Use Design to Put out the Fire: protecting against burnout in medicine
Thinking like a designer unlocks tools to create systems within the constraints of life.
When pandemic meets epidemic
According to the most recent survey on burnout in medicine, nearly 2 out of every 3 emergency physicians reported experiencing burnout last year, over a 20% increase from the year prior. It's just as high for emergency nurses. It's a severe problem in all of healthcare. Like mindfulness or entrepreneur, the term burnout seems to have lost its essence, its meaning. I've heard about the perils of burnout in medicine since the first day of medical school. During residency interviews, various program directors talked about everything their program was doing to address "wellbeing." Then we entered the COVID era; clearly, what we're doing to address burnout is necessary, though not sufficient.
As a new attending physician, I'm new to this. New to the life of a career physician, as a husband and father in medicine. I can't address this issue as an expert, but happiness and life satisfaction are things I've thought a lot about, and I want to share my thoughts on what I think you can do to buffer your life against our current challenges.
I would argue emergency medicine is the most challenging specialty to work in. I don't say that to scare anyone away from the field; I think its challenges make it potentially the most rewarding. What it does mean, I think, is that you have to be aware of that to create systems around the challenges to deal with them.
I would say three factors make emergency medicine the most challenging:
- Administrative barriers
- Workplace violence
- Dysfunctional outpatient medicine
Let's break these down a bit.
Administrative barriers
ED Boarding
I talked about this in my last post; A Thousand Cuts to our Healthcare System. It's terrible for patients, terrible for doctors, horrible for nurses. It's just awful and leads to worse patient outcomes. I won't go into it any further here.
Documentation
Often listed as the most considerable burden for physicians, charting is arduous. When physicians end their shift, they usually have several hours of documentation to complete. Adding to this is the defensive nature of our healthcare system. In many ways, charting is considered the last line of defense if a physician is sued, leading to unnecessarily long notes whose only aim is defensibility in hypothetical court.
This isn't a problem that's going away, likely ever. Instead of simply seeing it as an obstacle, I've found it's more helpful to find ways to use the tools an electronic health record offers to design the system around you, rather than adapting to fit the system. Every software platform is different but each has its own version of macros or ways to template your notes. Invest the 10-20 hours to set this up for the things you have to document most commonly. Pay attention to the 20% of things that take up 80% of your time and focus there. For me, that's documenting the "medical decision making" section of a note from an emergency department encounter. Lean into the "common" presentations and have a template ready for them.
Workplace violence
There's no other industry where violence (physical, verbal, emotion) against its workforce is more prevalent than healthcare. A recent survey of emergency physicians found 1 in 2 emergency physicians have been physically assaulted. The emergency department is a perfect setup for this because of the inherent severity of illness and the uncertainty of whether a person is acting the way they are because of a medical problem or simply a mean person. So we brush it off as a part of the job. We're taught - indirectly - that patient safety comes before personal safety. Imagine if half the staff at your favorite restaurant had been physically assaulted by restaurant-goers. It would be unconscionable.
Dysfunctional outpatient healthcare
There's an ironic tension building in the US; challenges in accessing traditional primary care and private on-demand style care at CVS, Walmart, Zoom Care, and other urgent care start-ups. The slow, incremental evolution of conventional medicine has created a vacuum that will soon be filled by large corporations that understand efficiency and customer service.
Until the upstarts have ironed out the kinks, we're left with a lack of accessible primary care. The dysfunction leaves patients to decide to wait a month to be seen while they worry about their health or go to the emergency department to be seen sooner (oftentimes sent in by their primary doctors to "expedite" their workup). It's not just primary care right now, though. Most medical and surgical specialists are scheduled months out. Not to mention psychiatry and behavioral health, which were lacking before COVID.
Four Areas of Wellbeing
I like a book entitled Designing Your Life: How to Build a Well-Lived, Joyful Life by Bill Burnett and Dave Evans. They're designers who teach at the Stanford d. school and have used human-centered design to approach career and life design. In the book, they lay out four key areas of your life:
- Work
- Health
- Love
- Play
They describe five "mindsets" that are important when approaching the design of your life:
Curiosity
Curiosity frees you from the status quo. I think of it as being open-minded. No matter the term, the willingness to sit with something new and explore it before saying "no" is vital for creating value for yourself or others. A designer is willing to sit in uncertainty while others say yes to the first thing that seems to "scratch-the-itch" as a way to remove the discomfort of uncertainty.
Bias to action
Experimentation and reiteration allow for low-cost feedback loops, which help you know where to invest your resources. The more common approach is to plan, plan, and plan, only to never actually get started because the fear of needing to plan more takes control. Instead, be willing to experiment and learn to view "failure" not as a negative but as just another data point.
Reframing
Reframing goes hand-in-hand with a bias to action; reframing is the willingness to change your mind about something when given updated information. It's about reframing a problem, idea, or viewpoint.
Awareness
An awareness that there's no "end-game." It's only a continual process of exploration, creation, feedback, and reiteration. You have to fall in love with the process.
Radical collaboration
Ask for help. Diversity around you will only help to create better solutions.
Designing a Life in Medicine
A lot of what I've learned has been a process of trial and error. I try to keep an open mind when thinking about how to improve my experience and life and become the person I hope to be. Let's go through each key area of life outlined in Designing Your Life as it's pertained to my life in medicine.
Work
The work area in your life may be the most challenging because of everything I mentioned before. You study and train for 7-8 years and begin a career where the system is broken, and the patients abuse you. The medicine isn't the challenge, but the moral injury created because of the barriers to helping patients. I think an essential step is reframing the problem. The problem isn't a broken system per se but rather a form of healthcare incongruent with your values as an emergency physician. That means you can either change your values or bring the system closer in line with your values.
A bias to action means you feel psychologically safe enough to put yourself out there within your organization or the healthcare system to effect change in a way you think would better align it with your values.
To do so requires a sense of agency, a feeling that you are the one in control of your future and can take steps to alter it. A bias to action means you feel psychologically safe enough to put yourself out there within your organization or the healthcare system to effect change in a way you think would better align it with your values. One small way I did this was early in my residency training; I started a blog where other residents and I could post content we created. It satisfied my desire to create (play: see below), educate others (a value in my career), and work with others (radical collaboration). It was low cost to me as it only required my time since then my training program was willing to pay for the website itself, and I didn't have to attach my name fully to it and would ultimately step away from it at the end my training.
More than anything, I think we need to push ourselves to stay curious and stay in the process. Medicine, in general, will forever be changing and challenging. There is no "work-life balance" in any career and definitely not in medicine. There will always be an ebb and flow to what balance means for you. If you can stay curious about your profession and view it as a life-long journey, you'll buffer against dissatisfaction when times are hard.
Health
It's one of the great ironies of medicine; do as I say, not as I do. We counsel patients to "drink plenty of water" and then don't give ourselves a break long enough to do so while we work. As an emergency physician, I don't sleep enough, and when I do, it's not always restful as you battle the challenges of shift work and circadian cycles. Just because something is the way it is, though, doesn't mean it has to be that way. Learning to design within constraints oftentimes leads to the most interesting solutions.
Physical Health
Diet
There will forever be people singing from the roof-tops about some new approach toward food. The only thing that will always be true is; everything in moderation, make most of your food plant-based. I always loved the approach Michael Pollan uses; you can eat anything you want, as long as you made it.
Sleep
This has been a bit more challenging for me since finishing residency. While you work fewer hours, your schedule feels a bit more variable, so your sleep schedule shifts. These are the components I've found to be crucial:
Black-out curtains
They are a must. There's evidence that any ambient light can affect your sleep!
How Does This Work
Sleep mask
Unless you tape cardboard into your windows, it's tough to keep your room black in the middle of the day. Use a sleep mask that has padding around the orbits of your eyes to allow your eyes to move freely during REM sleep. It's much more like you're just in a dark room than having your eyes jammed shut.
Sleep buds
While not a complete magic bullet, the second-generation Bose Sleep Buds are an excellent tool to improve your sleep. They're tiny earbuds that work as noise machines in your ears. I've slept with "airplane sounds" on as ambient noise for years. The Sleep Buds re-create that but also function as earplugs, which means you don't get stirred awake at 11 AM after an overnight shift while the rest of the world goes about doing everyday human things like mowing the lawn. They take a few nights to get used to, they're pretty expensive for what they do, and I've had one fall out a couple of times. They aren't perfect, but if the sustainability of your career depends on you adapting your sleep habits, they're well worth it. They also offer a discount to health care workers, so take advantage of it.
arkadycole
Sleep tracking
biodata and health tracking is an immensely sexy and attractive idea to many people. I think primarily; we've flooded our lives with statistics and metrics without any real sense of what to do with it. I track my sleep with an Apple Watch using Pillow and Sleepcycle. Pillow has a great automatic sleep tracker, and Sleepcycle has my favorite silent alarm that wakes you up over a set amount of time, based on your sleep depth. In other words, I set the silent alarm on Sleepcycle for 4:40AM, with a 20 minute window; at 4:20AM Sleepcycle starts to monitor my sleep and will start tapping my wrist when I transition into a light sleep. It helps avoid that dreaded feeling of being pulled out of the depths of slumber.
The things I pay attention to are:
- Trends in sleep quality, particularly around shifting sleep schedules. I've experimented with post-night shift sleep and the best approach to "flip" back to regular circadian cycles.
- Heart rate variability; it's effectively a proxy for the tone of your adrenergic system. Generally, higher variability is better. Lower variability can signify fatigue of the sympathetic nervous system and excess parasympathetic tone.
- Resting heart rate: typically, the lower, the better. I use it similarly to HRV. If I see it's creeping up, that's a sign of physiologic strain. Often I'll adjust my workouts to avoid things like high-intensity interval training or really heavy weight lifting to allow my body some recovery.
Here's a graphic that nicely demonstrates how my physiology changes in response to an overnight shift. You can see I went to sleep sometime around 8 AM and slept overall much less than usual. As a response, my resting heart rate trended upwards by 2-3 BPM and my heart rate variability dipped by 20 milliseconds or so. Small effects, but they compound over time and are important to pay attention to when trying to design a life for sustainability.
Intention
Some mornings I'll pop awake and want to spend time with Kyira and Everly. That isn't always sustainable on nights when I don't go to sleep before 3 AM after a swing shift. Before bed I've started to tell myself; "you are allowed to sleep as much as you need". I'll never be the husband, dad, or physician I want to be if I'm fried from not sleeping.
Exercise
I've always found exercise to be my keystone habit; everything I do after exercising is better than if I didn't. Therefore, I do it first thing in the morning whenever possible. Technology has made exercise so much more accessible than it has felt before. Fortunately for me, I've always loved sports, and training is as much of a hobby as it is a necessity. If you struggle to bring it into your day, make the threshold so ridiculously low that you would feel silly not doing it. If you don't feel like doing it, commit to putting on your workout clothes or shoes.
Mental Health
The challenges of mental wellbeing in medicine are for real. I've found what makes this particular area of wellness tricky is the insidious nature of the adverse effects on your mental health. It's the frog in hot water scenario; if you put a frog in a pot of boiling water, it will immediately jump out. If you put a frog in a pot of room-temperature water and slowly heat the pot, the frog will cook. The daily accumulation of residue on your mental health isn't immediately apparent until it is.
I've started to pay attention to small changes in my daily behavior as a barometer to gauge my mental health. More noticeable changes like poor sleep, irritability, and low motivation are easier to spot. Then there are the sneakier signs like poor food choices you make, difficulty concentrating (i.e. I scroll through websites instead of writing or look at photos while having a conversation), or getting side-tracked trying to finish an otherwise mundane activity. When I notice these behaviors, I've started to purposefully slow down when I would feel the answer would be to double down on effort in the past. I've found slowing down and pairing back on my commitments for a short while to help me then observe my thoughts. This pause helps me to let go of the weight I sometimes carry on my shoulders without knowing. Doing less will enable me to do what I am committed to, better.
The crucial piece is a system to instill some proactivity to understand how daily life affects your mental health rather than reacting when you're struggling. I'm fortunate to be married to a thoughtful, observant partner who also happens to be a mental health therapist. While she doesn't "do therapy" on me, she is skilled at noticing and asking the right questions to help me think about how my life and actions may be affecting me. Most people don't have that luxury, which means finding resources available to you to talk to someone who's trained in asking the right questions and then meeting with them regularly. I think of it like a haircut; you do it.
Love
The relationships that form your life most contribute to your sense of fulfillment. There's a reason most peoples' regrets at the end of life typically have to do with wishing they had done more to nurture relationships in life. The pandemic has made cultivating friendships particularly hard for me. I don't love talking on the phone. My ability for social interaction has been incredibly limited because I haven't wanted to take on any unnecessary risk of passing COVID to my daughter, who can't be vaccinated.
What I have realized I'm good at is not allowing separation of time and space to change how I connect with my friends and family once we reconnect.
It would be nice to be the type of person to schedule phone calls and reach out to the people I care about regularly to check-in. I don't do well with that type of thing. What I have realized I'm good at is not allowing separation of time and space to change how I connect with my friends and family once we reconnect. I think that takes an understanding and willingness to accept life for what it is and to recognize that neither one of you intended to "let time slip by,"; and it has, and that's ok. It's about being present. Reflecting on the depth and frequency of human connection you need to ground your life is essential to calibrating resources you put towards the relationships in your life.
One thing I've found helpful in my marriage has been what we call our "weekly meeting." It doesn't always happen weekly, but that's our ideal. The idea is to sit down each week, preview the upcoming week, and reflect on how we feel our lives are going. Treating our relationship like a board room might feel silly, but the structure helps to unlock spontaneity when the time feels constrained. We use an app called Notion and have a template for our weekly meeting.
Here's our template:
We've been developing our approach to this for a few years, and it's still very much a reiterative process. I've found that the value of this lies in the regular review of our lives; picking a time to sit down each week gets the ball rolling. Instead of allowing issues to smolder beneath the surface, we can talk about what's on our minds in a way that is separated from the more emotional day-to-day life.
One thing you're grateful for. One win. One compliment.
Kyira started this years ago. At the end of each day, we each share each from our day. I'm terrible at bringing it up, but I'm always grateful when we do. It helps to reframe your mind and shift your thinking from "the world is happening to me" to "I noticed this cool thing today."
Proactive > Reactive
There is certainly no magic solution to any of these challenges. Regular life maintenance is a much more sustainable approach than "going with the flow" and trying to repair things on the back end. Take stock of the key areas of your life and reflect on where your behavior may not fully align with your values. All of us have to navigate aspects of our lives that may consume resources and aren't designed to "fill your tank." It seems that the people who function at the top of their game find ways to design systems around themselves to proactively invest resources in things that do, and buffer the aspects of their lives that make take resources.
