During my medical training I learned that I can do anything for 30 hours, or 30 days. No matter how insanely busy my call night was, I knew that it was only a few hours from being over and that I would be able to sleep like the dead once I got home. And no matter how intolerable my work assignment was that month, I knew that I was just a few weeks or a few days from moving on to a new assignment the next month. I lived my life from call night to call night, and from monthly rotation to monthly rotation, trying to see or at least imagine the light at the end of the tunnel when things got really dark. But along the way I learned that the tunnel never ends. What I thought was the light at the end was really just a window, and the tunnel seemed to keep going on forever and ever and ever. How long was it? When I graduated from fellowship and started my first real job I tried not to think about that question. I knew I could endure for 30 hours or 30 days, but could I do this for 30 years?
Last year I wrote about my wrenching decision to move away from my first job. My wife and I wanted to strike a better balance between my work demands and my time available for family, and I’m happy to report that this move has turned out to be a good one for us. At the time I moved through my job search intuitively, not really knowing what I was doing but trusting that the Lord would guide me to make the right decisions. I trusted him to help me because I know that he loves me and that he wants to help me. Our decision was guided by the hand of Providence, and I feel like he has led us to our Promised Land. The thought of staying here and working at this job for the rest of my career makes me happy, and I have none of the burned-out or deflated feelings I used to have when contemplating the future of my career.
Occupational burnout is a form of psychological stress in which the sufferer feels distress, exhaustion, and decreased motivation. Workers who experience burnout tend to develop ineffective coping mechanisms such as cynical attitudes, compassion fatigue leading to empathic failure, or substance abuse. Health care workers have very high rates of burnout when measured using standardized scales. A 2014 survey of physicians found that over 50% exhibited at least one sign of burnout, which is higher than the burnout rate in the general US population, and higher than a physician survey from 2011 (see the American Medical Association info page). I was not surprised to find that my own specialty was above the average, with nearly 60% of neurologists experiencing burnout. Burnout is a subject that all doctors are intimately familiar with, but few seem to really understand it. We all have colleagues who are hopelessly burned out, and we all know what it feels like to keep working despite having no energy reserves, but we don’t really talk about how we feel because that would be a sign of weakness.
Last month I attended a lecture given by Dike Drummond, MD, who is a personal coach for physicians experiencing occupational burnout, and is the founder of TheHappyMD.com. I also read his book, Stop Physician Burnout. Dr. Drummond’s work shines a bright and hopeful light on this subject, and tries to break down the cultural taboos we have about discussing these things. He describes positive steps that every doctor can take to improve their work-life balance, and I have already benefited from applying some of his suggestions to my own practice over the last few weeks. You don’t even have to change your job to start making a difference today.
Endure to the End
Learning about physician burnout has led me to do some pondering. Jesus told his followers to be “the light of the world,” and to “Let your light so shine before men, that they may see your good works, and glorify your Father which is in heaven” (Matt 5:14-16). Surely he doesn’t want us to have our lights burnt out. God does not want us to feel hopeless, exhausted, ineffective, cynical, or trapped. He does not want us to fail.
The Book of Mormon prophet Nephi listed faith, repentance, baptism, and receiving the Holy Ghost as the first principles of the doctrine of Christ, and then added enduring to the end as the capstone:
“Wherefore, ye must press forward with a steadfastness in Christ, having a perfect brightness of hope, and a love of God and of all men. Wherefore, if ye shall press forward, feasting upon the word of Christ, and endure to the end, behold, thus saith the Father: Ye shall have eternal life” (2 Nephi 31:20).
Several years ago I taught a Sunday School class where we discussed this scripture. The word endure can suggest a negative or painful experience, involving prolonged suffering. We endure through trials, adolescence, call assignments, boring lectures, Sunday School lessons, etc. But I encouraged my class to ignore these negative connotations for a moment and to consider the definition of a related word: endurance. This word focuses more on the character of the person who is enduring, and doesn’t seem to have the same negative connotations. I offered a working definition of the word endurance: “the ability and strength of will to continue doing.”
The concept of gospel endurance is similar to athletic endurance. I run because I enjoy running, and I build my endurance so that I can run farther. Running is not torture or a negative experience for me, although it can sometimes be painful. But the pain is worth it. The feeling of having the strength and ability to continue and complete a long run is a wonderful feeling.
President Deiter F. Uchtdorf taught this positive concept of spiritual endurance in the October 2007 General Conference:
“Enduring to the end is not just a matter of passively tolerating life’s difficult circumstances or ‘hanging in there.’ Ours is an active religion, helping God’s children along the strait and narrow path to develop their full potential during this life and return to Him one day. Viewed from this perspective, enduring to the end is exalting and glorious, not grim and gloomy. This is a joyful religion, one of hope, strength, and deliverance. ‘Adam fell that men might be; and men are, that they might have joy’ (2 Nephi 2:25).”
The Light of the World
I am impressed by the remarkable resilience shown by Jesus during his ministry, when he was incessantly thronged by crowds of people for days on end. Mark chapter 6 describes a very stressful time, immediately after the senseless and horrific death of John the Baptist, when the public demands were particularly severe. Jesus suggested a short reprieve for himself and his apostles, “for there were many coming and going, and they had no leisure so much as to eat” (Mark 6:31). But as they began to execute their plans for a quick getaway they were intercepted by a large group of people eager to see and hear Jesus, and many who hoped to be cured of various illnesses.
This would be like suddenly getting 4 new Emergency Department consults at about 3:30 am, right when you were about to get something to eat and relax in the call room for the first time that night, during an 80+ hour work week near the end of a month on Q4 overnight call, with some enormous family stress happening at home at the same time. I have been in situations like that, and I have to admit that I was not always kind and enthusiastic about it. On a few occasions I had to quickly apologize to the ED physician after an emotional outburst.
So how did Jesus respond to this situation which would likely cause most people to break down? As always, he was our perfect example:
“And Jesus, when he came out, saw much people, and was moved with compassion toward them, because they were as sheep not having a shepherd: and he began to teach them many things” (Mark 6:34).
He spent all day teaching them, and at the end of the day the crowd contained about 5,000 men, plus women and children who were not numbered. Rather than send them away hungry he fed them all with just five loaves of bread and two fishes, one of his signature miracles. After the meal he sent the multitude away, and while the disciples crossed the Sea of Galilee in a boat Jesus climbed a mountain to pray by himself, finally getting some time alone. His respite was brief, and was borrowed from hours he could have spent sleeping. He spent the rest of the night walking on water to meet the disciples in their boat midway across the sea, and the very next day he was back to work teaching and blessing the endless throngs of people on the far shore.
This amazing spiritual endurance was not an isolated or occasional feature of Jesus’ ministry, but is present throughout all four gospel accounts. There are some particularly powerful examples at the very end of his life. While suffering unimaginably in Gethsemane, and despite his disappointment in Peter, James, and John for not being able to stay awake, he seemed to understand and take pity on their weakness. “The spirit indeed is willing, but the flesh is weak,” he said (Matt 26:41). We have no record of Jesus having slept during the night before his crucifixion, but he did not lose his temper during the illegal nocturnal trial before the chief priest or during his arraignment before Pilate. He found charity for the Roman soldiers who obeyed orders to nail him to the cross, not realizing that they were executing the Son of God, and he showed compassion for a thief who was crucified with him and for his mother who was standing by the cross.
Despite circumstances which were physically, emotionally, and spiritually taxing in the extreme, Jesus did not seem to experience compassion fatigue. He did not give way to cynicism. He never appeared to lose sight of his purpose or doubt his ability to succeed. Jesus, the “light of the world,” did not burn out (John 8:12). It is clear from the gospels that solitary prayer was a critical element in his burnout prevention strategy, and that suggests that it should be part of ours too.
I think that when the Lord exhorts us as his followers to “endure to the end,” or to “be not weary in well doing,” he is asking us to be more like he is, and he is also acknowledging our potential for burnout (Gal 6:9, Doctrine and Covenants 64:33). We are mere mortals, and most of us do not have the capacity for endless compassion that Jesus has. And we cannot simply wish away or command away our feelings of burnout. But we can work to improve the balance between the different demands on our time, and we can call on God for help if we are willing to follow his counsel. I can say from my own experience that he is willing to answer those prayers.
3 replies to “Burning Out and Back Again”
This was a truly awesome and timely piece. I am an M2, getting ready to study in earnest for Step 1 and begin my clinical rotations next year. We have just finished a unit on burnout and fatigue in one of our non-science courses. I understand that the 80 hour work week limit might be going away by the time we hit the floor as residents. So burnout is a concern of mine, as I have never gone an extended period of time without sleep. Even now I am able to get about 5-6 hours of sleep per night, minimum. It is great to hear this Gospel-centered perspective on burnout. It sounds like, from your perspective, it is important to put ourselves into a situation where we are capable of doing the Lord’s work and letting our lights shine, but it is also important to remember that the Savior gave a perfect example of what it looks like to let our lights shine when we are under significant stress. Thanks again!
Thanks for the comment. Don’t worry about clinical rotations and residency – you’ll be stretched to your limit but you’ll make it through and be a better doctor because of it. You will learn to drive yourself home after being awake for 30+ hours. Also, don’t worry about the work hour restriction changes. The genie is out of the bottle when it comes to monitoring and addressing extreme resident fatigue, and I don’t think there will be a return to the bad old days. There has been a cultural shift in residency programs which will not easily be undone. The work hour restrictions from ~2007 I thought were reasonable and struck a fair balance. I thought the ~2010 revision went a bit too far, so I think it is good to swing the pendulum backwards just a little bit. Good luck in your training!
I like my nephew Alan’s comments very much, Nearing the end of my career as a General Internist, I have learned some of these lessons the hard way. Implicit in his remarks are two realities: 1) We see the practice of medicine as a life CALLING- something beyond an occupation, and 2) the calling of medicine is completely open-ended: like being a lifelong bishop in the church where no matter what one does to bless the lives of those he serves there is always so much more one could have done. As a solo practitioner I could see more patients in the office, round in the hospital two times a day instead of one, go to nursing homes, visit people at home, work weekends, cancel vacations to serve sufferers, increase pro-bono care, serve on more committees and boards, do more teaching, etc., etc..
Christ taught that righteousness does not lie in prophesying, performing miracles, seeing visions, having transcendent emotional experiences – I imply this from Matthew 7:22-23. true righteousness lies in the simple quiet acts of feeding the hungry, giving drink to the thirsty, taking in the stranger, visiting the person in prison, clothing the naked. (Matthew 25) There are many ways to be thirsty, hungry, naked, in prison, and a stranger, and these very needs are nowhere more in evidence than in the exam rooms and hospital beds we attend daily.
You pointed insightfully at Christ’s attempts to take time off, which it seems to me, he mostly failed at. As always, we follow him distantly in these things. I suppose the idea is balance. The priorites of family, the limitations of our physical and mental bodies, demand us to say no- forcefully and repeatedly.
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