Old Flame

I listened to a Planet Money podcast, Episode #740, this week. Burnout dealt with the origin and characteristics of burnout, and I would highly recommend it.

You’ve all heard the term and have a vague knowledge of what burnout is, I’m sure. You may have experienced it yourself. It affects call center employees (as in the podcast), all sorts of service workers, doctors and other healthcare providers and countess others.

Looking back on it, I have experienced various degrees of burnout several times in my career in medicine. The symptoms I have fought with, sometimes silently, have included extreme fatigue, emotional withdrawal, disinterest, lack of a sense of purpose, lack of motivation, lack of joy, and decreased participation in enjoyable activities.

I was not depressed. One does not have to be clinically depressed to be burned out. I was simply existing, performing my various tasks and duties day in and day out with little sense of accomplishment or joy. I did not take to my bed for days or weeks at a time, I did not stop eating, and I was not physically ill in the strictest sense of the word.

It was also not directly or solely related to the number of hours I was working at the time. Lord knows there were times during my residency and moonlighting days that it felt like all I did was work, but I was not burned out. Not yet.  It was not related to the difficulty of the work being done. Even now, I average from 60-65 hours of work many weeks, and yet I have never been happier than I am right now.

What are some possible causes of burnout in medicine, or in other areas of endeavor, today?

We are living in an age of marked increases in bureaucracy, regulation, paperwork, and attention to electronic detail like no previous time in the history of work.

We are engaged in mindless busy work, often related to the changes above, that keeps us maddeningly active but leading to much less focus on what is important or even expedient. I have often told my staff that I look for efficiency of process, yes, but that much more important to me is evidence of efficacy in treatment. Both are necessary. I just happen to think that the latter is more important to the wellbeing of the patient.

We are often caught not seeing the forest for the millions of trees before us. In fact, we are now forced to look at so any trees, branches of trees, groves of trees, leaves on those trees, that we have almost completely forgotten what the concept of a forest as a whole is. We have lost sight of what is truly important. We can no longer focus on one paramount outcome or goal, because there are myriad concerns and regulations and rules and reports that must be completed on time, every time, to satisfy someone’s lust for minutiae.

Then there is the firehose phenomenon. No matter how thirsty one is, it is extremely difficult to drink from a fully opened and gushing firehose. We may start out our careers thirsting for knowledge, new skills and professional fulfillment, and even joy in our work, only to be drowned by the sheer volume of information, change, and regulation in our twenty-first century world. This is akin to emotional, intellectual and professional waterboarding, and we now know just how effective that technique really is.

So, all that being said, what works for me when I feel myself sliding towards burnout? I am almost ready to start my seventh decade of life, and there is one thing that has never failed me yet.

Stories.

When I get tired, overwhelmed, bored, or burned out, I have to tell myself, consciously sometimes, to go back to the basics. In medical school, I learned to solicit information by listening to stories. Stories from professors, mentors, and supervisors. Stories from patients, families, spouses, siblings, children and parents. Stories from courts, judges, attorneys and guardians ad litem. Stories from case reports, textbooks, “pot cases” in pathology (ask me about that another day), and grand rounds presentations.

My professional life, indeed most of my life in general, has been built on stories.

When I am sad, tired, fatigued, upset, feeling sorry for myself or feel that I have lost my way, I hit the reset button in my brain. I try to stop over thinking, worrying, obsessing, catastrophizing, planning, scheming, and controlling.

I listen to a good audiobook (or two). Churchill’s The History of the English Speaking Peoples and David McCullough’s The Wright Brothers are my current guiding stars. Oh, and I really listen to them. No multitasking allowed.

I go back to really listening to the stories of my patients. The happy, sad, terrible, frightening, terrifying, disgusting, off-putting, affirming, enlightening, and uplifting ones. All of them. I approach each patient encounter as an opportunity, and in fact a privilege,  to hear a new life story and do something about it. Just today, as I was writing the outline of this post, I resolved that I would start each patient visit this afternoon with the phrase, “Tell me your story.” I did just that. That little change in how I started my interview of my patients today made a world of difference in how I approached my job.

I listen to the stories of my grandchildren. What stories they can tell, long ones and short ones and one sentence ones and multi-paragraph ones about their bedrooms in their new house and their dogs, and their new baby sister, and Power Rangers. On one recent visit, it was so refreshing to accept my almost three-year-old granddaughter’s invitation to go up to her bedroom, lie down on the floor, and have her give me a running commentary on the recent activities of every Disney princess she and her siblings own.

I listen to the stories my love, who is now my wife of thirteen days, brings to our conversations. It doesn’t matter whether they are common stories we share from our teen years in Rome, Georgia, our recent travels to Europe, hiking in the mountains, or some of her trials and tribulations aboard an Airbus at thirty thousand feet over the Atlantic. They are words that connect us, that forge a strengthening bond that is one of the most cherished ones I have at this point in my life.

Life, my life, your life, is a story.

Mine began in Rome, Georgia, on October 24, 1957. I do not know when it will end.

I do know that it will continue to be a rich tapestry of work, play, disappointment, fear, exhilaration, wonder, challenge, and love. If I continue to actively write my own story, every day, being fully present in it, and listen to  the stories of others all around me,  I will continue to live life to the fullest.

Burnout is not the normal, or desirable, state of things.

Fire, as we have recently seen, can destroy and consume.

It can also light our path forward and keep us from falling headlong into the darkness of despair.

 

(Re) Charge!

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Good morning, dear readers. I trust that if this morning for you, as it is for me, that you rested well last night and that you are now ready to face another day and the challenges it will bring.

A friend of mine commented on a blog post the other day. She in essence wondered out loud how mental health professionals were able to unwind, de-stress and otherwise cope with the rigors of our profession.

Of course, down time is a very personal thing. We all cope in different ways. I thought I would share some of mine with you. 

It is very important to balance activities, as anyone will tell you. Anything done to excess can be detrimental and not helpful. For that reason, I have several kinds of activities that I really enjoy.

I am a middle-aged male. It’s important for me to maintain my physical health, my strength, and my stamina. I live alone, so taking care of myself is going to be more and more important as time goes on and I age-gracefully I hope! I have twenty-four-hour access to a gym where I live, a wonderful thing with my odd work schedule. I try to get there at least three or four times per week for at least 1-1 1/2 hours per visit.

I walk on a treadmill, use the elliptical machine, and lift weights using a nice set of free weights provided by the gym. It’s amazing how much better one can feel with just a modicum of physical exercise. I parlay this training into competition when I can, though not as much in recent years. I have always enjoyed the outdoors, so hiking, road racing, and now competitive walking have always been fun for me. I am setting my sights on another half marathon in the near future. I recently walked up and down the grassy green slopes of a Civil War historic site and plan to get out to other battlefields soon to do the same.

The bottom line for physical fitness that I have learned as I watch my own patients over the years? Find something you enjoy, do it regularly and keep moving!

I enjoy the arts very much. For this reason, I just purchased a pair of season tickets for four different groups in my area and am looking forward to the upcoming performance seasons beginning in the fall. I will see a stunning performance of Les Mis by the Players group in the next town, I will attend a cultural series in the theater of the local college, just a short five minute drive from my door. I will travel up the road to the capital to see Broadway shows and symphony performances at a wonderful venue on the University of South Carolina campus in downtown Columbia. All of these performances are wonderful ways to get outside of one’s self and experience the wide range of talent right around the corner. They are ways to transport yourself, if for just a few hours, to other magical worlds of light, sound, music and theater. 

I love to read and wish I had much more time to do it. At any one time, I have from one to four books going and try to visit each a few times each week. Right now, I have Deliverance going on my iPhone as an audible book, am reading Confederates in the Attic (I was told by a new friend that my not having read this book was a true emergency and that I must remedy that right away!), and am dabbling in C. S. Lewis, re-reading Mere Christianity. Once again, just as in live arts performances, reading is an excellent way to get away from the stressful world that is and discover new worlds that might be.

I love to travel and get out of town whenever I get the chance. Since off time in my profession, especially in telepsychiatry, is at a premium, this often takes some planning. It is worth it. My recent trip to visit with family, do a picture-taking hike and just get out on the open road to drive a while was rejuvenating in the best way. 

Of course, I love to write. Thinking through a topic, getting the thoughts out of my head and onto a page so that others may read them and respond to them fills a very big need for me on an almost daily basis. There is something about the process of creativity that both completes us and lets us contribute to the ongoing body of knowledge that is growing every day. I love being a part of that, and it is one of the best ways I have found to begin my day in a very positive way. Since you come back here from time to time to see what I’ve written, I hope you agree that this is a good use of our time.

So, my friends, these are only a few things that I enjoy that help me de-stress, relax, regroup and recharge. When I do them and feel more centered and at ease with myself, I think I most likely do a much better job of trying to help others. At least I hope that’s the way it goes.

What do you do to recharge? What activities, pastimes, and hobbies keep you going? 

I’d love to hear from you.

Pain

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“Yeah, Doc, I drink. I drink a lot. Some nights I drink a case of beer and a half pint. Can’t sleep if I don’t drink. Relaxes me. Pure and simple. Numbs me up like novocaine.”

A toothless grin.

“It’s the feeling of floating away. I don’t know, I just keep coming back to it. Stuff goes in, feel a little flushed, a little rush, then I go somewhere else, you know? I just kinda float off on a cloud for a while. Things back here hurt. I don’t have a job. I can’t buy my kids stuff. I can’t provide. I’m nothing, Doc. I’m nothing to nobody.”

One tear, sliding silently down the weathered cheek like a raindrop after a crashing, lightning-filled storm.

“It just feels good somehow. I know that’s weird. My mom freaked the first time she found out I do it. Oh, I don’t know, whatever I can find. My Dad’s box cutter, a kitchen knife. Razor blades are the best. I watch myself do it, you know? I sort of float over myself, watch myself cut. The lines are neat, sharp, clear. But it’s the blood that helps me. Watching the blood trickle down makes me feel something. It makes me feel human. It just- I don’t know- it just makes me feel something. Anything.”

A recent conversation with a friend made me revisit a concept that I return to over and over again in my professional life.

“We all just want to be significant. We all just want to know we matter.”

Simple concept, that. Self-worth. Self esteem. Mattering to your friends, your family, your spouse, your children, your employer. Should be a given, shouldn’t it? We’re all created, we all have a place here, and we all matter. At least we should.

What keeps some people from feeling that they really matter? What drives them to drink, to inject themselves with toxic substances and to incise themselves in neat, orderly rows of red ooze?

Pain. The common denominator is pain.

No, I’m not talking about the pain I felt when my doctor jabbed my knee with a needle last night to give me relief from unneeded fluid buildup. I’m not talking about the pain you feel when you hit your thumb with a hammer or burn yourself on a hot stove. I’m not even talking about the pain after surgery for the cancer that you now know will eventually kill you.

I’m talking about that deep, aching, throbbing, existential pain that makes you question why you are even here. Why you are alive at all. Can’t relate? I am so glad you can’t.

That kind of pain burns a hole in your soul like change hanging heavily unspent in a pocket. It demands to be felt. It will not go away. It eats at you, day after day after day, making you question your values, your worth to your children and your ability to contribute anything of value to the world at large. It wears you down like a slow-moving glacier, cold and heavy and relentless, sliding over the once-green bumpy mountainside of your life and reducing it to one, long, perfectly smooth expanse of nothing. It leaves no distinguishing marks. You become nothing. You are nothing.

And so you fight desperately to spend that pocket change, to trade it for something shiny and new, something that will make you feel good for a minute, an hour, a day. You try with all your might to melt that glacier, knowing full well that it is too large, too heavy, too wide and deep to extract from the hillside of your life below. You push up and out, but feebly. You take the last breath from the last air in the last pocket, and you resign yourself to the fact that no one will even know that you were here. You are nothing.

So you drink. You can quit anytime you want to. You’ve done it a thousand times. But you don’t.

So you push the plunger one more time, biting the rubber and holding it tight, feeling the inescapable, orgasmic flush of absolute pleasure that will kill you. You don’t care if it does, because for this one moment, this one beautiful moment in time, all is right in the world and God Himself is sitting here with you, stroking your sweaty forehead and easing you out of the world you’ve come to hate.

So you cut. You make the lines fine, evenly spaced, surgically precise. You wait for the first drop of blood, the first small rivulet that stands up for one second, supported by its own surface tension, that same surface tension that has kept your life intact for one more day. You watch the blood trickle down, a small red river of pain, tiny, tiny pain that flows out of you and is controlled by you and is something that you can deal with. Something that you can see, and feel, and hide from others for just one more day.

Maybe tomorrow will be better.

Maybe tomorrow the pain will go away.