August 2018—Jennifer Hunt, MD, gave it her best shot. While picking up her son after school one day (a task she only rarely had time for) and hearing staff ask, “Who are you?” yet again, followed by, “Oh, you’re Joel’s mom—we didn’t think you existed”—she thought she needed to be a more visible presence at the school.
“They were always surprised he had a mom and a dad,” says Dr. Hunt, chair, Department of Pathology and Laboratory Services, University of Arkansas for Medical Sciences, Little Rock. “So I decided I should be a parent volunteer.”
She pauses for a generous amount of time before expanding on her experience: “I volunteered once.”
It’s a familiar motif to working women, including pathologists and laboratory staff: There’s no way to do it all, no matter how hard you try. And trying can lead to burnout.
Burnout affects men as well, obviously. (See “Frontline dispatches from the burnout battle,” CAP TODAY, June 2018.) But there are arguments to be made—statistically and anecdotally—that it affects women more, and in different ways.
In Medscape’s 2018 physician burnout and depression survey, female physicians once again reported higher burnout rates than their male peers—48 percent versus 38 percent.
That disparity exists within pathology as well, according to Jim Hernandez, MD, associate professor of laboratory medicine and pathology, Mayo Clinic (in Arizona) School of Medicine and Science, who speaks frequently on the topic of physician burnout. “Family tasks fall more heavily on women pathologists,” he says. When he asks women colleagues at conferences to explain the gap, they tell him, We have to do so much more work at home in addition to professional work.
“Women have two jobs,” agrees David Hoak, MD, pathologist and former president, Incyte Diagnostics, Bellevue, Wash. One is at work, the other at home. “It’s impossible to please both. There’s a lot of stress, and probably even more guilt involved with being away from family for women.”
Bingo, says Dr. Hunt, who remembers one of her mentors telling her, “Guilt is a fact of a professional woman’s life. You can’t get away from it. You will feel guilty. You have to accept that.”If acceptance is the shot, then acknowledgment is the chaser. Pathologists can’t begin to get a handle on burnout unless they acknowledge it’s an issue, says Dr. Hernandez.
Talking about burnout before it becomes a problem is valuable, Dr. Hunt agrees. “There are known coping strategies that work well that you can learn and develop and incorporate into your life. And it’s easier to do that before you’re in turmoil.”
That doesn’t come easy to physicians regardless of gender. In Dr. Hunt’s experience, “I think no one wants to talk about it—except the people studying it.” But those conversations are starting to happen in medical school, she says. At UAMS, medical students now get lectures on mindfulness and have a student wellness center and access to support groups. The conversations may not be taking place in enough medical practices, though. It’s not for lack of awareness—she’s well aware that “burnout” and “wellness” are part of the current Zeitgeist. “We have enough attention on it now.” But the traditional health care system isn’t set up to allow physicians to act on it—their own wellness falls well below other priorities and competing demands.
“We’re all just on the treadmill, trying to run as fast as we can.”
Are men pathologists “allowed” to talk about burnout more than women pathologists? “My gut feeling,” says Dr. Hunt, “is that people assume men burn out because they’re go-getters, and high-powered leaders, and they’re doing amazing work. Whereas the assumption about women is that they’re burned out because they have families, and they’re pulled in different directions, and it’s more about the ‘softer’ side of what we do.
“There’s a stigma attached to that,” she continues. “As women we don’t want to admit or say that we’re burned out because we have so many directions we’re pulled in. Whereas if you’re a man saying, ‘I’m burned out because I work so hard,’ that’s very different. Most women are trying not to say that their career paths, or the ways they’re interacting with their profession, are any different from the way men are.”
Differences do exist, however, and the impact is real, with the #MeToo movement an especially stark example (Jagsi R. N Engl J Med. 2018;378:209–211).Gina Drobena, MD, chief of pathology, clinical laboratory, Arkansas Children’s Hospital, Little Rock, concurs that physicians are often reluctant to concede burnout—it’s almost antithetical to their job description. “As a whole we are the caretakers and stick it out until the end. This may be even more true for women who are caretakers at home as well as work. Doctors put others first; mothers tend to put others first.” Each tendency can be a step away from self-care and toward burnout.
And while women may not want to draw attention to gender-related differences, Dr. Drobena points to the very real physical strains that women undergo during pregnancy, childbirth, and nursing—challenges not (yet) faced by men. Women physicians tend to tough it out, she says. She recounts the recent experience of one pathologist who said she was sitting in a tumor board, dilated to 4 cm, and timing her contractions at 10 minutes apart. Says Dr. Drobena: “I’m mad at myself for being proud of her and trying to justify it.”
Women physicians might also be burdened by so-called imposter syndrome, Dr. Hunt suggests, which can lead them to doubt their accomplishments. That in turn can be linked to burnout, she says. “Because part of not being burned out is recognizing your self-worth—to the organization, to your profession, to what you do.”
She also sees women physicians setting impossible expectations for themselves, “that they should be able to keep their house neat and tidy, make dinner every night, get the kids on the school bus, and have a productive and wonderful career beyond the PTA. In other words, they try to incorporate every type of woman out there into one: stay-at-home mom, working mom, whatever. It’s this idea that you need to be everything to be a success.” When that fails, “you might become a victim of mom-shaming— ‘Oh, you’re Joel’s mom.’”
Such thinking happens professionally, too, especially in academics. Women often have role models—frequently men from a different generation—“who look like they did it all,” says Dr. Hunt. But that may not have been the case: “They were really good at the things they did.” The women she sees following in those footsteps, however, “think they should be able to look like that person academically and do everything else that a stay-at-home mom does. It’s really hard to look at our lives and say, ‘OK, what can I shed? What can I not do?’”Social media has been a bright spot for women seeking support, says Dr. Hunt, pointing to private Facebook groups such as physician and pathology moms groups, which provide a form of peer coaching and support. “People bring their most troubling concerns to that forum.”
Dr. Drobena has experienced that firsthand. “Social media has been a wonderful tool for me,” she says, noting the value of collective knowledge and accessibility. She belongs to a women physicians leaders group, where members frequently post articles, questions, and issues they might be working through.
Such outlets show a desire for peer coaching and mentoring, Dr. Hunt says, and might be useful in another way. “The issues around burnout are pretty private,” she says. “I bet most people don’t want to go to their department chair with a wellness issue, or talk about how to prevent burnout.” Social media, on the other hand, can offer privacy as well as national and international support. “Our communities are becoming global. It’s not just ‘at work’ anymore.”
Social media has also blurred the lines between work and personal life. Dr. Hunt finds this helpful. Finding a work-life balance may not be a useful concept, in her view, because it implies separating them. “Our work and our lives are intertwined,” she says. “You can’t separate them anymore. We should be thinking about work-life integration.”
She says she learned that lesson when she came to UAMS. Prior to that, she hesitated to send or accept Facebook friend requests from work colleagues. That changed at her current job, where, she says, “It’s really satisfying to have some of my best friends working beside me.”
It’s carried over to being online friends. Is she worried about this backfiring? Dr. Hunt says she does not initiate Facebook friend requests, though she accepts them all. “I don’t put anyone under pressure to be my ‘friend,’ but if they want me to be friends, I’m thrilled. Because I love seeing their kids, and I love seeing their weekends, and being part of their lives.”
It’s just one illustration of how work-life integration can be so satisfying, she adds. Moreover, it might help with avoiding burnout, she says, since building good rapport and having meaningful conversations with colleagues creates closer connections, provides support, and helps people feel valued.
Indeed, Dr. Hunt says, this is a leadership style in and of itself, one that many consider to be more “female.” Building strong personal relationships isn’t foreign to men, of course, “but it tends to be more prominent in women leaders.” Men who use this style typically find it a successful approach in female-dominated fields like pathology, where many technologists are women. “And guess what? They also enjoy it themselves,” says Dr. Hunt. “Because they’re also subject to burnout and need to find meaning in their work.”At Mayo, Jennifer Ford, MT(ASCP), SBB(ASCP), sees Dr. Hernandez building those types of relationships with his laboratory colleagues. (“He’s wonderful,” she says.) She also tries to build them herself; as operations manager, she oversees some 300 allied health professionals, including medical technologists, histotechnologists, phlebotomists, and processors.
The stresses on her staff can be acute regardless of gender, she says. When Arizona teachers went on strike earlier this year, the walkout affected “a lot of individuals in the lab as well as the hospital,” Ford says. Single moms were hit hard, she observes. Those whose children weren’t old enough to stay home alone had to quickly set up day care or decide whether to call in sick. “That’s a stressful situation,” she says. She likens it to a Jenga tower. “You take one little thing away, and it can come crashing down. We need to recognize that every day your life could be tipped one way or the other.”
Burnout manifests in a number of ways among allied health staff, including increased error rates, lack of attention, or so-called little errors creeping in. Some may stop following policies; others may show a shift in attitudes.
Certainly pathologist leaders can play a role in that. While individuals are responsible for their own work, she says, “It’s hard to work for a supervisor who isn’t engaged in their own job, right? You don’t have that trust, you don’t have that respect. It becomes infectious. If your leader is burned out, and they’re frustrated and irritated when they’re on the job, what are their workers going to see?”
Self-awareness is key, she says, though it’s rare. She herself tells her employees that March is a tough month for her and apologizes to them in advance if she seems to come to work irritated during that time frame. “It takes self-awareness to be able to have that conversation with your colleagues, sort of ask permission to not be OK.”
Being vulnerable also opens the door to other conversations. She says she’s the unofficial wellness champion within her department’s group. She’ll send email reminders about upcoming meditation sessions offered at Mayo, for example, or a weekend fun run. “I don’t want to say I inspire anyone,” she says, “but if I show them I can do this myself—that I can walk away from my office for five minutes to go climb stairs, for example—that tells them they can do it, too.”
She also tries to be supportive in other ways. “Sometimes I’m their ‘vent,’” she says.
She makes a point of extending her support to face-to-face conversations. When encouraging healthy lifestyles, for example, she’s aware that some might take it as judgmental. “I try to be good at reading body language. So if I’ve said something that may have offended someone, I try to step that back and apologize right away.” Technology doesn’t give her that chance, however. “I would choose face-to-face any day over a phone call or an email or a text.”Places like Mayo Clinic may be the exceptions that prove the rule, however. Medicine remains a strongly hierarchical profession, says Dr. Hunt, one in which the top-down, male-dominated leadership style is reinforced by the recruiting process. “It’s a self-fulfilling prophecy. It might take decades to move the dial,” she laments. “I wish it weren’t.”
Physicians are taught that this is the route to career success, she says. In academic medicine, for example, “You could ask 100 pathologists how to succeed, and they’d give you very similar answers: start here, then move here, then here, and then here.”
“But there are many, many, many more pathways,” she says. “It’s just that those aren’t what we’re taught.” She cites a friend who excelled at selling cars (“He loved it, absolutely loved it”) and as a result of his success was promoted to dealership manager. Two years of misery later, he returned to the showroom.
For many people, this would be a tragic tale—call it Death of a Car Salesman. But Dr. Hunt points out that her friend is now happier than ever. “That’s part of avoiding burnout—having joy in your work and life.” In medicine, that means, among other things, “that we should be talking about this before we put people on traditional pathways.”
Pathways also have their ebbs and flows, she says. “There have been times in my career where I’ve been more burned out and then less burned out. It’s probably a sinusoidal wave.” Dr. Hunt suspects there’s nothing unusual about this up-and-down experience (although it may not strike everyone as a road to success), and she recalls reading about the notion of “hibernation” in one’s career, usually after a period of intense activity. “You need to have some less intense, less chaotic times when you can rest and recover.” Before learning about that concept, she says, she would think of these fallow periods as wasteful, inactive, and, frankly, pathetic, especially since physicians are trained to push through almost everything, seek promotions, and “write the next paper before you’ve even finished the last one.” Now she reframes them as a time of rejuvenation.
Dr. Drobena frames the cause of stress and burnout as the difference between expectations (both internal and external) and perceptions of reality.
“Some of us are more sensitive to it than others,” she says, “but if you get those two factors far enough away from each other, burnout can happen for anyone. I don’t like to make generalizations based on gender, but I find that men tend to more effectively compartmentalize their obligations. Survival for a working woman with a family can greatly depend on her ability to multitask, but that can also be her downfall.”
Dr. Drobena sees several options for handling the dissonance: modify expectations, modify reality, or modify perceptions. Using exercise as an example, she says that someone who is unhappy because they can’t meet their goal of working out three times a week, for 30 to 45 minutes a session, can modify their expectation and try to go twice a week, for an hour each time. They can change their reality by having their partner take over more child care tasks and using the extra time to invest in themselves. “Or you can change your perception of the situation, go when you can, and quit being so damn hard on yourself.”
All three approaches “are reasonable strategies to me,” she says.
Echoing Dr. Hunt, she also champions a definition of success that has satisfaction as its goal, rather than meeting someone else’s idea of what’s important. “If I focus on my own satisfaction, what I’m working toward takes on more meaning”—crucial to avoiding burnout—“and seems a lot less like work.”
Dr. Drobena has had her own experiences with burnout, which she eventually parlayed into a new professional tack: She’s currently pursuing board certification in lifestyle medicine. Recalling a time when she was exhausted, sick, and stressed, she says the final straw for her was continuing to work while sick with pneumonia. “It wasn’t immediately diagnosed, so I didn’t feel like it was acceptable to go home and rest just because I was ill. There wasn’t anyone else telling me that. It is just the culture of medicine.”
She says she now intends to approach burnout in a more holistic way, drawing on her longtime interest in the role lifestyle factors play in health and wellness. “It isn’t just our mental game that has to be in top shape. It is critical to nourish our body with real, healthy food, move it with intention, and rest it adequately. To continue helping others, we must begin with healing ourselves.”
And then there’s Dr. Hunt’s one-and-done parent volunteer experience, which offers another approach to dealing with stress and burnout.
She purposely picked a time-limited, one-time event: co-chairing the school’s uniform resale event. “I did it, and I did it well,” she says. “It was actually kind of fun.” But at a meeting to discuss the following year’s event, when a PTA board member suggested a volunteer role for one mother, another member quashed the idea. As Dr. Hunt recollects, “She said, ‘Oh, no, she’s too busy—she’s a doctor.’ I was sitting there, listening to this, and so I said, ‘Um, I’m a doctor.’ And they all looked at me and sort of gasped: You are?”
She laughs at the memory. “It was so strange. But it was eye opening, too. I really don’t need to volunteer. There are other people who can.”
Karen Titus is CAP TODAY contributing editor and co-managing editor.