S6E14: Burning Out—Radical Honesty in Medicine

Margaux: Is it recording? I see the numbers. What is our cold open? We're the originals and . . .

Leen: The BOH OG.

Margaux: Yes. Anyway, we have the OG crew minus Bushra. But Margaux here with a hoarse voice because I have a sore throat and . . . I don't know, some virus that's not COVID. And Harjit might get it because she's here with me. She gave consent for me to take my mask off. And Leen. So this should be a good episode, because we're also doing it original style. I didn't make an outline. So that's going to be great.

Leen: Oh, God.

Harjit: It's going so be so poppin'.

Leen: Clearly, it's already popping.

Margaux: Yes. So welcome to "Bundle of Hers." The topic today and the reason why I didn't do an outline is just revisiting burnout. This is a topic we've done before, but we're now three years into residency. And I think a lot of us throughout this year, maybe even recently, have expressed to each other feeling elements of dehumanization, jadedness, not connected to our identities. We're really having to struggle and reconnect with the reasons why we went into medicine, and rooting this back into the system that we're working in and fighting that, I guess. And that can really burn you out.

And so we wanted to talk about sort of what we were calling radical honesty in medicine. And it made me think back to when I was a pre-med student and I had several doctors, older . . . And I'll be honest, older white men who when I would say, "I'm going to be a doctor. I want to be a doctor," they'd just be like, "Don't do it. Run away." And I'd roll my eyes and be like, "They're just grumpy old men. What do they know?"

But now I find myself feeling that way, wanting to tell people, "This sucks. Do you really want to do it?" Like, these people who are pre-meds that are very excited about the prospect of medicine.

And so I think we should have an honest and critical conversation about that. There's more to just being like, "Don't do it." I think we need to talk about why and really present the truths about why we feel that way, so people can think about it and come into medicine intentionally knowing that this is a system.

I think the other part is intentionally knowing that you might have to fight against the system or be part of restructuring and rebuilding a system that is actively burning out so many people in it right now.

Leen: I don't even know where to begin. That is such a loaded topic.

For me, I feel like . . . So I'm mentoring pre-med students, medical students, people going to residency, and they're asking me to read their personal statements, right? And they're like, "Can you send me your personal statement?" I'm reading it, and I'm like, "I don't want to send this to anybody because this was a person who was very passionate and ignorant. This was a person who was very naive about the entire field." And yet I feel like people read my statement, utilized that naivety and utilized that passion, and were like, "Let's get her to become a cog in the machine."

And so now I am here, almost towards the end of residency, and I'm sitting here and I'm like, "Man, this machine is a lot bigger than any of us. Who was I to ever think that any of it would change? And who was I to ever think anybody wanted it to change?"

But I'm sitting here, and I'm thinking, "None of this is exactly how I thought it would be." Especially post-COVID. And I know I don't have much evidence to speak of prior to COVID, but I know post-COVID I'm thinking, "Was this really the way it always was? Were patients always angry? Were waiting room times really that bad? Was primary care really that inaccessible? Was our field as a whole . . . We're called liars and we're called people who don't know what they're talking about, and we're just trying to please Big Pharma and Big Med." I don't know if that's a thing, but I'm naming it that way.

And I'm just sitting here, one person who the entire time was super not at all expecting this, and now I'm kind of like the person being blamed for it, right? And I'm just thinking, "Wow, what the heck did I get myself into?"

There was always an aspect of respect, per se. You're always wondering, "People are going to respect the fact that I got through all these classes and all these things. From P-chem to O-chem to all these things, I really sacrificed my 20s. I sacrificed my friendships and my relationships just so that I can learn this knowledge to be able to implement it on people who need it in the moment." And I'm not seeing that either.

If it's not from the patients, it's from the work environment as well, right? I'm the one also undressing patients and getting them on monitors and getting IVs and pushing them to scans and writing notes all day long. You're like, "Wow, pause. Is this really what I imagined it to be like?"

And if you speak against, saying, "Well, that's not what I wanted," then it's two things. One, are you just privileged to think that this is the way this is supposed to be? Or two, "Oh, but these are your patients. Why are you not wanting to help out to that degree?"

Just how much of yourself can you give to every aspect of care? There's only so much you can do. We can barely just keep our brains on constantly 24/7 doing problems in our head while doing the other stuff as well.

Harjit: I think those are some really good thoughts, Leen. And while you were talking, I've been thinking a lot about burnout in general, but also burnout with my own identities as a woman of color.

I think the way I feel burnout is very different than, say, someone with not my identity would feel burnout. And what I'm trying to say by that is I think a lot of the burnout that I feel is this constant push of showcasing my unique identity in a system that is very much not a part of that unique identity. And it's a part of that standardization, "make everybody else like everybody else," and that's why everybody else is burning out.

I think a lot of the stress, a lot of the sadness, a lot of the grief, a lot of the shame, and a lot of the guilt that I experienced in medical school, and still do, is because my values do not align fundamentally with this system.

So literally, my internal world is constantly at odds with my external world. And because of that, every day, I'm feeling like, "This is hard." Every day is hard because I constantly have to choose and be intentional to be myself, which is something that's not applauded, or recognized, or uplifted in the ways that it should be. And I think that's what really contributes to my burnout.

So my attempt is to go against that and be myself, but then it's also not working because it still contributes to burnout, right? Because you're going against a system.

But that is all to say that I think that I still have the same passion, or at least I want to believe I still have the same passion. It just looks different. And I've understood that I have to find different ways to kind of persist with that passion.

The other thing that I was thinking a lot about, Leen, while you were talking is it's like driving a car, right? You're turning right. You're turning left. When the red light is red, you stop. When the green light is green, you go. It's like this reflexive kind of movement through the day. And I think when you don't have a sense of purpose or intentionality to your choices that you make in every single interaction, they don't feel fulfilling.

I think that's our struggle right now, because we don't have the time for fulfillment. We are labor workers, we do what's told of us, we make things happen, and we've got to get work done, because in the end we do work in a very capitalistic society and what's rewarded is money. So in one way or the other, we're pushed for production.

When I was young, I was ignorant and innocent, but life is better sometimes in that way. But then I think, "Is it truly better?" No. I'm happy I know more. Yeah, it does make me a little bit more sad, but I am happy that I have the knowledge to at least understand why I'm in the position I'm in.

Margaux: I think what you said, Leen, about your personal statement and going back to look at it as something that . . . and reflecting on it as a completely different person or perspective, and kind of this innocence that you were talking about, Harjit, in our applications to med school and our applications to residency.

But the opposite side, and the thing that's interesting for me to think about, is the people who are reading those essays, who have already been in the system for quite some time, who are picking and choosing people to be accepted to programs based on these essays.

And I just wonder what it's like to sit there with these feelings that we are expressing now and look at these essays and think, "They just don't know about our, but we'll take them." Or do they connect with them on a different way that maybe the three of us haven't experienced?

So it's interesting, because then you bring them into the system that isn't changing, and produce people who change throughout, get burned out.

I think back to these doctors who told me to run away from medicine and not do it. And I think very much they had become burnt out, they had become dehumanized, detached from their identities. Like you talked about Harjit, they were not allowed to do what fills their cup. And that was not the culture. It still is not the culture of medicine.

But I think the culture of our generation and the generations below us is really pushing and understanding that filling our cup, doing what fills us, and following our true values and our identities is more important.

We're kind of stuck in this middle space of having to work in the system to be able to survive financially, get food, shelter, and those things, but also feeling at great conflict with our values and our identities in these systems that were not built for us.

So I think it's sad what these people who were telling us to run from medicine had endured, but I wish I could have seen it with a little bit more of a critical eye of, "Oh, this is what the system does, is burn you out and they don't care." Like you said, Leen, they're accepting you to be a cog in the machine and they're maybe just a little bit picky or choosy about, "Is the cog green or does the cog have this background?" It doesn't matter. You're still going to fit in the bigger wheel of capitalism, and churn out money for the hospital.

Leen: We have a cog for every type of pocket, essentially.

Margaux: Right. So it's really interesting to me, and I hope that there are admission committees . . . And maybe that's something we could think about in the future, is interviewing people who are on these committees and seeing what their experiences have been.

Leen: I think about that a lot. When I've done interviews and I read these applicants' personal statements and things like that, I'm just thinking, "Wow, they have so much passion." And I think, for me, I realized, "Wow, they have passion. I had that passion once." I don't want to take that away from them, and I feel we still need that passion in order to continue moving forward within the field, regardless of whether it gets stomped out of them or not.

An interesting aspect of it is when it comes back to what Harjit was saying, the burnout of identity, trying to keep up your identity, I just remember how many times do we have to encounter the fact that you come in different and now we have to teach you to be the same? It's like, "You're not confident. You have to be like this. You have to say it like this. You have to practice medicine like this. And you have to act like this and say this and exactly say these words this exact way."

You can try to shape me as much as you want to be the very "stereotypical female doctor." That ultimately in my mind is only just an extension of . . . We've talked about white feminism, and we've talked about the extension of looking like the white man in medicine. You can keep trying to fit me in that mold, and that mold will never fit.

I think one thing that really got to me this year . . . And it was such a guilt trip for me to finally put this boundary up. We worked through short staffing. It was like the national-wide nursing short staffing. And I found myself doing things for patients I never thought I would do as a physician. I'm not saying that it's below me. But I'm saying that it's not the job I wanted to do for myself, right?

I get that it was during short staff. That's what we had to do in order to continue to function and make sure that we don't miss any patients that direly need our help. But it's different when I do it versus someone who maybe looks stereotypically like a physician.

I do all this and then I say, "Hey, I'm Dr. Samha. I'm your doctor tonight." And then literally five minutes later, I have a patient screaming that the doctor never saw them. I'm like, "I literally was just in the room with you."

So I put that boundary up. I went to some of my leadership and I was like, "I can't do it anymore. I cannot." And it was a hard boundary because I think when I tell people that, they're like, "Wow, this person really doesn't care about moving the room. This person doesn't care about patients." And I think, for me, I had to put that boundary up. Why is that so wrong?

Margaux: Leen, it's not wrong, but the whole process of them making you feel wrong, making you feel like you're saying you're not a team player, saying you're not a real doctor for not wanting to do these things and setting up that boundary is just them pulling you back into the system of oppression, of capitalism, and the broken system that we're . . . Well, it's broken for us, working in monetary reasons, right?

So what's interesting to me is that they expect you during the national shortage to take on the work of other employees in addition to already your full-time job without additional compensation or acknowledgement. And that is the fundamental root of burnout that everyone's experiencing, is asking people to do extra work without extra compensation or acknowledgement.

And then not even acknowledging it and calling you not a team player, when you set a realistic boundary of, "You know what? Physically, mentally, and emotionally I cannot do this." No one is talking about this, and no one is acknowledging it.

And I even take it a step back and look in residency. There were a lot of things that we are expected to do above and beyond our daily duties, things like extra presentations, extra teaching "opportunities." And then it seemed like, "Oh, it's for your CV." They make it seem like it's for you, but the reality is the pressure to do all of this . . . and then you get home and you have one hour to yourself. We cannot keep living like this.

Harjit: In some instances, you can learn and grow. And maybe you can if you have a shit ton of capacity. But a lot of it is, "Yeah, it's difficult. I don't think the average person can do that." I shouldn't even say average person. There are just different types of people who can do different types of things, but it's difficult for anybody and everybody. And yes, it's the process you go through, but then you are wanting to admit unique people, but make them all the same by the end of it.

Leen: Exactly.

Harjit: It kills your spirit. That's the issue. It's the killing of your identity and your spirit that actually is what burnout is. Burnout is that we are slowly extinguishing ourselves, right? And that fight to not burn out makes its own burnout.

That's what I experienced, because I ain't going to change myself. I'm never going to change myself. I've always been this way since I was little. I will say that, yeah, I talk about how I burn out, but I ain't changing. And that's why I burn out, because I ain't changing. You know what I'm talking about?

Margaux: I don't think it's a battle that should be fought. I think it's a system that needs to be burned down and restructured, because it's not worth fighting for. But it's a time right now where things are fragile, and it's an opportunity to change things.

My advice to people coming in or thinking about medicine would be to think about that. Do you want to be part of a big transformation in a healthcare system that historically has not been accepting or comfortable for various different identities and has been a cog in the wheel? Or sorry, a cog in the . . . I don't know what I'm saying anymore.

Leen: It's okay. Our brains are burnt out too.

Margaux: In a machine that's churning out medicine for money. Anyway, I'm just on a rant now. Go ahead, Leen.

Leen: But honestly, one thing I was thinking is that the medical field relies so much on titles, relies so much on "What have you done?" to the point that you've check-marked the box of prestige, or at least check-marked the box of "Yes, this is credible."

And I'm thinking about it, and I'm thinking, "Wow. Now I'm in the last two years of my residency," and I had a full-blown panic. And I was thinking, "This is it? This is what I've worked for? This isn't it. This environment is not what I've worked so hard for. This is not at all what I thought I wanted to be as a doctor." I was having such a difficult time accepting that, that this was going to be it.

Margaux: Yeah, that brings up a great point, Leen. First of all, this idea of prestige and hierarchy, that doctors should be held on some pedestal or viewed with some idea of prestige is an old school idea that should not exist, right? And that can be a different topic for another day.

But I think what's happened, especially throughout the pandemic, is people's perception of medicine and doctors have changed. And there's been a huge shift in having mistrust towards the medical system and towards doctors. There's also been sort of a shift in the way we interact with each other just as human beings and our kindness and our respect for one another.

Leen: Totally gone.

Margaux: Yeah. I think, unfortunately, you guys as emergency medicine doctors are seeing the brunt of that. I think it's reflected in that this past year, the emergency medicine specialty across the nation had 500 open seats during match. That just means that people were not choosing emergency medicine as their specialty.

I'm curious what that means to you, Leen. But for me, reflecting on it, I think it means people are choosing not to want to have to be in the system that they see ahead of time as being burnt out. And maybe this is the first light of beacon of, "Hey, look, you're people who are the frontline of a lot of medicine." People are realizing that that's a huge point of burnout and not choosing that. We need to start there and we need to change things.

Leen: I mean, I still remember when my medicine resident in med school, when I told him I wanted to do emergency medicine, said, "Oh, really? Well, okay, I have a patient for you to go see." And he sent me down there not knowing anything about the patient.

I ended up in a room with a very agitated, aggressive patient. He starts throwing trays and everything, and I did not know how to deal with it. Obviously. I didn't have the skills, right? I didn't even have the knowledge of what was going on with this patient.

And I remember just coming back and being like, "Wow, that was scary." I had to be bailed out by the EM attending that was in the ER at that time. And he was like, "See? Do you still want to do that?" And I'm thinking, "Wow."

I wonder how much of this is also perpetrated from the other fields as well. How much down talk do we do to each other about each other's fields? None of us knows or experiences what it is to be in each other's field, and yet we talk down to each other.

I mean, there are memes and TikTok videos all about it, cardiology versus nephrology, EM versus the hospital, peds versus parents, and we just laugh about it like, "Ha-ha, that's so funny." But how much of that is truly toxic to each other? The best way to conquer a system is to break it down and we've broken each other down into these groups.

Harjit: Yeah, but also, Leen, this brings up a whole other kind of side story, which classic OGs as we are we'll do. It's really a piece of security and insecurity, right? Confidence and not confidence. Competence and not competence.

There are two things that you said there that are really critical. I think the need to want to pull down other fields is not having a surety in your own self and your own abilities, is number one.

The other thing is a constant of burnout. You can't have burnout without having fear. And we're taught to always have fear. "I'm going to fail a test, and I'm going to get kicked out of med school. If I get kicked out of med school, how am I going to pay for my loans? If I don't do XYZ research, I'm not going to match into residency. Oh, shit, I only have six interviews. Will I match into residency? Let's look at the statistics. I should have 13 interviews." When you get to match, "Oh, thank god I got a spot. Forget even if it's a good spot, but I got a spot. Now I can't lose that spot."

It was so funny because I was talking to a fourth-year med student who was very paranoid and was like, "Oh, I need to do these things on time because I can't believe it. I don't trust the system. They're not going to give me my spot." And in my head, I was like, "Why is this person so stressed out?"

They literally can't run without you. No one will ever fail you, but if you don't show up to one day of Transitions of Medicine, they're going to reprimand you and say, "Oh, we could fail you and you could lose your residency spot." But will they really do that? No, because they're just instilling fear.

So it's this constant installation of fear. That breeds insecurity, and insecure doctors, what they will do then is . . .

None of us have good processes. We don't have good defense mechanisms. We'll project that shit onto other people. We'll project it onto our subordinates. We'll also not feel secure in ourselves, so we'll start saying, "Oh, this specialty is wrong. And this specialty is wrong. And this specialty is wrong."

So when anybody shits on psychiatry, I'm like, "That says something about you and not me." But what makes me sad is I also don't want you to be in a position where you're not secure and happy and fearful as well. That is another contribution to burnout.

Leen: Absolutely. And the fear continues, and it continues even as a resident. I'm just thinking, "Oh my god, you guys. When did we forget the human body was one system? The brain doesn't work without the heart, doesn't work without the kidneys, doesn't work without emotions, doesn't work without emergencies that cause within it."

Margaux:It's basically the system working as it was designed to, that the system is able to make money. And we as the people/the laborers in it, instead of looking at the system as the problem, we look at each other as the problem. We look at ourselves as the problem, because that's the way it was designed, for us to fight ourselves and fight each other, not the system.

Harjit: That's a great quote. Chloe, that should be our thing. Sorry, side note.

Margaux: The quote for the episode?

Harjit: Yeah. Go on.

Leen: Oh, I have so much to say, but I don't know how . . . It could take me eons. I don't even know where to start. One thing bounces from the other to the next to the next. It just shows you how multi-dimensional this whole issue is. You can say, "Oh, go be well. Go do things you like. Go take a walk in the freaking park." And at the end of the day, it's like, "Well, okay, but I also am now reminiscing about how much time I've lost."

And I'm telling you, it's so multi-dimensional and that's the way they want it to be because there's no way you can target so many freaking dimensions of burnout.

Harjit: But also, Leen, I think that goes into a whole different array of stuff. I still think that our primes are ahead of us, hopefully. We need to also change the way we think about things. But if we wouldn't have these thoughts, if we had time that was designated in the system, which it's not designated . . .

I think that really kind of relates to . . . This episode is kind of . . . figuratively, the way that we went from one topic to the next really tells you how scattered our minds can be sometimes because of the way that we've been treated.

Margaux: Yeah. Leen, when you mentioned the wellness, essentially wellness is a requirement, but it's an extracurricular in addition to all this shit. So it's like, "Okay, we're still going to keep burning you out with the same system, but now we have this wellness."

And I love what you said of, "I'm going to go walk in the effing park and then think about how shitty my life is." I think that is the key of where we're starting to realize that things are not good.

And so hopefully that is the tipping point of what will start and inspire change. Already people are quitting the job, and if there are no people to do it, then the systems are not going to make money and they're going to have to change. So effectively it is working. Unfortunately, we as residents are stuck in our positions, and so we get the brunt of this burnout.

But all of this to say to our listeners who may be pre-meds or pre-residents, which are also called med students.

Leen:No, they're pre-residents. Sorry, the system is inaugurating you early, okay?

Margaux:Pre-residents. Yeah, residents who are just pre-attendings who are just pre-retirees and then just pre-dead. So maybe we're all just pre-dead.

Leen: We are pre-dead.

Margaux: All of this to say, yes, run, because this is not anything that allows people to be . . .

Harjit: But wait. Radical honesty, we do have to recognize that sometimes this is the only option for people to get an out from their life and their situation. I knew that was my circumstance growing up, so I would still choose medicine FYI. Wait, Margaux says . . . I kind of just stole the mic from her, so I think she was going to say all of this anyway.

Margaux: You can finish. I love how I say, "Run," and she just rips the mic out of my hands.

Harjit:I was like, "Don't run out if you really need this."

Margaux:Anyway, what I was going to say is, yes, run because this is a burning system. And no, don't run because if medicine is what you want to do, there are really good things that come from being a doctor.

And you can see that as evidenced in a lot of our other topics and podcast episodes. We wouldn't be here laughing after having such honest conversation. It helps because look at us, we just processed a lot of this trauma that we've experienced and now we feel a little bit lighter I think, or I like to think.

But I think it's important that we are honest about what is happening and that we feel this way, that the system does this and it is designed to be a moneymaker.

Whatever you say in your personal statement that you think makes you unique, that are your values, that are your identities, that is amazing. Remember those. Keep those with you, because the system does not care. They see you as a cog. It's going to be challenged. You are going to have to bring those with you and fight every day.

Thank you for listening to our rant talk. There should be TED talks, though, for ranting.

Harjit: I know.

Margaux:So that concludes this episode of "Bundle of Hers" with Leen, Harjit, and Margaux. Please download our podcasts wherever you podcast, and follow us on Instagram @bundleofhers.

Harjit:Also, we have pins, and if you would like a pin, please send us a message about your burnout story @bundleofhers on Instagram.

Leen: We'll reward you for your burnout.

Harjit: I know. We will at least give pins.

Margaux:We need to end. Okay, we're done, Chloe. You can stop it.