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Burnout, anxiety, and depression affect individuals living in poverty, those who are just getting by, and even the ones who, by most visible metrics, are “killing it.” This has been an enormous focus of mine since medical school for a couple reasons:
1. Have you SEEN the statistics on depression and suicide in the medical profession? A recent study on physicians and nurses found that 61% report a high level of job burnout. For a profession I’d dreamed of obtaining the privilege and pedigree to enter, I couldn’t fathom how upon my arrival I would have any emotion except gratitude.
2. “Mental illness doesn’t run in my family, it gallops” is a phrase my wife and I both stole from someone (tv?) and wear like suits of armor. If we make light of it while also recognizing how susceptible we may be to the effects of stress and burnout, perhaps we’ll stay on our toes and recognizes the early signs.
I spent excess time in med school surveying the group who are frequently listed as top 5 in burnout in medicine- Emergency Medicine physicians. Our first paper Impact of Physician Workload on Burnout in the Emergency Department showed a few themes, most importantly that a lack of control over your working environment significantly contributes to burnout. This is intuitive, but also one of those actionable things we don’t think about when we’re stuck in the morass.
The second paper, the very wordily-titled Self-Reported Modifying Effects of Resilience Factors on Perceptions of Workload, Patient Outcomes, and Burnout in Physician-Attendees of an International Emergency Medicine Conference built off our initial findings. We investigated actions we could take to foster resilience and reduce susceptibility to burnout. In this, we identified:
…as meaningful ways to lessen the impact of the factors that provoke burnout.
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I hadn’t thought much about this work until I re-listened to a podcast interview Scott Galloway had with Chris Williamson. In it, he talks about how he is prone to “going dark,” and slipping into a depressive funk. When he talked about his protocol to fight off the downward slide, I realized how similar it was to some of these resilience factors. It also made me realize how during some moments of exceptional workload over the past year how my own mood got a bit…prickly. Regaining some control over the factors that I could smoothed out some of the pricklier edges, and low and behold, also related to reversing some of the drivers of burnout from the first study.
I’m going to completely quote Galloway here, because he is right on target.
“[Physical fitness] has been my antidepressant… you know, I struggle with anger and depression. I finally got better at managing it, and I can recognize when I’m going into a dark place…. I just start having really ugly thoughts- I’m pissed off at people all the time, really angry at myself, see everything through a dark [lens]… ‘oh, ok I’m going dark.’ Right when I have that feeling I’m going dark, I know, I have a method for how to deal with it. I use an acronym, it’s called SCAFA. And:
1. The first thing is ‘sweat.’ Sweat right away if you’re in that dark place, sweat right away. I find sweating is like restarting a computer. Like, I don’t know what the f*ck’s going on, so I’m going to turn it off and on. That’s what I do; I reset my brain by sweating.
2. ‘C’ is ‘clean’- I try and eat really clean, I stop eating out.
3. ‘A’ “abstinence,” and what I mean… is abstinence from THC and alcohol. I love both of those things, I’m pretty good at them, uh, but when I’m in a bad headspace I give my senses a break from that… stimuli.
4. ‘F’ for ‘family,’ I find that being around my boys, it’s really healthy for me….children in general are so…demanding that it forces you to take yourself out of yourself. You don’t have the luxury of focusing on how upset or pissed off you are, because your kids demand your full attention (less so as they got older)…
5. The last ‘A’ in SCAFA is ‘affection.’ I will tell my boys I’m not feeling really well, and when I’m not feeling really well, I want you to be affectionate with me. What does that mean? I want you to sit on the couch and throw your legs over mine. I want you to sit close to me on the couch. I want to watch TV with you. I’ve told me kids, especially now that they’ve gotten older ‘I get, you know, sometimes I get upset and down, and it really helps me to be close to you guys.” And they’re great about it now! Not only that…we’ve normalized affection in my household….it’s wonderful.”
Galloway is occasionally a polarizing figure- particularly when some of his statements get taken out of context or are poorly paraphrased. I find his reflections on this area of health and wellness to be extremely insightful, particularly when received from the perspective of a busy professional.
It is easy to say “my stress is related to work, so if I spend more time on this and make progress, then my stress will improve.” I am perpetually guilty of this, but in reality, the workload treadmill will ensure there is something coming to occupy your attention. That lack of control over a workload primes us for burnout. Sacrificing exercise and family time for work then makes us susceptible to burnout, anxiety, and depression.
Looking at Galloway’s SCAFA, I have similar recommendations I give to patients, friends and myself in this situation. When you feel yourself going dark:
1. Exercise- yes, sweat, because it can combine a number of other resilience-promoting and burnout-busting factors.
A.) It takes you out of your head, cuz safety during something like a bench press or squat requires complete focus
B.) If you’re working out with a partner or in a class, you benefit from social connection
C.) If you are consistent, you will see progress. There are few guarantees in life, but if you truly truly truly give a reasonably-designed workout your all a few times per week, within a few weeks you will be stronger, leaner, and more fit. We can’t always say the same about our day jobs. This (nearly) guaranteed positive outcome is a great way to earn that sense of accomplishment, an important factor in fighting that feeling of lack of control that fuels burnout.
D.) Biochemistry. Some don’t get the “runners high,” but maybe they get the “deadlifter’s delight”- I completely made that up, but there’s some truth to it. In a separate interview, Galloway talked about the importance of truly feeling strong. To paraphrase “you should be able to walk into a room and know that if sh*t went down you could kill and eat [your adversaries] or run to safety.” That confidence and self-assuredness has rippling effects into the rest of your life.
2. Nutrition- cut out some of the junk, but especially cut out alcohol and cannabis. It used to irritate me when someone said “alcohol is a depressant, so it’ll make you depressed.” I’ll now admit that while that’s not exactly what the term means, the intent is accurate. Even for those who can maintain a “healthy” balance with alcohol/cannabis like only having a drink a day or only enjoying a THC product before bed, these may still be negatively impacting mental health- especially if these indulgences are impacting REM sleep.
3. Checklists- these also serve two purposes. You’ll offload your brain by getting your “to-dos” on paper, and you get the positive feedback of "progress made" when you check things off the list. Some professional self-help types are mixed on checklists, especially when you’re someone who has a revolving, never-ending list. If you chronically end the day with too many things incomplete, the plan has backfired as it raises your anxiety.
I view checklists as harm reduction. You’re already going to be keeping a running list in your head, so you might as well put it on paper. It’ll reduce the demand on your cognitive bandwidth, while also giving you a semblance of control each time you complete a task on there. I also find that refining my list the night before is a great trigger to tell my brain to dial it back for the rest of the day.
4. Sleep! Besides nixing the booze/THC before bed, do everything else in your power to optimize sleep quality.
A.) Allow yourself the proper “sleep opportunity.” Don’t go to bed exactly 8 hours before your alarm if you need 8 hours of sleep…that’s not how this works. We need time to let our minds calm, so the opportunity needs to be a bit longer than your intended sleep duration
B.) Minimize blue light and cognitive stimulation before bed. This isn’t a secret, but minimize social media before bed as the algorithms intend to rile you up and get you engaged. Don’t let Elon and Zuck’ ruin your sleep.
C.) Get your core temperature down- good, restorative sleep depends on a cool, dark room and optimal attire. Comfortable “bed socks” on your feet permit the blood vessels in your hands to dilate and radiate heat, facilitating the beneficial drop in core body temperature.
D.) Speak with your medical team about reducing any medications that may negatively impact sleep quality (benzodiazepines, certain beta blockers, etc.) and any supplements that may help- magnesium glycinate or L-threonate, ashwagandha, phosphatidylserine, etc.
These are the moves I make when I, too, feel myself going dark. In some cases, these moves may be inadequate and feel like bringing a squirt gun to a raging brushfire. Speak with your doctor about your mood and other potential treatments for it.
I have heard truly countless individuals- friends, family, patients- all say the same thing. “I didn’t realize how bad I’d felt. I wish I’d gotten some help sooner.” Medications for mood aren’t necessarily forever, but they can get you through the tougher patches. The advice I always give is this: even if depressed mood is triggered by an event, antidepressants may be helpful. No, they won’t change your situation, but they can change the way you see and approach a challenging situation.
So lift heavy, sleep well, engage your support network of family and friends, and take control of what you can. Seek help for what you can’t.
Be well.
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