[00:00:00] Christine Ko: Welcome back to SEE HEAR FEEL. Today, I am honored to be able to speak to Dr. Michi Shinohara. Dr. Michi Shinohara is Associate Professor, Associate Chief of Dermatology and Director of Dermatopathology in the Division of Dermatology at the University of Washington. She attended Reed College in Oregon, starting as an art major before majoring in chemistry. She got her Medical Degree from the University of Washington School of Medicine and completed both an internal medicine and dermatology residency. Subsequently, her dermatopathology fellowship was completed at the University of Pennsylvania. Dr. Shinohara runs the Cutaneous Lymphoma Clinic at the Fred Hutchinson Cancer Center. Her research interests are quality of life for patients with cutaneous lymphoma and mentorship and sponsorship of women and those who are historically excluded in medicine. She has written on burnout, a very important topic for us all to be familiar with. There are links in the show notes to two of her articles on burnout.
[00:00:52] Welcome to Michi. Thank you so much. Thanks for having me. We're gonna just jump right into it because this is a very busy lady, and I'm lucky that she is willing to talk to me about this. Can you explain how burnout is defined?
[00:01:05] MIchi Shinohara: Burnout is... it's a slippery concept. Okay. So if you ask people. Do you feel like you're burned out? It's surprising, but a lot of people will say, No, I'm doing fine. But there are actually criteria for how do you measure burnout. This goes back to the seventies, to the psychologist Freudenberger, who first defined it as a syndrome characterized by a triad of emotional exhaustion, depersonalization, and decreased personal accomplishment. And it's all centered around work.
[00:01:35] That's kind of the most prevalent description of burnout, and that's what's incorporated into the Maslach Burnout Inventory, which is one of the most common ways that we assess burnout. I like the World Health Organization definition though, because they really anchor it a little bit more around the person and more around the system.
[00:01:54] So they, they define it as a syndrome conceptualized as resulting from chronic workplace stress that is not being successfully managed. I just, I really like that because I think the original definition, you know, kind of talks about the symptoms of it really well, but doesn't really address the cause. The WHO definition does a little bit of a better job about saying like, Look, this is stuff that's happening to you. These are symptoms you're having, but this is something that's happening to you.
[00:02:20] Christine Ko: Great. Yeah. So workplace stress that is not being managed correctly.
[00:02:24] MIchi Shinohara: Yeah.
[00:02:25] Christine Ko: And sort of the system factors that create that workplace stress are very important.
[00:02:29] MIchi Shinohara: Absolutely.
[00:02:30] Christine Ko: Okay. Yeah. I, I had recently read, or I think listened to Dr. Maslach explain burnout.
[00:02:37] MIchi Shinohara: Mm-hmm.
[00:02:37] Christine Ko: And she says, I think she was involved in the WHO definition, and she says that burnout is actually not an individual problem.
[00:02:44] MIchi Shinohara: Right.
[00:02:45] Christine Ko: It's really a system problem. And so for one thing, none of us should be ashamed if we feel burnout because it's not my fault if I feel burnt out.
[00:02:53] MIchi Shinohara: Yeah, absolutely. And I think, you know, one of the kind of other sticky parts of it is that so many of the interventions around burnout are targeted to the individual reinforces that, Well, if you just do enough yoga, if you just meditate enough, you could get yourself outta this hole. But I like that there's been this sort of shift towards focusing on the fact that it's a combination of factors that have happened to us. And I think with the pandemic that has really been emphasized. You know, so many people who have never experienced burnout before are burned out now.
[00:03:21] Yes. One
[00:03:22] Christine Ko: of your studies talks about how there are gender differences in those symptoms. You know, again, it's a system problem.
[00:03:28] MIchi Shinohara: Yeah.
[00:03:28] Christine Ko: But in the symptoms that the main two genders, I guess, experience. In one of the papers, it was binary, still male versus female. Can you define that a little bit?
[00:03:37] MIchi Shinohara: Yeah. There's pretty good literature to support that men and women, those who identify as men, and those who identify as women, experience burnout slightly differently with women experiencing more emotional exhaustion. And men experiencing more depersonalization. But I kind of think of these three parts of burnout as kind of like the stages of grief. You know, like you can jump in and out of them. You might have all of them at once. There are some models of burnout that look at it kind of like a march. You know, that you start with emotional exhaustion, move to depersonalization, and then when it gets really bad, you might really start experiencing, like, loss of accomplishment at work.
[00:04:13] But it's not perfect because some people do jump in at different phases, and there's some literature that, you know, women tend to experience emotional exhaustion more. And, uh, those who identify as men tend to experience depersonalization. You know, it's really probably just based on our, our social conditioning about our gender roles. But we're all capable of experiencing all of the components. And we likely all do.
[00:04:37] Christine Ko: Okay. Can you define emotional exhaustion and depersonalization?
[00:04:42] MIchi Shinohara: Yeah. Um, emotional exhaustion is, it's something that when you think about like, what does it mean to me, it's easy to kind of say like, Well, I know when I feel it. It's a feeling of depletion, feeling like you're giving more than you're getting. And I think people who are healthcare workers, people who are caretakers, which, you know, happens to align a lot with traditional gender roles for women, which is why I think women experience more emotional exhaustion, that, um, we, because of our own expectations or societal expectations, tend to, to give more than we get. So that's the emotional exhaustion.
[00:05:15] Depersonalization to me. I think about it, like for me, a feeling of resentment. Like I stop looking at people, for example, for patients, if you're a provider, you stop looking at them as people and more as objects. You know, I'm not seeing, you know, this issue that you're coming to me with in an empathetic way. I'm seeing it like you're bringing a problem to me. Um, that's depersonalization.
[00:05:38] Christine Ko: Great. Yeah, those definitions really help. Thank you. So not to make this an individual problem, since you just discussed, it's a system thing, but can emotional intelligence help combat burnout?
[00:05:50] MIchi Shinohara: How do you get out of emotional exhaustion? You can't will yourself or like think yourself out of burnout. An important part of leaving burnout is removing some of the stressors. We have to do systems changes. Yes. And like, what can I control about myself? I can only control what's in my immediate environment. I can try to keep moving things in the system. When somebody's drowning, you don't say like, Don't worry about it. We're building a new boat. You know, you throw 'em a floaty, right? We can throw ourselves floaty. I love this book, uh, by the Nagoski sisters called Burnout: The Secret to Unlocking the Stress Cycle.
[00:06:23] I just love their terminology, the way they tell really great stories in there. They talk about the concept of emotional exhaustion as that feeling when we're stuck in an emotion. Like you can't get through it. It's like you're stuck in one of the phases of grief. And that also explains why like, doing things like taking a day off, you know, actually probably isn't gonna help that much with your burnout. So systems things are important. Lightning workloads. But they're not gonna be enough. You need to also do things. Not just sort of thinking about, How do I get through this? But actually physically taking care of ourselves, completing the stress cycle. For me it's things like exercise, making, art, meditating, hanging out with my kid, going to therapy, you know, all those things that I know I need to do to complete my stress cycle.
[00:07:07] For my husband, it's gardening, spending time with our kid. So I think it's a little different for everybody, but I don't actually think.... If being aware of your burnout, if being emotionally intelligent means you're being aware of it and you're doing it in a mindful way, that might help. But I think just saying like, Yes, I'm identifying that I'm burned out. I don't think that's enough to get through it. Right?
[00:07:27] Christine Ko: Yeah. Yes. I love that definition of burnout by the Nagoski sisters as well. I will admit I have yet to read that book. It's on my list, but yeah, I've heard them say that, just as you said, burnout is described by them as you're in a tunnel, and you're stuck in that tunnel, and you may see the light at the end of the tunnel, but you can't get there.
[00:07:50] One of your articles cite research that says that women have at least about eight and a half hours more home responsibility than men. For me, especially during Covid has been. Home stuff has been a huge stressor. More so much of the time compared to work, which also has had its own stressors.
[00:08:10] MIchi Shinohara: Right.
[00:08:10] Christine Ko: Based on your research and reading, is there some way to address that, to balance work in home, especially for women or partners who have more of that home load?
[00:08:21] MIchi Shinohara: Yeah, that's an impossible question. I can't answer it.[ laughs] I can try. The real answer is we need, as a society, to acknowledge and address the inequities and extra burden and expectations on those who identify as women in our society. That's the fix, you know, Smash the patriarchy!, but we can't control all that again. I can't control what others think. To me, I can only control what I do, my behavior, what I think of myself. I led this AAD session for several years and had lots of speakers come and talk about this. You know, how do we balance work in life? And as part of that, someone recommended do one of the implicit association tests.
[00:08:59] Cause what can you control about yourself? So I did one. And you know, I consider myself a feminist. I was raised in a household with a mother who worked out of the home. My eight year old looks at us, my husband and I, and says like, Well, Mommy's the stronger one. You know, like, I feel like I have done this right. But I took that implicit association test and learned that to my own horror, I have an implicit bias against women in the workplace. And that it was just something really important for me to reflect on because I don't think I'm unique in that. And what that means for me, I recognize, is that I probably create some of my own problems.
[00:09:35] I'm not saying that the system doesn't need to be fixed too, but I can also contribute in some ways. So after I went through that, you know, grief and acceptance around that, I, um, realized that, Oh, I have these expectations of myself at work. I'm gonna, you know, be promoted. I'm gonna be this national expert, be the most amazing person, mentor, and I'm gonna go home and be like a Pinterest mom, you know, who bakes cupcakes and has them decorated and makes her own Valentine's. And the reality is nobody can do all that. How did we expect that we were gonna be so incredibly perfect that we were gonna bring them the bacon and then like, cook it up and make it into like a, you know, like a bacon sculpture too?
[00:10:18] For me, it's been a lot of letting go. I have decided for myself, these are my priorities. I love my son. He knows that he's important to me. Love my husband. I can't live in that traditional gender role. It's not working for me. I think everybody has to define for themselves, what do they really value? If that is your value to you, that feels like success to, if making that bacon sculpture is the thing that's gonna bring you joy, then you should, you should do that.
[00:10:44] But if it's not, then you gotta let it go, like you have to let it go. I think that's the only real way to achieve balance and feel like you. Maintaining sanity because it's impossible for anybody to do all of that.
[00:10:55] Christine Ko: Yeah, of course. I gave you a very hard question that really doesn't have an answer. You're right. Yeah, I agree with you. I think that since I started discovering a lot of this cognitive psychology, the tools that can help me, that was my conclusion with really. Emotional intelligence, metacognition, burnout, whatever concept- that it comes down to me, partially, right? System factors, et cetera. They're always gonna be there. But in terms of that floaty, until the system really gets fixed, what's helped me the most is to truly be aware of what my priorities are and what my weaknesses are, of course, what my strengths are as well. And so it's interesting that you say, yeah, go ahead and take that implicit association test. I will put a link in the show notes to one of those tests. And I'll admit I haven't taken one yet and I will take one before I release this episode. But I did take a brief one when we had a diversity equity inclusion talk at our grand rounds a couple years ago. The speaker put up a couple of photos and just, you know, what's the immediate thing you think? We would just call it out and we realized that, as you say, um, many of us in that room had certain biases based on gender alone, someone's appearance alone, whatever. Something about that image that was flashed up that that sort of is, is typical. Yeah. Yeah, yeah.
[00:12:14] MIchi Shinohara: And your implicit associations, they don't equate with your values, but they may equate with your unconscious thoughts and actually some behaviors, whether you like them or not. So I just think it's important to be aware of it, you know?
[00:12:26] Christine Ko: Yeah, yeah. I didn't ask you about how metacognition can combat burnout. You actually just touched on that, that yeah, our unconscious biases, which are part of System 1 thinking, that dual process theory, do influence us. And on the contrary, my System 2, my logical analytical mind, doesn't think that way. You know, I'm not biased against women, right? Like, why would I be, but I may very well have that implicit bias and yeah, then that will, that will affect me without my realizing. This has been wonderful. Do you have any final thoughts?
[00:12:58] MIchi Shinohara: I think just my final thoughts about burnout. I support a lot of my faculty, have a lot of mentees. Just my message is always like, be so gentle with yourself. And when I tell people that, I'm telling myself that too, because like we have gone through an incredible amount of stress in the past few years and we're already in stressful jobs. So, just acknowledge that. Be nice yourself. Find ways to move your body and take care of your brain. Spend time with people who fulfill and love you, and remember burnout's not your fault, but you can help yourself get out of it.
[00:13:32] Christine Ko: Yes. Oh, this has been wonderful. Thank you so much, Michi, for spending time with me.
[00:13:38] MIchi Shinohara: Yeah, you're so welcome. Thank you again for having me.