celebration in my heart​. ​

Yet, I wanted to make sense of it all. How to endure the moral injury? How to continue working here? I desperately needed to make sense of my job.

Why Me?

jule santos

In addition to therapy, I went on leave. I flew away and spent time in Mozambique, an LMIC, with many more difficulties, compared to Brazil. They were just beginning to develop the first emergency medicine residency program, and they had a lot more work to do. They were seemingly starting from scratch, and they had fewer resources than we had in Brazil. I found their enthusiasm and resourcefulness more inspiring than I thought possible.

It wasn’t because I could see how lucky we are in Brazil, but they did their best even though they were aware of their problems. I knew that there was no way that I could give up after seeing them.

I returned to Brazil, where people were eager to work with me. I felt they had missed me. They showed me that I made a difference.

I was fortunate to see my work environment improved. The administration had started to ‘get it,’ and now they cared about what we do. They realized that efficient systems saved money, so they were helping us achieve better care for our patients. Our department was renovated. They hired more people, and we got better medications. It all helped. It felt as though they were listening.

So recovering from burnout not only helped me to accept that problems are a part of the system but also made me realize people make the system. Therefore we can change it to accommodate our needs. Not the contrary. We need to END moral injury by addressing it and demanding solutions! We don’t need to be resilient to it!

In the beginning, I understood that I needed to be ​present​ in all my tasks, but that’s a challenge in the hectic world of emergency medicine. In truth, we are not as good at multitasking as we let ourselves think. However, we get better at prioritizing and scheduling tasks as we develop as clinicians. More importantly, we learn to give each task the proper time and attention it deserves.

As time passed, my most challenging feelings diminished. I redefined my responsibilities and my choices, redefined my motivation, my ambition, my purpose. I adjusted my expectations. I found a new power.

Then, ​gradually​, the love for Emergency Medicine and the energy to become the doctor I aspire came back. However, I still had to face my demons and deal with the most painful side of emergency medicine: Delivering bad news.

“Most of the time, the fact that you care is enough”​ is one of the most effective pieces of advice that I ever received. It helped me relieve the intense pain that I didn’t even know it was there. I still remind others and myself of it regularly.

For example, I dealt with the tragic case of pediatric cardiac arrest, brought in by another medical team. We did CPR over an hour, as this was a very delicate situation with a child. At the debriefing, I was careful with both teams from the other hospital and our own. Although I was worried about having the conversation I did, I was shocked and stunned to hear the reply. The doctor shrugged and said:

– Yeah, right. Can I go now?

He was in a rush. He didn’t even want to hear the debriefing. He didn’t appear to care! The disdain broke my spirit, and the whole team felt the same anger. It made everything harder to cope.

I took a deep breath, thanked the team for all the effort, asked them to prepare the body, and went to the waiting room to talk once again with the father. I had been there a lot of times, talking through everything as we were trying to resuscitate, so he already knew me, and immediately recognized my expression of bad news. I sat next to him and told him everything we did. I was trying to remedy the anguish while allowing time for understanding.

– There was nothing more we could do. I’m so sorry, but he died.

The father stared at the floor for a while.

– My wife is eight months pregnant. What should I do now?

He was in despair. Next came tears. I waited. Present. Then, he looked at me with honest:

– Thank you, doctor, for everything you did.

I will never forget them.

“Most of the time, the fact that you care is enough.”

I can’t stop people from getting sick. I can’t even guarantee who will survive, much less, meet the expectations of families. I can’t fix all the system by myself. Yet, I can show that we care, which is now my purpose and mantra.

Now, when I have to deliver bad news, I try my best to be there and look in the eyes. I patiently wait to make sure until there is no doubt. I don’t try to hide my feelings, ​and I finally feel I’m always telling the truth:

– We are doing everything we can.

I ensure that they know​ we care.​ I make a difference there. My pain eases as theirs alleviates even a little.

“Most of the time, the fact that you care is enough.”

I can’t stop people from getting sick. I can’t even guarantee who will survive, much less, meet the expectations of families. I can’t fix all the system by myself. Yet, I can show that we care, which is now my purpose and mantra.

Finding My Ikigai

ikigai

Ikigai is a Japanese concept that means “a reason for being.” In English, the word roughly means “thing that you live for” or “the reason for which you wake up in the morning.” Each individual’s ikigai is personal and specific to their lives, ​values​ , and ​beliefs​. It reflects the ​inner self​ and faithfully expresses that, while simultaneously creating a mental state​ in which the individual feels at ease.

The thing I like most about ikigai is that it is for everyone. You have to understand yourself to achieve this deeply. Seeking self-knowledge can be the most challenging part.

– Am I doing something that I love?
– Am I doing something that the world needs?
– Am I doing something that I am good at?
– Am I doing something that I can be paid for?

YES!

So, where am I now?

Well, I still love heart attacks! I love the look of amazement of the interns when we save a life. I love the self-satisfaction of the residents when they can do something correctly for the first time. I love how happy the team gets when we can do perfect resuscitation. I love the peculiarities of each patient, their life, culture, and beliefs. I love to learn something new every day. ​And that’s why Emergency Medicine!

I love heart attacks! But when we can't save, when the system fails, when the patient dies but I feel that I softened the pain, even a little bit, by showing that we care, I know I can endure.

And that's why, me.

Cite this article as: Jule Santos, Brasil, "Why Me? The Story of My Burnout – Part 3," in International Emergency Medicine Education Project, January 6, 2020, https://iem-student.org/2020/01/06/emergency-medicine-why-me-the-story-of-my-burnout-part-3/, date accessed: July 4, 2022

Why Me? The Story of My Burnout – Part 2

Why Me? The Story of My Burnout - Part 2

The story continues from link (Part 1)

I had already been tired and sad. Now, I was also feeling wronged.

The Dangers of Burnout

It meant that heart attacks stopped being exciting. I started to resent them as they now caused me to suffer. I have nowhere else to refer the patient, or the specialty doctors criticized me. 

They mistreated me, perhaps because of a lack of trust, or they too were damaged by the system. Maybe it was about payments and expenses. I did not know, but the effort of constant fighting was exhausting.

The system hit me hard. It was clear: irritation, stress, discontent, three quarrels with my team and my superiors in one week. I was burned out. That was putting my good work at risk.

Sad person

I felt like everything I was doing was meaningless. I aspired to become the best possible doctor through studying, traveling and sharing, but I always returned to the conditions that made me feel that all was in vain. My stagnant environment was full of burnout people, unjust deaths and endless problems regarding insufficient resources versus higher and higher demand.

That saddest thing in medicine is a doctor without hope.

I felt that each patient brought more pain than joy, even when we had excellent outcomes. It made me sick. I felt like I had unlearned hope. To make matters worse, I could not contain these emotions.

One day a patient asked me, “Am I going to die, doctor?”

I had just seen the results. It suggested cancer, but what would happen now? We wanted an expert to lead him, necessitating an evaluation by the oncologist. Still, the oncologist would not see the patient until the biopsy result, despite the imaging strongly suggested cancer. That meant we had to ask the general surgeon to do the biopsy, but in return, he asked us to refer the patient to another surgical specialty, based on the location of the tumor. So we tried, but this type of specialist did not serve in our region.

The patient’s and our growing stress and conflict eventually led the general surgeon to do the biopsy, but the patient had to wait 30 to 45 more days for the result. Only then, he would be able to go back to the oncologist. When he did, tho oncologist asked us for phenotyping. One more week passed until we finally get the patient to oncology, only to be declared too sick for treatment.

I had experienced this so many times before. Meanwhile, patients were getting more sick, and repeatedly ended up in the emergency department, sometimes got admitted, only to treat infections or pain. In the end, they were sent by the internist to die in our emergency room. They could not do end-of-life care properly. I frequently talked to an enraged family, not because of cancer, but because they were led to believe there was a chance of treatment.

My opinion is that the problem wasn’t lying to the patient about cure cancer, but how often the system don’t even give them this chance of a fight, lying about a chance to treat, but in really being just harmful for everybody because disorganization, corruption, and for didn’t care.

We do not cure death. Ever.

Sometimes we can prolong life. We hope for a good life with meaning, so that they can enjoy some more years, months, weeks or days of celebration, and prepare their wishes for a decent death with their family.

My opinion is that this realization is important not only when we talk about cancer, but any condition, even like a heart attack. We do not cure death, ever.

Coming back to that new patient, the words and the questions bounced in my head:

– Am I going to die, doctor?
– Don’t think about it now. We will take care of you.

I don’t know what the patient saw in me. To me, It felt like lying. When I said we would do our best, it wasn’t me but the system lying. Even if we as emergency physicians or I as an individual did everything possible, I felt the system didn’t care. I knew the system could do better. What could I say when I knew that the journey I want for my patients is so unachievable in the system I work in. I no longer knew what to say under these circumstances, and I felt the patient recognized that in my soul.

I felt hurt, guilty, beaten, and bitter.

That saddest thing in medicine is a doctor without hope.

I never thought this could happen to me. Not with me! How could this happen to me? I was in love with Emergency Medicine! Wasn’t I?

I’d said a billion times how I loved Emergency Medicine and didn’t know how to live without it. I’d shared my passion, convincing others that Emergency Medicine was the answer. Now, it felt like Emergency Medicine was killing me. And worst, I felt that I was not doing good for my patients as my lies were hurting them.

I must take a deep breath. I must ask for help. ...to be continued...

Cite this article as: Jule Santos, Brasil, "Why Me? The Story of My Burnout – Part 2," in International Emergency Medicine Education Project, January 3, 2020, https://iem-student.org/2020/01/03/why-me-the-story-of-my-burnout-part-2/, date accessed: July 4, 2022

Why Me? The Story of My Burnout – Part 1

why me - the story of my burnout

This story starts like almost every other: I fell in love.

The thing is, I LOVE heart attacks!

I know this is a weird statement, maybe even a little ​overstated. I know that people can get uncomfortable when I say this. When I said it for the first time, full of enthusiasm and with sparkling eyes, my ex-fiance looked at me in a concerned and puzzled way: ‘Can you say that?​’ – He asked, wondering if it was appropriate for a doctor to say that they actually enjoyed the experience of people being so unwell.

Clearly, as a doctor, I have nothing against people. Quite the contrary, I unceasingly fight for them to survive and thrive. Yet the paradox is real, despite my battle to save my patients, I am so in love with heart attacks!

Why? Perhaps I love the puzzle behind it. When the patient arrives, I see the position of the body, the hand on the chest, fingers tightly pressed against the skin, the skin color, the sweating… I consider the nuances of pain types, the comorbidities, the risk factors… All are informing my judgment and decisions even before I get to look at the ECG.

I love knowing the diagnosis as it reveals itself. I love that I can treat it. And when it works, I’m the queen of my craft. The scores of survival game change. 1 for me, 1 for my patient, and 0 for the heart attack!

So that’s why you would see me so happy when a patient arrives in my ED. I love this feeling. I love this adrenaline rush that is emergency medicine and me! I love leading a code, guiding actions, organizing my team to the point of ROSC. I love that roaring energy that runs through the whole team as we effortlessly move to the next stage of resuscitation.

This is why I love Emergency Medicine.

Emergency Medicine is new In Brazil. The general assumption is that ED is where junior physicians serve until they choose another specialty or other specialists work to earn additional income. Until recently, working in the ED was a difficult job with no career advancement. So, when I realized that I was so in love with more than heart attacks that I could not leave my work as an Emergency Physician, people started to ask me, “Are you sure? Do you want to work forever in an ED in Brazil? What about when you get older? Don’t you think you will get tired and burned out?”

jule santos

I don’t think so. I reply, I love my job. When you love your job, you don’t ever get tired.”

How naive I was.

Emergency medicine is tough, sometimes even painful. Deaths, we can’t help. Diagnoses of incurable diseases. Bad news. The pressure to be good, perfect, productive. Adding to that, many of us work in corrosive health systems: The result? Emergency Medicine can burn you to your core.

Being in love​ with Emergency Medicine is enough to protect us?

Emergency Medicine can burn you to your core.

Leaving the Comfort Zone

I am a curious soul. While I learned more about emergency medicine, I discovered another world with worldwide Emergency Physicians, who could understand my difficulties and help me learn remotely from them. I fell in love again with #FOAMed.

Hearing the experiences of my colleagues from all around the world inspired me to travel and meet those people. I wanted to learn with them and to compare how Emergency Medicine is in those places.

I love #FOAMED

My newly found calling took me to Sydney in Australia, such a lovely country, which had beautiful and polite people, good public transportation, beautiful scenery, and even a public healthcare system too!

I was lucky enough to spend time in an excellent hospital in NSW. I witnessed them receiving a trauma patient and listened to them as they plan patient management. I was speechless. I felt a sudden sadness to the degree that I wanted to crawl back to my mother’s womb.

When I tell this story, people often react, “You don’t need fancy stuff to practice Emergency Medicine,” but it was not what I saw there. What was it? It wasn’t the video laryngoscopy. It wasn’t the infinite bougies and disposable LMAs. That’s true: The facilities in Australia were incredible and so much more were available than back home in Brazil. But it was still the people.

When the paramedic team arrived, the whole team discussed the patient plan. They were so courteous and respectful to each other, focused only on doing the best for the patient. They were excited about the case, energized, and happy for doing their best.

I’m not saying their life is easy. I’m not saying they don’t suffer moral injury. But I’m sure they don’t show ill-will to their peers and most importantly, to their patients. I want so badly to be able to do that kind of medicine, but the realization of this new health system made me feel envious and perhaps even hopeless. Their experience was so positively different from mine.

Teamwork

I spent the next day in my room, lying depressed in bed, staring at the ceiling, trying to figure out what to do now: “How I would love to have that experience in my hospital!”

I thought a lot about what happened there. Why did it hit me so hard? I knew that not all hospitals were the same in Australia as some hospitals had problems and struggles like in Brazil. I already knew that we had hospitals in Brazil better than mine. Why did I feel so hopeless then?

Now, looking back, I can understand better. I was pushing my comfort zone further than I ever did in my entire life. I was discovering a lot about myself and my capabilities. I was achieving success through FOAM. And so, I saw my limitations, I strumbled in a deep Impostor Syndrome and lost some excellent opportunities. I was in such a fragile mindstate that I felt like the system was unfair to me.

Sad Clown

In my hospital, which is always overcrowded, I work with physicians that don’t have the mindset of Emergency Medicine. When a trauma patient arrives, it feels like a battle. Physicians challenge paramedics: ​“Why did you bring this patient here when we don’t have bed enough?”​ or​ ​“​we don’t have enough surgeons!” or “why does nothing here work?”

All too frequently, the team ends up shouting at each other.

I tried hard to spread the ideas and visions I was learning. One time, I asked for an ultrasound machine, my boss laughed in my face: “Where do you think you are?” Everybody seemed so consumed by pessimism and fatigue that they lost all hope.

I had already been tired and sad. Now, I was also feeling wronged. ...to be continued...

Cite this article as: Jule Santos, Brasil, "Why Me? The Story of My Burnout – Part 1," in International Emergency Medicine Education Project, December 30, 2019, https://iem-student.org/2019/12/30/why-me-the-story-of-my-burnout-part-1/, date accessed: July 4, 2022