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What if the cure for physician burnout has been making it worse the whole time? Lisa Rubiano, an internal medicine physician and physician coach, spent over a decade as a hospitalist before burning out in 2021 and stepping back to figure out what really went wrong. This episode is based on her article “Why resilience is not the cure for physician burnout,” published on KevinMD. You will hear why the resilience narrative quietly shifts blame onto individual physicians while letting toxic systems off the hook, how the Quadruple Aim turned clinician well-being into a vague self-care mandate, and what it actually takes to unlearn the belief that you should be able to push through anything. Lisa breaks down why setting boundaries feels so hard, why systems have no real incentive to change, and where physicians are quietly building their own way out. Listen for the moment that makes the self-blame stop.

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today we welcome Lisa Rubiano. She’s an internal medicine physician. Today’s KevinMD article is “Why resilience is not the cure for physician burnout.” Lisa, welcome to the show.

Lisa Rubiano: Hi Kevin. Thank you so much for having me.

Kevin Pho: All right, so just briefly share your story and then tell us why you decided to share this particular article on KevinMD.

Lisa Rubiano: Sure. So, internal medicine, as you named, I was a hospitalist for about 12 and a half years. I burned out in 2021, after COVID. You can imagine that was a great time for everyone in medicine on the front line. And yeah, it was a tough time. So after things improved, I decided to go per diem because I was just so burned out.

I needed to step away and gather a little bit of space, and I had to re-explore what my purpose was because I felt I was really disconnected from it. At that point, I’m like, why am I so miserable? If medicine was my calling, if this was my purpose, how am I just so miserable every day? So I started to explore what I really enjoyed in medicine and I learned about lifestyle medicine and I was starting to create a path, going in that direction with lifestyle medicine.

I wanted to help people initially with weight health and I also learned coaching at the time. So that was my plan. And then life happens. When we create plans that kind of blew up, and this was as I was in my coaching course, and after some more re-exploring of purpose and what I want to help with, I decided I wanted to really help other physicians who had been through burnout or going through burnout.

And I really focused on what I would have wanted or needed during that time. And that’s really kind of where this article, my whole message comes from, because the more time I had away from everything that went on, I was able to look back at my journey and I realized, oh my gosh, I was burned out a lot sooner than I realized, and that it wasn’t my fault.

That was the biggest realization, because I spent a lot of time spinning my wheels. What am I doing wrong? Like maybe I just need to round faster. I need to dictate less when I’m doing a note. Oh, I just, maybe I don’t need to double-check it so much. I was trying to find every single way that I was doing something wrong, and I realized it’s not a me problem.

Yeah. It’s not coming from something I’m doing wrong. The entire system is set up for burnout and kind of this exodus we’re seeing in medicine to happen, like this systemic problem. So that’s where this article came from, and that narrative of resilience.

Kevin Pho: Yeah. So tell me that point where you realized that the problem wasn’t you, it was the system. How long did it take you to realize that point?

Lisa Rubiano: It took a long time. I have to tell you, I think it was 2022 when I learned about coaching and I entered a coaching program. I thought by that point I had been doing my per diem work for almost a year. So I was like, oh, I’m good. I’m traveling, living my best life, figuring out what my next steps are.

And even after that, I was still actually burned out. And I hadn’t really reflected on it. So it was some point in this journey when, I told you, life blew up and then I really had to pause. Evaluate kind of my whole thinking process? Yeah. My whole identity in medicine. I realized so much of it was just tied into doctoring.

And this bigger part of me was really tied into helping and healing people more than the role. So somewhere in there I thought about what healing really takes. That’s how I started kind of just seeing this pattern in medicine, and that we don’t actually have a way that’s built in for us to function as humans.

Like it sounds so silly, but I keep actually meeting more and more physicians that talk. So many physicians now that say the same sentence, which is the silliest thing, is that we’re not robots. We really have this deeply ingrained belief that we can push through anything. We can handle anything. And we can. We’re a super resilient bunch.

And that’s when I realized, wait a second, this isn’t a problem with resiliency. And that’s what the whole narrative kind of around burnout felt like. Like, oh, you just need more resilience. And I’m like, no, I didn’t. I didn’t need that. I needed to connect with being a real person, right? And all the things that we go through in medicine and what our patients are going through, how it affects us, unexpected outcomes. And people deal with so much, like lawsuits, and we’re humans and we can feel ways about that. So it was, I have to say, a couple of years probably after that point where I went per diem that I really started seeing the whole picture with the system. And I started thinking about, well, what would it look like if we did have a system that actually supported us and resourced us? And that’s where that all came from.

Kevin Pho: Now, when you said that people kept telling you and other physicians that you needed to be more resilient, who was they? Who was sending you that message?

Lisa Rubiano: I think it’s both an explicit message in some ways. Let’s say I finished my training in 2011, and the people that came before me come from that background, right, of this resilience and kind of harshness. And some of the way, I’ll say, that we were raised in residency was through a teaching method based in shame and humiliation.

So I think that’s where more explicit messages came from. It’s like, you just need to push through this. You just need to work harder. This is just the job. You just see the patients, like there’s no boundary there. So that’s the explicit messaging, and somehow that becomes our internal dialogue and it becomes my own messaging, like, oh yeah, I should just be able to do these things.

So I don’t think it was, let’s say, my boss saying, you need to be more resilient. It’s just built into the expectations. And deviating from that is like, oh, why would you need to work anything other than 80 hours a week? Like, that’s what we do, the status quo, and anything that deviates from that is like abnormal.

Kevin Pho: It’s almost like you’re saying that traits like perseverance and grit, they are super powerful and physicians do need those traits to be successful in medicine. Yeah. But past a certain point, that trait becomes harmful, right?

Lisa Rubiano: Yeah. I think, like any trait, things that are our strength, when they’re overused, they can become shadows and they actually can become our own weapons that we use against ourselves. And they keep us stuck in these narratives and we can’t see past that. We had blinders on about it.

Kevin Pho: Do you feel that narrative around resiliency, does that help systems avoid accountability when it comes to systems problems?

Lisa Rubiano: A thousand percent. Yeah. When I was studying for my lifestyle medicine boards, I read about kind of this, it was the Institute for Healthcare Improvement. They introduced the Triple Aim in 2008, which is about improving patient outcomes, population health, and lower costs.

And then that was where I think a lot of burnout started because clinicians were left out of that. Then they introduced the Quadruple Aim, which included clinician well-being. But then it became this vague mandate about, like, physicians, you must take care of yourselves. But the problem was always the way it was baked into the system.

So then it became an individual problem as opposed to the systems having any responsibility of how that happens. It’s not, let’s see how we can support our clinicians and support our people. It’s like, well, you figure it out. You’re burned out, you’re having an issue. This is a you thing.

So it totally takes any of the blame off the system to actually create any change. Plus it’s profitable. And we’re pretty altruistic at baseline. We’re used to overextending, going the extra mile, seeing the extra patient, whatever it is, we think it’s our duty. And then that means they don’t have to set up any backup plans or any ways to facilitate a different model.

Kevin Pho: Now, what are some of the things that you did to shift the focus back on these systems problems instead of the spotlight on physician resiliency? What are some of the things that you did to really point us towards the proper direction when it comes to physician burnout?

Lisa Rubiano: Yeah, I spent a lot of time writing about it. I post on LinkedIn because I really want physicians, clinicians to get the message that it’s not them. I don’t know, frankly, if it’s going to be one person from the top that can dismantle what we have as an infrastructure in our systems. I work on an individual level. I’m a physician coach, so my goal is to help physicians unlearn these things.

I think as they start tapping back into this part of themselves, they start to rise and they can be in these positions of power in their institutions and they can start there where change is supported. And I know, up-leveled, because it has to come from both an individual and a system. But there has to be a drive for that. There has to be a reason for that.

Kevin Pho: You used the word unlearning. What does unlearning that reliance on physician resiliency, what does that look like?

Lisa Rubiano: That is for the physician to unlearn. It really entails setting boundaries and raising the bar of our own expectation. Unlearning the narratives that this broken system has to depend on us to be the bandage for it.

We have to start saying no. When it’s costing us our own health and well-being, we can’t wait for them to fix it because right now they don’t have an incentive to. It’s so much easier just to rely on us, so we have to take matters into our own hands. Start regaining our own power and our autonomy to do what we can to support ourselves.

Kevin Pho: So when you coach physicians or when you institute these techniques yourself, when you say saying no or setting boundaries, do you or your physician clients encounter pushback from the system? Whenever physicians try to set those boundaries that may not have been there previously?

Lisa Rubiano: I mean, I think every physician has to determine for themselves what happens after that. Because some things are, let’s say, manageable and small. Maybe they’re grievances, but I’m talking about real toxicity, because I think we stay in it too long. We allow ourselves to stay in harmful systems, making small negotiations with ourselves.

So it’s really learning that process first of what standards of our own are being breached and where we’re making those little rationalizations about why it’s OK. So yeah, it’s not easy. I wish it was an easy, straightforward solution, but everybody has to decide what level of harm they can handle. Because, as I know, you interview a lot of folks who are leaving medicine. A lot of people burned out. Unfortunately there’s a lot of suicide in medicine.

So I think we need to start figuring out what our own internal standards are before it gets to a point where it’s affecting our mental health, our physical health, and all of that.

Kevin Pho: Now, give us a small story of success. What would something that either yourself or one of your physician clients did that measurably changed the system for the better?

Lisa Rubiano: I don’t know if I have a story that tells you that it made a system better. What I can tell you is that some physicians who have left toxic systems have found joy. In another way of doing different, let’s say, nonclinical things.

A lot of physicians I work with are, let’s say, working right now on a bridge, like a bridge plan, where they’re creating some space to figure out how they want to create the medicine that they want to practice. So I think a lot of the people I work with are figuring out their own way to not necessarily be in the system, because maybe the goal is to create our own.

Kevin Pho: We’re talking to Lisa Rubiano. She’s an internal medicine physician and a physician coach. Today’s KevinMD article is “Why resilience is not the cure for physician burnout.” Lisa, as always, we’ll end with some take-home messages that you want to leave with the KevinMD audience.

Lisa Rubiano: Absolutely. Yeah. The main message is burnout and sometimes that moral injury and the feelings of misery, it’s not your fault. It’s a natural process that happens when you’re in a toxic system that was never designed to support you. And when you reclaim your own autonomy and your own power and take responsibility for what you can change, things do change, and for the better. So yeah, that’s my main message.

Kevin Pho: Lisa, thank you so much for sharing your perspective and insight. Thanks again for coming on the show.

Lisa Rubiano: Thank you, Kevin. Appreciate it.