It was only after attending the WIWC Virtual Conference a few weeks ago that it finally dawned on me – the realization that I had finally arrived at a place that just four short years ago, I never thought I’d reach: the other side of burn out.
To be honest, I’m not exactly sure when or how it happened, but I just realized that at this point in my career and life, I have a sense of peace that I have not felt in years. To understand my journey to the other side of burnout, one must start at the beginning. Chapter One would have been entitled “I Never Really Wanted to be a Physician.”
I have heard countless physicians (including my husband) explain that they knew they wanted to be doctors at a very young age. My husband has literally ALWAYS wanted to be a pediatrician. I never had that dream. I know it may sound strange to some, but I sort of “fell” into medicine. When I was a young girl, my dream was to become an elementary school teacher. Later, after taking a Psychology course in high school, the dream morphed into a desire to be a counseling psychologist. Off I went to college, with the goal of ultimately going to grad school, and becoming a psychologist specializing in working with children. That dream persisted, up until my senior year of college, when my mother offhandedly suggested “why don’t you go to med school?”
As an MRI Supervisor, my mother worked with doctors on a daily basis, and felt that going to medical school would allow me more opportunities – I could do clinical OR research OR a plethora of other things “that only doctors get to do,” according to my mom. I would like to say I thought long and hard about it, but having absolutely no idea what I was really getting myself into, I rather quickly came to the conclusion that my mother was right – becoming a doctor would give me more flexibility and opportunity. I decided that I would build on my dream of being a child psychologist and instead become a child psychiatrist (same general field, different privileges). I graduated from college and spent the next 2 years completing a post-baccalaureate program in order to take the Science and Math prerequisites for applying to medical school. I went to medical school that following year.
During the grueling Basic Sciences years, I spent most of my days convinced that the decision to go to medical school had been the wrong one. However, many of my 3rd and 4th year classmates encouraged me to keep going, dangling the carrot that “once you get to clinical rotations, it gets so much better.” I found, for the most part, that those upperclassmen were correct.
On my clinical rotations, I got my first taste of helping others who were sick (or hurting in some other way). I felt deeply connected to the patients I saw, and for the first time started to feel that my decision to become a physician had been the right decision. I graduated med school and completed a General Psychiatry residency, and then a Child & Adolescent Psychiatry Fellowship. Although residency and fellowship were no cake walk, I had a general sense that I was in the right place, mainly because I felt I was helping to make a difference in the lives of my patients. I looked forward with great anticipation to becoming an Attending. I decided to remain at the same academic center where I had completed my training, to work as the sole Attending in one of their outpatient mental health clinics.
For the next several years, I absolutely loved my job. I was helping underserved children and their families, with a goal of treating each of my patients and their families the way I would want someone to treat my children, or my family. I felt that I was largely successful at doing this, and the work was in many ways even more fulfilling than I had imagined. Chapter one ended on a high note, but it wouldn’t last. Enter Chapter Two: “How Did I Get Here?”
As my years working in the outpatient clinic rolled by, I started to see shifts in the way in which the clinic was run. The electronic health record was introduced, and shortly thereafter, productivity seemed to be mentioned more and more frequently. The whole idea that I was not “meeting productivity” seemed crazy to me, since I never once felt like I had TIME to be nonproductive. I spent my days seeing patient after patient, charting on said patients, returning phone calls and calling pharmacies between patients, and of course periodically dealing with the random inevitable crisis during my last appointment of the day. I don’t ever recall a day where I actually left the clinic at what was supposed to be the end of my workday – how could I not be meeting productivity?
Despite this, I was encouraged to “double-book” my patients, to account for the high no-show rate amongst the Medicaid patients I was serving. It began to wear on me – slowly and insidiously at first, but eventually gaining pace and culminating in the sinking feeling that I no longer loved my job. It was a chore to go into the clinic each day, and I felt as if my life force had somehow been zapped. Once again, I questioned my choice to become a physician. I rationalized that I just needed a change in scenery – I had been working in the same clinic, in an academic setting, for almost 10 years. That’s how I began Chapter Three: “Same Stuff (for those of you who aren’t offended by a carefully placed curse word, feel free to substitute here), Different Day.”
I resigned my job at the academic center and took a job at a different outpatient mental health clinic, one not associated with an academic center. I thought a simple change of scenery would somehow stave off the burnout that was slowly creeping its way into my psyche. I was wrong.
At the new clinic, there was an even greater emphasis on productivity, I had even less control of my scheduling, and again the talk eventually turned to “double-booking,” including for intake appointments. I received daily notices in my clinic mailbox about the EHR charting that I had not had time to complete the previous day, and I was encouraged to complete my charting during my patient visits. I realize that some physicians have found a way to make charting during patient encounters work, but I always felt that typing away at my keyboard while an adolescent talked about things they hadn’t been able to share previously with anyone else seemed to me to be antithetical. So, I instead jotted down brief notes to assist me in charting outside of my actual patient care, so that my patients could feel that they had my undivided attention during their visits.
I saw patients all day, then would spend at least 2 hours at the end of my day returning phone calls, completing forms, and completing as much charting as I could. I would then rush home to (hopefully) spend a little time with my husband and children (which didn’t always pan out). I spent my weekends completing my charting from the previous week, and consequently had very little time to spend with my children or with my husband on the weekends. Then every Monday morning, the cycle would start over. I felt like work was beginning to increasingly take over my entire life, and simultaneously that my ability to help my patients in the way I really wanted to was quickly dwindling (I never really found a way to be truly effective while seeing two medication management patients in one 25 minute appointment slot).
I felt like a hamster on a wheel, running in circles but getting nowhere. No one in administration seemed to care that my patients felt safe talking to me, or that many of my patients told me that I was the best doctor they had ever had. The only thing that seemed to matter to them was productivity (i.e., the billing and the money). I didn’t feel good about rushing through seeing my patients in an effort to maximize my productivity, and I began to feel that I was actually doing more harm than good. A realization that the system was broken came crashing down on me – the system was now set up in such a way as to be at complete odds with my providing thoughtful, quality care to my patients.
With this harsh realization, and after another two years of working in that outpatient mental health clinic, I became the poster child for burnout. I dreaded going into work. I felt demoralized by the total lack of control I felt I had over any aspect of my work life and became increasingly cynical about healthcare in general. At the beginning of Chapter Four, which would have been called something like “Clinical Care is Choking the Life Out of Me,” I made the decision to leave clinical practice. I remember feeling like a part of me had been slowly dying over those last 2 years in the clinic – a part of me that I knew was a critical part of who I am as a person – a genuine desire to help and make a difference in the life of others. I had to make a choice so that part of me could continue to live, and it ultimately came down to a choice between clinical care or my happiness and well-being. I knew that I had to choose me, but it wasn’t an easy decision to leave clinical practice.
I was filled with a sense of guilt and fear – guilt about leaving my already underserved patients, fear that I would never again feel that sense of fulfillment that came with helping my patients. I took an administrative role at the State Health Department, with Medicaid, but continued to struggle with feeling like I was not making the type of impact in other’s lives that I wanted to make. After 2.5 years, I left that position and took a position as Medical Director with an insurance company that contracts with Medicaid in my state.
As I sat through the WIWC Virtual Conference a few weeks ago, and listened to the stories of other amazing women in medicine, I thought a lot about where I am now compared to where I was a little over 4 years ago. I am currently utilizing my clinical skills in an administrative role, my weekends are mine to spend with my husband and children, and I am no longer feeling the pressure of keeping up with “productivity” at the expense of quality patient care. As these thoughts ran through my mind, I had a sort of epiphany, and realized that had arrived at Chapter 5: “On the Other Side of Burnout.”
I realized for the first time that my job as a physician (whether clinical or administrative) is not the entirety of who I am, it is simply what I do. Who I am is someone who has a genuine desire to meet people where they are and help them with whatever they might need, in any capacity that I am able. It means being a support to a co-worker who received news that her mother was severely ill and hospitalized a continent away, or getting to know and care about other co-workers on a human level – I do those things, which are totally unrelated to patient care, because of who I am. I realized for the first time that I don’t have to be involved in direct patient care to achieve the sense of fulfillment that comes from helping others. I just need to be me, wherever I am, and whatever I do. I realized that I was only able to come to this conclusion four years ago by choosing ME over clinical practice. That’s what my journey to the other side of burnout has shown me.
So many of us entered medicine based on an altruistic desire to help other people, only to become disillusioned by the everyday reality of what it is to practice medicine today. For me, getting to this point has required me going outside my comfort zone, exploring other career options, and taking some risks. My advice to those who are still struggling with the burnout that unfortunately seems to be inevitable in medicine these days:
- Remember that your desire to help others is a part of who you are, separate from your job title. Being a doctor isn’t who you are, it’s just what you do.
- You are enough, just as you are. You make an impact on others, even when you don’t think you are or realize that you are, just because you’re YOU.
- Always choose you and your well-being above everything else. If you are ever faced, as I was, with the prospect of choosing to stay in clinical medicine and losing who you are as a person vs. leaving, I say choose YOU – I can guarantee that you’ll never regret it.
Malika Closson, M.D. is a Child and Adolescent Psychiatrist, who works as a Medical Director of an insurance company in Maryland.