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45. Burnout in Healthcare: Recognizing the Signs with Dr. Jessi Gold

• Elise Fallucco

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HALF of all healthcare workers are Burned Out.  But most of us typically power through without recognizing the classic signs.  How can you tell when you're going through burnout? And more importantly, what is it about the culture of medicine and healthcare that increases our risk of experiencing burnout? 
To help us sort through these issues and RECOGNIZE signs of burnout, we talk with Dr. Jessi Gold, Psychiatrist and Chief Wellness Officer of the University of Tennessee Health System.  She is the author of a memoir called How Do You Feel? One Doctor's Search for Humanity in Medicine.  This book highlights her experience taking care of healthcare workers during the pandemic, and  emphasizes the *emotional toll that it is involved when we're taking care of others*. 

** What are the signs of burnout?

** Why is it so hard to recognize burnout?

** How can we start to notice when we are going down the path of burnout?

Dr. Jessi Gold is an Associate Professor of Psychiatry at UT Health Science Center. Dr. Gold is not only a psychiatrist, but she is a mental health advocate and fantastic writer whose work has appeared in the New York Times, The Atlantic, InStyle, Slate, and Self. 

https://www.drjessigold.com/

Her new memoir is called
 How Do You Feel? One Doctor's Search for Humanity in Medicine available on Amazon at
https://www.amazon.com/exec/obidos/ASIN/1982199776?tag=simonsayscom

Check out our website PsychEd4Peds.com for more resources.
Follow us on Instagram @psyched4peds

Dr. Elise Fallucco:

Welcome back to Psyched4Peds, the child mental health podcast for pediatric clinicians, helping you help kids. I'm your host, Dr. Elise Fallucco, child psychiatrist and mom. Today, we're going to be talking about burnout in healthcare. Now you may know that half of us in healthcare have experienced burnout at some point in time. But how can you tell when you're going through it? And more importantly, what is it about the culture of medicine and healthcare that increases our risk of experiencing burnout? To help us sort through these issues. We have a special guest, dr. Jessi Gold Chief Wellness Officer of the University of Tennessee Health System and an Associate Professor of Psychiatry at UT Health Science Center. Dr. Gold is not only a psychiatrist, but she is a mental health advocate and fantastic writer whose work has appeared in the New York Times, The Atlantic, InStyle, Slate, and Self. Her clinical practice largely involves taking care of healthcare workers, including trainees, as well as college students. And today we are going to talk about her new book, which is called How Do You Feel? One Doctor's Search for Humanity in Medicine. And this book is a memoir that highlights her experience taking care of healthcare workers during the pandemic, and really emphasizes the emotional toll that it is involved when we're taking care of others. I'm so excited and I just want to welcome and say thank you to Dr. Jessie Gold.

Dr. Jess Gold:

Hi, thank you for having me and thank you, back for the kind words and the reading of my book. It's great. I really appreciate it.

Dr. Elise Fallucco:

I think our listeners are going to be really excited to, to hear about, what you've experienced and what you've written and I cannot recommend this book enough. I think we don't talk enough about the emotional toll involved then when we take care of other people and how it impacts us when we go home at the end of the day. So glad to highlight this on the pod. In your book, one of the main topics that you cover is burnout. And we know that about half of us in health care have experienced significant burnout. But there's a lot of confusion about what that really is. Can you give us your working definition of burnout?

Dr. Jess Gold:

For sure. So I think the confusion comes from the fact that mental health words tend to be like co opted colloquially. So we'll say I'm depressed, but we don't mean I have diagnosed like major depressive disorder. We'll say I'm anxious, but we don't mean we have an anxiety disorder, right? Burnout's very similar. I think people have started to use it like work is hard, I'm burnt out, or I'm tired from work, I'm burnt out. And that degree to which it is actually an issue gets minimized in that conversation. And I think that it becomes harder for people to actually know what's going on or know if they're burnt out. So the definition I use is the one that you probably see for the most part in studies where the numbers you pulled came from. It's a workplace associated condition, which is something that is really important to say up front, meaning that It's not considered a behavioral health disorder. It's considered in the ICD codes to be a workplace associated condition. I'll just clarify that when we say workplace, if you're a stay at home, mom, your workplace is home, if you're a college student, your workplace is school, right? It's a kind of loosely applied workplace, but then it's a constellation of three things. The first one is emotional exhaustion. I think in a lot of people that looks like physical exhaustion, but I just describe it as by the end of the day, you're just like, I've got nothing left. I'm spent. The second one, depends on who you ask, can either be cynicism or depersonalization. Depersonalization is really like disconnecting. from the work that you're doing in the workplace. So in some ways, we do that as a protective mechanism in medicine to go through patients and not be affected. But it's if you did that to an extreme and you were never really connected. So you're viewing patients sort of like objects. And the cynicism part is more like anger, frustration in the workplace with colleagues, with the work you're doing, that sort of thing. We often neglect anger as a symptom of anything, but it is something to pay attention to. And the last one is a reduced sense of personal accomplishment. In most people you notice this one because you care when you get work done or you care if someone else tells you if you are getting work done. And so the last one tends to be the one that I see people like show up in my office about because someone pointed out something at work about them not getting things done or they felt like they were becoming less productive and that made them anxious. It's not the other two. The other two, I feel like we go work is hard. I'm supposed to. To be tired from it. Work is like emotionally investing in patients and their lives. And of course I'm emotionally exhausted. And then I'm just protecting myself from the content by depersonalizing. And then it's not really until it starts to affect our work or someone else starts to notice that we go, Hey, like maybe this is something I should worry about.

Dr. Elise Fallucco:

That's an excellent recap using normal human words and getting away from dSM bullet points and psych, psychiatry jargon. And I just want to go over just to recap for our listeners. Burnout is environment specific, like specifically it has to do with how you feel related to your workplace and, symptoms that occur in the context of wherever you work and then number one of the three symptoms is emotional exhaustion. And as soon as you said feeling tired every day or most days when you come home from work, not physically tired and just spent. And I can completely relate to that. My kids can tell you that for sure. And then the second one is cynicism or depersonalization. I think when people hear words like depersonalization, they're like, that sounds psychotic. Like what does that really mean? But I like how you recapped it and just talked about instead of. Putting your heart in your work and enjoying what you're doing, you're to the point where you're going through the motions, but you're not as connected to your patients connected to the work that you're doing. And I think that is can be really subtle. It's not necessarily like you care so much and then the next day you don't care at all. I think it's a slippery slope Yeah,

Dr. Jess Gold:

I'll just add sometimes people will say like the thing that makes them who they are, the thing that like you would pick going to me as a psychiatrist or going to you would be the thing that might be missing, right? Like you're not making errors. You're just not you. And so that part, like maybe you're still really good at your job and maybe you're still an awesome diagnostician and maybe you're still not going to hurt anybody as a patient, but you're not you and you're not the person that they like chose to see because you're just not as invested and probably you are a person who would be.

Dr. Elise Fallucco:

And it's something that it's probably more obvious to you and which reminds me of something you said in the book about, for those of us who are very type a and hardworking, oftentimes we can continue to go through the motions and get things done and achieve. And work is like the last place where you start to see problems and errors. And then that brings us to the third symptom of burnout, which is a lack of a sense of personal accomplishment. Or as you put it really nicely, it's almost like you've stopped caring as much about things at work that you would typically care about like showing up early or making sure that your notes are really high quality. And this could be a really hard thing for us to figure out in ourselves or to recognize when it's happening in our own lives, because it's not like our grades are failing. Or the hospital dictation service is calling us because we owe them a thousand notes. It's more of a subtle, emotional switch and a change in how we're showing up at work. And I imagine that our listeners at this point are wondering how then do you distinguish between burnout and depression given that. Some of these symptoms seem to overlap.

Dr. Jess Gold:

I think about the difference between depression and burnout as Burnout being a sort of precursor or step to depression. So we know that burnout is correlated with depression. It's correlated with suicidal thoughts, but they are not the same thing. That's in part because Burnout is workplace associated and that is where it stems from and depression doesn't have a location or a circumstance that is the direct cause of it. Depression's main symptoms are also depressed mood and change in interest or we use the word anhedonia to mean that. You might see that in burnout as a sort of after effect, but it is not a key symptom of burnout. With depression, you also see things like change in appetite, change in sleep, suicidal thoughts, change in concentration. A lot of those symptoms, again, might be something you could see with emotional exhaustion, but they're not. the same that you would see in depression in the same sort of cluster you would see in depression. Depression also has a time frame. We say two weeks, at least two weeks of symptoms. Burnout doesn't currently have a time frame associated with it, if that makes sense and is helpful.

Dr. Elise Fallucco:

So typically with burnout, we wouldn't expect to see changes in sleep or appetite or concentration. But as you pointed out, it does seem like it's a little tricky to disentangle. The differences. And I would say, regardless of whether we're experiencing symptoms of burnout or depression, I think this is definitely time to see somebody. To help us sort out what's going on and figure out next steps. Without giving things away in your book, you talk about About your own personal journey and moments or a moment when you recognized, Huh, I may be going through burnout. What do you think are ways that we as clinicians might recognize when we're beginning to tip over into burnout?

Dr. Jess Gold:

Yeah, what I would tell people and I tell patients is we tend not to notice this until it's really bad. We blow past. like the sort of subtle signs and symptoms that we might experience. I did this myself very obviously. I still do it sometimes. I would say in that sense too I'm a burnout expert and I'm not really great at applying burnout to myself, so like, why should you be good at it, right? In our lives because we pay so much attention to other people, we don't notice subtle things in ourselves and we don't stop to ask ourselves how we're doing. by the time you're super angry in the workplace and really disconnected from people, you've blown past that. By the time that someone might mention that you are not doing your work, you've blown way past that. By the time you're like me and are sleeping every day after work uncontrollably and wake up seven hours later. That's a problem. You skip some stuff. And I think the subtle stuff is, for me, something as simple as like email or like inbox makes me so mad, like not, Oh, look, I have another email. It's if somebody sends me another email, I'm going to pick up my computer and launch it across the room. And that reaction. Is not normal, I've been told, but also it is as a result of me knowing that email or my patient inbox is someone asking me for something and I don't have the capacity to give it, right? And so I never really stopped and thought about it. I was like, so what? Sometimes emails make me angry. And it wasn't a thing that I was really thinking about. And I realized, in reflection of what are my subtle signs and symptoms, which I would recommend anybody do, because as much as I can rattle off signs and symptoms, what it looks like in you might be super different and paying attention to some of the early signs for you might make you better able to go, Oh, I'm shifting towards somewhere I don't want to be. If someone sends me an email, it's here's this other thing that I would want you to do. Cause email tends to be like a transactional thing or a question or something you have to answer. Same with patient inbox. And so my reaction is very much about that. I'll say other people have just anger more generally. Other common things would be like, Subtle schedule changes, so if you're a person who super likes to cook, and then all of a sudden you just start ordering takeout, or you like exercise and you pull back on it, or you like hanging out with your friends and you just don't have capacity for that anymore, I think those are signs that things are not going in the way that you want to be going. That a lot of people mentioned to me as patients or that I've experienced myself. We tend to just go I'm having a bad day, but that bad day turns into a bad week, turns into a bad month, turns into you're burnt out.

Dr. Elise Fallucco:

Yeah. And I think it's sometimes it's helpful to have people like loved ones, colleagues, whoever around us who can who we trust and who can call it out for us or maybe it's helpful if we listen to them when they say things like I think you need to take a deep breath or, is everything okay?

Dr. Jess Gold:

Yeah, in the workplace, people tend to point out a flaw instead of really checking in on someone so that the reaction tends to to be how dare you say I'm not doing my work as opposed to, yeah, you're right. I'm not doing okay. And so I often tell supervisors or people that like, maybe starting a little later and not pointing out the flaw would have gotten a little more buy in, I didn't know I was burnt out until my therapist told me, right? So like sometimes external eyes can make a big difference, but even earlier I was having friends and family say what's the deal with your texting? You're not texting back. And I just was like yeah, I'm over it right now. But I'm a really efficient texter. If I could get an award for that, I might and so having friends or family say what's the deal? This isn't right For you. Are you fine? I just was like why are you talking about my text messaging? But it really is a sign if I didn't take it as like an affront to my texting ability.

Dr. Elise Fallucco:

No, but it's it's such a great example too, about how, when people point out something that is different about us, like your family saying you're not texting back or the medical records office saying, where are those notes or, whatever it is that you get defensive and you're like, I'm busy. I remember feeling this this image of there were all these vultures pecking at me from all different directions can you do this? Or we want you to do this talk and we also need you to write this thing and we need you to help out with that. And, so and so called out sick, can you cover this shift and that shift? And of course, when you're carrying a lot and when you're working really hard, any extra ask is really challenging, but I think at some point The point where you, it just makes you angry and that's your body's way. I'm saying this in hindsight, I didn't recognize it at the time, but I guess of us don't, I think that's the truth, like it's your body's way of saying this isn't right. Something needs to go like red alarms are going off all over. And I think we're used to just pushing through the red alarms. You said this beautiful quote in your book. You said, mental health outcomes are an occupational hazard in healthcare. Wow. And, you talked about how there's lots of literature showing that we as healthcare workers have alarmingly high rates of depression, of post traumatic stress disorder, of suicide, certainly anxiety. Let's talk about how does the culture of medicine inadvertently increase our risk for negative mental health problems?

Dr. Jess Gold:

It's a hundred percent an occupational phenomenon and for a long time we didn't want to talk about it I think the pandemic sort of compounded these really deep existing bad problems and people finally started to pay attention, right? For me, writing the book reestablishes that conversation to say it's not going to get better. It was only going to get worse. So we need to talk about it. In our culture, Stoicism is valued, and so is um, perfectionism. And both of those are challenging for things like emotions and paying attention to yourself. We also have a culture that we put other people before ourselves because We are selfless humans who were like that probably before we went into medicine. And then it was repeatedly emphasized to us that we needed to do that. So we learned through what we would call the hidden curriculum, really to focus on others way before ourselves, that our own problems are interfering, and we're not allowed to express them or deal with them. And then at the same time, we see modeled, People who are not emotional, who get good feedback for being not emotional, and people who show up to work sick as a dog and get praised for it. So we have a big culture of presenteeism, which is the opposite, opposite of absenteeism. We're going to go to work sick and data would show that too. Even if we're seeing like immunocompromised people and everybody I know can give you this bonkers story of someone who did something in the workplace that they saw because they were sick. Oh, I remember this time when this resident came in and they were throwing up, but they put an IV in their arm and dragged it around and saw patients. How cool was that? And they say it like that. They're

Dr. Elise Fallucco:

tough. This is what you should be doing. And there's judgment who calls in sick to work? Are you kidding me? When I was in residency I did X, Y, and Z. Yeah. And we're, in some ways we're perpetuating the culture. This is what we grew up in, in the culture of medicine. And then, working with younger trainees and younger people, I commonly hear my colleagues say Oh, they're so ridiculous. Look at them going home before 6 p. m. Cause they want to be with their family.

Dr. Jess Gold:

How dare they. And so then we get called weak and we can't cut it and all this kind of stuff, or the person who does choose to stay home sick, they get joked about them the whole day on the wards. We would do it with Jenny, but Jenny's not here. And so that's, we learned that. That is bad, that we show up no matter what, and so we show up, we can't feel, we can't put ourselves into the equation, and so we really stop paying attention to our cues, because we even stop physical cues. We're not allowed to be hungry, not allowed to go to the bathroom, so we can't pee and we can't eat, we definitely can't cry. And if we can't skip work unless we're, like, hemorrhaging, we definitely can't skip work for burnout, right? We're, like, it's just impossible. So the culture makes it. Emotions don't even get a blip on the chart of what is an acceptable reason to not be somewhere. And all of the stuff in medicine, we burden a lot of people with our choices. So if we don't show up for work, it burdens patients, it burdens the team, maybe someone has to be called in instead of us. All of that, Also contributes because we have a complete lack of redundancy in our culture. So if we're not there, it's a big problem. And we feel that despite the fact that we know we probably shouldn't be there. And so we show up and it's probably not good for anybody that we do, but the culture is a culture of showing up way before you show up for yourself.

Dr. Elise Fallucco:

Yes, I can think every single time that me or my husband, who's also in healthcare gets sick or have some reason where we probably shouldn't go to work, the first thing that comes to your mind is, I have a clinic full of patients. Or who's going to reschedule? Who's going to see them? How is this going to work? There is not a big backup system. And I

Dr. Jess Gold:

look at who the patients are and I'm like, can these people wait? If I cancel, I can't invent new days. So you might not get back in for months so it's do I need to go to my 10? Because my 10 can't afford me not to come. And is that a thing? And that's also hard. I think.

Dr. Elise Fallucco:

Yeah, and this feeling that there, there's not a buffer, there's not a lot of backup, there's not a lot of other places where we can go and take care of these kids, take care of these patients, It's definitely a reality and it's not something that we're going to be able to change overnight. And so the hard part is just trying to figure out like, how do you move within that? And how do you honestly acknowledge, yes, this is really hard. This is something that you need to do for yourself and you'll show up better the next day or the next week or whenever it is for the patients. So for our psyched for Peds listeners, I'm going to recap some of the highlights from our conversation. We talked about how common burnout is in healthcare affecting about half of us and that the very things that make us excellent clinicians like our selflessness and our desire to help people and our caring nature may actually increase our risk for experiencing burnout. And that part of our job is to try to pay attention to the subtle signs of burnout in our own lives so that we can do what we need to do. To get healthy. And so when you get a moment to reflect, maybe ask yourself some of these questions to see. If you're experiencing any symptoms of burnout. Do I feel exhausted at the end of work most days? Have I noticed that I'm more cynical or angry when I'm at work? Have I noticed that I'm not really putting my heart into work as much as I typically might? Do I feel less connected to my patients? Am I showing up at work the way that I want to? And I know for me personally, I have definitely answered yes to a lot of these questions. And so our next step is to join us next week, where we're going to really talk about what do we do about burnout? How do we as individuals survive in this culture of health care and take care of ourselves and help our colleagues and so that we can all help our patients. So please tune in next week to psych for paeds. As we continue this discussion with Dr. Jessi gold. Thanks for listening.