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We welcome Mary Braun, an internal medicine physician. Mary shares her insights on how perceptions of responsibility for patient outcomes have evolved throughout her career, particularly in light of systemic challenges like the COVID-19 pandemic. Through candid reflections and real-life experiences, she explores the delicate balance between accountability and self-care in the face of overwhelming demands on health care professionals.

Mary Braun is an internal medicine physician.

She discusses the KevinMD article, “From passion to burnout: When a doctor’s love hurts.”

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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 Mary Braun. She’s an internal medicine physician. Today’s KevinMD article is “From passion to burnout: When a doctor’s love hurts.” Mary, welcome to the show.

Mary Braun: Thank you, I’m glad to be here.

Kevin Pho: So let’s start by briefly sharing your story and journey.

Mary Braun: In retrospect, it was crazy that I ever thought I should do anything besides be a doctor. I went to college, and math classes were easy for me, so I ended up getting a degree in math with the idea that I would work as a computer programmer. And I did that for about three years.

And then I got pregnant with my first baby, and in that sort of hormone infused, sleep deprivation state of postpartum, I realized I was not doing the right work for me. I was not doing my work. And I set off in search of what it was that I wanted to do for work, or what I thought would be my work.

I started thinking I would be a birth doula, and I started volunteering at a place that trained birth doulas. Soon after I started volunteering there, I heard a bunch of people who’d already done the birth doula course talking, and they were trying to remember whose blood was in the placenta. Was it the baby’s or the mom’s blood in the placenta? And they couldn’t quite sort it out. And I realized I knew.

I had really enjoyed, when I was pregnant, I’d really enjoyed all of those pseudo-medical books that you read. And it was kind of like when you’re putting a plastic toy together and you’re just shoving and shoving, and then all of a sudden it clicks and everything is in place. That’s kind of what it felt like about the world. Suddenly everything clicked and was in place and it made sense, and, oh, I should be a doctor.

I like science, I’m good at science, I can think about that stuff. But I also like people, and I really love talking with people. And I love figuring out what exactly someone is thinking. How did you come to this conclusion? How does your brain work, so that you can look at these facts and come to a completely different conclusion than I do? I love that, and I think that’s really fun, and I think those are really key skills of being a doctor.

So that was how I figured it out, and then I started taking premed classes, and I got into med school. I was trying to figure out what I wanted to do. I had it limited to internal medicine, family practice, and psychiatry. Those were the last three that I really thought I liked, and which one of them did I want to do. And then I pretty much just fell in love with internal medicine.

Kevin Pho: All right, tell us what your practice is like today.

Mary Braun: Because I have a hospice and palliative care background, a lot of my patients, and I think people who are fragile see that I have that background and see that I’m an internist, and think that I would be a good choice for them, which is true.

And so a number of the patients I take care of are quite old. It’s not uncommon for me to have a day when I don’t see anyone younger than 60, maybe 70, and certainly when the majority of people I see are in their 80s or 90s. Currently I think I only have one patient older than 100. She’s fairly new to me, her doctor retired so she switched to me.

So typically I see fairly old and frail patients who have multiple organ systems that are in disagreement about what needs to be done. I like it very much when one is in the stage where the kidneys and the liver and the heart and the lungs all have different needs, and you have to try to figure out what it is that is going to make the person happiest.

And in order to do this, you have to figure out what is it that the person wants, what makes their life worth living, which is really fun to do. I think that’s the whole point of why one gets into the helping professions, is to figure out who are these people in front of us. So it’s all part of the whole mixture. And then, once you know what it is that’s important to the person, trying to figure out how you can optimize what little they have left of each of their organ systems.

Kevin Pho: All right, so let’s talk about your KevinMD article. It’s titled “From passion to burnout: When a doctor’s love hurts.” So tell us, for those who didn’t get a chance to read it, what your article’s about.

Mary Braun: Oh, it’s a really complex article in some ways. I realized, after not looking at it for a few weeks, that it really should be several articles. There are several important ideas in there.

But the main idea, the most important kernel of the article, I think, is that I have a dysfunctional idea about the way the world works. I would rather feel that I have done something incompetent that has caused one of my patients to crash and burn, than to recognize the true fact that sometimes people just crash and burn, because that is the nature of life.

And so I often find myself, when something bad has happened to one of my patients, like they’ve gotten gallstone pancreatitis, or some other kind of pancreatitis, or autoimmune liver failure, or one of these pneumonitis, one of these sorts of things that just happen to people somewhat randomly, or cancer, some kind of horrible cancer, I would rather feel that it was a deficiency on my part that caused this, than accept the true fact, which is that sometimes, and in fact always, bad things happen to people, and none of us lives forever.

Which, I understand that none of us lives forever. It’s so ironic that I’m having problems with this issue, because I’m a hospice doc, I know that none of us live forever. But I’m finding myself searching around desperately to find what I did wrong that caused my patient to have something bad happen to them, when in fact it’s just the nature of life that bad things happen.

And I would rather think that it was a fault on my part that caused this bad thing to happen to my patient, because then I would think, well, if I just worked harder, then I could keep bad things from happening to everyone I love.

Kevin Pho: So how sustainable is that mindset?

Mary Braun: Of course it’s not at all sustainable. It’s not at all sustainable, and it is a true testament to my delusion that I’ve been able to sustain it for so long. It’s not sustainable at all.

I do understand this, and I’ve put all kinds of things in place to make it sustainable. I don’t work full time, I haven’t worked full time in a long time. I am pretty good at taking care of myself, in the sense of saying, this is my limit, I can’t do more than this, I can’t take more patients, I can’t work more hours, I can’t have this kind of turnaround for labs, or whatever. I’m very good at putting those kinds of limits in place, which allow me, in a sense, to have this crazy idea that I can control everything.

Kevin Pho: Now, has that mindset changed? How has that mindset been over the last few years?

Mary Braun: Yeah, I think the thing that really caused this mindset to start unraveling was COVID. I was able to continue with this mindset even into COVID and past some of COVID. As bad things happened to my patients, for each individual one I would work through it, and I would come to the point where, no, of course I understand that something bad has happened to this person, because they’re 97 and they don’t want to live forever.

But the awareness of catching myself in it, and then being able to realize, because I caught myself in the midst of it, I was able to recognize what was afoot, that is a fairly recent development in my personal history. Prior to that, I think on an individual basis, each time something bad happened I would work through it and, as I said, come to the conclusion that, well, yes, bad things do happen. But now I’ve been able to catch it just a little bit earlier.

And COVID, and the burnout that came from how much harder and how much less pleasant medicine is post-COVID than it was before, helped me, or forced me, to realize that I needed to start actually looking at the self-help literature and figuring out what kinds of things I could do.

And one of the things that the self-help literature says to do is pay attention to what you’re doing and how you’re feeling. And I had the experience of having prescribed a medication for a patient, something bad happening to them, and then spending a couple of days dragging myself over the coals for why it was on the Beers list, and this patient was 87 or whatever. Dragging myself over the coals, why did I do this?

And then I looked, and actually this condition the patient has isn’t even one of the post-marketing side effects of this medication. It’s just not connected to this medication. And I felt an initial wave of just such relief. And then I felt, all of a sudden, more anxious again. What is that about? And then, as I thought about that more, I realized it’s because that means I don’t control the world.

Kevin Pho: I am sure that there are plenty of other physicians who have that mindset, who take that undue blame for unfortunate situations that happen outside of their control. What kind of advice can you share with these physicians?

Mary Braun: I think the key is really to pay attention to how you feel, and to query it. Not in the sense of asking yourself, why am I feeling this way, not in the sense of, as we were taught in medical school, why are you feeling this way, you shouldn’t feel this way, because that’s unprofessional.

I suspect you had the same kind of training I did, that most doctors I know had, which teaches us that we’re not really supposed to have these feelings, not really supposed to have feelings of any sort. And there’s some truth to that, and I certainly don’t mean to say there’s not, there is some truth to that.

But there’s also a lot of truth to paying attention to the feelings you have, kindly and with curiosity, the same way that I would actually approach one of my patients. You just realized that you didn’t cause this patient’s life-threatening condition, and you felt relief for a second, but now you don’t feel relief. What is going on with that?

I mean, I guess to some extent it’s to treat myself with the same kindness that I treat everyone else. That’s probably it. The same kindness and the same interest and the same kind of curious compassion that I treat everyone else with. I think that’s probably the advice.

Kevin Pho: So after you shifted this mindset, especially after COVID, do you feel that somewhat mitigated some of your feelings of burnout?

Mary Braun: Yes, yep, I do. As a part of that, being aware of what is mine to be responsible for and what is not mine to be responsible for. That I actually didn’t cause the patient to smoke for 30 years or 50 years, and their lungs are not bad because of anything I did or anything I had any control over. And the same thing for their kidneys, and the same thing for their heart. So that’s being really aware of that.

And even the things that happen more proximately. I am not responsible for the fact that sometimes my patients wear ill-fitting shoes and trip, and have cute little throw rugs on their floor that they trip over and break their hips. I’m actually not responsible when Mildred breaks her hip. That’s not really on me. So yes, recognizing that definitely makes my life easier.

Kevin Pho: We’re talking to Mary Braun. She’s an internal medicine physician. Today’s KevinMD article is “From passion to burnout: When a doctor’s love hurts.” Mary, we’ll end with some of your take-home messages that you’d like to leave with the KevinMD audience.

Mary Braun: I think, as I said before, to treat oneself with the same kind of gentle, friendly compassion that one treats one’s patients. I think that’s a pretty good piece of advice.

Kevin Pho: Mary, thank you so much for sharing your story, time, and insight, and thanks again for coming on the show.

Mary Braun: You’re welcome, thank you.