Burn Out

[Marasmus1]

I believe I have finally burned out. However, surprisingly it came during the chief residency when I have some sort of real power and autonomy. Regardless, I am looking for some remedies from colleagues who went through or have been going through this. The reason I wanted to discuss this in psychiatry forum is because of significant denial my colleagues from other departments exhibit. In addition to that, I believe psychiatrists are more insightful. This can also serve as a thread for some who are not coming forward but in need for suggestions.

I am a psychiatrist ( well, almost 5 more months ) and obviously inclined to observe a lot. I can cite social isolation due to pandemic, significantly decreased in person patient visits, working with patient population that has significant antisocial character pathology, increased EHR use during pandemic for excessive documentation, due to lack of staff during COVID being asked to give LAIs, do referrals to detox/rehab, obtain insurance authorization, swab the patients for COVID etc. as main factors, respectively.

I experience cynicism, apathy, loss of empathy (mostly for staff not for the patients), decreased sense of accomplishment, irritability and lethargy (laziness in lay term)

I sought help from a therapist who turned to be an analyst (Yes, they still exist). I started feeling a little uncomfortable when he associated my boredom with the departure of my mother in early age. I asked what to do about it. He said will work it through in 3 to 4 times a week sessions (Seriously????). I realized that the sessions regress me more than I can tolerate so I quit.

I have never been a huge fan of CBT because of my failed attempts engaging it with my own patient population. Found it somehow concrete and superficial. I am trying peer counseling now which is basically pure supportive in its approach and seems like helps me get going.

I dont want to lengthen the post and bore my colleagues further , what are the recommendations? Any source to overcome this? If you went through something similar personally, what helped you?

Thanks for the suggestions

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[dl2dp2]

Pretty interesting, and definitely not uncommon. I don't have "advice" but just a few random thoughts.

1. It's kinda early to experience burnout in your career. What it means is that you found the niche of psychiatry you don't really enjoy. For me, that was CL and emergency psychiatry. I think as time goes on you'll be able to identify the niche you enjoy more. I wouldn't generalize it necessary across the entire field, and certainly, there's no reason to expand it into anything that has to do with you as a person ("holy **** I made a huge mistake and need to quit medicine, etc")

2. Psychoanalysis requires a mind frame and is not purpose-driven as you know. It may be "fun" to do but it doesn't solve problems--it often makes you aware of problems you weren't previously aware. That can be a very useful exercise for a period of time and is a creative endeavor, but I wouldn't feel guilty about any of this. I.e. it's not that you can't "tolerate regression" as if you have some skills deficiency. You made a decision to end a treatment frame that is not compatible with your current career and personal life. Maybe later. Maybe not. No harm no foul.

3. CBT-style therapy *can* be quite deep. This is usually in the rubric of schema-based treatment, and reserved for people who are "very ill". However, in my experience, this style of therapy is also very useful for high functioning people who are interested in scrutinizing existential issues but from a behavioral (and cognitive) perspective rather than a humanistic perspective. i.e. the Tolstoyian idea that the meaning of life resides in the *work* (i.e. more explicitly, the behavior you express). So creating meaning has to do with creating behavior.

4. I have not experienced this personally (yet) but I have seen many colleagues experience this, and in general, it's plenty helpful to find confidants in addition to formal therapy work. I also find that doing therapy to people who actually benefit from therapy was actually very helpful in introducing meaning in my life (see point 3). Don't get me wrong, I love meds too, but meds are not as visceral a sensation when you really have a patient *trust* you and you are working together on a journey.

 

[Bartelby]

I will just throw out there that you are not alone. I feel burned out, in large part because (like in your system) many staff have left and I am covering a lot of things, all while dealing with constant slow-downs from pandemic restrictions and a less fulfilling home life. I have been strongly considering an option you don't yet have, which is to quit my job, and I go through real ebbs and flows in my level of bitterness. Burnout has not really been an issue for me in psychiatry before this year, so I am hopeful for those of us in our situation (new burnout that seems clearly related to the stress of working in a hospital system during a pandemic) things will get better as the pandemic finally comes under control.

Aside from that I am exercising, trying to resume a practice of brief meditation most days, trying not to let my diet slip too far into eating junk, and talking with my wife about it (she is also facing a little of her own burnout at work). If I find something that's a great fix I will let you know

 

[wolfvgang22]

I still have SI from burn out that came to a climax 2 years ago. With reduced hours and responsibilities I still work full time. I strongly agree with Bartelby and Sluox's posts. You aren't alone.

I find the cognitive aspects of CBT most helpful for me. Consider seeing a skilled CBT therapist. Often what you see in residency training is not particularly well done and superficial due to time constraints in training. Consider reading some books and watching videos by Beck and other skilled psychologists, this has helped me a great deal. CBT combined with my religious faith together are critical for me in addition to what other posters have said.

 

[psychacad]

I burned out during my last year of residency as well, even though it was pretty chill. At some point, the years of training and the pressure of living up to expectations will get to you. I think chronic pressure can be just as burdensome if not more than acute pressure.

Life gets a LOT better as an attending (if you play your cards right, and don't go to one of those crappy places out there). What helped me is simply taking it slow after residency, making sure I have plenty of time for myself and was essentially working part time hours. Needed a couple of months then pretty much back to 100%. So I guess, what I'm trying to say time off and taking it slow is a big deal, and if you can afford that, don't hesitate.

 

[Merovinge]

I think you've been exposed to poor CBT and would strongly encourage you to try finding a psychologist who really specializes in it (that is, CBT is the only thing they do, have published on it, etc.) before you write it of, not only for your sake but for the sake of the throngs of people you will care for in the future.

That said, being burned out by COVID interacting with residency I would not even formulate as burn out. It's at worst an adjustment disorder and one that I think a large percentage of folks are experiencing across the globe. This past year has been tough for a lot of people, and that's okay, it's what happens during pandemics. The key difference between this situation and burn out is that you have to do nothing and things will get better for you, it's just a matter of completing training and the world getting vaccinated. If you can take vacation (presuming your vaccinated/COVID numbers are reasonable) before starting as an attending, I highly recommend it. Try and find the best possible job, but also don't stress too much, >50% of new docs change within their first 2 years. Once you're an attending, if you are still experiencing the concerns above, then I would try and figure out what can be done to make your practice best fit your ideal role as a psychiatrist.

 

[wolfvgang22]

I think you've been exposed to poor CBT and would strongly encourage you to try finding a psychologist who really specializes in it (that is, CBT is the only thing they do, have published on it, etc.) before you write it of, not only for your sake but for the sake of the throngs of people you will care for in the future.

That said, being burned out by COVID interacting with residency I would not even formulate as burn out. It's at worst an adjustment disorder and one that I think a large percentage of folks are experiencing across the globe. This past year has been tough for a lot of people, and that's okay, it's what happens during pandemics. The key difference between this situation and burn out is that you have to do nothing and things will get better for you, it's just a matter of completing training and the world getting vaccinated. If you can take vacation (presuming your vaccinated/COVID numbers are reasonable) before starting as an attending, I highly recommend it. Try and find the best possible job, but also don't stress too much, >50% of new docs change within their first 2 years. Once you're an attending, if you are still experiencing the concerns above, then I would try and figure out what can be done to make your practice best fit your ideal role as a psychiatrist.

I think it can be dangerous to assume someone has any diagnosis over the internet based on one post. People can minimize a lot. I agree about seeking a qualified therapist for evaluation and treatment.

 

[Sushirolls]

Burn Out. What the APA pushes out in the monthly articles, what the Big Box shops push out is complete garbage. I've had big box shops drum up email roar about new well being committees and social outings, heck. Which are too few and ultimately poor attendance because people can't get away from work. Even had a big box shop hand a book to you as cure for burn out - but what free time do you have to read a book when they fail to recruit new psychiatrists for years (overworked) and you document for hours and hours. Big Box shops are the problem and its ironic the lip service they play to it and push the agenda its your fault and just do some more mindfulness, mkay? Oh, and don't forget we need those TPS reports done now, not in a month, but in less than 48hours. Oh, and the TPS reports, you can't use a template or copies anymore, you need to do them fresh and hand written every time! [<-- that was a reference to the movie Office Space for those who may be younger, or older?]

Big Box shops with endless meetings, ridiculous charting requirements, EMR warnings, patient satisfaction scores, running off the good staff, adjusting your pay metrics so its harder and harder to hit ideal income ('welcome to the mine son, that there is the company store, they own you'), telling you to do lot of things that are better suite for others in the health system, etc, etc, etc

The real solution is fight for yourself, no one else will, and regain as much control as you can of your day to day and clinical practice. Intuitively, we are in Psych, we already know how to strive for work life balance and smell the roses. For me, I did that by opening my own solo practice. Getting far away from Big Box shops. Is it perfect for me? No, I still over chart, and dealing with a few bad insurance companies and other bureaucracy. But I see the light at the end of the tunnel, I know the solutions, and I have control to change, and have option of when to change them. It is not about CBT, or mindfulness, or going on walks. Burn out is pure surgical, look at the Scat in your day to day routine and things you have control over, and seek to excise out what you don't have control over to gain more. We see this in our patients all the time, they are working a bad job with bad coworkers and the solution is put up and deal with it - or quit and move on; very rarely is it a true HR issue that has a happy middle ground solution that yield a better work environment and more supportive admin. We as license physicians have the ability to control a lot - the greatest gift - opening our own practice.

Burn out = Scat overload.
So, reduce the scat.

 

[wolfvgang22]

 

[Marasmus1]

I will just throw out there that you are not alone. I feel burned out, in large part because (like in your system) many staff have left and I am covering a lot of things, all while dealing with constant slow-downs from pandemic restrictions and a less fulfilling home life. I have been strongly considering an option you don't yet have, which is to quit my job, and I go through real ebbs and flows in my level of bitterness. Burnout has not really been an issue for me in psychiatry before this year, so I am hopeful for those of us in our situation (new burnout that seems clearly related to the stress of working in a hospital system during a pandemic) things will get better as the pandemic finally comes under control.

Aside from that I am exercising, trying to resume a practice of brief meditation most days, trying not to let my diet slip too far into eating junk, and talking with my wife about it (she is also facing a little of her own burnout at work). If I find something that's a great fix I will let you know

Thank you for opening up. In some ways, I feel like burn out is as debilitating as clinical depression for physicians as our job occupies big chunk of our lives.

What kind of meditation do you practice? I keep reading and also hearing from my patients how much meditation relaxes their mind. My own experience with meditation was not very positive as the more I tried to focus on breath more negativity influx.

 

[Marasmus1]

I still have SI from burn out that came to a climax 2 years ago. With reduced hours and responsibilities I still work full time. I strongly agree with Bartelby and Sluox's posts. You aren't alone.

I find the cognitive aspects of CBT most helpful for me. Consider seeing a skilled CBT therapist. Often what you see in residency training is not particularly well done and superficial due to time constraints in training. Consider reading some books and watching videos by Beck and other skilled psychologists, this has helped me a great deal. CBT combined with my religious faith together are critical for me in addition to what other posters have said.

Sorry to hear that. Do you have any book recommendation?

 

[ArdorAyurveda]

CBT-style therapy *can* be quite deep. This is usually in the rubric of schema-based treatment, and reserved for people who are "very ill". However, in my experience, this style of therapy is also very useful for high functioning people who are interested in scrutinizing existential issues but from a behavioral (and cognitive) perspective rather than a humanistic perspective. i.e. the Tolstoyian idea that the meaning of life resides in the *work* (i.e. more explicitly, the behavior you express). So creating meaning has to do with creating behavior.

I have not experienced this personally (yet) but I have seen many colleagues experience this, and in general, it's plenty helpful to find confidants in addition to formal therapy work. I also find that doing therapy to people who actually benefit from therapy was actually very helpful in introducing meaning in my life (see point 3). Don't get me wrong, I love meds too, but meds are not as visceral a sensation when you really have a patient *trust* you and you are working together on a journey.

any suggestions on where i can read further about the topics you bring up?

Leisure as the Basis of Culture really opened my mind.

 

[wolfvgang22]

Sorry to hear that. Do you have any book recommendation?

A good starting place are the same books I recommend to many of my higher functioning patients. Mans Search for Meaning by Viktor Frankl is a good introduction to early cognitive therapy, and The Feeling Good Handbook by David Burns is a great book introducing practical every day CBT.

There are many good videos of a vigorous Aaron Beck himself from the 1980s on YouTube, as well. Beck is 99 now and so his more recent videos, while interesting, are not as educational. These should already be part of any therapy training in residency, so you may have already read and seen them. If not, I hope you enjoy them.

 

[Monocles]

However, surprisingly it came during the chief residency when I have some sort of real power and autonomy

No my friend, that power and autonomy is an illusion. Being chief is one of the most underpaid, dirty jobs you can get. The admin makes you *think* you have power when in reality they just make you crack the whip on your fellow residents and draw the blame away from admin.

OP why not work towards FIRE? I am burned out too but luckily in this market I'll be out of medicine within 9 years MAX of graduation.

 

[Stagg737]

Also currently dealing with burnout again during my outpatient year (first time was in med school) and am praying that things will improve once July comes around. I get what you're dealing with and understand the frustration. It's good that you have support at home and can share the experience with your wife, having colleagues to discuss this with can also be helpful. Just having an outlet to vent and share can be very therapeutic in itself. If you have any time outside of work, find a hobby or something you enjoy that is meaningful and that you can consciously escape into, not something where you'll turn your mind off and pass 3 hours without realizing it. Feeling joy or happiness in other areas of life has been helpful to me in the past to get through periods of stress that you can put an end date on. Physical activity is also beneficial in general if you have anything you particularly enjoy.

Also agree with the above regarding therapy, sounds like you and your therapist just weren't a good fit in terms of relationship or modality used. CBT with someone you connect with positively can be very beneficial. We all know the answer to the PRITE/board question about what the most important factor in successful therapy is and I can say from personal experience that it is more true than we probably realize being on the physician side of the relationship.

Thank you for opening up. In some ways, I feel like burn out is as debilitating as clinical depression for physicians as our job occupies big chunk of our lives.

What kind of meditation do you practice? I keep reading and also hearing from my patients how much meditation relaxes their mind. My own experience with meditation was not very positive as the more I tried to focus on breath more negativity influx.

Calm is decent for some meditation, there's also a ton of free content for breathing exercises, progressive muscle tension/relaxation, or just general medication on YouTube. Find something that changes your mindset and physical awareness and practice it. Don't be afraid difficulties with negative feelings initially. The first time I did guided meditation was with a therapist in med school, I was so stressed and tense (not necessarily anxious) that I started trembling pretty severely, was tearing up, and couldn't control my breathing very well which was something I'd never experienced before. After practicing a few more times it became a significantly more positive and relaxing experience (probably about 2 weeks later). Have recently been doing some meditation again and noticed similar tension as before and had some trembling, but I've been more relaxed in terms of stress than I was previously. I still feel pretty burnt out and somewhat apathetic, but my overall stress levels are much more manageable and I've been less irritable.

 

[Bartelby]

I do a mindfulness of breathing meditation. I went to a silent meditation retreat quite some time ago and frankly found the meditation worthless until I had probably close to 50 hours of meditation time under my belt. At that point I was finally able to elicit what some literature has called the "relaxation response," the sense of calm and seeming decreased sympathetic activation. I haven't kept up with a regular meditation practice as life has gotten busier, but I do find that when I am particularly stressed or dealing with something like inability to fall asleep doing a 10 or 15 minute meditation session often makes a meaningful difference. From my own experience, one thing I would encourage is giving yourself enough time to get used to meditation. I think it really is a skill that must be learned in order to get much benefit.

I'm glad we have a thread like this going now honestly, as these responses show I think those of us feeling burned out are in good company especially this year.

 

[psychacad]

No my friend, that power and autonomy is an illusion. Being chief is one of the most underpaid, dirty jobs you can get. The admin makes you *think* you have power when in reality they just make you crack the whip on your fellow residents and draw the blame away from admin.

OP why not work towards FIRE? I am burned out too but luckily in this market I'll be out of medicine within 9 years MAX of graduation.

Isn't that a recipe for more burnout in the next decade? The average resident will be in his 40s when FIRE happens, already had the fun parts of life behind and having worked their a*** for 10 years.

My recipe, absent of a life passion where you know you can work 50/60 hours with no qualms, is to work less, enjoy life out there, do things you're passionate about, have as much control as you can (which means as much control over finances, time and location). This is all doable in psychiatry. You may not make 600k, but can easily make 200 to mid 200s. More if you set up a small successful PP.

 

[Sushirolls]

I do a mindfulness of breathing meditation. I went to a silent meditation retreat quite some time ago and frankly found the meditation worthless until I had probably close to 50 hours of meditation time under my belt. At that point I was finally able to elicit what some literature has called the "relaxation response," the sense of calm and seeming decreased sympathetic activation. I haven't kept up with a regular meditation practice as life has gotten busier, but I do find that when I am particularly stressed or dealing with something like inability to fall asleep doing a 10 or 15 minute meditation session often makes a meaningful difference. From my own experience, one thing I would encourage is giving yourself enough time to get used to meditation. I think it really is a skill that must be learned in order to get much benefit.

I'm glad we have a thread like this going now honestly, as these responses show I think those of us feeling burned out are in good company especially this year.

Going to the range is just as good. Nothing like putting a few dozen rounds into a target. Same goes for archery.
Zen with achieving tight groups, the tangible achievement of seeing accuracy and precision with your target.
Elements of biofeedback with range time, be it munitions or arrows, have to control your breathing and follow the ritual of the steady release.
Not relaxed, you pull the shot.

 

[watto]

I wouldn't even necessarily look to therapy. A process group or even speaking to an older psychiatrist who has had a lot of work experience may help you hone in on your true values and how to design a life around them.

It's okay to take advice from people who have been there, done that. Mentors are great for this purpose. And, SDN.net.

 

[Stagg737]

Oh, and don't forget the value of getting good sleep, both in quality and quantity. Best decision of med school was when we bough a new mattress. I had very significant improvements in my mood and functioning within days of getting quality sleep.

 

[Monocles]

Isn't that a recipe for more burnout in the next decade? The average resident will be in his 40s when FIRE happens, already had the fun parts of life behind and having worked their a*** for 10 years.

My recipe, absent of a life passion where you know you can work 50/60 hours with no qualms, is to work less, enjoy life out there, do things you're passionate about, have as much control as you can (which means as much control over finances, time and location). This is all doable in psychiatry. You may not make 600k, but can easily make 200 to mid 200s. More if you set up a small successful PP.

Not necessarily! A big part of FIRE is being frugal and saving as much as it is about earning. If your lifestyle is frugal, you can work a lot less to support it. Sure you can work hard to earn 400k+ in psych, but you can easily just take a chill 200k job part time and "coast" your way to FIRE.

In recent talks with recruiters, I had told them about my FIRE plans and current financial situation. It was between deciding to take a very chill ~30 hour job and work 9 years to retirement, or taking a more intense 50 hour job and getting out in 5. I didn't think I would be able to power through the tougher job, whereas the easier job would leave me time to start a PP clinic and make some extra cash for less overall hours.

 

[the5thelement]

It is a mentally demanding job and the need to schedule vacation time regularly is a must.
The pandemic has been especially brutal .
Humans are happy when they act in accordance with their nature, and that is to
think rationally.
Read Meditations by Marcus Aureleus and "Happy" by Derren Brown.
Get a oculus quest 2 and Vacation simulator , 30 minutes bid !

 

[finalpsychyear]

I think i took 6 months off after graduation and reset my mental stamina and of course board studying was a part of that but i enjoyed it. It has really helped me have a great start to now my 5th attending year. I know some who started very soon after residency but i feel the time off for me allowed me to make it up regardless and since i lived on my residency budget for most of the time helped me start saving/investing. The next 5 years after this one I plan to start slowing down and to be 0.5 FTE by 2026. Make sure you take a good chunk off after residency and even after boards. All the best.

 

[Marasmus1]

Has anybody tried Transcendental Meditation? I keep seeing the ads everywhere I look in the net nowadays. They claim it to be evidence based and no effort from the meditator whatsoever.

 

[Marasmus1]

Isn't that a recipe for more burnout in the next decade? The average resident will be in his 40s when FIRE happens, already had the fun parts of life behind and having worked their a*** for 10 years.

My recipe, absent of a life passion where you know you can work 50/60 hours with no qualms, is to work less, enjoy life out there, do things you're passionate about, have as much control as you can (which means as much control over finances, time and location). This is all doable in psychiatry. You may not make 600k, but can easily make 200 to mid 200s. More if you set up a small successful PP.

I understand the logic here.

To me, the problem has never been ``psychiatry`` itself. It is the blocks around ``psychiatry`` that I had to navigate around daily. I would really appreciate one of our experienced colleagues illuminating the topic with his/her insight about an ideal setting for clinicians who want to minimize bureaucratic tasks and scut work so that he can only focus on ``psychiatry``.

I guess PP is a general consensus. However, I find my colleagues in PP working harder than colleagues practicing full time at Hospitals.

 

[Liquid8]

I felt I had managed reasonably well during the pandemic, but noticed that I was slowly burning out at the end of last year. What brought this on was an inpatient that had really drained my reserves prior to the Christmas break, and this led to a planned break not eventuating.

This patient is best described as a time sink. At the best of times they’re repetitive, dependent and can be hard to disengage from. As an outpatient it’s not a problem, but in the ward setting it always feels like they are purposefully ignoring social cues and make repeated attempts to re-engage by dwelling on longstanding past grievances - material that had been covered multiple times for years, and again impossible to resolve in any practical sense. Unlike some patients who always demand medication inappropriately, this one always demand one on one time and can consume a lot of it if one isn’t careful to set limits.

When they arrived on the ward two things bothered me – they had not been completely honest about why they needed to come in, and when the problem was revealed it wasn’t something that was really going to benefit from an admission (an impossible relationship situation that they’d initially denied was a problem). They had also made a comment about having seen other health professional and feeling pleased that they were “getting what they paid for,” which also irked me as I had not been charging them any out of pocket costs for some time. For the first week or so they’d basically not been able to do much but feel sorry for themselves and wallow in self-pity.

Although I had planned to discharge them at a time that would coincide with my break, they wanted more time and weren’t happy with the prospect of having someone cover for me. I figured I could handle an extension of another week as the covid travel situation wasn’t resolved yet, but when that finished they still wanted more time and thought I’d arranged cover. At this point their OCD was actually getting quite bad, which in normal circumstances would be a legitimate reason to continue, but it did seem like a reason to prolong things which added to the frustration. Ended up doing some in depth exposure work which they did benefit from, and this also helped change the dynamic of consultations too.

When they were finally discharged, instead of 2 weeks I only a couple of days off until I resumed clinic. Then I got a call from a patient who had on two past occasions declined planned admissions but now wanted to come in. At that point I realised I wasn’t right and needed to take back some control, do decided to delay this admission for a few weeks.

There were some positives identified as a result of this. For this specific patient, the next admission will be at a specific speciality unit (where I do not have admitting rights so they will be someone else’s problem). Most patients I admit do not require more than 2-3 weeks, but this year I’m trialling a new policy where a month prior to any planned leave period, I will not take on any elective admissions.

 

[watto]

I would really appreciate one of our experienced colleagues illuminating the topic with his/her insight about an ideal setting for clinicians who want to minimize bureaucratic tasks and scut work so that he can only focus on ``psychiatry``.

I mean, I don't want to give away too much info because it's the sweetest gig I've ever had, but I am lucky enough to have found an org that will pay me full freight for evaluations, one hour, simple report, no scut, no follow up. Super easy, and very rewarding because you get to focus all your energies on making a good diagnosis.

You have to first know that you want such an opportunity to be in a position to find and accept one. There is so much out there in psych. Be honest with yourself about what you loathe and what you want and match those factors to the jobs you take (or the PP you create).

 

[calvnandhobbs68]

I understand the logic here.

To me, the problem has never been ``psychiatry`` itself. It is the blocks around ``psychiatry`` that I had to navigate around daily. I would really appreciate one of our experienced colleagues illuminating the topic with his/her insight about an ideal setting for clinicians who want to minimize bureaucratic tasks and scut work so that he can only focus on ``psychiatry``.

I guess PP is a general consensus. However, I find my colleagues in PP working harder than colleagues practicing full time at Hospitals.

I think the reason people work harder in private practice is different though. Either 1) Someone wants to make more money or 2) They feel bad because so many patients want to schedule with them/are on waiting lists that they schedule over the amount of hours they originally wanted to work (I know a few C+A psychiatrists this applies to...).

To me, those are much more reasonable reasons to work harder than having to deal with admin BS at some hospital or big organization or having to spend a week freaking out because of a joint commission inspection or some crap. Or just having extra patients thrown on your schedule just cause, or now telling you you need to see patients in 20min instead of 30min because that was never specified in your contract.

 

[psychacad]

Finding a big box shop (thanks sushirolls) with a non-malignant and supportive culture is tough, but not impossible. You won't find them with recruiters. That's actually one of the main advantages of going to top programs. It's not the pay, but access to working environments with high standards and a supportive culture (and this is not uniform, either). In any case, residency sucks. Being supervised all the time sucks. Chief residents actually have it the worst. Never got the appeal of such a "job".

Other things you want to do is to fight aggressively for what you're worth, don't shy from (gentle) confrontation when needed, have high standards and don't accept bs, never make it look like you have your eggs in one basket, don't show your full deck and always dangle leaving as an option. Remember the market forces are decidedly in your favor. This is probably general advice for every job out there, but I think after years of brainwashing in med school and residency, residents do not know how to manage the professional world.

 

[clausewitz2]

I think the reason people work harder in private practice is different though. Either 1) Someone wants to make more money or 2) They feel bad because so many patients want to schedule with them/are on waiting lists that they schedule over the amount of hours they originally wanted to work (I know a few C+A psychiatrists this applies to...).

To me, those are much more reasonable reasons to work harder than having to deal with admin BS at some hospital or big organization or having to spend a week freaking out because of a joint commission inspection or some crap. Or just having extra patients thrown on your schedule just cause, or now telling you you need to see patients in 20min instead of 30min because that was never specified in your contract.

This was definitely me. In residency I was very much about work-life balance and always strictly out the door on time come hell or high water. Then I went into PP and a switch flipped and I haven't had any weekdays off that weren't Xmas/NY/Tgiving since. I now find myself wondering if I could fit another side gig into the three hours I'm awake after dinner each night.

Turns out when you pay me by the hour I suddenly find the drive to work a bunch of hours, who knew.

 

[Bartelby]

This was definitely me. In residency I was very much about work-life balance and always strictly out the door on time come hell or high water. Then I went into PP and a switch flipped and I haven't had any weekdays off that weren't Xmas/NY/Tgiving since. I now find myself wondering if I could fit another side gig into the three hours I'm awake after dinner each night.

Turns out when you pay me by the hour I suddenly find the drive to work a bunch of hours, who knew.

I have thought about private practice and wondered if this might end up happening. Do you find that you are happy working those long hours / not taking much vacation at all? And if not too personal how has that worked out in your private life (family time, social life etc)?

 

[When is graduation again?]

I agree with all the recommendations for high quality CBT. I'll add that something that has helped me is using ACT principles on myself. Specifically, identifying my own values and using that to take actions that align with my values. I think back to the happiest moments in my life and reflect on what that says about me and what i should be doing. This has lead me to starting writing again, working out, cooking, and reaching out to old friends which has been amazing for me. It also helps with defining career goals, if that is something that is an issue.

 

[Stagg737]

I understand the logic here.

To me, the problem has never been ``psychiatry`` itself. It is the blocks around ``psychiatry`` that I had to navigate around daily. I would really appreciate one of our experienced colleagues illuminating the topic with his/her insight about an ideal setting for clinicians who want to minimize bureaucratic tasks and scut work so that he can only focus on ``psychiatry``.

I guess PP is a general consensus. However, I find my colleagues in PP working harder than colleagues practicing full time at Hospitals.

I'm not that experienced, but one of my attendings in med school was cash only PP with paper charts. No dealing with insurance. No need to follow meaningful use or any other requirements of EMRs, just you and the patient with notes however you choose to write them. Obviously this potentially opens you up to medico-legal issues, but by far the most relaxed and non-administrative position I've ever seen (in any field).

 

[Marasmus1]

I'm not that experienced, but one of my attendings in med school was cash only PP with paper charts. No dealing with insurance. No need to follow meaningful use or any other requirements of EMRs, just you and the patient with notes however you choose to write them. Obviously this potentially opens you up to medico-legal issues, but by far the most relaxed and non-administrative position I've ever seen (in any field).

That sounds pretty good. However, I am not sure cash only PP is a viable option fresh out of residency. Most of the cash only psychiatrists I know have many years of experience behind and network in the area.

I am recently hearing a lot about chill full time salaried job (32 - 40h max) with cash practice on the side. When cash practice builds up, switch to full time cash PP.

 

[clausewitz2]

I have thought about private practice and wondered if this might end up happening. Do you find that you are happy working those long hours / not taking much vacation at all? And if not too personal how has that worked out in your private life (family time, social life etc)?

Without getting into too many details, I have some obligations that I have to be able to deal with flexibly and with COVID I simply couldn't have handled them if I had to be on the clock consistently 8-5 5 days/w. So in a way it has helped with dealing with my life. I do plan to ease up some when my panel hits my target (150 or so) and am already limiting intakes to 2 per day.

I think probably ideal would be dropping one of my two 8 hr/wk gigs and replacing it with 4 more hours of PP. A break like that would make this a lot more sustainable.

 

[Sushirolls]

That sounds pretty good. However, I am not sure cash only PP is a viable option fresh out of residency. Most of the cash only psychiatrists I know have many years of experience behind and network in the area.

I am recently hearing a lot about chill full time salaried job (32 - 40h max) with cash practice on the side. When cash practice builds up, switch to full time cash PP.

Why can't cash out of residency by doable? Look around at what ARNPs, DCs, NDs, LAc, DDS/DMD are doing fresh out the gate. Why hold yourself back?

 

[Marasmus1]

Why can't cash out of residency by doable? Look around at what ARNPs, DCs, NDs, LAc, DDS/DMD are doing fresh out the gate. Why hold yourself back?

I guess It can be doable ? I am not sure. It is just not the way to go for many residents due to low experience, unfamiliarity with that cash paying patient population, networking and referral issues, wants good benefits early on in the career etc.

 

[Stagg737]

I guess It can be doable ? I am not sure. It is just not the way to go for many residents due to low experience, unfamiliarity with that cash paying patient population, networking and referral issues, wants good benefits early on in the career etc.

This would be the barrier. It may take a bit to build the practice up and if you're needing cash and benefits ASAP it could be a pretty risky gamble. If you've got an SO that can maintain the financial stability though it's certainly viable depending on the demand in your locale. Knowing the wait time in my area just to see a resident, I'm fairly confident that it would be doable in my city if executed correctly.

 

[AD04]

This was definitely me. In residency I was very much about work-life balance and always strictly out the door on time come hell or high water. Then I went into PP and a switch flipped and I haven't had any weekdays off that weren't Xmas/NY/Tgiving since. I now find myself wondering if I could fit another side gig into the three hours I'm awake after dinner each night.

Turns out when you pay me by the hour I suddenly find the drive to work a bunch of hours, who knew.

I recommend you diversify your income sources. For the 3 hours at night, why not do some part-time gigolo-ing.

 

[Monocles]

I guess It can be doable ? I am not sure. It is just not the way to go for many residents due to low experience, unfamiliarity with that cash paying patient population, networking and referral issues, wants good benefits early on in the career etc.

I used to think this way too. I went the long route of doing CAP fellowship (financially TERRIBLE decision but I love working with kids/teens and hate grown-ups)... just for funsies I went on psychology today to see if I recognised anyone near me. There are NPs who went through their 2 year advanced psych practioner degrees with me when I was a pgy2 who are now graduated and charging $250+ an hour cash for PP. (Not to knock on NPs by any means, the ones I worked with are clinically pretty good, just saying that the demand is so high right now that even non-MD can now get fairly premium rates)

 

[24blue8]

I felt I had managed reasonably well during the pandemic, but noticed that I was slowly burning out at the end of last year. What brought this on was an inpatient that had really drained my reserves prior to the Christmas break, and this led to a planned break not eventuating.

This patient is best described as a time sink. At the best of times they’re repetitive, dependent and can be hard to disengage from. As an outpatient it’s not a problem, but in the ward setting it always feels like they are purposefully ignoring social cues and make repeated attempts to re-engage by dwelling on longstanding past grievances - material that had been covered multiple times for years, and again impossible to resolve in any practical sense. Unlike some patients who always demand medication inappropriately, this one always demand one on one time and can consume a lot of it if one isn’t careful to set limits.

When they arrived on the ward two things bothered me – they had not been completely honest about why they needed to come in, and when the problem was revealed it wasn’t something that was really going to benefit from an admission (an impossible relationship situation that they’d initially denied was a problem). They had also made a comment about having seen other health professional and feeling pleased that they were “getting what they paid for,” which also irked me as I had not been charging them any out of pocket costs for some time. For the first week or so they’d basically not been able to do much but feel sorry for themselves and wallow in self-pity.

Although I had planned to discharge them at a time that would coincide with my break, they wanted more time and weren’t happy with the prospect of having someone cover for me. I figured I could handle an extension of another week as the covid travel situation wasn’t resolved yet, but when that finished they still wanted more time and thought I’d arranged cover. At this point their OCD was actually getting quite bad, which in normal circumstances would be a legitimate reason to continue, but it did seem like a reason to prolong things which added to the frustration. Ended up doing some in depth exposure work which they did benefit from, and this also helped change the dynamic of consultations too.

When they were finally discharged, instead of 2 weeks I only a couple of days off until I resumed clinic. Then I got a call from a patient who had on two past occasions declined planned admissions but now wanted to come in. At that point I realised I wasn’t right and needed to take back some control, do decided to delay this admission for a few weeks.

There were some positives identified as a result of this. For this specific patient, the next admission will be at a specific speciality unit (where I do not have admitting rights so they will be someone else’s problem). Most patients I admit do not require more than 2-3 weeks, but this year I’m trialling a new policy where a month prior to any planned leave period, I will not take on any elective admissions.

I mean no offense by this question but what state do you work in? Is this a specialized psychiatric facility? I am not familiar with such generous or even possible "elective admissions" of such length. EDIT: Ah you are in Australia?

As we are discussing "burn out" this seems very apt. I can be notorious at times for doing "too much" for patients (in the eyes of supervisors, other trainees or family when I vent) but I literally can't imagine cancelling a vacation to stay at work and care for a patient (especially not one that seemed to be, despite the best or worst of their intentions or disorder) manipulative. I have come to accept I am not that important or irreplaceable in the grand scope of things despite what I may have wanted to once believe or our training fosters ("How can you call out sick when you have a full clinic day and no free appnts for 7 weeks?!?") or what my patients profess. I do what I can, and do it well when I'm there-- and patients are appreciative-- but I will not work harder than the patient is willing to or capable of.

I will make sure my family knows to "electively" admit me if I ever do something like cancel a vacation to care for non emergent/essential patient care. Or any patient period.

 

[AD04]

OP, I can't say I experienced burn out in residency. I had to deal with a bunch of crap in residency as well. What especially irked me was when someone shirked from responsibilities and the whole program was punished and I (among others) had to pick up the slack. But as I look back into the past, residency was a wonderful time for me. A part of it was due to a good social life. I became friends with a lot of my co-residents. I dated quite a bit. The other part was due to looking forward to the future. I knew things were going to be better and I enjoyed imagining what the possibilities could be.

But once I finished residency and entered the real world, life wasn't as exciting as it thought it would be. I got bored and discontent. I would frequently go on long walks and wonder if this will be the rest of my life. I started to ask myself, "Is there something else I would rather be doing?"

A year ago, the answer was yes. So I made it happen and pursued the something else.

I sill ask myself the same question today: Is there something else I would rather be doing? Today, the answer is no.

Burning out and being bored are two sides of the same coin: you aren't doing work that is congruent with your values. In residency, you don't have much options so you have to look to something outside of residency for fulfillment (e.g. social life or future in my case). You'll have more options once you finished residency. In the meantime, prepare yourself for attending-hood. Examine yourself to see what brings you contentment. For me, it is being a linchpin so I can call the shots at work and customize how I work (e.g. 30 minutes for outpatient follow ups instead of 15 or 20 minutes, doing psychotherapy inpatient if needed) and being paid well for the work I do and having enough but not too much time alone to get lost in my thoughts so I can better understand God and the world and think of new ways to evolve my life. These fit my values as I am highly independent (highly disagreeable) and a workaholic (highly conscientious).

If you don't have an answer as to what will bring you contentment, then do anything. Then ask yourself, "Is there something else I would rather be doing?" If yes, eliminate your current option and pivot to something else. You may stumble across your answer through process of elimination.

If you do have an answer, then go after it.

P.S. Some good skills to develop are 1) how to detach yourself from work, especially when you're off from work, and 2) how to sleep well.

 

[ArdorAyurveda]

Other things you want to do is to fight aggressively for what you're worth, don't shy from (gentle) confrontation when needed, have high standards and don't accept bs, never make it look like you have your eggs in one basket, don't show your full deck and always dangle leaving as an option. Remember the market forces are decidedly in your favor.

Coincidentally, this is also good dating advice

 

[PsyDr]

Some thoughts:

1) Conceptually, burn out is a condition wherein prolonged environmental demands exceeds one's ability to meet those demands with the actual resources available. It may be the case that the individual receives punishment when demands are not met. (Aside: it's not negative reinforcement, it's positive punishment).

2) Looking at ability: In that equation, people seem to overvalue ability. You cannot change ability. However, many people engage in negative self talk where they tell themselves their ability is the variable causing failure. But, you don't judge a fish by it's tree climbing ability.

3) Looking at resources: One's ability to meet environmental demands is predicated upon the individual's personal ability and the ACTUAL resources at hand. NOT the idealized version of a resource. As we know, one of the maxims in psychotherapy is "Never work harder than your patient". It may be the case that staff is lazy, or patients are unwilling to engage in treatment, or EHR notes take an actual 15 minutes to complete, or insurance is going to send pre-authorizations. That is the simple immutable reality. If your success is predicated upon an idealized version of resources, you are always going to fail. However, you can modify your acceptance of environmental demands if you accept the actual resources. If staff is inherently lazy, and you're judging them by your own idealized version... you're going to be angry. Or, of course you're going to be angry if you expect the EHR to take 5 minutes, and it is always taking 15 minutes. This is part of the meaning making the literature talks about.

4) Looking at environmental demands: Environmental demands are partially created by the individual's agreement to meet these demands, or take on problems that are not yours. Asking firm questions to establish the parameters of these demands prior to agreement helps. This is partially the control the literature talks about.

5) Like a lot of health advice, CBT seems stupid but it works. The more you do it, the more it works. You wouldn't expect results after a week of sit ups or a week of cutting out sodas. And you wouldn't stop eating a healthy diet because your morbidly obese patients say that they keep gaining weight even though they are eating 1200 calories a day.

6) Psychoanalysis is decent if you are trying to learn about yourself, but it is not great at treating acute pathology. Learning about the underlying processes and relationships between ideas is nice. But it rarely helps in the immediate condition.

7) When falling behind at work, people tend to engage in work more. Time is finite. Let's say you need 8hrs of sleep, you're working 8 hours a day, and it's not enough. You at least have 8hrs to have some break from that punishment, or even get some positive experiences. But let's say you start working 12 hours a day to get caught up. Now you're getting 12hrs of punishment, 8hrs of sleep, and 4hrs of relief or fun. You've just made your problem worse, not better. And less sleep is not going to make you work more effectively.

 

[Monocles]

A year ago, the answer was yes. So I made it happen and pursued the something else.

I sill ask myself the same question today: Is there something else I would rather be doing? Today, the answer is no.

Wait, AD04 are you saying you no longer work in medicine? What did you end up doing if I may ask?

 

[psychacad]

Coincidentally, this is also good dating advice

The part about market forces though is not always true, lol.

 

[AD04]

Wait, AD04 are you saying you no longer work in medicine? What did you end up doing if I may ask?

It's funny that you mention that. I did leave medicine to work on entrepreneurship and to gather more clarity about my direction in life. That was before finishing residency. After deep self-reflection, I came back and finished residency. I'm still in medicine (in psychiatry) and I don't think I'll ever leave or retire. If I am able to save lives, it would be selfish not do do so at least on a part-time basis. My change from a year ago pertained to location and type of work in psychiatry. Although I will never leave medicine, I do try to diversify and establish projects and create sources of income outside of medicine (which is why some time alone to think is so important for me).

 

[Marasmus1]

What is the forum`s opinion about tele-psychiatry`s impact on burnout? I find it against the nature of our work and a barrier to the human contact. I am not finding it as gratifying as in-person sessions. One of the factors that led to my burnout is decreased human contact during the pandemic and add EMR/Charting on to that

I am perceiving myself as a drug rep who is trying to expand the market by reaching out individual clients, especially with 15 minutes med checks over the phone. I am wondering If anybody feels that way? What are the possible solutions to that ?

 

[dl2dp2]

What is the forum`s opinion about tele-psychiatry`s impact on burnout? I find it against the nature of our work and a barrier to the human contact. I am not finding it as gratifying as in-person sessions. One of the factors that led to my burnout is decreased human contact during the pandemic and add EMR/Charting on to that

I am perceiving myself as a drug rep who is trying to expand the market by reaching out individual clients, especially with 15 minutes med checks over the phone. I am wondering If anybody feels that way? What are the possible solutions to that ?

I find that having people show up once a while in person helps a LOT with this issue.

 

[Sushirolls]

What is the forum`s opinion about tele-psychiatry`s impact on burnout? I find it against the nature of our work and a barrier to the human contact. I am not finding it as gratifying as in-person sessions. One of the factors that led to my burnout is decreased human contact during the pandemic and add EMR/Charting on to that

I am perceiving myself as a drug rep who is trying to expand the market by reaching out individual clients, especially with 15 minutes med checks over the phone. I am wondering If anybody feels that way? What are the possible solutions to that ?

I actually like telemedicine. So much more effecient for patients and myself. Does impact the therapy side of things some, but when I'm mostly med management, I'm liking it.

I'm almost dreading opening things up again.

I've even been looking into the use of Starlink internet to facilitate a move to the middle of no where and still doing telemedicine for the office in current geographic area. Keep the the assistant in a small office here locally while I Telecommute from a forest.