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Join Dike Drummond, a family practice physician, as he brings his rich experience and deep understanding of the medical profession to discuss a critical issue that touches many in the health care field: physician burnout. Through our conversation, we’ll explore the subtle yet powerful messages of our inner voices, the balancing act between rational thought and emotional intuition, and the different levels at which burnout manifests in a physician’s life. Dike will share personal stories and insights, revealing how listening to the “little voice” can lead to transformative changes in both personal and professional realms.

Dike Drummond is a Mayo-trained family practice physician, burnout survivor, executive coach, consultant, and founder of TheHappyMD.com.

He discusses the KevinMD article, “The ‘little voice’ physician burnout survey.”

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast, and get CME for this episode by clicking on the CME link in the show notes. Today we welcome back Dike Drummond. He’s a family physician, executive coach, and founder of TheHappyMD.com. Today’s KevinMD article is titled “The ‘little voice’ physician burnout survey.” Dike, welcome back to the show.

Dike Drummond: Well, thanks for having me again, Kevin. Good morning, little voices, I love it.

Kevin Pho: All right, so to hear Dike’s story, go to KevinMD.com/podcast, search for his name, and you can hear his story on prior shows. But today let’s jump right into your most recent KevinMD article, “The ‘little voice’ physician burnout survey.” So what’s this one all about?

Dike Drummond: Well, one of the things that gets blocked by medical education is your ability to listen to your own inner wisdom. So one of the things that we’re taught to do through the course of med school, residency, and practice is follow the two prime directives.

Two prime directives. One of them is conscious: patient comes first. And I think you and I and our dear listeners will agree when I ask this question: can the patient come first 24/7 and you have any hope of having a normal life? And the answer is no. So there’s got to be an off switch on that.

And the second of the two prime directives is the unconscious one, the one that we never speak, which is never show weakness, never do anything to let anybody think you haven’t got what it takes. And this particular piece of programming is the source of impostor syndrome.

And impostor syndrome is when you have a little voice in your head, we’ll just start with this little voice because it’s probably the most common one: what if they find out? What if they find out I’m struggling? What if they find out I need help? What if they find out that I’m doubting whether this is the right course for my career? What if they find out I want to quit?

And typically what happens is that when a doctor hears a little voice like that, what if they find out, shh, keep working, you can do this, just work harder. By the way, that’s actually the voice of Einstein’s insanity trap. Double down, double down, just work harder, you can work through this.

So all of these are things that stop the practicing physician from being able to build a rich and fulfilling life around their practice of medicine. And this is the way I experience it personally, this is the way I see it in most of my coaching clients.

The challenge of the modern doctor is, you feel, especially when you made that choice at the light worker’s fork, you feel being a helper and a healer, a light worker, making a difference in the world, you feel that real deeply as a calling. The challenge is that calling is what may tip you over into burnout, because the better doctor you are, the more you care about your patients, the more likely you are to overextend yourself.

So the challenge is, how do I have a vocation, a living, a calling as a physician, and yet wrap a full life around it? Because a piece of you at the point where you decided to go to medical school had this thought process that I’m making an extraordinary decision, and this will enable me to have an extraordinary life. And these days, especially with current market conditions, it’s hard to have a life at all.

And so what often happens is a quiet, it’s actually a silent conversation you have with yourself. Let’s just talk about the levels of distress that the little voice in your head will talk to you with in the quiet moments.

Kevin Pho: Yeah, so let’s do that. So I think that a lot of physicians who go into that scenario, like you said, they have these little voices of doubt, but they’re not able to articulate that for any number of reasons. So the majority of physicians who are burned out, walk us through that scenario and tell us what their little voices are saying.

Dike Drummond: Well, and the thing is that you can’t talk about it with anybody else because of the taboo, never show weakness. You tend to doubt your own sanity when you hear these things, because your life’s been stacked up to give you the results that you’re getting right now.

So what I want to do is normalize the fact that your little voice talks to you. And then when people ask me, am I burned out, I say, well, what’s your little voice saying? And they say, what are you talking about? And I start going through the examples.

So the typical one is, and these are typically people that I work with as a coach, so I work with people who are still connected to their calling to see patients. They don’t want to jump out of medicine, they don’t want to escape, they don’t want to run away, they want to figure out a way to make it work.

So the first level voice is, man, I still love my patients, I love being a doctor, but man, I hate this job, this job makes it so darn difficult. And most people, because that is more emotional than blocking you from taking care of your patients, you’re still getting enough joy in the times when you’re behind closed doors, or the curtain’s pulled and you’re knee to knee with the patient.

By the way, there’s a couple of distinctions that are important here. I divide physician lives in general into four different segments: job, practice, career, life. Your job’s your job, you know what that is. Your practice is what you do when you’re alone with the patient and the family in the room, that’s where your magic works, that’s where your calling is exercised. There’s your career, the arc of your jobs through your life. And then there’s your life itself.

So we’re talking mostly, little voice is mostly talking to you about your job. Level one: I still love my patients, I still love being a doctor, but man, this job. And if you keep hammering to meet the definition of productivity and the job description that you were handed by your employer, just note, you had no role in designing that job description. It’s a quid pro quo, you’ve got to decide if the juice is worth the squeeze.

Level two, down the road a touch, and this is the voice of burnout talking right at you: I’m not sure how much longer I can keep going like this. Now when I do a live presentation, and I’ve trained 40,000 doctors in live settings, I start my presentation by raising my hand nice and high and saying this: how many of you have ever had a week or a day so stressful that in a quiet moment afterwards a little voice in the back of your head says something like, I’m not sure how much longer I can keep going like this? And I keep my hand up, and every hand in the room goes up with me. So we know we’ve all been there.

Now if that happens, and then you somehow make an adjustment and it backs off because you recharge, you get yourself back away from that edge, cool. Everybody has to deal with that edge all the time. It’s when it’s always like this, you’re always drained, you never recharge, you’re having all three symptoms of burnout, you get to level three little voice.

And level three little voice is actually the speaking voice of the third symptom of burnout. First symptom of burnout, exhaustion. Second one, compassion fatigue, cynical, sarcastic. Third symptom is, what’s the use? The little voice will say, man, I’m not sure how much longer I can keep going like this, and what’s the use, I’m really not making any difference at all.

And remember, part of the reason that you went to medical school, a big piece of the calling, is to be a helper and a healer and to make a difference, to make a difference in your patients’ lives. So this is where you’re close.

And by the way, here’s the tragic thing. I sort of wish, even though it is a crisis, I sort of wish there wasn’t such a thing as chronic burnout. I wish it was an unstable state, you get there and you either crash and burn and have a crisis and recover from it, or you bounce back up again. But people can stay here for a very, very long time.

And then the last one is when you begin to doubt your calling. So I’ve got somebody who still loves seeing patients, still loves being a doctor, is still resonant with the calling that happened in the first place, but the little voice now says, I should have never become a doctor in the first place, this was a big mistake. And most of the times that’s followed with, but I don’t know what to do except this. And again, that’s where you tend to get stuck.

So let me give you also a little turn of phrase. Let me give you, because a lot of times I deal with sayings, I work in sayings, because typically like stereotypes they’re true. So check this one out. When you find yourself in circumstances that are not optimal for you, you want something to change, this isn’t working right. Notice that you don’t get what you want in life, you get what you tolerate. You don’t get what you want in life, you get what you tolerate. And the key for escaping Einstein’s insanity trap, the key for turning burnout around, is to stop tolerating something less than what you really want.

However, when I meet someone and they’re coming to me for a discovery session, first of all they’re concerned that they’re probably burned out, they ask me for my opinion, which is fine, but my opinion doesn’t mean anything. I’m not going to diagnose them or anything like that. I’m just going to ask them, well, what’s the chatter in your head? What do you think needs to happen right now? If you had a magic wand, what would you change about your life? And this little voice survey can be a very, very valuable hint to how you’re doing.

Kevin Pho: So tell us a story where one of your clients comes to you and says they have that level one inner voice, that seed of doubt. Tell us your approach and how you would guide that particular physician in a case like that.

Dike Drummond: Well, if they say, I’m not sure how much longer I can keep going like this, I love seeing patients but this isn’t the way I like it, what I try to do is to shift the normal reticular activating system response of the human brain.

And the normal response of the human brain in times of discomfort, pain, crisis, is fight or flight. You’re reacting, it’s a reflex reaction to circumstances that you don’t want. And there’s actually two more that are maybe even more common. So there’s fight, there’s flight, there’s freeze, put your head down, don’t draw attention, pray, hope for divine intervention but don’t do anything to protect yourself. So fight, flight, freeze, or pray.

And what I ask people is, what’s going on? And they typically go straight into a diatribe of everything they hate, they want to get away from, they’re in their flight, they want me to help them flee or somehow magically solve it all.

And I noticed years ago that if the only thing you’re concerned about when you’re looking at burnout is escape, and I’m going to make a motion with my hands here, I’m going to point to the left because these are two opposites, so I’m going to demonstrate this with my posture, you can avoid everything you don’t want and you still won’t get what you want. Because the only way to get what you want, now I’m switching 180 degrees, is to figure out what you want and go get it.

So there’s a whole bunch of people, for instance, that you’ll see on the internet, especially in the big groups like Physician Side Gigs, Nisha Mehta’s Facebook Physician Side Gigs group that I think has 140,000 people and stuff, that are believing that what they want is to jump out, they want to escape. And what I find is, I’m pretty sure that’s not true for the majority of them. However, they’re in a situation where they can’t feel that they’re making the difference they would like to make. So the fantasy is flight, that’s a flight fantasy. They talk about it a lot, maybe build a side gig, but most of them still make a living as a physician.

The first thing I try to do is take somebody who’s focused on what they don’t want, on fleeing, and ask them, hey, I really do want to hear what’s going on with you, it’s important to me, I just don’t want to hear it first. We’ll talk about it in a second, but first let’s take a few minutes to figure out, if you had a magic wand, if you were the king of the forest, if you could design your own personal job description, what’s your ideal job description?

Most of the time I get an open mouth goldfish stare, because no one has ever asked them that. So think about this, from the time of your first day of medical school to today, and I’m assuming that our dear listener, you are in private practice, you’re out in practice, you’ve graduated, and even though you’re a resident or a medical student you’re even farther down this hole. When did anybody at any point in time ask you what you want? In med school, I don’t think so. Residency, not a chance. In your job, no freaking way.

77 percent of American doctors are employees right now. You had no role in designing your job description. So what’s happened is, without knowing, you were interviewing like a resident, you took a job, and somebody else’s job description, that is boilerplate, came out of a box, they didn’t adapt it to you in the least. Now, what are the odds that somebody else’s job description is going to be pointed right at your ideal job description? And the answer to that question, what are the odds, is a word that begins with a Z: zero.

So burnout’s inevitable. Burnout’s inevitable along the course of an employed physician job description, being forced to produce, because the business wants productivity and profit, you want to make a difference. Those are two completely different games on different playing fields.

However, the real question is, when you know what you want your job to look and feel like, can you find enough wiggle room here to make that happen, to feel like you’re making the difference that you wanted to make, to feel satisfied about your career? Can you make it happen here, or do you have to go someplace else? And the saving grace these days is, if you can’t make it work here, the job market is going to be, it is already, and it’s going to be so fantastic for you if you know what you’re looking for. You still need to do your ideal job description. If you know what you’re looking for, and then you can listen to the little voice chatter.

This is also, by the way, one of the great uses for the practice of gratitude, which is to notice what’s going right regularly along the way, as a counterbalance to what your inner voice is typically telling you, which is pointing out the things, again, it’s the voice of your reticular activating system on the lookout for danger everywhere all the time, it’s telling you other things usually.

Kevin Pho: So tell us a success story. Tell us about one of your clients who came to you with one of the four levels of the inner voices that you had described, and you guided them and you moved the needle in their professional, personal life. Give us a case study.

Dike Drummond: Had a fellow that was in a production oriented, full-service, multihospital medical group, pediatrician, and he was one of those really high producing pediatricians. Big tall guy, very fatherly, big masculine, I’ll take care of you, husbandly energy. And at the same time he had two kids that were in their early teens, and his wife was divorcing him. So he was burned out from both work and home stresses.

And what we did was go through this process of him defining what his ideal job is, and him figuring out that what he was getting here as a result of his current job description wasn’t matching that very well. As I remember, his satisfaction score was at three, three out of 10. His Venn overlap was about 25 percent, the overlap between how his ideal job would feel and how his current job feels, it was about 25 percent.

And in the midst of all the stuff going on in his divorce, we tried for about six months to work with his leaders and work with the people in his pediatric department, where he was I believe the chair of that department at the time, to adjust his practice to get this to where it needed to be. We only got to about a 50 percent overlap with his ideal job description, and his reputation was being poisoned in the town he lived in by the divorce proceedings.

So he ended up triggering a job search. We found him a job about 70 miles away, so he can see the kids and everything on weekends, where he’s in another pediatric leadership role in a different organization.

And the thing about making a clean start for a job search is, you really get to roll the dice all over again. It’s easier to find what you want with a job search than it is to make it happen where you are. So for instance, we always go with, a seven out of 10 is the satisfaction score we’re looking at, that’s good enough to stick. So if I meet somebody who’s two out of 10 in satisfaction, working a plan to get you to seven here is a six to nine month plan, and you’ve got to actually be actively working on it every week. If you’re going to quit that job and go find a new job, you wouldn’t take a job that wasn’t a seven. So it’s a one-shot really quick fix.

And he was able to do that, and his life was structured in a way that he needed to change locations anyhow. And his name’s John, I’m not going to give you his last name, he’s a great guy, and he’s taken off flying, graduated from coaching, I haven’t talked to him in a couple of years. But that’s just one example.

Kevin Pho: We’re talking to Dike Drummond. He’s a family physician, executive coach, and founder of TheHappyMD.com. Today’s KevinMD article is “The ‘little voice’ physician burnout survey.” Dike, as always, let’s end with some of your take-home messages that you would like to leave with the KevinMD audience.

Dike Drummond: Yeah, listen to your inner voice. Listen to your inner voice, it tends to tell the truth. And when your inner voice is telling you, I’m not sure how much longer I can keep going like this, just look around and notice, what are you tolerating? What are you not facing, what are you not changing, that is draining you, that is getting in the way of your expression of your essence as a light worker? What’s getting in the way, and what’s a baby step?

I always deal with baby steps because everybody’s always on the edge anyhow, right? What’s a baby step you can take that would help you turn that particular toleration around? It may be decommitting from the tumor board at the hospital on the first Tuesday of the month. It could be any one of a number of different things. It may be not continuing to tolerate feeling like a broken record in your practice and templating up that EMR and templating up that patient education work that you do. It could be any one of a number of different things.

But listen to that little voice, and know that in most cases doubling down on working harder isn’t going to work for you. That is the voice of Einstein’s insanity trap. The tagline in my book Stop Physician Burnout: what to do when working harder isn’t working. That’s helping you out of your workaholic programming, which we all earn righteously through our training process.

And it is a challenge if you’re an employed doctor. So you’re a physician with an employment contract, there is a fundamental battle going on at all times, where the business is trying to maximize profit and you’re trying to do a good job helping, healing, and making a difference. Those are two different games. So managing your job, managing your relationship with your boss, it’s going to be an ongoing thing you have to do to get just enough ability to care for patients that you feel good about this position. And that’s a struggle that gets more intense over time.

Kevin Pho: Fantastic. Dike, thank you again for sharing your perspective and insight, and thanks again for coming back on the show.

Dike Drummond: You bet.