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How Toughness Is a Setup for Burnout

Jennifer L. Lycette, MD

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June 10, 2021

A memory from before the pandemic came to me the other day of a time when we gathered in clinic to witness patients’ bell-ringing ceremonies, signifying the end of their cancer treatment. I didn’t always make it to these. Often, I’d be with another patient already. But there was one, in particular, I’d set aside time to attend.

This patient had brought with them an entourage. Numerous family and friends formed a large circle spilling into the hallway. I didn’t know if it was planned or spontaneous, but the patient traversed the ring, going from one person to the next, trading hugs and kisses, until circling back to the start. Then they took a deep breath, closed their eyes, and rang the bell.

All of us on the medical team—doctors, nurses, medical assistants, customer service reps—broke out in applause along with the patient’s loved ones. I don’t think there was a dry eye in the room.

That’s when I realized what made them so special. My patient was the type of person who invited everyone into their circle.

A smile broke through the exhaustion on their face, and I thought of all they’d been through to get there. I was struck by the difference we sometimes see. I thought of the people who bring no one, who insist to “tough out” their treatments alone. Of the times I’d had to break the news to a patient’s family in the hospital that the cancer was end-stage because the patient decided to “spare” their loved ones that news until the very end. We have to respect the wishes of our patients, of course, but so often, that brand of toughness does more harm than good.

What my patient had, I remember thinking, was the true definition of resilience. From the beginning, they’d been open with their diagnosis and treatment. They’d allowed all these people to be a part of their journey. To see their struggle. They didn’t try to hide what they were going through—to “tough it out.”

My mind was wandering over all of these things when my patient beckoned to me.

“You came!” they said.

I was reluctant to take their attention away from their loved ones. And at that moment, I felt like a fraud. Because, you see, a few months before that day, when my patient was still in the midst of their treatment, I’d left my practice—for burnout.

Even though I couldn’t name it at the time, I know now that’s what it was. But maybe I was too ashamed to let even myself see it. Because doctors are supposed to be tough, and admitting to burnout would be weak.

After all, those of us who make it through med school and residency—and whatever steps come beyond—are nothing if not tough. Medical training makes us that way. But what does it teach us about resilience? I think perhaps we confuse the two.

Toughness, I think, too often is a mask.

Toughness doesn’t permit any acknowledgment of vulnerability.

Toughness leads to shame.

My patient made me wonder, how many physicians could invite those around us to witness our vulnerability like they did during their treatment?

Back during my leave, a short while preceding this, I’d run into a former colleague who’d said to me, “Good for you for taking a break. You wouldn’t want to get that—what’s it called nowadays—burnout!”

I responded in a mumble, “Yeah. I wouldn’t want to get that.”

Shame, the ever-present companion of medical culture, once again getting in the way of an honest conversation.

That day at the bell-ringing ceremony, watching my patient surrounded by their support team, I thought about how their journey included letting others in on their suffering. They didn’t tough out cancer therapy on their own; they invited everyone in to help.

We’re not taught to do that as doctors. We’re not trained to let others in—we’re taught to compartmentalize.

And, maybe, that’s how burnout happens. In a way, we’re set up for burnout. By always having to be tough. By denying ourselves compassion.

Because we have to be perfect as doctors, right? But we’re not perfect. We’re human. How do we handle this dichotomy? How do we leave room for our imperfect selves?

The system tells us to build up our armor. Be resilient. When what they really mean is, be tough. And the armor we build, while it may make us tough, is perhaps the opposite of true resilience. The toughness gets in the way of resilience.

Here’s one of the hardest things I learned in my journey back from burnout: I was a highly empathetic person for others, but I had no self-compassion. No self-empathy.

So I’m working on that. Freeing myself from perfectionism, untangling achievements from worthiness, and separating external validation from internal acceptance.

Accepting myself as a vulnerable human being. The same as my patients.

And when my patient invited me into their circle—and I heard their voice in my ear say, “Thank you. You saved my life”—a part of me wanted to push them away. Because it felt so uncomfortable to allow myself to be vulnerable in that moment. My learned instinct, my armor, was to dismiss their gratitude and not allow myself the feelings. Because feelings make us vulnerable. But instead, I took a deep breath, closed my eyes, and hugged them back. I felt the emotions. I accepted their gratitude in the way they intended it.

And I thought, No. Thank you. You saved mine.

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About Dr Jennifer Lycette
Jennifer L. Lycette, MD, is a rural community hematologist-oncologist, mom of three, and recovering perfectionist who's writing her way back from physician burnout, one word at a time. Her essays have been published in The New England Journal of Medicine, JAMA, JAMA Oncology, Journal of Clinical Oncology, The ASCO Post, and more. Connect with her on Twitter @JL_Lycette or her website.

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