What happens after burnout?
Burnout is a label we associate with people being tested beyond the limits of their resilience; working beyond emotional and physical capacity into the River Styx, paying Charon the ferryman our few cents to get out, and back into the land of the living aka NON MEDICINE.
I myself always diagnosed it as something terminal; nefarious and malignant; a cerebral and motivational sort of cachexia where people wish to depart their hum drum hospital lives for a place they don’t have to toil whilst the moon shines. But I think many of the factors that lead to burnout are inevitable, important, and need to be addressed. Not all heat starts a flame after all, and a bit of pressure can cause an exothermic reaction. Burnout can be slowed, reduced, prevented and treated.
When we feel pressured beyond all reason and forbearance, we are able to govern ourselves, and over a longer time period our circumstances. Quitting has negative connotations, but strategic retreat is actually a tactic found in the Art of War.
What I found is that having a more optimistic approach to medicine, its governance, and the people it contains, has really muffled my anxiety for the future.
My burnout – a mixture of intellectual frustration, post traumatic stress, long commutes, nightshifts, a change of governance, hospital, social circle, living arrangements, and family illness, was the archetypal recipe for burnout, but despite getting through exam MCQs by diagnosing the first two words of the sentence, I wasn’t able to see it coming, express it to anyone, or really have a clue how to fix it. There is an attentive focus on the prevention of burnout, but not its treatment.
First of all burnout is not new. All trainees are in a deanery system which has a deanery support unit which can help with pretty much anything and they know everything about wellbeing at the moment as it is a huge topic for the workforce crisis. There is also a national charity called WARD (Wellness and Resilience in Doctors) I urge you to google right now. If you are like me, you never listened to wellbeing claptrap because it didn’t affect you, because you are a marble bastion of fortitude and you’re good at your job, so you don’t expose yourself to scrapes.
First of all this is a myth; I haven’t spoken to a single figurehead so far who a) hasn’t questioned if medicine is correct for them b) or left to do something else for a bit c) relived a traumatic experience or had flashbacks. Whether you are the professor of an Ivy League University or a medical student from a broken home with three siblings misusing drugs and a two year old you fathered when you were 17; you can be derailed. And the more inured you are to the idea of derailment, the harder it will hit you if it occurs.
I had a charmed life; wonderful family, little financial stress, exams were easy and out the way first time, didn’t have a year out, thankfully got the jobs I needed, and tended to get on with everyone, eat well, and exercise regularly. I’ve seen plenty of deaths, trauma, family rifts, accidents, amputations, suicide attempts, was on call the evening of the Manchester arena; the bodies were in our morgue; and despite being immersed in death, despair, illness for much of my time outside the home, relatively unscathed. I’d used red towels on carotid blowouts, been faced with toddlers and acute heart failure in a DGH alone in the early hours, stabbings, maternal deaths, and once as a foundation trainee, been trying to work out what the hell to do for a patient who was having a pulmonary haemorrhage on heparin. The on call medical consultant told me to give protamine and bronchoscope (the latter contraindicated in MI), the cardiology consultant dropped a paper at my elbow about protamine causing acute coronary thrombosis, whilst I was on the phone to the medical consultant; neither would make a plan and kept talking to each other through myself, and when I asked radiology for a CT chest they suggested this wasn’t a Chinese takeaway and I’d needed to find someone more senior to request it. I can’t remember where my reg was; but I’m fairly sure they’d abdicated any decision making at this point also, as was a busy weekend on call in a hospital with unsurprisingly terrible outcomes. The cardiology consultant continued to give me passive-aggressive instructions in the form of literature-based evidence, yet after googling how fatal pulmonary haemorrhage was, we went with the heparin. And none of this has ever particularly caused me huge emotional or catcholaminergic stress; in fact I tend to thrive on chaos.
So you see, my burnout was as unexpected and unpredictable as a wild horse bolting loose on a stormy night. I started not sleeping, having hallucinations that people were dying in front of me, was persistently tachycardic and frightened of driving on the motorway. I either ate nothing or three Mcdonalds in a row. I dreaded going to work, every anaesthetic I did made me question my own mortality, culminating in a 2 day period where I couldn’t speak to anyone without ‘seeing’ them pass away as I was talking to them. My patient at the time, a rugged COPD type, told me I looked young, nervous and green and asked when I’d qualify as a doctor (I was ST3). Because I’m so new to my region, people around me couldn’t spot this change; and whilst I knew something was very badly wrong, it didn’t feel easy to tell strangers – and supervisor meetings felt like something you’d book for next week at a convenient time, not an emergency. Plus I was continuously on-call or on nightshifts, or left solo; again, I must have seemed competent there, because I got excellent feedback.
I have no idea why it happened. It was linked to a traumatic ICU death, but triggered by seeing by horse put down, followed hours later by three 12 hour nightshifts endlessly filled with 18yo brain tumour resections (she was due to go to uni to be a paramedic ☹). I am not somebody that cries, but I would strap on a theatre mask and sit hunched over the anaesthetic machine with the chart for a few hours, surrounded by a scrub and anaesthetic team I hadn’t met before, and well, neurosurgeons.
Ultimately this all ended because starting my next rotation, I absolutely could not sort parking, had a ridiculous obstetric haemorrhage, failed intubation, 4.5 hour section, my first shift in a brand new hospital, in a building as the only anaesthetist, starting on nights, knew where nothing was, and then, patient finally alive and well, had to pay £25 for my parking when I walked out into the sunlight some time later. I think this unleashed whatever demons had been quietly residing in my viscera for the previous 5-6 months. £25!!!!! OUTRAGEOUS.
I angrily wrote a 3am blog, got many wonderful messages of support, and within days (and whilst I moved house) the Guardian had published all the dark and gloomy stories of what happens to junior doctors. I spent much of that time packing, trying to persuade my hospital not to fire me for speaking out, working, answering messages, and trying to ensure the suicidal people were still alive and safe and were going to their GP. If you have ever been up at 3am at home trying to persuade 3 or 4 people at once life would be okay, as your own is being immolated, and then checking in with them after your theatre brief, you would know this is enough without trying to manage errant journalists and the hospital media team, and the estate agents. Finding GP and deanery help for myself, at this point, wasn’t something I felt I currently had time for, and I would get round to it once I’d moved house. I did look at the deanery support application form, but it was eight pages! And I didn’t currently have time for that either.
However the dust did settle. The support was astounding. I think of over 1000 people, only 2 told me I was in the wrong job/lacked resilience. I also had some really special opportunities.
With a local GP I went to some point to points as a doctor-observer. I went to Gatcombe and had lunch in the lunch tent and met Princess Anne. I was able to use my anaesthetic doom-mongering to suggest someone awaiting a mitral valve replacement with acute onset chest pain and breathlessness (now stabilised) should go to the closest cardiac centre not the closest hospital, which is a Herculean task to persuade the ordnances of the Ambulance Service. I gleefully glued minor scalp lacerations, lost any of the hypothetical bets I would have placed on my favourite horses, and met some very interesting doctors.
Whilst we buzzed through a field of corn on a quad bike, one invited me to go and see a human centrifuge and the military-research centre she spent time at, after telling me about her time as a medic for professional footballers. She also taught me about dog training.
I also have a heart-fluttering affection for a certain Royal College President who took me under her wing for a day, taught me why large bottoms can be associated with certain congenital gut diseases. They bought me millionaire’s shortbread for breakfast, two lunches because I couldn’t decide which I wanted (I am nearly 30 yes), and recounted some of her most horrible times as a trainee too, as well as explaining why her route has not been clear cut too. When the Guardian got hold of the material, she was concerned for me, gave me media advice, promised to stick up for me and I was able to at least modify some of the article findings as I was a lot more positive about medicine at this point, and wanted doctors to have hope. That journalist was actually very professional, courteous, and understanding of the bigger picture when it comes to the unease of anything akin to whistleblowing when it comes to the health service.
I had invitations to visit hyperbaric pressure chambers, come work with other people, had phonecalls with all sorts of interesting people from the GMC, BMA, Health Education England, the British Antarctic Survey; I was invited to speak at loads of different venues. I had the most amazing audience at the Women in Medicine conference in Bristol recently. I had all these little fireflies of hope. If we gave other trainees even 5% of this attention they might feel nurtured too. I had messages from Matt Hancock’s team (they haven’t got back to me yet, I think the leadership bid happened…).
I didn’t take time off, which I probably should have done. My deanery were amazingly supportive at my ARCP (so much so I felt really guilty I didn’t tell them sooner!). I got some time back I was owed, and one consultant kept telling patients I was a celebrity, colleagues even started to know who I was. (I would advise name badges not newspaper articles).
Thus; less gracefully than a phoenix from the ashes, I really feel rejuvenated. So many problems are still there, but more importantly when I am feeling triggered in future, I will know to tell someone; anyone. This experience has made it obvious who I can go to, but for those that don’t; tell anyone and they will point it out. There will always be someone who says it is weak or unprofessional but 99% of people are sane and understanding. None of us would have made it through life in medicine so far if we weren’t both a) human and b) forbearing.
Training programs can seem so rigid and unyielding, but they are a skeleton of what medicine actually represents; kindness, talent, intellect, compassion, education and excitement. The curriculum is there to be done, and the work is there to be done; but there is interest and excitement out there, even if it takes a bit of lateral thinking to find it.
I am not sure why medicine is so stern of face, but Juno-esque I have found it to have a soft side. One that understands. When you are greeted with empathy and not resistance, the pressure melts. The medical system needs to advertise that it is a body that cares for its own, because far now from feeling frightened, drowning, angry and bitter – I feel emboldened and understood and able to work with a clear mind. Doctors (and nurses, and every other professional, even the cleaners and porters and volunteers) are the connective tissue of medicine. We are not parallel lines, we are interwoven. I found an immediate kinship with incredible plastic surgeon Miko (Mindbodymoko.com) who burnt out down under, due to obscene working practices. She has just got a book deal which will be sublime, I can’t wait.
It is very hard to recognise let alone express discomfort in a high achieving world of stiff upper-lipped academia, and I know via the messages I received, it can be impossible to guess who is walking a knife edge. I find it bears badly on both myself and the system that a patient told me I was nervous long before me or my colleagues came into intellectual contact with the idea. I really hope that for anyone suffering, or for anyone who suffers in the future, you know it is not fate to burnout. Being pressured in this way, though awful, has taught me how to govern myself and truly question what I want from life rather than rolling along. Sometimes it takes a dance with the macabre to bring a flush to your cheeks, and I’m very fortunate it has turned out this way. Soberingly, there are many similar stories with a different ending.
Please look out for strange behaviour in each other, and remember something as banal as chocolate shortbread is resuscitation for the soul 😊 to kidnap a very spiritual deliverance it really felt like the body of Christ. And it cost about £1. I cost >£50,000 a year and several 100,000 to train. I do however really resent the parking (still!). As a human being, my welfare is too high a cost, for poorly thought out systems and ‘petty tortures’ to exploit. It isn’t fair that simply due to poorly staffed rotas, a strident work ethic, and the choice to be there for people at their lowest, we are put at risk of experiences like mine. Fortunately when it comes to guarding the guardians, we ourselves have an excellent skillset.