Emergency Medicine Australasia (2006) 18, 510–512 doi: 10.1111/j.1742-6723.2006.00875.x

© 2006 The AuthorJournal compilation © 2006 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine

Blackwell Publishing AsiaMelbourne, AustraliaEMMEmergency Medicine Australasia1742-6731© 2006 The Author; Journal compilation © 2006 Australasian College for Emergency Medicine and Australasian Society forEmergency Medicine2006184510512MiscellaneousOn burnout and other demonsM Cannon

Correspondence: Dr Marianne Cannon, Emergency Department, Princess Alexandra Hospital, Ipswich Road, Wooloongabba, Qld 4102, Australia. Email: mariannecannon@optusnet.com.au

Marianne Cannon, MB BS, FACEM, Staff Specialist, Senior Lecturer.

PERSPECTIVE

On burnout and other demonsMarianne CannonEmergency Department, Princess Alexandra Hospital, Brisbane, Queensland, Australia

Abstract

A personal perspective on the subject of burnout in emergency physicians. Causes, iden-tification of and potential pitfalls as well as possible remedies are discussed.

Key words: burnout, emergency physician, stress.

I first came across the term well before I was a medicalstudent. Graham Greene wrote of Querry the famousarchitect who had achieved much but could feel noth-ing. He flees to a leprosarium in the Congo where hemeets the physical equivalent of his internal emptiness– the burnt out case of leprosy, mutilated but no longerin pain. Dante describes it as well ‘I did not die yetnothing of life remained’. The American College ofEmergency Physicians (ACEP) recognizes it and haspublished on it, responding with a ‘Physician Wellness’subgroup. When it strikes it does so with slow onset,stealth and harsh consequences, with denial as a cardi-nal symptom.

It is little wonder that emergency physicians getburnout. We subject ourselves to long hours caring forthose in crisis of all sorts, many of whom do not – formany reasons – show gratitude. We are sleep-deprivedat times and see the end result of lives unravelling orsuddenly snuffed out. We are expected to respond withlittle emotion, as it might impair our performance in thenecessary tasks. With little formal training we counselthe bereaved and traumatized and need to be leaders inclinical and non-clinical settings. We battle with admin-istrators who are driven by fiscal targets, and whorarely have to deal with the direct consequences of thepolicies they embrace – overcrowded undignified

circumstances for people who are sick and vulnerable,and whom – deep down – we know are not being treatedoptimally as a result of those policies. In some placeswe are punished for advocating for a better deal forpatients.

It is the most caring conscientious of us who getburnout – the person of high ideals and personal stan-dards, the one who puts duty first, not the guy who isout the door on time all the time, who is somehow neverable to swap a shift. The qualities that predispose todepression also make us susceptible to burnout. Wemight read or go to talks about how to prevent it . . . bydealing with stress in a ‘healthy’ way, getting work life‘balance’ and looking after ourselves . . . easy if youhave not been there or are well into recovery. The lastperson to realize he or she is burning out is the personthemselves; indeed rather than admit we are impairedwe will blame other people and circumstances in ourlives for making us unhappy. The symptoms, as ACEPdescribes them, are:• Withdrawal from family then friends• Denial• Overwork• Anxiety• Dread• Anger

On burnout and other demons

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• Isolation• Martyrdom• Risk taking• Depression even leading to suicide

Talk to your colleagues. Many became sad and moodyat different times; in some cases clinical depression setin. Relationships buckled under the strain, and familiesfailed to understand the dynamic of a person who, hav-ing reached a tangible outside measure of ‘success’, feelsaimless and empty – someone whose emotional well isdry by the time he or she gets home. Burnout mightstrike at any time, but particularly mid career, alongwith the so-called midlife crisis. Along with adolescenceand retirement, the middle years of life are transitionalyears, where emotional upheaval can be regarded aspart of normal developmental crises. There is question-ing of the values that family and society might haveimposed, and we look for different remedies for ouraltered perspective in life. For those who have led asheltered life from school to medical school to residencyand family commitments, are finally out in the openwaters . . . our choices have come home to roost what-ever they might have been. And it is scary, as is thefuture, if we do not see the possibility of change fromour current circumstances. We are disgruntled, unap-preciated and inward looking. It goes with the territory.

We cope with stress just like everyone else and toreduce our distress at what we feel we use the samedefence mechanisms: denial, repression, rationalization,regression, intellectualization, displacement and projec-tion among others. Black humour, the stalwart of juniordoctors is a good example, as is ignoring our own dis-tress by worrying about others – either colleagues orpatients. Compensation, an extreme type of denial, isdemonstrated by how a person acts . . . taking on moretasks and responsibilities to avoid the distress ofmourning. How often do we see colleagues throw them-selves into more commitments at work while theybecome unhappy at home and in poor physical health?As doctors, we not only make poor patients, but areunwilling to admit there is problem, right up until it istoo late. Most of us know of at least one colleague whohas worked right up until their own tragic suicide.

When you look at the Diagnostic and Statistical Man-ual of Mental Disorders – Fourth Edition criteria fordepression, they line up remarkably well with those of‘burnout’. An emotional numbness, sense of deperson-alization, an inability to empathize – ‘compassion burn-out’ to use a popular term – weight loss or gain,insomnia, feelings of worthlessness or excessive guilt.Alcohol might be used to lessen the feelings of distress

and hopelessness. At the end of the spectrum is clinicaldepression and suicide. Dealing with a friend or col-league who we think might be burned out or isdepressed is often met with denial, or downright hostil-ity. Recognizing it in oneself is well nigh impossible.

So how do we deal with and prevent burnout? Theconventional wisdom from ACEP is not surprising, andmakes good sense. First, it must be recognized, and ittakes a concerted effort to tackle it, especially if indenial, or when the response is hostile. I will tell of myown experience. When I was there I was lucky enoughto have the candour of my kids who demanded ‘theirold mummy back’. For me, this forced me to realize Ihad to pull back, reassess my priorities, and, if need,seek professional advice. I had been somewhat hostileto my friends who said they were ‘worried’ and sawtheir advances as those of busybodies.

There are no hard and fast answers, but the common-sense wisdom of regular exercise, healthy diet andproper sleep are vital. I read the Dalai Lama (a wonder-ful being who has no kids or partner) and a couple ofpopular psychology books, all of which enlightened me,but did not fix my problem. It was a case of physicianheal thyself, and I saw admitting I had a problem asakin to weakness, or as failure to cope. Like the ‘Atlassyndrome’ that I have since discovered, I took on theworld’s problems, and like of a good energetic emer-gency physician, somehow made them my own.

The path to recovery was slow, and I had to admitsome unpleasant truths of myself. It meant that inrecovery I consciously have to keep time for myself, –and for those who, and that which sustains me – in anemotional, spiritual and creative sense. While I ampartly defined by my profession, it is only a smallaspect of what sustains me. Moreover, to do it well, Ican’t let the well run dry again, and act in ways I wouldhave seen as selfish before. As well, I saw how easy itis to be self-denying when caring for others, to the pointof neglecting those who depend on us personally, espe-cially our offspring.

Paradoxically, the personality traits that predisposeto burnout are ones I hope to foster, and those thattypify the people who I hold in highest esteem. If ourempathy for the suffering of others leaves us, we arehusks, and unable to heal anyone except in the nar-row, mechanical sense of the word. Taken in its bestlight, burnout is akin to what the philosopher TomMoore calls the ‘long dark night of the soul’. It is atime of doubt and dysphoria, but necessary forgrowth, and a chance to see the world in a whole newlight.

M Cannon

512 © 2006 The AuthorJournal compilation © 2006 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine

If we can destigmatize it, look it in the eye and allowour selves to heal, it can be give rise to a determination,even optimism that will take our aspirations waybeyond the corridors of hospitals and bureaucracies ina way previously considered beyond us.

The most productive strategies (and mistakes) for meare summarized here:

Seek out those who know you best – that is, fromchildhood – and seek comfort, if not advice. Work men-tors might not be the best life mentors. Some of thosewho offer ‘help’ might have their own agenda, and/or‘issues’. Your real friends won’t seek to exploit you invulnerable times. Take time away from work and itspeer group. Doctors have a bias that says work is allimportant, but compared with your psychologicalhealth and your family it is not. Listen to your owninstincts. They can be very impaired when you areunhappy, so allow others who know and love you tocare for you, until you can trust your own again. I wishI’d taken a few months off to get back to ‘normal’.Forgive yourself, and seek help from others when youneed it. Many long-standing friendships begin withsomeone else in need – accept that this time it might beyou. Allow yourself lots of downtime in places thatenrich: for me, the bush, the ocean, the outback . . . longwalks in nature, and open-minded, thoughtful adultcompany. Much can be learned and gained from chil-dren, even if they are not your own.

If more than one person gently suggests you need pro-fessional help, get it. I wish I’d done so earlier than Idid. Many psychiatrists have a special interest in doc-tors and you get unbiased perspectives from an expertwhile you clarify what really matters to you. Even tohear that what you are experiencing is a normalresponse to stressful times leads to speedier recovery.If depression has set in, you are in the right place.

Reading personal development books like ‘The Art ofHappiness’ ‘The Road Less Travelled’, ‘Don’t Sweat theSmall Stuff’ might normalize what seems a disorientat-ing time, and although they seem narcissistic at timesmay validate one’s experience.

Giving my kids the time we deserved was crucial; youcan not get their childhood back. No amount of ‘qualitytime’ is enough when children feel squeezed betweenwork and your ‘real’ interests. Play is good for all ofus . . . and reminds us life is an adventure, after all, nota chore. Taking yourself and them to the developingworld is a ‘grounding’ experience. Like their parents,kids can become selfish and spoiled, so that theirachiever/materialistic streak runs rampant. As lovelyas they are you need bursts of time away from them,as does your partner.

Opening one’s self to other people’s reality (e.g. viaAmnesty, Oxfam, MSF) – and giving what you cangives a sense of being part of something larger andintrinsically good. Volunteering enriches – be it at theOxfam stall at the Byron Peace Festival or teachingremote practitioners, or internationally. Growing herbsand trees (or whatever you love) allows you to gentlynurture a living thing; like fires, earth, water and danc-ing there is something primordially comforting andrewarding in tending a garden.

Defer making big decisions until when you are happyand stable. Changing jobs/location/partner when youare impaired can make things worse for everyone. Mindyou, in the case of the first, reducing hours might beexactly what is needed; most families prefer to have youaround – and healthy rather than to have extra wealth.Accept that you – like everyone else – are vulnerable,and that your experience will make you a more tolerantcaring person at the end of the day. Apologize if youhurt people; they might not understand, but do it any-way, they might come to understand one day. You makeyour own choices and this is an adult one that is usuallycathartic. Realizing life is a journey not a competitiongoes a long way to prevent us judging ourselves – orothers – en route . . . seeing other people’s innocence aswe do our own can leave tolerance instead of a scar.

It is my view that we live in strange and unhealthytimes, where despite wonderful communication technol-ogy, we can find ourselves feeling that much is missingfrom the fabric of our daily lives, that public moralityis a myth, ridden with double standards and hypocrisy,and that real compassion is sometimes lost in talk andself-interest. Finding kindred spirits is not alwaysstraightforward, especially in hospitals, and suburbs –they are there, though, of that I am sure. I do not meanto be prescriptive, but this has been my experience.After you pass through this time you might see life intechnicolour, and full of possibilities, inspired by thefact that many people feel as you do. That they too arefed up with the greed and chaos of modern life, andwish to finish their medical days in the developingworld, with an easel or sheaf of short stories to leavetheir mark. It sounds trite, but do not let go of yourdreams, they enable you to transcend the stuff that eatsat your well-being until you turn the corner and havethe wherewithall to go in their direction.

Accepted 27 March 2006