On a damp, overcast Friday morning, I was wandering around the downtown area of a nearby city with my camera. I found an interesting scene and photographed it, carefully adjusting my camera’s settings and the composition until I felt I’d conveyed what I’d felt when I saw it.
Lowering my camera from my eyes, I realized that, for the first time in months, my mind felt clear and my heart felt open. This realization struck me so hard that I sank onto a park bench. Tears of relief and sadness leaked from my eyes.
Burnout–sometimes referred to as moral injury–is common among physicians.
Too often, the care we give is influenced by the time available; for instance, it’s tempting (because it’s quicker) to prescribe antibiotics or other medications instead of educating a patient about symptom management.
I teach and practice in a family-medicine residency. Like many health organizations, my institution offers wellness courses, and I’d thought I had developed decent coping strategies. I genuinely enjoy seeing my patients at the residency’s family-health clinic. I’ve known many of them for years, and it’s an incredible privilege to see their lives evolve over time and to share their most poignant moments. I thought that I’d achieved a reasonable balance of clinic time, call time and teaching time; I meditated regularly; I’d set aside at least twenty-four hours every week during which I didn’t have to use the electronic health record.
And yet, I now realized, burnout had snuck up on me.
When I looked back on the past two years, it was easy to see how. A clinic-remodeling project had meant extra noise and chaos in my work spaces; staffing shortages had added to the difficulties. Each morning, I’d log into the computer with trepidation. My schedules were often completely booked, days ahead; my email inbasket was full of messages–abnormal lab results jostling for my attention along with routine prescription refills and patients’ requests for paperwork or for online advice in lieu of appointments.
Many messages were insurance companies refusing to give prior authorization for inexpensive, necessary medications or for tests recommended by specialists. There were also patients wanting to conduct their health care via messaging, because they couldn’t afford copays, or following up on tests they’d had at urgent-care facilities because they couldn’t take time from work to visit our clinic, despite our extended hours.
During appointments, a patient might bring along a family member–“While we’re here, can you just listen to her lungs? I want to be sure she isn’t having an asthma flare”–not knowing that addressing this simple, reasonable request would add at least three minutes to an already full twenty-minute visit, thus eating into the next patient’s allotted time.
I felt so chronically overwhelmed that I felt the urge to snap at staff members who needed to interrupt me or ask questions; they too looked so tired and overwhelmed that I couldn’t bear to add to their distress. Too many days, I felt like a pinball in an arcade game, careening from task to task–mundane, serious, everything in between. My sleep suffered; most mornings, I needed a second alarm clock to get up. My psyche felt scraped raw.
The night when I threw my pager across the living room in a fit of frustration, I knew that I needed a break asap.
After several discussions with the department chair, medical director and residency director, I was able to take almost a month off from work, although not until several months later. My shame at needing to ask for the time was outweighed by my desperate wish for it, and my fear of damaging my professional relationships by expressing my frustrations inappropriately.
Photography has long been my refuge from the world’s chaos. It’s a way to communicate what I’m seeing and to inform myself of what emotions may be bubbling under the surface. I was able to arrange a mentorship with a photo instructor I know, which would give my time off structure and purpose and also meant that I’d be held accountable to my mentor and myself for the time. It also pushed me into the role of learner instead of expert–a switch that brought up unsettling feelings of insecurity and vulnerability, but also excitement. I’d explained my current situation, and that I hoped to create a series of images conveying some of the sense of disconnection, chaos and distress that I’d been experiencing. Every Monday, I would send the week’s images to him, and we’d have a videoconference to review my progress and set new goals for the coming week.
My colleagues, fortunately, were extremely supportive. They all understood the appeal and necessity of being able to take a longer stretch of time off; the message I heard was mostly to take care of myself.
At the beginning of my time off, I struggled with distractibility. Out in the field, I’d worry about how certain patients of mine were doing, whether my colleagues were overburdened by covering my practice or if I’d made mistakes at work that would only now be surfacing. I kept checking my phone for emails–most of all at night, as I processed the day’s images on the computer. I’d find myself bouncing from processing an image to pulling up maps to plan the next day’s adventures to clicking on the latest national news, wondering what the latest fiasco was coming from Washington. I worried that I wasn’t doing enough photography, and that my work wasn’t improving. I also felt uncomfortably fearful of hearing criticism from my mentor–a feeling, I realized, that likely parallels my patients’ feelings when they come in to see me.
But two weeks into my break, on that Friday morning, I felt calmly organized, focused and peaceful. Nothing mattered in that moment but me, my camera and the world of things to see.
It strikes me that my patients deserve this degree of openheartedness in our encounters–but there are so many obstacles. I’m not alone in feeling so stressed by my work environment; nowadays, despite the wide range of physician-wellness programs, the burnout epidemic continues.
I am grateful beyond words to have had my month of photo-therapy. I’ve been back at work for six months, and the positive changes have persisted. I’m much more aware of when my body tension is increasing, when my shoulders start to rise. My camera is never far from me; after a difficult session, I often grab it and go for a walk. My eye tends to be drawn to things that reflect my emotions–locks and bolts when I’m feeling boxed in, or patterns of broken glass after I’ve seen patients who have gotten sicker. During the COVID-19 pandemic, my camera walks have been invaluable.
I’m deeply perturbed that such a profound degree of dis-ease exists among health professionals. Somehow, I believe, we need to change our focus. Sick time and disability are available; perhaps we also need to develop wellness-leave programs.
It is good when we can heal our injuries of mind and spirit; we need to go beyond that to preventing them.