It’s Okay to Not Be Okay
I’ll be honest. As a resident, the word “wellness” evoked feelings of discomfort and annoyance. I didn’t find benefit in participating in required group discussions or completing a yoga session with my peers. My brain resisted the idea that residency’s long days and emotional toll could be cured with occasional small, planned activities.
Flash forward to today where residency is behind me but the common feelings of being overwhelmed, overworked, and frustrated by our medical system persist. Recurrent, often infuriating news headlines amplify what many of us physicians and trainees are currently feeling: burnout and hopelessness.
The COVID-19 pandemic pushed burnout rates into peak levels, with a survey of thousands of clinicians reporting 60% of workers felt burnout in late 2021. https://jamanetwork.com/journals/jama-health-forum/fullarticle/2799033
Burnout is an occupational syndrome characterized by emotional exhaustion, depersonalization, and a low sense of personal accomplishment at work. As we are all aware, it can lead to medical errors, depression, anxiety, substance dependence, and suicide. https://www.ncbi.nlm.nih.gov/books/NBK595228
A contributing factor to burnout is moral injury, which is “the lasting psychological, biological, spiritual, behavioral, and social impact of perpetrating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs and expectations”. Examples include feeling guilty of being unable to provide appropriate care by insurance restrictions, or rushing patients through clinic visits due to institutional pressures. https://pmc.ncbi.nlm.nih.gov/articles/PMC9377663
Addressing moral injury and burnout can include individual-level support; however, solutions must extend to organizational and systems levels.
Going back to my personal journey of well-being, it took some maturing to realize that building habits to strengthen my physical, emotional, and social well-being was necessary for success. I found a gym where I developed cardiometabolic fitness which translated to improved mood and fewer depressive thoughts. I explored psychotherapy, journaling, and gratitude practices, and I prioritized deeper connections with friends and family. Residency made me cynical and burnout, but after trying out a few things, I became a believer in many practices under the wellness umbrella.
Is my depression in remission? Fortunately, it is, for now. Am I still stressed and anxious and fearful of the future? Yes, and the main lesson I’ve learned from my journey, is that it’s okay to not be okay.
Negative feelings such as stress, depression, or worry, can arise both acutely (for example, “I’m extremely behind in clinic,” or “I heard something awful in the news and now I feel terrible”) and chronically (the day-to-day grind of primary care practice). As cognitive behavioral therapy has taught me, acknowledging and naming the feeling of stress or worry is the first step. Acute symptoms can be addressed individually with quick downshifting strategies such as paced breathing. Cognitive reframing and problem solving can follow.
It’s essential for physicians and future physicians to develop individual strategies to respond to negative feelings rather than to let them take over, which can impact our health and our relationships with others.
Please learn from my mistakes of being resistant to self-help. Be willing to experiment with practices to help improve mood and build skills to handle life’s stressors. Physical activity continues to be a major source of my mental well-being. A systematic review and meta-analysis in JAMA Psychiatry found that even small amounts of physical activity were associated with a lower risk of depression. https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2790780
Now, for the elephant in the room: systems change. Burnout and moral injury evidently require policy and systems transformation. Health care leadership must address the root causes. Given administrative burden, staffing shortages, and access barriers for patients, structural reforms are essential to prevent burnout. Health policy restructuring is necessary to move forward, and I encourage people to explore ways to get involved with advocating for change (such as through the CAFP). Institutions should also promote and provide wellness resources, and change the culture of medicine to openly acknowledge distress, especially during times of trauma.
Managing or preventing burnout and moral injury will be a lifelong process for many of us. Developing both individual and collective resilience can help make the dark days better. During these times, I encourage physicians and trainees to reach out for help, whether through peer support programs, counseling, or close friends and family. To help promote organizational change, start discussions with leadership to raise questions and concerns about current practices. I’m hopeful that systems-level change will happen, but it will take time and organizing. Until then, we can support each other while protecting our own personal wellbeing, remembering it’s okay not to be okay, and that there will be brighter days.
