Mental Health and Burnout, Part 1

Burnout has unfortunately become an exceedingly common experience for healthcare workers, even independent of the COVID-19 pandemic. In this episode, we start a conversation about burnout, its signs/symptoms, and its potential repercussions with Internal Medicine resident Dr. Allison Ibarra.

Learning Objectives:

1. Define burnout according to the World Health Organization.
2. Learn and be able to recognize common signs of burnout. 
3. Identify and recognize the potential consequences burnout can have on physicians’ and medical trainees’ physical and mental well-being.

Credits:
Guest: Dr. Allison Ibarra
Co-Hosts: Dr. DJ Gaines, Branden Barger
Executive Producer: Dr. Tammy Lin
Co-Executive Producers: Dr. Pooja Jaeel, Dr. Maggie Kozman
Associate Producer: Dr. Candace Sprott
Senior Producer: Dr. DJ Gaines
Editor/Assistant Producer: Clara Baek
Production Assistants: Nilgoun Farhadi, Leyna Nguyen
Website/Art Design: Ann Truong
Music: Chris Dingman https://www.chrisdingman.com

Continuing Medical Education/Maintenance of Certification (CME/MOC) credits are available through the American College of Physicians for both members and non-members. To submit for CME/MOC credit for this episode, visit: https://www.acponline.org/cme-moc/cme/internal-medicine-podcasts/the-dei-shift

Connect with us on Instagram at @thedayshift.pod and via email at thedayshifthealthcare@gmail.com

Transcript

[00:00] : DJ Gaines: Welcome to The DEI Shift, a podcast focusing on shifting the way we think and talk about diversity, equity, and inclusion in healthcare. My name is Dr. DJ Gaines, a hospitalist in San Diego. I am here with my co-host…

Brandon Barger: Hi, I'm Brandon Barger. I'm a fourth year medical student with UC Riverside. Today we're discussing a super important topic, mental health and burnout.

DG: Yes, the topic of mental health and burnout has become a focus point in the medical field. Many institutions are implementing some form of education on mental health and burnout in their curriculum. Given the vastness of this topic, we have decided to make it a two-part series. In part one of our series, we will go over some of the basics of burnout and hear an experience from our first guest about how they dealt with burnout. In part two of our series, we will hear from our second guest about their experience with burnout and discuss potential sources of burnout and ways we can combat it.

[1:03]: BB: Let's cover some of the important basics of mental health and burnout. DJ, would you mind defining some burnout for us?

DG: Of course. According to the World Health Organization, burnout is, "a syndrome conceptualized as resulting from chronic workplace stress that has not been successfully managed." They go on to say that it has three primary characteristics:

1. Feelings of energy depletion or exhaustion.
2. Increased mental distance from one's job or feelings of negativism or cynicism related to one's job.
3. Reduced professional efficacy.

I know myself and many of our listeners have experienced some, if not all, of these characteristics at some point during their training and career, especially with the COVID-19 pandemic.

BB: Absolutely, I 100% concur. Even recent data from the American College of Physicians shows that about half of all U.S. medical students have experienced some form of burnout. And for residents, that number has been reported as high as 60%. For attendings, that is also around 50%. So, with such high numbers, this is a very timely topic for us to be talking about.

DG: Yeah, and you know, those numbers are quite high, but I'm not surprised. Just looking back on my experience, the stress that one experiences through medical school until attending-hood is quite high, and it can really be compounded if there is a lack of support.

BB: Absolutely, and burnout, I think, has a really significant effect on our physical and mental well-being. It's been associated with increased rates of depression, suicide, substance use, medical errors, increased dropout rates from the medical field and an increased physician turnover. And a lot of that data has been shown over the last couple of years, especially because you had mentioned the COVID pandemic. Unfortunately, I think many of us have heard really tragic stories of our colleagues, our friends, our fellow trainees who have lost their lives as a result of burnout.

DG: Yeah, and really could spend hours discussing the many aspects of burnout among medical trainees and attending physicians. But for this series, we felt that it would be more impactful to hear true stories from people who have experienced and dealt with burnout during their medical career. For the second half of this episode, we will hear from our first guest, Dr. Allison Ibarra, about her experience with burnout. For part two of this two-part series, we will hear from our second guest, Dr. Anand Jagannath, about his experience with burnout. Afterwards, we will discuss potential sources of burnout and how we can combat it. We hope you enjoy!

[3:43] : DG: Hi, Dr. Ibarra, thank you for joining us today! Here at The DEI Shift, we call each other by our first name. Do you mind if we call you Allison?

Allison Ibarra: No. Yeah, of course.

DG: Awesome. Thank you. So before we start, can you tell us a little bit about yourself?

AI: Yeah, so I'm currently finishing up my third year of internal medicine at UCSD. I think I'm like a week away, which is kind of crazy, but exciting. I'll be doing Chief year next year and I'm hoping to apply to GI. I've been from California my whole life and I've kind of stayed here for all of my training. And then I think otherwise just some little things, like I'm like first-generation everything, which has played a role in my journey. Mexican, college, med school, and then I also identify as queer, which has also played a role. (barking in the background)

DG: And you have a wonderful dog!

AI: Yeah, sorry!

DG: We'll keep that in the recording. No worries.

AI: He's very vocal. He's a picky eater.

DG: He wants to join.

BB: Please drop his Instagram handle in the chat and we'll make sure to put it in our show notes for sure!

AI: Will do!

[5:00] BB: So, thanks Allison for sharing a little bit about you and your journey. As you know, this episode is about mental health and burnout, and as part of this episode, we are asking folks at different points in their careers what burnout really feels like and looks like to them and how burnout has impacted their medical training at some level and, hopefully, how you have successfully combat burnout and by sharing that, we can work together to not only combat root causes of it, but also help folks who may be in a similar position. Just really humanize the process of medical training a bit more. So, if you wouldn't mind sharing with us, any sort of times in which you have experienced burnout as a resident or any point in your training, what that sort of looked like for you?

AI: Yeah, I feel like that's a really interesting question, especially about the different stages. Cause, like reflecting back, I think I've experienced burnout at multiple stages throughout my medical career, but maybe didn't quite realize that it was burnout kind of earlier on. I think in medical school I honestly really enjoyed my time. I got to meet new friends. I lived in San Francisco, which was amazing. And honestly, third year was my favorite year, even though I know that's a hot take, I really enjoyed it. And it wasn't until studying for Step one, that's probably the first time that I actually experienced burnout.

My school, we did it after third year. So I just remember studying and it became super monotonous. You would see friends, but not really hang out with them. And I ended up having to take extra time to study for Step one before taking it, so I think that kind of played a role in my mental health too. But I do remember just the stress of all of it that kind of piling up on top of me. I remember walking from my home to my coffee shop, and then from the coffee shop to the library, and then in between during those walks, I would just be crying on the sidewalk, which in hindsight was definitely not normal. And I think around then is when I realized I kind of needed some help. I don't know if I had thought of it as burnout, but looking back, I think that was burnout. And that's actually when I started seeing therapy for the first time, which I think was super helpful. I've seen them intermittently throughout my medical career. That was one of the big times that I saw them.

And then I kind of took a little pause when I moved for residency over here to UCSD, and then I actually started seeing them again midway to the end of my intern year to the beginning of our 2nd year, because I think that's where another point when I had burnout and then I actually realized that it was burnout. I was going through a pretty tough time and intern year’s rough on everybody. Your schedule is crazy. You don't see loved ones for a while. It's really fun being on the job here. I love all my co-residents and they make the day worth it, and so do my patients. But at the end of the day, it's hard on you mentally and physically. And around that time, I also ended up coming out, which went well with some people and unfortunately with other people, it didn't go so well. So that was another thing that was weighing on my mental health and applying to gastroenterology, there's a lot of stuff on my plate. I was trying to do research at the same time and I didn't realize that my research was getting away from me. I wasn't responsive to things like I used to be. I was missing meetings. I was missing emails and was kind of starting to feel like overall pretty down, wasn't really looking forward to hang out with friends anymore. And it felt like I was fighting back some kind of wall or wave that was about to crash over me, but trying really hard to resist it.

And I actually ended up talking to one of my co-residents who also went to med school with me and we're super close, and kind of telling her everything about how I felt is how she actually helped me realize that I actually had depression. And then through that, I was able to go back to therapy and get on medication and honestly feel way better after that and kind of got back on top of things. Obviously medications and therapy isn't a fix all. I would say that I still had some burnout and then it kind of came back, I think in third year a little bit. Our schedule was a little rougher than it had been in the past. So a little bit of burnout came from that and I think I'm still trying to learn completely how to overcome it. I don't know if that's a journey that you'll ever finish, kind of like imposter syndrome. It's something I've been battling my entire medical career and I'm finding ways to fight against it, but I don't know if I'll ever fully overcome it, just find new ways.

I think one of the best ways that I've been able to work through burnout, honestly, is just talking to people. I feel like that's something that we don't do enough in medicine. We talk about our successes and maybe cool patient stories, but I feel like we don't spend enough time talking about the times that we didn't do as well as we had hoped. Or maybe the times that we didn't get something that we had wanted. So when that happens, it almost feels like you're all alone and that everyone else is succeeding, but you're not—kind of like that imposter syndrome thing again. But once you actually start talking about it, you realize that everybody else is feeling the exact same way that you are and that you're not the only one who's gone through hardships. And there's other people who want to help you who are your friends in your program or just friends in general. And I think once I started talking more about my struggles is when it started to be easier to handle.

And then it's actually interesting, I started to have people come up to me who are going through similar struggles, who I honestly hadn't really talked to before or didn't really know, and they just came to talk to me because they had heard that I had gone through something that they had gone through. And I actually made some friendships in medical school that way, which was a really cool byproduct of just really being open. I feel like that openness would just help with mental health overall within healthcare because we hold ourselves to an impossible standard and I think as we all realize that that standard is impossible to reach, then we all become more okay working with each other to try to attain something along those lines.

DG: I really liked your story and there's a lot of things I think we could expand upon too or just touch upon. I think something really important is that through talking to people, you see that there's a lot of people going through the same struggles that you are going through and I think that's probably the most important thing because we can internalize a lot of things and then we get a kind of cyclic thinking in our head. Like, I don't know what I'm doing, I did the wrong thing. And so I think it took me a while personally to kind of get to that stage where if I am like, especially like on the wards, not sure what I'm doing, I always just talk to my colleagues or even the residents.

[12:00] BB: I don't think it's fair that people have to go through this, but I do appreciate when folks are open and willing to share that story. Because again, I think it humanizes physicians and medicine and healthcare workers in general for the stress that we not only place ourselves under, but the stress that our systems place us under. What sort of support systems do you think that you have both taken advantage of, as well as things that you think we should be expanding upon so that this kind of coupled effect of burnout and mental health doesn't start to get worse or spiral?

AI: Yeah, I think the support systems is a really important thing to touch on. Mine kind of changed throughout my journey. I think in medical school, it was friends. I made a super tight friend group. We still talk to each other, even though we didn't all go to the same residency program. And just being able to commiserate with them honestly, and then help each other, like bolster each other. There was a block or two that I didn't pass the first time in medical school and went through the whole, like, “Oh my gosh, why am I here? I don't belong here.” And I was pretty worried and felt pretty down about it. And then I found out that my roommate, who's one of my really good friends, actually hasn't passed that same block too. So we were able to talk about it together and kind of help each other study for the upcoming makeup exam and that was very helpful.

I think one of the hard parts about residency—and I would say maybe specifically for residents across the board for my year—is that we started residency in the middle of COVID, before the vaccines came out. So when we started residency, you actually weren’t allowed to hang out with each other because of the risk of spreading COVID and the impact that can have on the healthcare system and on the program and that we just all had to stay safe and healthy. So that really impacted one of the big support structures, which is the ability to make bonds, make new friends. Your co-interns are supposed to be some of your best friends for life and it was really hard to get to meet each other in safe ways during that time. So I think that's what made it pretty difficult, and I think that's what honestly made the burnout across the board my residency year kind of higher, maybe, than in the past, with like the COVID class. The impact from not being able to make friends and honestly kind of just like a lot of trauma that comes along the lines of starting your medical career, starting your career as a doctor when there's a pandemic going on and nobody knows what's happening.

So for the support systems, yeah, it's really my friends. My family's been there to help me as well. I actually lived with my little sister my intern year, so having her there at home was really great to come back to and laugh and kind of get my mind off of it. She wasn't in medical school yet, so it was nice to not talk about medicine for a little while. And then I guess another area that maybe a lot of other people started doing during COVID is I got a puppy and he's definitely been great support. It's actually registered as my ESA and especially during the hard times, sometimes it's just nice to have somebody there who's going to be there for you no matter what. It can be comforting to have on the couch. And when times get really tough, honestly, it forced me to get out of the house to go for a walk, to take him outside and to take care of him and take care of myself as well. So I think that's a support structure that I hadn't really expected.

Then one in medical school that I felt like there was a bigger role for than I've noticed in residency is kind of just built-in support structures into the program itself. So, first generation in medicine, LMSA or the Latino Medical Student Association. We had a LGBTQ organization at our medical school. Being able to be in those communities and have people who can empathize with you and your experiences. And then also have the ability to connect to mentors who have gone through what you have gone through and want to help you kind of move up the chain, move up the ladder, continue to succeed, because coming from some of those backgrounds, you don't necessarily know the beginning steps that everybody else knows.

I remember going to an AMSA meeting for my first time in undergrad and they were talking about an MCAT and I was like, what the heck is an MCAT? I have to take another test? I took the SATs, what's this other test that I had to take? And then through undergrad, honestly, I just learned what it took to apply to medicine because it was new for me and for my family. I was the first college grad. And actually, because of part of that, one of the things that I've been working on this past year and I'll continue to work on as chief, is working with the program to create an LGBTQ in GME community. And our main goal is just to create a community space for members who identify as LGBTQIA+ to be able to meet and hang out with each other and kind of just empathize with each other through this whole experience of residency from multiple departments and hopefully create some kind of mentorship. We have quarterly meetings where we really just kind of have drinks and snacks and talk to each other and support each other through this and provide that sense of community that when I was asking people around, it was a community that they wanted that hadn't been provided yet. So it seemed like a good place that I could step in.

DG: I think something that's really important you brought up is the transition of going from medical school to residency. In terms of medical school, there's more structure, given the nature of medical school. You're kind of there to learn, but when you go to residency it is a little different. I think trying to create these initiatives just to have a space, just to hang out, just to talk to people so that you're not wallowing alone. Like in these situations and internalizing all these feelings that you're having when you're dealing with mental health and burnout. I think it is really important. And so I think it’s hard in some ways. And I think, like you've mentioned before, it's a journey and trying to apply the things that you learned in the past into like these new spaces that you find yourself in.

BB: You mentioned coming home at the end of the day and finding opportunities to not talk about medicine and I think that is something we as physicians and physicians in training are terrible at. We find opportunities at all times to talk about our jobs, talk about our patients, talk about the stressors and the administrative hurdles and the bureaucracy that is a hospital. What are some of the topics that you enjoy talking about that are not medicine related?

AI: That's a really good point. And honestly, I think that's a lesson I didn't really start learning until like around now-ish. When you start residency, medicine becomes your whole life, and then when all your best friends are also in medicine, it becomes your everything.

[18:57] BB: You previously mentioned how you started this journey of intermittently starting and stopping therapy, getting on medications, doing things that were right for you. I think, obviously that's a very personal decision for a lot of people, but for folks who may be feeling, in a similar position, but don't necessarily know where to go or who to lean on or what to look for, do you have any particular advice or resources that you really stand that you think could be helpful to other people sort of in this similar situation?

AI: Yeah, I think a big thing to remember is that just because you start something doesn't necessarily mean that you need to continue it, which I think could be like a very intimidating thing for somebody. Like, oh my gosh, I'm going to start therapy. What if it's not right for me? I'm gonna have to talk to somebody. What if I start medications? What if I don't like how it feels? What if it makes me feel weird and different? The nice thing is just you can always stop it or talk to your therapist about a different option. Or if you don't like one therapist, go find another therapist. It might be that you just don't really jive with this person. So I think that's one important thing to keep in mind.

Unfortunately, it is really hard to get mental health care right now. And part of that is because it's so impacted, which on the one hand is almost like reassuring because like, you know, you're not alone because everybody's trying to get the same kind of help that you're getting. But it doesn't make finding it easier. For me, what's always been helpful is that I guess, I've been lucky, or I've been blessed that my institutions that I've practiced medicine in, or been on this journey with have always had a mental health resource. So in medical school, I talked to the mental health counselors that were available through student health. Here in residency, we have an amazing program called the HEAR program, which is kind of like our own mental health resource as well. I didn't see their counselors because I was looking for a more longitudinal or long-term thing, but they were able to get me in touch with therapists and even get in touch with a second list of therapists when the first round didn't really quite work out.

There's also a bunch of apps out there for people to use and I think Ginger is an app that our program offers. I tried the apps out. They weren't really for me. I think just typing out my feelings just took way too long and I'm too lazy to do that. I kind of like the in-person thing, partially because it's like a mental thing. I like to go somewhere and be like, this is a room where I'm just going to dump my feelings out and I'm going to cry, and then when I leave, I can leave fine just for a little bit, at least until next week. And then even just free applications as well. I’ve tried Calm out, which is great for meditation and even just breathing. I guess like breathing apps that you can go through where the ball will expand and contract slowly and you're supposed to time your breathing to it. I've also done Headspace to try to do some guided meditations and then also for some nighttime recordings that help you fall asleep or guide you through a meditation to fall asleep.

And I think another thing to remember through this journey is to be gentle with yourself. I mean, that's something that took me a while to learn. I've tried all of these things because I tried them for a little while, maybe really liked it, and then eventually fell off the bandwagon. I've been trying to get back to meditating for years. And I'll meditate maybe for like a couple of days or like maybe a month if I'm lucky and then I'll fall off the bandwagon. And I think I used to be really hard on myself. Like, why aren't you meditating? Like, it makes you feel better. You should be doing this, allot time for it. But having that harsh voice against yourself doesn't really help when it feels like the whole world is like talking down on you. You have to be there to talk yourself up, which can be really hard, but it's important to remind ourselves of. So I've learned to try something and if I don't do it today, that's okay. Maybe I'll be able to do it tomorrow when I have a little bit more space. But overall, just continuing to work on trying to essentially make myself feel better so I can be better for myself, be better for my friends and family, and be better for my patients as well.

[23:21] DG: Well, thank you Allison for sharing all that with us today. We really appreciate it. I know our listeners are going to love hearing your story. Are there any take home points you'd like to share with us?

AI: Yeah, I think my first take home point would be to just be kind to yourself and to remember that you are important and you're worth your own time and investment. I mean, all of us on this medical journey obviously know how to dedicate ourselves to stuff and to work hard. And I think throughout that, it's easy to forget that you need to work on yourself too and invest in yourself because you're just as important, if not more important, than that test you're studying for, than that research project that's waiting on you. I think that's an important thing to remember.

And I think too that you're not alone. There's other people who are out there who are feeling exactly how you are during this journey. And there's people out there who want to help you. It's hard to reach out for help, but it's always important to remember to do so. One thing I try to tell myself is if a friend was to talk to me about this right now, would I want to help them? And the answer is yes, so I should be nice and give my friends the opportunity to help me too, just like I hope that they give me the opportunity to help them. Yeah, I think those would be my two big points.

BB: Thank you, that was beautifully said. It was wonderful to talk to you.

[24:39] DG: Thank you for listening to another episode of The DEI Shift. As always, we encourage you to keep the conversation going by following us on Instagram and X, formerly Twitter at the handle @TheDEIShift or emailing us at thedeishift@gmail.com, and that's DEI spelled D E I. You can also head to our website at www.thedeishift.com to access further resources on this topic as well as our learning objectives, show notes, and a full transcript of this episode. And don't forget to claim your CME and MOC credits for listening to this episode at the link that will be in our social media posts and on our website. We hope you can join us next time.