Mental Health and Burnout, Part 2

We're closing out Mental Health Awareness Month with the 2nd part of our discussion of burnout. Join us as we learn from Dr. Anand Jagannath, a clinician educator hospitalist who experienced burnout as an early career physician, and then learned strategies that individuals and institutions can implement to better recognize and combat burnout.

Learning Objectives:

1. Learn and be able to recognize potential sources of burnout.
2. Learn various individual methods one can use to combat burnout. 
3. Identify various methods institutions can implement to help mediate burnout among their students, employees, and faculty. 

Credits:
Guest: Dr. Anand Jagannath
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

Instagram: @thedeishift
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Website: https://www.thedeishift.com
Email: thedeishift@gmail.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] Dr. 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…

Branden Barger: Hi, I'm Branden Barger. I'm a fourth year medical student with UC Riverside.

DG: Today, you will be listening to part two of our two part series on mental health and burnout. In part one, we heard from Dr. Allison Ibarra about her experience with burnout during medical school and residency and how she combated it. For part two, we will hear from Dr. Anand Jagannath about his experience dealing with burnout as an early career attending physician and some of the many modalities he used to address it. We hope you enjoy.

[00:54] DJ: Hi, Dr. Jagannath, thank you for joining us today. Here at The DEI Shift, we call each other by our first names. Do you mind if we call you Anand?

Dr. Anand Jagannath: Absolutely, DJ.

DJ: Awesome. Thanks, Anand. So, before we start, we would love to hear a little bit about yourself.

AJ: Sure. I'm a clinician educator hospitalist at the Portland VA up in Portland, Oregon, affiliated with OHSU. I came here via the San Diego VA, and UCSD, where I had the pleasure of meeting you, DJ. I was there for four years while my wife was doing fellowship in Gynecological Oncology. And before that, my wife and I were at Montefiore Medical Center in the Bronx for our respective residencies in Internal Medicine and OBGYN for my wife. Before that, we met each other at Tufts. I am a reformed engineer. I used to work in medical device design, had a quarter life crisis in my mid twenties before when I switched to medicine. And my sort of path in medicine is really around clinical education and clinical reasoning. Really interested in teaching how we think about solving clinical problems and making management decisions about our patients while keeping their priorities at the front of our minds and really enjoying learning from our patients and learning from our learners as well too.

[02:15] BB: Thanks, Anand. It's great to hear a lot more about your journey. As you know, today's episode is about health and burnout with such high rates and statistics that are being quoted on physician burnout, especially as we kind of curtail ourselves out of the COVID-19 pandemic, or at least the height of the pandemic. We feel it'd be really impactful to hear from people who are at different stages in their career about a time in which they've experienced burnout – how they may have addressed that burnout and really just shedding light on what is likely a very unsaid issue? So would you mind sharing us a time in which you may have felt this, or you know in retrospect, may have thought that this was the sign of burnout for you?

AJ: Sure. I love that you guys are doing this episode because I think it's something that affects us at all levels of training. I definitely felt burnout every year of my residency program. Also during my chief year as well. And I've had periods since then, and I don't want to say it's a normal part of residency training or any kind of medical training. But in a sense, it is, because there's so much that we have to deal with. Or I shouldn't say deal with, there's so much that we have to navigate as physicians, and we're taught in medical school how to diagnose and treat patients. But then when it comes to the actual stories of our patients and the dynamics of working in a medical system, both locally and kind of as part of a larger regional and national health care system, there's a lot of factors that you're somewhat protected from as a trainee, or not necessarily privy to as a trainee that as they, those layers, enfold you, you have to navigate those things.

As a clinician educator, I think recently, as an attending, my burnout has come in the form of my role as an educator. And so I think I first felt this actually when I was at UCSD in my first couple of years, and my burnout really was centered around feeling inadequate as a teacher, which is kind of ironic because it was kind of what I dreamed to do. I wanted to be a clinician educator. I wanted to teach. I wanted to learn from my learners. I was hoping to impart some knowledge and some know-how as well, too. Just after finishing my chief year of internal medicine residency, I was really energized, enthusiastic and powered by the San Diego sun. Really ready to go, which was awesome. You know, a lot of promise. And I met DJ pretty early on. You were a second year resident when I first joined. And I remember meeting you very vividly. One of my cases had been recorded on the curbsiders podcast. And you approached me in the hallway and said, "Hey, I'm DJ and I heard you on the curbsiders." And that gave me a lot of joy, to be honest.

Coming to a place that is just so supportive and such a fantastic place to be with learners, it seems ironic that one would get burned out in a setting like that. But coming to UCSD, I think one of the things that I realized was the diversity that exists in medical training. This is something that I was told as a medical student applying to residency, but as a resident, you're so immersed in your day to day that you don't necessarily see outside the four walls of your training institution until you have the opportunity to go somewhere else. And at UCSD one of the things I noticed very quickly after my first couple times in the wards were, “Wow, everyone is so smart. They know so much. They're really well read. They're up to date on evidence in the literature.” I feel pretty inadequate. And, nothing against my residency program. I really enjoyed my residency program, the training environment was excellent. It was very high, fast paced. It was in a very underserved area and we did a lot of triaging as residents there. And a lot of my training came out of knowing how to recognize sick versus not sick, doing that at a high pace and high volume, and learning how to triage care appropriately and diagnostic workup as well, appropriately too. And not to say that things weren't busy at UCSD, but I think the level of support that was available from an institutional standpoint was a little bit different and it allowed residents to have that time to think a little bit more deeply, even if it was an extra 5 minutes here and there about what they were doing.

And as a result of that, I was kind of washed over by this amazing wave of medical knowledge and know-how by the residents in my first couple of years that had me feeling a little inadequate and feeling uncertain about my own medical knowledge. I felt a little bit behind there with medical knowledge with evidence. And at first I was like, “It's okay. I'm attending now. I've got some time between rounds and checking in the afternoon that I can do some reading and catch up.” And I definitely did that. I spent a lot of my time on the computer on Up-To-Date reading resources, talking to mentors, fellow colleagues as well, to kind of make sure I knew what I was doing and gain some more confidence in my abilities. But, after a while, I realized that this feeling of inadequacy wasn't really going away. And it kept on coming back. There would always be some new question that was being asked by my learners, the trainees. There was a new encounter with the patient or a situation that was unfamiliar with having to deal with or manage or navigate with a patient, a trainee, a family situation, what not. And I just really found myself burning out at that point, feeling like I was unfit to do the job that I'd trained for because I just felt like I didn't always have the answer.

And that was a really powerful moment for me. And it was one that I burned out. Yeah. I didn't know exactly what was going on at the moment, which I think often happens with burnout. You kind of are burning out and don't realize it until a little bit afterwards when you have the moment to hit pause and say “What's going on?”. And I just felt like I was burned out from being inadequately able to handle uncertainty in front of my learners. So I recognized that. That handling of uncertainty was kind of like the focal point, or the pivot point, of my burnout in my early stages as an attending, and that kind of sat with me a little bit. I thought that as an attending, I shouldn't be uncertain of the things; I should be confident, I should be knowledgeable. And I think as many trainees feel like once they're in it – once they graduate residency or they pass through the pearly gates of knowledge and wisdom – all of a sudden they know everything, which is clearly a misnomer. I can say pretty confidently now, and I can also say pretty confidently that attendings continue to learn throughout their entire career. And it truly is the practice of medicine, because we're continuing to practice gaining knowledge, continue to practice how we reason, how we make decisions, how we navigate uncertainty in different scenarios.

[9:01] : And so I guess the second part of your question was regarding how I managed or dealt with that burnout of handling uncertainty. I think I initially did what a lot of people do: turn to your support group, turn to my wife, turn to my mentors, turn to colleagues as well, who I had gotten close with over those first couple of years and say “Hey, what's going on here? Why do I feel this way?” And I had read that just having some good conversations with them about similar experiences that they had had were somewhat reassuring. But I just still felt unsatisfied at that point, because it's nice to have a shared experience, but it doesn't necessarily solve the problem or give me a path towards solving that problem. And it was around that time that I started to encounter some literature on Growth Mindset – Carol Dweck's book on Growth Mindset. The literature around that and navigating uncertainty too, combined with some mentors of mine, really turned the page a little bit in terms of giving me a path towards being able to handle that burnout or handle that situation of finding myself uncertain.

I realized that there were a couple of things that were key to me. It was rereading an old paper, some old literature that talked about what it is that learners find desirable in a teacher. And one of the things that I'd read before, but didn't really make a lot of sense to me or didn't resonate fully with me, or on a different level with me, until that time, was that they look for people who serve as role models. People that have medical knowledge or technical skill or what not, these are good characteristics. But people who act as role models, or able to model certain behaviors, were helpful and beneficial to learners. And it was something that I realized “Hey, maybe there's a way that I can use this to my learners advantage and also to my advantage and kind of lean into uncertainty”. Realizing that not only is this a shared experience amongst attendings of different levels of their careers for different stages of their attending careers, but it's something that maybe our learners should know about as well, too. And I kind of really leaned into that.

The clinical problem solvers, Rabih Geha and Reza Manesh, made the words pretty famous from the diagnostic reasoning lens of just being empowering words. But I wanted to go past the words of, “I don't know.” Those three words, “I don't know”, because I think that that can quickly become a shield and not necessarily show people how you as a person or an individual or attending as a teacher navigates those periods of uncertainty. And so I wanted to try to be more specific about how I was dealing with uncertainty, whether it was a medical knowledge question, whether it was a particular patient scenario, that had an emotional trigger for me that I didn't necessarily know how to deal with. I thought I felt that it was something that, if I was going through, then probably some other people were too. And I wanted to really broadcast that, how I was thinking about it to my team as well, and use that team room as a venue to really think through and gain wisdom from other people as well, because everyone's life experience is a little bit different. So maybe someone has encountered a situation that I haven't, that I can learn from, take lessons from. And while we didn't always find solutions to every little problem or question that we had or felt uncertain about, I think there was almost this collective weight off my shoulders. Like, “Hey, this is a shared lived experience and getting some feedback directly about feeling that it was okay to be uncertain and that there was ways to deal with that and handle it” made me feel really good about leaning into that a little bit more. And I think my burnout with respect to dealing with uncertainty kind of started to slowly melt away as I kind of spoke knowledge to power, truth to power to that. Yeah, that's kind of my story around how uncertainty led to burnout and how I kind of dealt with that.

BB: Thank you. I mean, that was so powerful. Correct me if I'm wrong, but it feels like a lot of what you were saying is this culture surrounding physician perfectionism, and where it intersects with our personal sense of imposter syndrome, has really kind of contributed to a generalized sense of burnout among many people. Always feeling that they have to be the most knowledgeable person in the room, the most confident about their answers, because I think in the back of your brain, you're like, “Does this impact my patients? Will this impact their health? Will this impact my career? Are other physicians going to think I'm stupid?” So, I really like what you were saying of leaning into that level of uncertainty, bringing a sense of humanism to the idea of being a physician, realizing that we are not robots, we cannot regurgitate Up-To-Date in every moment of the day. So I really appreciate you sharing all of that, and especially as a clinician educator, as well as your own level of attending, how do we backtrack that culture of imposter syndrome and perfectionism to then not reciprocate that cycle among our new medical students, our new residents who may be feeling a lot of the same things.

AJ: Branden, I couldn't have said it any better than you. I applaud you for interpreting what I said over however many minutes and encapsulating it so articulately, so thank you for doing that for me. It was really nice to hear someone reflect on my journey and encapsulate it so powerfully.

DG: I think, too, it brings up a very important point that you all have said it, that just the way we're trained, even before going to med school, there's a sense that you have to be the smartest, you have to get the highest test scores, you have to get the best grades. Now with some of the changes in the STEP system, maybe hopefully that kind of helps. But even then, like some of us that had the STEP 1 that kind of determines your whole career, it's a lot. And then when you're kind of on your own as an attendant, then you're like, “Okay, well, I'm supposed to know everything” and then you quickly realize you don't and it's almost impossible to honestly, it can be a lot for some. Knowing you personally, when you said you felt inadequate and that everyone seems so smart. But from our standpoint, when you came in, like this guy is a genius. This guy is so smart. He figures out every case. He knows all the diagnoses. And I think that's important because I think sometimes we, and I, we all do this, we harp on the negative things in our lives that we do. It's hard to focus on the positive. And that's why I think it's so interesting. Everyone thought, Oh man, Anand, he's the top dog here at the VA. He knows everything. He's so smart. So I think it's very interesting. Just that perspective, you know, that perspective that you may be having, it's not what everyone else might be perceiving. So it's very interesting.

AJ: DJ, thank you for those kind words. I think that insecurity sometimes drives us to work harder and be better as well too, but when they get to the point of making one unable, or when they get to the point of reaching a breaking point or feeling burned out, then it's a time to pause and look back and reflect. But no, I appreciate that. That's very kind of you. And, again, I think that any one person's wisdom is built on the knowledge and successes of other people as well. And the success of trainees is truly the teacher's ultimate reward. No teaching award or anything like that could ever surpass seeing their trainee kind of achieve their dreams and their goals. So that in a form is a way of kind of combating burnout and continues to drive me as an educator.

[16:55] BB: You mentioned previously that you, in leaning into that uncertainty and trying to combat your own burnout because of that uncertainty, you are trying to cycle back with your trainees and almost giving them an insider's perspective as to how your thought process is concerned. Because, like DJ was saying, you may walk into a room and everyone thinks you have everything figured out, but they didn't see the back end of that where you, as an attending, were up all night also searching for the right answers. And you may also not know the right answer, but you were working all the same. For other folks who are in your role, folks who are either attendings on their own or folks who have large swaths of trainees carting around them behind in the wards with their little wows and their white coats. What advice would you give to other folks at your level, to also combat their own sense of burnout, in order to, again, not reciprocate this cycle?

AJ: Sure. That's a great question. I'd love to use a different word than level because it, in my mind, creates a hierarchy, which I try to actively kind of work against because I do think we're just all at different time points in our learning journey. So, yeah, I still consider myself a PGY-9, I think I'm going to be PGY-whatever-it-is when I retire. I send these pre-rotation emails to my team saying I'm a PGY-X, or PGY-9 at this point. So, I know what you're saying, Branden, but I'd just like to avoid using the word level because it creates a sense of hierarchy. But beyond that, I do appreciate that question, Branden, because I think it raises the point of, again, role modeling to our learners, and how we can be more effective in that way. And I think sharing one's thought processes or cognition can be really powerful because a lot of times we've all probably experienced this at some point in our career. We'll probably experience it again, even as attendings, where someone will swoop in and just give the answer and then fly out, but without helping you understand how they got there. So I think sharing cognition is really, really important because it gives something, it shows a path to our learners. And it shows how we think and solve problems, whether they're problems of uncertainty, problems of diagnosis, management, or problems that we feel very confident in. Also knowing how one got to that solution is really important.

I'd love to shout out Dr. Jack Penner, Dr. Jess Dreicer, and Dr. Gurpreet Dhaliwal, who I recently worked with writing a manuscript on something called Cognitive Apprenticeship and Intellectual Speaking. And we actually presented a workshop a couple of weeks ago at Society of General Internal Medicine's National Meeting on this as well, too, because they were really keen in kind of forming this discussion around handling uncertainty and broadcasting cognition as a teaching tool specifically. But I think it doubles as a tool for mitigating burnout as well. Knowing that these feelings of inadequacy pervade the medical culture and just knowing that it's something that is not unique to a trainee at one time point in their journey, but throughout the time course of a career in medicine, they may become fewer, they may become a little bit different, but they don't ever go away and being comfortable with that, being able to lean into it and showing other people how you handle that, I think is really important. Even if someone doesn't ask, I think it's one of those things when we say there's no dumb questions, and if you ask a question, someone else likely has the same question. Sometimes you have to be able to role model or see the elephant in the room and be able to kind of talk about that. That would be my suggestion. And again, it's biased because that's what's worked for me. But there seems to be a whole community of teachers and educators out there that feels similarly.

DG: I really like that. And actually, that's funny because my go-to phrase. I sometimes can tell if, you know, the resident or medical student doesn't understand something from a consultant or, you know, whomever we're talking to. So I'll just say, “Hey, for my learning, can you explain this?” And even sometimes I've had different staff members, they'll say this acronym and I have no idea what they're talking about. It's like, “Hey, for my learning, What does that mean?” And so, and it's funny, 'cause I think a lot of people love to share, you know, their knowledge. So I think it kind of creates that environment where everyone, you know, can share, I don't wanna say their inadequacies, but maybe, it's like a learning, nurturing, more learning kind of forward environment. So I really like that, you know, kind of showing that we don't know everything.

[21:47] BB: I do have a quick follow up for you, Anand. As someone who has navigated multiple institutions and has worked to find positions that fit well, that speak to you, that have a good institutional vibe, I think we here at The DEI Shift, also want to talk on more of a systemic level. How do our workplace environments better support our staff at all points in their journeys? To take a rule out of your book, instead of calling it levels, how do our institutions, our medical schools, our hospitals, our training pipelines, how do you think we can better structure our environment to contribute to a world in which our trainees and attendings do not feel this kind of sense of inadequacy and burnout that has been, you know, obviously very pervasive over the last few years?

AJ: That's such a good question, Branden. I don't know if I'll have the perfect answer. I can give a perspective, but I know that this is a multifaceted sort of issue that any one particular solution is going to have roadblocks to it as well. So, but that being said, I think if I were to summarize it, I would say managing expectations and I'll dig into that a little bit more. We've covered a lot of the sources of burnout being what we expect of ourselves as learners and how the medical system and the educational system as it exists, sets these expectations in our minds as to what success is defined as. And we hold ourselves to those standards. I think that if we fall short for any reason whatsoever, that we feel inadequate as a result of that. And one specific example I'll give in terms of how we can use our words to manage expectations differently, is when you become a resident. And DJ, you've seen this as well on residency evaluations. There's this level of this usually a five or six point Likert scale of how you perform on a given rotation to get an evaluation for. And the last one invariably says something about an aspirational sort of pattern of behaviors or knowledge or whatnots, and usually accompanied by the phrase “ready for independent practice”. And I think that is something that I've seen at three different institutions now, those exact words in an evaluation, “ready for independent practice”.

And I think that, you know, as a trainee, I certainly thought that meant, again, pass through the pearly gates of medical knowledge and attending-hood, and then you know everything. That's what I thought independent practice was, but I really do think that independent practices, when we say that you have reached a level of knowledge and problem solving ability that you can figure out, or, you know, where to go to help figure out any issue that you come across, right? And that can mean consulting a subspecialist, it can mean knowing when you have to talk to one of your colleagues to run something by them, or knowing when you have to kind of pause and take a step back and like take a different approach, right? Whereas you would need guidance to do that before because you wouldn't have known otherwise. And you're still on that learning journey. And so I think those words, “ready for independent practice”, are like an example of how expectations can sometimes be misinterpreted because we don't truly know what that means as trainees. We see it. We take it at face value. That means after this, I'm all by myself, but there's no one, there's no safety net, that the cord is cut. I mean, that couldn't be further from the truth. I can't tell you how supported I felt throughout my entire journey as an attending at UCSD, now here at OHSU. For everything that I do clinically, academically as well, too. And it's one of those things that we just don't necessarily see in the future because our expectations are managed in a manner that makes us think that we have to achieve these particular steps in order to be successful. And if you don't meet that minimum threshold, then you're not successful. And I think that's, that couldn't be further from the truth. That's just one kind of one perspective or one piece of the very large complicated pie.

[25:49] DG: One question I had for you, I know some people for them, since the source of burnout is at their job or their training or school, sometimes they'll lean into other things outside of work. Was there anything in particular that you leaned into that you think kind of helped mitigate some of the burnout you were feeling?

AJ: Oh sure, the Southern California sun helped a whole bunch. It was there year round. It was awesome. No, I'm half joking with that. The weather definitely did help. And now in Portland, I do love Portland. It's a beautiful place. I'm looking outside my window and it's just so green and just lovely. But during the wintertime, you know, I did miss the sun a bit too. So I think the weather did help for sure. I think that one of the things that really was helpful was the time that I put into the relationships I had both in and out of medicine. And what I mean by that is like my academic mentorship, sort of community that I built within the walls of UCSD, and also external to it, prior to my arrival there, were really helpful, because we talk about having a diverse set of opinions that we surround ourselves with so we don't get necessarily siloed into only one way of thinking. But sometimes having people who are like minded or have had similar journeys as you in terms of career path can be helpful to bounce ideas off too because there's a degree of relatability there. And, you know, you can say, “Hey, when you were getting started in clinical reasoning or when you were getting started as a clinician educator attending, Did you ever encounter XYZ? It's like really just, you know, really eaten at me and I'm having a hard time like navigating this. How did you deal with that?” Being able to ask those questions and not have to necessarily explain the full backstory because there's a shared understanding there can be really helpful.

We talk about mentorship networks and developing mentorship families, people who fulfill different roles as a mentor, whether it's systems, knowledge, whether it's sponsorship, whether it's like kind of helping with generating ideas, et cetera. But I think that's kind of the traditional thought behind a mentorship family is around scholarship. But I think it also really applies to these areas of your own personal well being, because if you choose a career in academic medicine, the trials and tribulations of that career path will definitely have been shared by other people, regardless of the institution. It's a similar theme, maybe just manifest slightly differently. If you choose not to do academics, I think any career path also has areas in which you can or points in which you can experience burnout, too. And I think that having your mentorship community in your practice area, whether it's as purely as a clinician, as maybe an administrator, as a QI researcher, as a process person, regardless, having a group of people who have similar interests at different points in their career can be really helpful to look up to, to provide that sort of guidance and counsel. And then I'd always recommend that if you're going to receive that counsel, you should always make yourself available to try to provide your experience as well, too, because undoubtedly someone's going to be following in your footsteps. And I think it's part of our jobs as mentors and mentees to be able to kind of pay it forward, too.

[28:47] DG: Thank you so much for sharing your story and all those amazing pearls. It was extremely impactful and I know our listeners will learn so much from you. So I want to say thank you so much.

AJ: Thank you so much, DJ and Branden for having me here today. I think this was an incredible opportunity and the people who know me well, have kind of heard the story at some point, or kind of seen me go through it at different points, but being able to kind of speak to it a little bit more directly has been somewhat therapeutic for me as well, too. And it will be a nice reminder in the future when I undoubtedly have a period of burnout. Again, I can look back on this story and kind of remember it. Gain to reconnect with an old friend, you DJ, and gain a new friend, Branden, as well too. So thank you so much for the opportunity.

[29:29] 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.

The DEI Shift podcast and its guests provide general information and entertainment, but not medical advice. Before making any changes to your medical treatment or execution of your treatment plan, please consult with your doctor or personal medical team. Reference to any specific product or entity does not constitute an endorsement or recommendation by The DEI Shift. The views expressed by guests are their own, and their appearance on the podcast does not imply an endorsement of them or any entity they represent. Views and opinions expressed by the DEI Shift team are those of each individual and do not necessarily reflect the views or opinions of the DEI Shift team and its guests, employers, sponsors, or organizations we are affiliated with.