Three energetic bank accounts you don't want to deplete
In my work with overstressed physicians, I have noticed a consistent misunderstanding of burnout’s pathophysiology—the hidden methods burnout uses to sap your energy and steal your passion for medicine. Knowing these hidden methods is vitally important, because once you can clearly understand how physician burnout operates, you will begin to see the simple ways you can keep normal physician stresses from crossing the line into threatening your career, your marriage, and even your life.
STRESS VS. BURNOUT
The activities and responsibilities of being a physician are always stressful. Each and every shift in the clinic or hospital requires a significant input of energy. Doctors are drained on multiple levels by the demands of the clinical practice of medicine every single time they see patients. In addition to the “normal” stresses of clinical practice, they are also drained by dozens of additional stressors that have nothing to do with clinical activities. Here are just a few: billing, coding, maintaining one’s Electronic Medical Record, malpractice risk, clinic culture, and political uncertainty.
STRESS IS WHEN YOU ARE DRAINED AND STILL ABLE TO RECOVER
Physician burnout begins when you are drained and are not able to recover between your shifts. Burnout can take you on a relentless downward spiral that has been graphically described by Christina Maslach, the original burnout researcher, as “an erosion of the soul caused by a deterioration of one’s values, dignity, spirit and will.”1
PHYSICIAN BURNOUT PATHOPHYSIOLOGY: THE THREE ENERGETIC BANK ACCOUNTS
When you cross the line from the normal stresses of being a doctor into physician burnout, you will begin to notice one or more of the following symptoms. These three main symptoms of physician burnout are measured by a standardized research survey tool called the Maslach Burnout Inventory (MBI). The measurements are 1) Emotional Exhaustion, 2) Depersonalization, and 3) Personal Accomplishment (see page 5).
A battery metaphor is often used to describe stress and burnout. “My batteries are run down,” or “I’m recharging my batteries” are common phrases you might hear. But that analogy is inaccurate.
Consider what happens to a child’s toy when the batteries run out. It stops working, right?
That’s what happens with batteries. But physicians are perfectly capable of running on empty and continuing to see patients long after they are completely drained and exhausted. Developing this capacity to work despite complete exhaustion is a core component of today’s medical education. Learning how to keep going no matter what is part of surviving residency. the clinic or hospital, you expend physical, emotional, and spiritual energy. Once you become aware of the existence of the three energetic bank accounts, your job becomes very clear: keep all three accounts in a positive balance. Evaluate where you are right now by considering this simple visual representation (Figure 1).
This survival mechanism makes sense if you have a defined end point, such as graduation. However, once you enter private practice, your whole life stretches out ahead of you. You can continue to function on empty for only so long before something bad happens. And for many, empty is just the beginning.
A more accurate metaphor is that of an Energetic Bank Account. And like most bank accounts, this one can have a negative balance. You can overdraw your energetic bank account and continue to see patients. Your work will not be the very best you’re capable of, but you will keep at it, just like you did as a resident.
MBI SYMPTOMS AND THE THREE ENERGETIC BANK ACCOUNTS
The key to understanding the pathophysiology of physician burnout is to recognize that each of these scales on the Maslach Burnout Inventory corresponds to its own Energetic Bank Account within the individual physician.
- Exhaustion = your Physical Bank Account
- Sarcasm, Cynicism, Blaming = your Emotional Bank Account
- “What’s the use?” = your Spiritual Bank Account (which refers to your deeper connection with meaning and purpose in your practice)
This energetic bank account metaphor helps to explain physician burnout and its treatment.
Each time you are seeing patients in the clinic or hospital, you expend physical, emotional, and spiritual energy. Once you become aware of the existence of the three energetic bank accounts, your job becomes very clear: keep all three accounts in a positive balance.
Evaluate where you are right now by considering this simple visual representation (Figure 1). Point to where you feel your current balance is in each of the three accounts.
- Physical - How is your energy? Are you in a positive balance?
- Emotional - How are you feeling emotionally? Are you getting your needs met in your most important relationships?
- Spiritual - How connected are you to feeling like your work makes a difference and is a meaningful path for you?
PREVENTING PHYSICIAN BURNOUT - THE TWO CORE METHODS
With the three Energetic Bank Accounts as a way to understand how physician burnout does its dirty work, it quickly becomes obvious there are two main ways to both prevent and to treat physician burnout.
- Decrease the Drain
- Become Skilled at Making Deposits
Preventing and treating burnout involves a series of simple steps, but those steps aren’t easy for a practicing physician to carry out because they sit in a huge blind spot created by one’s medical education.
Physicians have deeply ingrained unconscious habits from their
training that set them up for burnout in the first place.
Doctors have never been taught how to lower their stress levels or create work-life balance. An entire wall of shame and guilt has been built around getting one’s own needs met. A second wall, denial, prevents doctors from asking for help or support, no matter how burned out they might be, because that would be admitting they aren’t tough enough to take it. Physicians have deeply ingrained unconscious habits from their training that set them up for burnout in the first place.
Preventing physician burnout is not a simple flip of a switch. It involves a series of little steps, done consistently, that collectively produce significant changes. It is a process that takes some time and will absolutely require you to do things differently. No sudden moves, such as resigning, are advised here. Most physicians find that 70 percent of the time, they will be able to get back to positive balances without having to quit their current positions. Here’s how to get started:
DECREASE THE DRAIN
When you think back over the last several months:
- How draining is your average shift at work? What are the situations, people, activities, and other elements that drain you the most? How can you set yourself up to do fewer of those?
- What are the things you find the most rewarding and enjoyable at work? How can you set yourself up to do more of those?
Decreasing the drain begins when you take a good hard look at what you hate about work, accept it for what it is – stop the blaming, complaining and making excuses – and make changes to eliminate some of that stress. Here are a few examples:
- Learn how to lead your team more effectively so that members do some of the activities you find draining and also activities that don’t require an MD in the first place (you know the ones I am talking about). Delegate them now!
- Get some lessons on how to become a Power User of your EMR from the person in your practice who is acknowledged to be the best at it and the least stressed by it.
- Exercise any flexibility you have over work hours and days. Make your schedule work for you.
- Work less, give up call-and-refer to a hospitalist service, and stop taking an insurance that is a major pain.
You can also decrease the drain by doing more of the things you love at work. Here are some possible examples:
What types of patients and/or procedures do you really enjoy? How can you get more of them on your schedule? If you are expert at a particular diagnosis/treatment you love to do, consider who doesn’t know about your skills in your local community and when and how you will reach out and tell them. These people are potential referral sources who could help you have a better day.
INCREASE YOUR DEPOSITS
What are your favorite recharging activities?
- What things do you do outside of work that you find the most restful and rejuvenating? When can you do more of those?
- How can you take better care of yourself through exercise and eating right?
- Which of these things could you begin to incorporate into your office day?
- What relationships in your life give you the most joy and satisfaction?
- When was the last time you paid them significant attention?
- When can you spend some quality time with these people? (Schedule it now!)
THE PARADOX OF PURPOSE
Your Spiritual Bank Account is the only one where triple deposits are possible. Whenever you have a patient encounter that leaves you feeling so good, you say to yourself, “Oh yeah, that is why I became a doctor,” you have just made a deposit into your Spiritual Bank Account. At the same time, you will notice increased Physical and Emotional energy. Connecting with purpose and meaning in your practice is a leveraged activity that drops deposits in all three accounts.
How can you get more of those encounters in your work day?
You must first be clear on the kinds of things that feed your spirit at work. Remember the last office encounter that gave you the feeling described above? Take a moment and write down the details of that patient/problem/situation/diagnosis so that you are very clear on who and what you are looking for. How can you structure your week so that there is a higher likelihood of having these types of interactions? What if you set an intention at the start of each office day to be on the lookout for an interaction like this? One of my clients calls this creating a “treasure hunt.” You can do it too.
As you look at the lists of options above, pick one and get started. Notice the difference this change makes in how you feel on the very first day you try it. If you would like specific advice and support on getting started, consider a confidential Discovery Session with a burnout prevention specialist. Your goal is to develop new habits that maintain a positive balance in all three accounts. If you look closely at your colleagues who never seem to be stressed or burned out, you’ll find that they have all accomplished this feat. Very rarely does it happen naturally. More often it is because of a brush with physician burnout that motivated them to do the exact work outlined above at some point in their careers.
Dike Drummond, M.D., is a family physician, executive coach, and creator of the Burnout Prevention Video Training Series. He provides stress management, burnout prevention and physician wellness, and engagement coaching and consulting through his website, The Happy MD.
1. Neil Baum, Roger G. Bonds, Thomas Crawford, Karl Kreder, Koushik Shaw, Thomas Stringer, and Raju Thomas, eds., The Complete Business Guide for a Successful Medical Practice (Springer International Publishing: Switzerland, 2015), 250.