Psychological stress characterized by exhaustion, lack of enthusiasm and motivation, feelings of ineffectiveness, and frustration or cynicism which leads to reduced efficacy within the workplace. 
I “decided” to become a physician as a pre-teenager, knowing essentially nothing about the profession. I achieved good grades in school, medicine sounded like a noble profession, and I assumed there would always be job security. The last part was especially attractive because I’ve been risk-averse since childhood, an interesting trait I had to work through to become a surgeon (the area of medicine which matched an even more important trait—love of creativity and working with my hands). The journey through training and practice has been a fascinating one, filled with both joy and angst. I would choose it again without hesitation if given the opportunity to do it all over, despite creeping dangerously close to burning out and risking losing everything I hold most precious in my life.
Proposed susceptibilities relevant to physician burnout include the long training period and associated delayed gratification, the unique physical, emotional, and spiritual demands of training and practice, the need to spend more time with documentation and other mundane tasks than with actual patient care, sometimes unfair or unhealthy compensation structures, long hours away from home, balancing the needs of both family and patients, evaluation by factors outside providers’ control (e.g. governmental organizations and insurance carriers), and the like. After adjusting for age, sex, relationship status, and hours worked, physicians are at nearly twice the odds of experiencing burnout compared to people in other fields, and the problem is getting worse [2-3].
Dr. Dike Drummond’s assertion  that we physicians are taught to never show weakness and that the patient always comes first is completely consistent with my experience. I’m embarrassed to say that I went eight years without shedding a tear. I know this because I remember the bookends of that time period vividly. I went for a run along the East River in New York City before my first overnight shift at a new hospital. Unlike other shifts where we worked as a team of residents, I would be the only resident covering a busy Labor and Delivery ward. I felt anxious, overwhelmed, and terrified, and all of that emotion erupted with tears streaming down my face as the sun started to rise over the city. I pulled myself together, took a shower, went to work, and made it through my shift. The next time I cried was when I realized early into my first faculty position that my marriage was falling apart.
My own exploration with burnout began two years ago when I volunteered to give a talk to physician trainees in my field at our annual conference. The topic was selected because of increasing awareness in the lay and medical literature of burnout’s emergence as a serious problem in medicine. It didn’t take much to realize I was “at risk,” if not already wading into those waters. I imagined preparing for the talk would be therapeutic, in that it would force me to introspect, and to investigate what others have done to find success—in achieving goals, and in finding balance in life. In some ways, it was a bit of an experiment, one that I both failed (and learned from) and succeeded at (and learned from as well).
I think the most important insight I gained during that first exploration was a recognition and acceptance that my career is an important part of my identity and that perhaps the “work-life” divide might be artificial. I love what I do—not just for the external rewards but because I find my work intrinsically satisfying, to the point where many aspects don’t feel like “work” at all, more a vocation than a job. Incomplete understanding and miscommunication about that was a big part of what lead to my divorce. I ended that examination determined to be authentic with that aspect of my identity, but not become one-dimensional.
The next breakthrough I had came in the summer of 2017, at our annual surgical “boot camp” for trainees in my field. My partner, Rick, runs the Los Angeles office of a consulting firm, and has extensive training and experience in leadership development. He agreed to speak with us about attention management. Note that the topic was not time management. We can’t “manage time,” it moves continuously without our control. We can, however, choose where to put our attention with the time that we have. It was an excellent talk that was very well received and, after re-reading the slides months later, I slowly began to incorporate some of the suggested habits, such as blocking off time for projects, turning off notifications, and reflecting at the beginning of the week on what I want to accomplish.
This summer I began replacing music with audiobooks on my runs, and I discovered several that had a profound effect on my thinking and behavior. Perhaps most influential was Steve Magness and Brad Stulberg’s Peak Performance: Elevate Your Game, Avoid Burnout, and Thrive with the New Science of Success. In this work, the authors describe the “growth” equation: stress plus rest equals growth. The idea is that we need a certain amount of stress (“just manageable challenges”) to push us beyond our comfortable limits. But in order to grow, we also need time to rest. The authors demonstrate with examples from athletics, the business world, the arts, and academics that alternating between deliberate demanding practice, followed by periods of rest, allows us to improve our skills and become masterful with our passions.  The concept made complete sense to me, and despite good intentions to employ this strategy, I chose to ignore the rest part of the equation in my daily life. This week has been a wondrous re-examination of how I can be a better self through owning both sides of the growth equation.
In academic medicine, the pressure to succeed in teaching, research, and clinical excellence, and my personal drive to achieve in all of these areas, keep me at risk for burnout. The challenge of avoiding burnout often feels like two steps forward and one step back. Let’s face it—change is hard and happens slowly. I can’t conquer burnout any more than I can conquer success. I recognize I must breathe, live in the moment, and remember that rest is as important as stress to pull myself away from that cliff edge of exhaustion. In all of the reading and listening I’ve done on the subject in the last two years, a universal theme among all the advice was to practice. The only way to replace unhealthy habits with healthy ones is to try new behaviors, and keep going back to them, even when the old ones re-emerge. When I allow feelings of being overwhelmed to dominate, it’s easy to get discouraged, but when I take a step back and look at where I’ve come over the last two years, I’m proud of my progress and the ways that I’ve grown. I’ve come close, but I am not burned out, and I remain hopeful about the future.
Here are some habits I’ve begun to incorporate into my life that help me steer away from burnout. I certainly don’t practice all of them all the time, but I would never have believed that incorporating these, even to some degree, was possible ten years ago. And the more I do them, the easier they become—practice.
It wasn’t until recently that I began questioning the pervasive devaluation of sleep in our culture. I bought into the macho notion that sleep was weakness, a necessary evil best kept at a minimum to maintain productivity. The college and medical school all-nighters, followed by requirements to stay awake for sometimes 30 hours at a time during residency, simply reinforced the fallacy. Somewhere in the past few years, I began noticing stories in the media that pointed out that limiting sleep is actually detrimental to productivity. I remember being so fascinated with Terry Gross’ interview with sleep scientist Matthew Walker on her show, Fresh Air , that I listened to it twice. We’ve had The Sleep Revolution  on our shelf for a while, but I picked it up this summer and am nearing completion. I am now much more consistent with what time I go to bed (early) and when I wake up (early). I don’t take my laptop into the bedroom, we keep the temperature cool, and play gentle white noise on the sound system. I read for usually 5-20 minutes under low, warm light before closing my eyes. While I can’t take my phone out of the bedroom completely because of my job, I turn it facing away from me, and I don’t check it in the middle of the night or for at least the first 15 minutes after I get up in the morning. I taught myself a calming technique for the times when I wake in the middle of the night and worry about not falling back asleep. I remind myself what a gift this moment is—even if I can’t sleep, how often do I get to be this calm, in a space this comfortable, with the person I care about this much, and just rest? Isn’t that a wonderful place to be? Inevitably, after giving myself that lesson of appreciation, I fall back asleep. Changing habits that affect the duration and quality of my sleep has improved my energy, disposition, productivity, and sense of well-being.
I ran the New York City marathon in 2008, 2010, and 2017. Each time was a tremendous experience, but also quite painful because I was not deliberate about training. I told myself countless times that if I were better about stretching and took up yoga I’m sure my exercise aches would improve. I don’t know what finally convinced me, but two months ago I finally got up the courage to attend a Tuesday morning yoga class at my gym. It’s called “Power Yoga” and it’s intense! I find that the physical and spiritual challenge incredibly rewarding, however. Instead of making excuses not to go, I re-arrange my schedule so that I don’t miss it. As someone defiantly reluctant for over a decade, I encourage all the skeptics to give it a try. It may not be for everyone, but I never thought I would find it as enjoyable or valuable as I do.
I first learned about meditation during my fellowship training. After completing an OB/GYN residency, I spent two years learning minimally invasive surgery and the evaluation and treatment of chronic pelvic pain. Chronic pain is a poorly-understood, difficult to treat condition which affects a remarkable number of people. Of the adjuncts to typical medical and surgical approaches, mindfulness-based meditation nears the top of the list of successful strategies for mitigating and coping with chronic pain. As I began to explore more about it, I quickly learned that evidence supports the value of meditation for all sorts of conditions, such as addiction, anxiety, and depression, and many have attributed the practice as cardinal to their success in overcoming these afflictions. I am in the infancy of my own meditation practice, but I can already see the benefits in subtle ways. Just like yoga, I would have never believed I could convince myself to take time to meditate, but now I will sometimes break up my work with walks through the hospital’s healing gardens and rest my mind with stretching and breathing exercises. I feel especially lucky that, here in Los Angeles, I can walk outside nearly any time of the year for a dose of fresh air and sunshine. I also find meditation helpful when I am feeling down or troubled. Changing my outlook by focusing on the moment does wonders for putting my worries in perspective.
Alcohol became an easy way to shut my racing mind off during those 80-hour work weeks as a resident. The drug was ubiquitous in New York, aided by the fact that no one drove, and as the “city that never sleeps,” we could go out for team drinks even at 8 o’clock in the morning after working a night shift. I never drank to get drunk or because I found it an essential social lubricant; it was a simple, albeit unhealthy, means to escape the chaos of the day. I grew up in a home without alcohol and I think, somehow, drinking also felt “adult” or a little rebellious. This Naked Mind: Control Alcohol, Find Freedom, Discover Happiness, & Change Your Life by Annie Grace was another of this summer’s books worth a few listens. I found her rational, matter-of-fact approach to de-bunking common beliefs about the benefits of alcohol convincing. Alcohol doesn’t help us sleep better, have more fun, make us more interesting in social settings, help us truly relax, or deal effectively with our stress. The idea here is to take the pressure off—it’s not about depriving oneself of something great; it’s just a choice to avoid something not especially helpful or healthful.
I’ll admit that, although I enjoy reading, I’m not someone who picks up a book and will finish it over a weekend. In recent months, though, I’ve gotten back into the habit of reading before bed. I find it relaxing and I like the ritual of it. Sometimes it can be hard to put down a good book when I know it’s time to call it a night, but thankfully I’ve never found that reading keeps me charged in a way that interferes with me falling asleep. I like the feel of paper books, and I like to listen to them when I’m exercising, especially running. I usually run for an hour or so, which is enough time to really engage in the material, and I find the combination of movement and listening fosters my imagination. In addition to the ones already mentioned, the references below include a few others which piqued my interest [8-11].
I have often laughed at the difficulty Rick and I have with the easiest of decisions, like choosing a restaurant or what to do for fun on the weekend. We spend our days at work constantly making critical decisions, and, by the time we get home, there’s little mental reserve left. Psychologists call this “decision fatigue.” President Barack Obama and Facebook CEO Mark Zuckerberg attribute wearing the same thing every day (dark suit, grey t-shirt) to avoiding the phenomenon, saving mental energy for more important tasks by taking the decision out of mundane ones completely. As a surgeon, I have the luxury of wearing scrubs and a white lab coat every day, and I choose an outfit and pack for the gym every night before bed. Rick and I have a short menu of healthy items we prepare for dinner (a protein, arugula salad, and roasted vegetable usually) that we mix and match with little effort. Keeping the simple stuff simple gives me more energy for the complex decisions.
I find it helpful either on Sunday evening or Monday morning to take a little time to list out the major projects I’m working on (writing a manuscript, preparing for a talk, planning a simulation session for residents) and think about which are of highest priority and when I might set aside time in the week to work on them. I often will also make a daily list that includes the prioritized bigger projects as well as the small ones that need to be completed that day (write clinic notes, call referring doctors, book a flight, etc). I obviously don’t get to everything on my list every day, but I find the process of listing helps me consider what is most important, avoiding getting anxious or distraught by all of the ongoing tasks, and get some satisfaction out of crossing things off the list. Rick calls this “weekly reflective time.”
Attention management practices
Concentrating in the operating room is effortless for me. Surgery is my “flow,” described by Dr. Mihaly Csikszentmihalyi as a state of consciousness represented by total concentration and absorption in the task at hand . The more academic parts of my profession, such as research endeavors and writing, require much more effort for focus. For these, I’m most productive when I block time in my schedule to work on them and then turn off all notifications that I can (my team knows to call if there is an emergent patient need). I find a quiet place, usually my office, the hospital’s medical library, or a corner of my gym near the yoga studio where I can stand while I work, and I set a timer for 50 minutes. During that time I don’t check my email, I don’t look at my phone, and I don’t respond to texts. I keep a notecard nearby and, if a task or idea pops up that I don’t want to forget, I just write it down and keep working. I try not to over-think writing and just start typing, knowing I can edit later. When my timer goes off, I take a walk, drink some water, and stretch or meditate. If I have time and energy, I might do another 50 minute session, but rarely more than two in a row. These few simple techniques have really helped me harness my attention when I really need to.
“There’s no such thing as an urgent email.” That’s a quote from Dr. Miguel Burch, a colleague of mine at Cedars-Sinai and my partner’s surgeon. He chooses to let his patients communicate by email, but warns them that urgent concerns need a phone call. Highly productive individuals such as Shonda Rhimes, the creative mind behind hit television shows Grey’s Anatomy and Scandal among others, and author Malcolm Gladwell (Outliers) have attributed some of their success to limiting time spent with email [13, 14]. In a recent Thrive Global podcast, Gladwell joked that he could even send an indirect signal of importance to an individual by simply by the act of responding within 24 hours. I used to spend excessive amounts of my work day checking and responding to email. I read and re-read my notes before sending them, and wasted a lot of valuable time doing so. Now, I may quickly scan my inbox on my phone while I’m waiting for the elevator at the hospital, but I try to save going through messages with more effort until the end of the day. Rick laughed when I discovered his long-held realization that many things work themselves out by the end of the day, obviating the need to even respond. He actually automatically filters message importance by whether they were sent to him directly or if he was cc’d on the message (as general manager at a consulting firm, his inbox makes mine look like child’s play). Email doesn’t require as much mental effort for me, so doing it at the end of the day saves more valuable time for tasks with greater need of concentration and effort such as clinical care or writing. Here are some other tips of “email hygiene” I’ve picked up along the way:
I wrote in a journal every day during high school. I still have those notebooks and I look forward to one day re-reading them with laughter and nostalgia. Although not every day, I’ve returned to the habit this year and find the practice helpful not just for chronicling events, but also for introspecting on what I could be doing better, checking in with my emotions, and considering what I want to change for the future.
Making deposits in the relationship bank
Early into our relationship, I convinced Rick to begin seeing a therapist. We had some pressing things to work through, but mostly I wanted to get out ahead of some obvious threats to our longevity—each of us were married when we met, and we both went through recent divorces. There is a large age difference between us, and we come from very different but equally challenging backgrounds. Perhaps one of the most important insights I remember from those sessions was the idea that each time you do something kind or thoughtful for your partner, you’re making a little “deposit” in your relationship bank. Not only does this make your significant other feel special and loved, but it helps your relationship withstand the inevitable disagreements and conflicts that will arise. The more you invest, the easier it will be to weather those difficulties. Deposits can be as simple as doing a chore, giving a back rub, or telling your loved one how nice she looks or that you’re proud of something she’s accomplished. I try to write Rick a little sticky note and make him coffee every morning, and he usually makes the bed and unloads the dishwasher. We both love fresh flowers, and liberally get them for one another. We send each other selfies from our phones at the half-way point of our favorite runs—a loop around Beverly Hills and another through Runyon Canyon. I’m convinced these investments make the tough times easier.
Thirty years ago, Nike launched its “Just Do It” ad campaign, and the phrase not only catapulted the company beyond its competitors in the 1980s, it became a part of an American, even global, lexicon. With any of these wellness-promoting, anti-burnout, habits, I think you have to just do it. Try what works, remind yourself the benefit it brought you when you need the motivation to do it again. But, when you find something good, just do it. Over and over. And eventually, with practice, you’ll notice your life moving toward a place of health and away from the despair of burnout.
1.Ruotsalainen JH, Verbeek JH, Mariné A, Serra C. Preventing occupational stress in healthcare workers. Cochrane Database Syst Rev. 2015 Apr 7;(4):CD002892.
2.Shanafelt TD, Boone S, Tan L, et al. Burnout and satisfaction with work-life balance among US physicians relative to the general US population. Arch Intern Med. 2012;172(18): 1377-1385.
3.Shanafelt TD, Hasan O, Dyrbye LN, Sinsky C, Satele D, Sloan J, West CP. Changes in Burnout and Satisfaction With Work-Life Balance in Physicians and the General US Working Population Between 2011 and 2014. Mayo Clin Proc. 2015 Dec;90(12):1600-13.
4.Huffington, Arianna. Thrive Global. Hippocrates, We Have a Problem: Doctors Are Burning Out at Surprisingly High Rates: Almost two-thirds of doctors in the U.S. say they’re burned out, depressed or both. https://www.thriveglobal.com/stories/36171-doctor-burnout
5.Magness, Steve and Stulberg, Brad. Peak Performance: Elevate Your Game, Avoid Burnout, and Thrive with the New Science of Success. Emmaus: Rodale, 2017.
6.Gross, Terry. Fresh Air. Why We Sleep, interview with Matthew Walker on July 20, 2018. https://www.npr.org/2018/07/20/630926599/why-we-sleep
7.Huffington, Arianna. The Sleep Revolution: Transforming Your Life, One Night at at Time. New York: Harmony Books, 2016.
8.Grace, Annie. This Naked Mind: Control Alcohol: Find Freedom, Discover Happiness & Change Your Life. ASPN Publications, 2015.
9.Halliwell, Ed. Into the Heart of Mindfulness: Finding a Way of Well-being. London: Piatkus, 2016.
10.Coyle, Daniel. The Culture Code: The Secrets of Highly Successful Groups. New York: Bantam Books, 2018.
11.Burchard, Brendan. High Performance Habits: How Extraordinary People Became That Way. Carlsbad: Hay House Publications, 2017.
12. Csikszentmihalyi, Mihaly. Flow: The Psychology of Optimal Experience. New York: Harper & Row, 1990.
13.Gross, Terry. Fresh Air. Shonda Rhimes On Running 3 Hit Shows And The Limits Of Network TV, interview with Shonda Rhimes on November 11, 2015. https://www.npr.org/2015/11/11/455594842/shonda-rhimes-on-running-three-hit-shows-and-the-limits-of-network-tv
14.Huffington, Arianna. Thrive Global Podcast. Interview with Malcolm Gladwell on August 26, 2018. https://www.thriveglobal.com/stories/40974-malcolm-gladwell-email-hack