How to Avoid Burnout on Repeat

Rachel Morris: Have you wondered recently if you’re burning out, or perhaps you know that you’ve been burnt out in the past and have barely recovered before you started working again at full throttle. And you’re wondering how to avoid ending up in exactly the same situation as before. When the pressure and the demands on you just seem to be increasing rather than letting up.

Many of us have suffered burnout, even if we didn’t call it that at the time, we can often look back at points in our careers and recognize times when we were pretty close. Burnout is such a significant and miserable thing to go through, you’d have thought that we’d do anything in our power to avoid it. But unfortunately, often we just go back into an identical situation without making any significant changes. And then we wonder why it happens to us again and again. Or perhaps we recognize that we’re only just functioning one or two levels above burnout and feeling pretty miserable. But we think that while we’re still able to work, we have no choice but to soldier on.

In this episode, I chat with Dr. Claire Ashley. She’s a GP and burnout specialist who has experienced burnout on repeats. We talk about what happens to our brains in burnout, the guilt and shame which we feel which prevents us from asking for help or making the changes we need to. And we tackle a very real issue of how to avoid burning out again when you’re working in a system over which you have very little control. So listen to this episode to find out What The 12 Stages of Burnout are. And if you can recognize yourself in any of them, what to do to avoid it in the future.

If you’re returning to work after burnout, and nothing has changed, and how your values and outlook on life may change after burnout. And how you can, in fact, use that to your advantage.

Welcome to You Are Not A Frog. The podcast for doctors and other busy professionals in high-stress, high-stakes jobs. I’m Dr. Rachel Morris, a former GP, now working as a coach, trainer, and speaker like frogs in the pan of slowly boiling water. Many of us don’t notice how bad the stress and exhaustion have become until it’s too late. But you are not a frog.

Burning out or getting out are not your only options. In this podcast, I’ll be talking to friends, colleagues, and experts and inviting you to make a deliberate choice about how you live and work, so that you can beat stress and work happier.

Are you a busy, even overwhelmed leader struggling to manage your own work on top of what you’re doing for everybody else? Do you find advice about setting boundaries and saying no just doesn’t supply because the bug always stops with you?

Join me for a free, upcoming training, called If I Don’t Do It, No One Will: The Ultimate Guide to Loving Your Limits For Leaders Who Do At All. You’ll learn practical ways to reduce stress and create more time, even when you’re the person everyone else relies on. It’s happening on the 27th of March at 8 pm. And there’ll be a recording if you can’t make it live. Register for your place at the link in the show notes or at shapestarget.com/doingitall.

It’s wonderful to have with me on the podcast today, Dr. Claire Ashle. Now Claire is a GP currently working as a locum, and she describes herself as a burnout survivor, and a burnout expert. Now welcome to the podcast, Claire.

Dr Claire Ashley: Thank you for having me, Rachel. It’s a pleasure to be here.

Rachel: So I’ve got Claire on the podcast today to talk a little bit about burnout. About her own personal experiences, how she got through, and also what she thinks is necessary to help other people. Because Claire, I know that you’ve experienced burnout sort of once or twice how many times now, as you say,

Claire: I initially burned out in 2019, which is coincidentally the same year that the who finally recognized burnout as a syndrome. It’s been known about since the 70s, in fact, but it didn’t receive its official recognition until 2019. And unfortunately, when I burned out in 2019, I made some mistakes with my recovery. And alongside the mistakes that I made, we also had a pandemic that kind of got in the way of my recovery.

And last year, I slid again into burnout. But luckily, the second time around, I was able to recognize what was happening to me at an earlier stage and get help at a much earlier stage. And do some real deep work and make the changes that I really needed to make in order to recover and stay recovered at that point.

So yeah, it’s been one burnout crisis in 2019 and difficult periods last year of several months actually. Where I ended up under practitioner health with the help of a GP and a therapist I have been able to get into a position now where I feel much better in myself and I’m and I’m able to work sustainably as a result of the help that I’ve had.

Rachel: I think that’s really interesting, Claire because I have noticed that this is really, really, really common. It seems to be that people don’t just have one burnout often it can be a recurrent thing. And I often talk to people who are really beating themselves up about it. And feeling really guilty or really silly that, “Oh, I just burnt out again, I’m so stupid.” How could this happen to me, but it seems to me to be quite a common pattern of what happens. Why do you think that is?

Claire: So I think there are several reasons as to why this happens. So the first thing is that we cannot ignore the elephant in the room, which is that you burnout when you have been subjected to unsustained and uncontrolled stress at work that has not been successfully managed. And one of the problems that we have, certainly as healthcare professionals, and working within the NHS at the moment is that those pressures are really, really pervasive and really, really tough at the moment.

And the difficulty that we have is that we–if we continue to work within those systems, and were subjected to those pressures, continuously, it doesn’t matter how much work you might do on yourself. How much therapy you might have, if you’re still in the fire, you’re still going to get burned. And I think unfortunately, this is a huge issue within the NHS at the moment because I don’t see any kind of push for change coming from the top down. We’re in very, very difficult circumstances post-COVID. And it’s, it’s just the perfect storm and environment for burnout and multiple burnouts as well.

One of my favorite quotes about burnout is that, “You don’t need a more resilient canary if they keep dying in the toxic environment of the mind.” And I think that fits really nicely with what is happening within healthcare at the moment. And I think that healthcare workers in general, carry a huge sense of responsibility and wanting to do the right thing. You know, we tend to be people pleasers, we’re caregivers.

We go into the profession to work for our patients, and to put them first. And that’s really what drives us our jobs are vocations. And when our jobs harm us, and they actively work against us, I think quite often we see ourselves as the problem. And we blame ourselves, we carry a lot of guilt and shame associated with our burnout. And I think that’s partly due to our own internal factors.

I think a lot of us carry similar personality traits that are put, unfortunately, put us at risk of developing those emotions and those feelings. But we also have a problem within our working culture that weaponizes that guilt against us. You know, we’ve all had pressure put on us to fill on gaps in the rotor or to step up outside of our competencies by our managers, or supervisors, or our consultants. And that guilt is normalized, and it’s weaponized against us. And I think that that can impact on our decision-making when it comes to burnout as well. So not only are we working within a system that doesn’t allow us to really fully recover if we’ve experienced it, we also carry a lot of internal factors, personality traits, guilt, and shame that, unfortunately, might prevent us from recovering fully. And that’s where we might slide into burnout again in the future.

So I, that’s a very long-winded way of saying I think it’s, it’s multifactorial. Just to add, whilst I’m saying there that I think that we carry a lot of our own internal risk factors for burnout and for multiple burnouts. That doesn’t mean that you’re at fault if it happens to you. And it doesn’t mean that you’re at fault if it happens to you repeatedly. What it means is that you are working within a system that is completely broken, and asking too much of you for too long. And that’s why it’s happened.

Rachel: Yeah, I think you’re absolutely right. Because if you keep on doing what you’ve always done, you’re always gonna get what you’ve always got. And I guess that you then face the dilemma and the real quandary. That if you are going to choose to carry on still working as a doctor unless you can choose to go work somewhere completely different, which is also a valid choice. And many, many people do that. You can choose to carry on working in that very, very difficult environments, on the basis that you can’t often change the environment unless you’re the CEO. And even then they would say, “Well, I can’t change it either.”

You then have to look at changing yourself changing that internal guilt stuff. And I think that’s so important about weaponizing guilt about how we might go back with all these resolutions. Okay, I am going to say no, I’m going to put the boundary here. I’m not going to do that. But then as soon as someone asks us we feel dreadful as soon as someone maybe insinuates that we might be coping or implies that we’re being a bit selfish, that just does us in and we sort of crumble and we end up doing it. I mean, have you seen stuff like that happening or experience it yourself?

Claire: Oh, 100% I’ve experienced it. I think, you know, it’s probably one of the things that unites us as healthcare professionals and certainly as doctors working in the NHS. And I can give you some examples of how that has been used against me and affected me in my own burnout recovery as well. So when I initially burned out, I was working in a surgery where unfortunately, we didn’t have enough GPS to meet the demands of our patients.

And when I hit a crisis point, and I hit a crisis point really, really hard. I mean, I was in a very, very difficult place. When this happened to me. And I probably should have taken some time off sick, but I didn’t. Because a lot of external pressure was put on me to not do that, because of the impact it would have on my patients. So I have my own list of patients, because of the impacts that it would have on my colleagues who were already struggling themselves. And that plus my own internalized guilt and shame. And I was deeply ashamed of what had happened to me. I sailed through medical school sailed through my postgraduate training with not a whiff of a mental health problem. And six months into being a GP, I was an absolute wreck. And I was absolutely desperate, I was clinically depressed, I had very severe anxiety. And I completely blamed myself for what had happened.

I didn’t even know what burnout was at that particular point, I didn’t know it was a word I didn’t know it was a thing. I just knew that I didn’t recognize who I had become. And it had completely destroyed my confidence as well. And so when you’re at that point when you’re feeling incredibly vulnerable, and it’s very hard to advocate for yourself.

When you’re in that position, to then be told by your bosses, we don’t want you to go off sick, because it’s going to affect the service. Of course, that affects your decision-making. And as a result, I didn’t take sick leave, they did make some changes that work in order to accommodate the fact that I was finding things I was struggling very, very hard. And I really should have taken some time off though. And knowing what I know now about burnout recovery, I absolutely shot myself in the foot by staying at work when I really should have had probably several months off sick in order to fully recover. But I didn’t know that at the time. And, and that was something that has, unfortunately, I think, affected my long-term recovery and was probably a factor in me sliding again, because I didn’t go through that initial period. But it’s not just myself, you know, I am very active over on Instagram, I have 12,000 followers, and my DMs are full of healthcare workers and people largely in the public sector actually, as well.

So teachers, social workers, etc, telling me about their journeys, and about the pressure that is placed on them as well. And absolutely guilt plays a huge part in them staying in jobs, perhaps that are harming them, and absolutely affects their self-esteem, their confidence, and their decision-making, unfortunately,

Rachel: Yeah, we see this all the time. So when in fact, it’s interesting when I run training sessions on all of this particular on why we find it difficult to say no. The biggest objection people have, well, they don’t like saying no to patients, they feel really bad. But actually, it’s the thought that you’re going to be dumping on colleagues is the biggest one, I think for healthcare professionals.

And the problem is it’s not in your mind. I might just dump on colleagues, actually, you totally will. That is the problem, isn’t it? That is the reality. If you go off sick, then someone else has to pick up the work unless they then choose to say no to the work. And that’s, I guess another whole podcast topic about how we say no. This is the work that we can do as a practice. And this is where we need to draw the line. And we’re very, very, very bad at doing that. So what would you now said to that, that Claire back then who was just feeling really, really awful about possibly dumping on colleagues?

Claire: That’s a very, very interesting question. I don’t know if there’s any advice I could have said to that Claire, at that particular point in time. That would have changed how I was feeling and the decisions that I was making. I’d like to think that I would have listened. But knowing how stubborn I am, I probably wouldn’t have done. So yeah.

When it comes to the guilt, I think it’s really, really hard for us to put ourselves first and our own needs first, because we’re so habitualized into putting other people’s needs first. And actually, on that note talking about the impact we have on our colleagues, we have a problem within our medical working culture, whereby we feel bad about impacting negatively on our colleagues if we go off sick, for instance, or if we’re not able to work at this the pace or the level of intensity that our colleagues are working out, or at least we perceive they’re working out.

But we do have this culture of not really being tolerant or kind to people that are struggling. And I think that’s definitely something that needs to change in order to support our colleagues. So what I really needed back then, were my colleagues to say to me, “Claire, We know you’re really struggling, you just take the time that you need to get over there.” So you know, “go and speak to someone, go and speak to your GP, get some help, go and see what they recommend, and then come back to us, and we’ll be happy to support you.” That’s what I needed to hear at that particular point in time, but unfortunately, I didn’t.

I think one of the biggest realizations I had post-burnout was that the guilt that I was experiencing, was inappropriate for the situation. So if you think about guilt, guilt is a really uncomfortable emotion. And it’s designed to be uncomfortable. And you’re designed to experience it when perhaps you’ve made a decision. Or you’ve done something or you’ve said something that doesn’t really fit with your own ethical code or your internal moral compass.

And the reason why you feel guilty is because when you do things like that, it’s a prompt to make you reflect on what you’ve done and think, maybe I need to go back and undo that. Or perhaps I need to go and do something differently, perhaps I need to go and fix what I’ve done. And then you go away, and you fix what you’ve done wrong, and then you feel better and your guilt is alleviated.

What happens in healthcare, however, is that guilt that you’re experiencing isn’t because you’ve done something wrong, it’s because of the way that we’re working. And, for instance, a lot of the guilt might come from, you know, when you’re interacting with your patients, and they’re distressed, but you’re not able to provide the care that you want to because you’re pressurized for time or resource, and then you feel bad about it. And then when you start to feel bad quite often in burnout, your thinking processes get quite disordered.

And I know certainly mine was and the leap I made was I’m feeling bad. Therefore, I must be bad. And so I started to think that there was something fundamentally wrong with me. So not only did I feel guilty about things, I also genuinely blamed myself as well. And so in terms of giving advice to the client that was in burnout crisis, I think it would be about focusing on that and telling her that, because just because you are feeling this doesn’t mean that you’re a bad person, it doesn’t mean that you’re a bad doctor. And it’s not your fault.

Rachel: I totally agree. I think the problem is that often we wait for our colleagues to validate our decisions, and we wait for other people. So yeah, “It’s okay, please, please go you’re sick, please go, you’re sick.” But frankly, that is not going to happen. If you are working in somewhere where everybody is stressed, and everybody is under pressure. Unless you have some very, very enlightened very, very wonderful colleagues, not many people are going to go “You know what? You take all the time you need will just absorb the work. We’ll be okay.” So if you’re waiting for your direct colleagues to give you permission to take time off work, you might be waiting a very, very long time. But that doesn’t mean you don’t need to take time off. So if anyone is in that situation, right now, this has made clear, we are giving you permission to take the time off that you need. Because actually, in the long run, that’s going to be better for your colleagues. Because it is as you said, Claire, the longer you leave it before going off, the worse things get. The longer it takes to recover. Was that your experience?

Claire: Oh, yeah, absolutely. So the evidence tells us that people need on average three and a half months off sick before they even contemplate going back to work. But it can be up to a year in fact. And that’s because burnout does such a number on your brain’s structure and function. And because it changes your physiology as well in the way that it up regulates your stress hormones. And I think it’s really important, and I didn’t realize at the time, unfortunately. Just how important it is to have that time off in order to start the recovery process.

And me not taking that time off sick definitely drew out my recovery, and meant that I slid again last year, unfortunately. And what you just said that Rachel, about in the long run, you will end up infecting your colleagues more if you don’t take the time now. That is something I think that medics really struggle with in particular.

At what point do you say I need to go off now because as you said, no one is going to give me permission to do it. And so I think I think it’s really important that you take action as early as you possibly can. It’s like anything in medicine. You know, if you’ve got someone who has a very high blood pressure, as a GP, I don’t sit there and go, “Well, I’ll just wait for you to have a stroke.”

And then I might do something about it. You know, because it will be that much harder to recover from a big stroke. But treating someone’s high blood pressure is so much easier. You know, we know as medics that prevention is better than cure. Early intervention is better than late intervention. And the same is true of burnout as well. It’s just about giving yourself permission to be able to make the decisions that you need to, to get better. And it’s really hard. It’s really hard.

Rachel: And I know because I’ve been there and I think everything you say you know, it will be better for your colleagues. But actually staying at work, you’re going to be making more mistakes. Yeah, we know that doctors who have higher levels of burnout have it I think something like a 63% higher chance of medical error. You get presenteeism, so you’re not doing a great job anyway, when you’re working in a state of burnout, are you?

Claire: Yeah, that’s one of the features of burnout. Actually, one of the three components of it is reduced professional efficacy. Which might mean making more mistakes. Quite often your cognition is affected with burnout. So you might get reduced attention and focus, decision fatigue, memory problems, these are all features of burnout.

And at work, certainly how it manifested in myself was slower decision-making. And having to spend longer with patients struggling to make decisions that prior to the burnout, I would have made in an instant. I was very, very efficient at making decisions. I was a very functional trainee, actually. But I really struggled during the burnout to make those decisions. And as a result, I’d kind of ruminate and mull over the decisions.

And just spend so much more time and energy making those decisions. And without a shadow of a doubt. You know, at the end of the day of work, I was not the same doctor as I was starting the day feeling a little bit more refreshed. But actually, one of the other things I want to add to that is that burnt-out, doctors continue to work.

And just because someone is turning up to work and seemingly functioning doesn’t mean that they’re not in a state of crisis. It doesn’t rule it out, because I am still going to work, even though I was very severely depressed. And I was having panic attacks. And I shouldn’t have been at work. If you’re trying to work out whether or not your colleagues might be going through it just because they’re there doesn’t mean that they’re not struggling.

And just to add to that, as well, there was very recently a study that was in the BMJ that talked about medical errors in burnout as a huge meta-analysis. And whilst the figures made for quite sobering reading, in a way, so burnt out doctors are more likely to make mistakes. And they’re also more likely to have complaints made against them.

I think what we should do is see that as something for leverage for change. Because I think if burnt out, doctors are turning up to work and still doing their job. Even, albeit perhaps, at their own individual cost, their mental health. In terms of service provision, you’re still turning up and doing the work. But if it becomes a patient safety issue, this is the leverage that we have to push for change. Because if you’re still providing a service, then the powers that be don’t really care that you’re really struggling. But if it’s affecting patient care, then this is the leverage we have for change.

Rachel: It’s all really hard, isn’t it? I think what you said about believing our feelings and feeling bad and then thinking, Well, I’m feeling bad, therefore, I must have done something wrong. And that’s what guilt does. It’s like you said it alerts us to, “I might have done something wrong. I might need to change my reaction.”

And I always been saying for the last few years, “Oh, we just need to ditch the guilt.” And then my colleague Caroline Walker, the joyful doctor says “No, it’s not about ditching the guilt. It’s about embracing the guilt.” Because it just means that you’re a good person. Just means that you’re not a psychopath. You actually do care about your colleagues.

Where I think it gets really toxic is when you sort of bring the amygdala into it. And our amygdala is always searching to belong to a group. And it and it raises a threat if it thinks that you’re going to be physically attacked. Or you think the group is going to going to throw you out. So people pleasing is a massive thing. If we think we’re going to upset somebody, makes its flares up. It puts us into our threat, flight, fight, or freeze zone. Lots and lost of adrenaline going around. And we absolutely do not think straight anyway.

And so this guilt feeling that we’ve got, it gets amplified. We always go to the worst thing because the maxidus is meant to keep us safe. The reason why we’re so sensitive to upsetting people is when we lived in caves. We upset the group. [We] would be chucked out of the cave and [we] would die of exposure or beaten by a lion or something like that. So we are overdeveloped to worry about upsetting people.

And when we feel these feelings, we feel really awful. But I was watching an amazing YouTube video by Tara Brack the other night, where she just kept talking about these feelings which were real, but not true. Real, but not true. These thoughts being real, but not true. But sometimes it’s really hard to get to the truth of the matter. When the system is saying, “Well, you’ve got to carry on working.” Your colleagues saying, “Well, we really do need you to keep workin.” And you’re saying, “Well, I really should keep working.” So what advice would you have to someone in that situation to break through all those different voices that are putting the pressure on?

Claire: That’s a very, very difficult question to answer. Because I think quite often when you’re in that position, your thinking is very, very disordered. And it’s really, really hard to break out of that cycle. Part of that is because burnout changes your brain. So you mentioned the amygdala there. In burnout, the amygdala gets bigger and the amygdala forms part of your emotional regulation. And it forms connections with your prefrontal cortex. And those connections get changed and burned out as well.

So what you see is the amygdala getting bigger, those connections getting weaker. And you cannot control your emotional responses to stress. Be it physical or perceived stress at work, for instance. You can’t control it in the same way compared to people who don’t have burnout. And the worse your burnout, the bigger the changes on functional MRI scans as well. So I think you know, your brain changes with burnout. And so it’s really, really hard. When you have those changes, to be able to accept that. And to break that cycle.

A lot of my work now is about sharing the spiral into burnout and the stages of burnout. There are 12, theoretical stages of burnout, in order for people to recognize where they might be on that cycle. And to be able to take early intervention, because I think if you get it sooner rather than later. You know, we’re not given the skills or the knowledge to be able to recognize burnout.

If you don’t have that those skills with that knowledge, you don’t know that you need help. You don’t know what you don’t know, do you? So it’s important that people know that burnout is a thing and what the stages are so that they can recognize it and get help sooner rather than later. And then in terms of recovery, I think it’s about if you’re in a crisis point, recognizing that you’re there. And that is actually really, really hard to do.

And I think, in terms of advising other people, I think it’s probably about a combination of doing some reflective work on how you’re feeling. And asking your loved ones, if they’ve recognized any changes in your behavior. Now, this is actually really difficult to do. But in the 12 stages of burnout, which is a theoretical model of the stages that people go into before they hit a crisis. Behavioral changes that your loved ones might recognize is one of those stages. So listen to what your friends and your family are telling you. If they’re telling you we’re a bit worried about you.

Or if they’re saying why you being so grumpy, why you being so irritable, instead of feeling threatened or defensive. It’s about using that as a prompt to think, “What’s really going on here?” And in order to work out what’s really going on, I think having some sort of reflective practice. So a journaling practice is really helpful to be able to recognize that. And that’s something that has become a regular practice of my own in order to recognize how stressed I am and whether or not my stresses getting worse, getting better. Where I am, in terms of my mood. You know, it’s really important to be able to check in on yourself regularly. And that’s probably the easiest way of doing it, I think and the most accessible way as well.

Rachel: That’s great advice. But we are quite un-self aware. A lot of us until it’s until it’s too late. I’m interested, what are the first few stages right at the beginning.

Claire: So this is a theoretical model of burnout. And I don’t personally feel that you have to go through every stage in the sequential order, in order to get to burnout. I also think that a lot of the stages are very similar to each other. But I think it’s a really interesting way of getting to learn what burnout does to you. And the extent to which it changes you quite often before we even realize it’s a problem. So the first stage is excessive drive or ambition. So feeling an obsessive compulsion to prove yourself and demonstrate your worth.

So I think quite often how that manifests is, you feel like there’s a bit of a problem. And you do the classic thing that we’ve been taught since day one in medical school. Which is you can solve all your problems by working harder. So that’s what we do to start with. We start working harder. We work longer hours. We commit everything that we can to fixing our problems by working harder. And the second stage is pushing yourself to work harder and being unable to switch off.

So not being able to switch off from your work. Taking it home with you. Not necessarily physically. I never took my work physically home with me but emotionally and mentally I couldn’t switch off. And I worried all the time about the decisions I was making with my patients. The first stages neglecting to care for yourself. So poor sleep, fatigue is a huge component of burnout. And something that I’ve suffered with quite severely, in fact. Eating badly, so some people eat more when they’re burnt out. Some people eat less. You can go one of both ways.

The fourth stage is displacing conflicts, that seems not dealing with your problems in a healthy way. Basically, sweeping them under the rug, feeling threatened, feeling panicky, starting to feel a bit jittery. The fifth stage is revision of values. And that’s when your work becomes more important than your friends or family. So you might see some social withdrawal, in this stage.

The six stage is denial of emerging problems, So denial that there’s anything wrong with your behavior, blaming things on your work, blaming things on your patients, and being intolerant and grumpy with your colleagues. Then the seventh stage is withdrawing from social life maintaining very little social contact. You might turn to alcohol or drugs to help be through this stage. Which obviously is a maladaptive coping strategy.

The eight stages exhibiting behavioral challenge changes that are obvious to both friends and family. Which we just talked about. The nine stages is depersonalising. So this is where you start to feel like it’s all worthless. It’s all meaningless. You stop being able to recognize your own needs or to perceive them. And feeling that you’re that your contribution is not valuable. Stage ten is feeling empty inside. And again, you might look to alcohol or drugs to fill the gap. Again, that’s very similar to stage seven.

So you can see why I said some of the stages are very similar. Eleven is feeling depressed and exhausted. And then twelve is burnout crisis, basically. So you can see with that theoretical model, there are lots and lots of stages that you go through in theory. Before you end up in a burnout crisis. It took me about six months from being completely functional, feeling absolutely fine, never had a mental health problem to being in a crisis.

So six months to go through that. And at no point did I recognize that I was entering any of that. I knew something was wrong. And I was working really hard and I was exhausted. But I had no recognition about anything to do with what was happening to me, and what burnout was. I didn’t recognize it about. I wasn’t taught about it in medical school or in my postgraduate training. So why would I have recognized it?

Rachel: I think that’s really helpful. And, and even if you don’t go through those in different sequential steps. I’m sure that there’ll be people listening to this podcast saying, “Oh, my gosh, that’s me. That’s me, I recognize me in that.” And I think that’s really, really helpful. So Claire, I’d like to ask you a couple of things. Firstly, if you recognize that’s happening to you, what are the first steps that you can do to prevent it? And then what should you do if you feel that you are in burnouT? If you can spot it early, and take some steps to treat it much, much better. I’m presuming much, much more efficient, and than going into full-blown burnout.

Claire: I think in terms of prevention, the good news is that if you don’t end up in a burnout crisis, you’re not likely to need an extensive period of time off work. You might not necessarily need to have medical support from your GP. You might not necessarily have to go have some psychological support.

I think if you get it early enough, what you really need to do is to address how you can perhaps gain some control or autonomy over your work. And also to engage in some evidence-based techniques to manage your stress and your overwhelm. So the thing about burnout is, when you hit a burnout crisis, no amount of self care, or yoga, or mindfulness is going to help you unfortunately.

What you need is a multi-faceted recovery plan. And it’s hard, it takes time. Whereas if you get before that point, you won’t have to go through that process and do that really deep work. One of the biggest things that makes a difference to burnout prevention is working within functional teams. And so I think creating an environment at work where you feel psychologically safe. So by that, I mean, you feel safe to be able to raise concerns without judgment. You feel safe to be able to share your feelings with your work colleagues. That’s really important.

So having peer support and working within functional teams is really protective against burnout. If you have, for instance, imposter syndrome, or perfectionism in particular, these are risk factors for burnouts. So if you can do some work around that, and reduce the impact of those things, on the way that you think. Then that can also reduce your risk of burning out if you’re worried that you’re at risk of it happening to you. In terms of what you can do to manage your stress levels. So you know, as medics, we all know what’s what is evidence-based.

You know, getting some sunshine, doing some physical activity, eating nutritious food, making sure you’re getting adequate sleep, social connections as well is really important. And so it’s about prioritizing those things. And so far, as much as you can. Interestingly, in terms of building resilient teams, as well as socializing with your peers, that makes a big difference to how you perceive your work and your risk of burnout as well.

So if you can spend time with your teams, and build those relationships outside of work that will help you from burning out. I think there is probably some benefits to having therapy. Potentially if you recognize that you have a lot of negative thoughts or if you have any unhelpful thinking styles like catastrophizing, black and white thinking, you might think actually, I probably could do with a bit of psychological help with that.

Rachel: I would agree with that comment about therapy or even coaching. Because I think we’ve already talked about those, those internal scripts that you’ve got around the guilt, and “I should be able to do this”, “Why is it me?”, “I’m dreadful”, I’m acopic”, “I’m not any good.” if you can actually catch those stories, and get some help in how to change those stories.

When I’ve been in therapy recently, and it’s so funny. So I’ll say something to the therapist, and she’ll go, “What did you just say? What were you telling yourself?” and she’ll go, “Ohhh”, and they’ll go, “Oh, it’s that not normal? I must always be perfect” for example, yeah. And she’ll go, “No, that’s not right.” You know, and just to have someone reflect that back to you.

It’s been like journaling, isn’t it? Because once you write down what’s your internal thought processes are someone reflects that back you go, “Oh, my word, I am thinking ridiculous things.” I guess that in a way, being with a peer group that can help or just for people that really know. You know, “Can I run something by you? I’m thinking this”, and they can go, “Oh, no, is that what you’re thinking? Oh, my word. We don’t think that about you. And you certainly shouldn’t be thinking that about yourself.” Right?

Claire: I was just gonna say, Dr. Sarah Golding, who I know that. I think she’s been on the podcast, I hasn’t she?

Rachel: Yeah, she did one about imposter syndrome. She’s done about stuff about careers on the podcast. Yes.

Claire: Yeah. So she says, “What are the stories you’re telling yourself?” And I love that question. Because it forces you to recognize that what you’re saying inside your head isn’t necessarily true. And that you form this narrative, but you then feel that your behaviors will come off of that narrative, don’t they? And your decisions, and that they’re not necessarily the most helpful things that you’re telling yourself, isn’t it?

Rachel: I mean, I think I think stories in your head are really, really powerful. And we ask people that all the time on the training. Because it’s like, you know, “What is the story in your head here? And what is actually true?” And I guess that brings us back to the whole, “How do you get out of that guilt of dumping on your colleagues?” When your brain has changed. When you’re in your amygdala zone.

I guess one way to do it, is just to ask for help quite soon. Because if you’re asking for help, you’re not saying “I need to go. I’m sick,” or that you’re just asking for help. To me is just sense checking stuff. “I need some help, I think I might be–Can I send to check some stuff that I’m feeling or thinking and get a neutral person.” He doesn’t have any vested interest in you carry on with your work. So actually just assess that, I would be really, really helpful.

Claire: So I am Evangelical, about therapy, I had a very intensive course of therapy through practitioner health to help me with my burnout. And specifically to help me with the anxiety component of my burnout. Because that was the thing that was really affecting me last year. And I threw myself into it, because I felt so awful. I was like, “I’ll just do anything to feel better.’

But I don’t. I didn’t actually think it was going to help. Right? I was like, “I’ll go through the process, I’ll do it. And I’ll engage with it.” But I don’t think it’s actually going to do anything. But let me tell you, I was blown away by how much it transformed how I how I think and how I behave. And the effects have lasted as well. That therapy that I had, and I had a combination of CBT and ACT therapy was incredible.

It was very draining. And I didn’t enjoy the sessions at all, because they were so intense. But I did it. And I still use the techniques to this day. You know, if I’m feeling overwhelmed, in the moment, I’ll go through some of my act techniques like diffusion. If I notice that I’m getting into negative thinking habits again, I stop and I’m like, “What is this thought? Can I form an alternative thought? What’s really true in this situation”, and that is completely transformed how I feel about myself, it’s amazing. So everyone should have therapy basically.

On the other hand, is that is a tricky part. But I do recommend it. And there are ways that you can access it as a healthcare professional. So through practitioner health, for instance, then there are various charities and organizations that also provide support. I think the Laura Hyde Foundation is one such charity.

Rachel: So, we’re nearly out of time, but I just wanted to ask you about a couple more things. Because we’ve talked about how to prevent it. We’ve talked about things that are really protective for it. We’ve talked about what you can do when you spot it. Some of the things we talked about struck me that maybe not so much in your own control.

So the sort of team you work in whether it’s a really well functioning team. Well, there is things that you can do but quite a lot of time that’s not in your control. The workplace environment that you’re going back into, that’s not often under your control. And we know that patients’ demands, COVID, NHS, and that sort of stuff really isn’t under your control.

If we go back to the initial premise that if you go back into exactly the same situation, and nothing changes, you are just going to burnout, okay. It does seem to me it is about things that you can do and you can put into place that’s going to stop that in the future. So what do you wish you’d done differently when you went back the first time? That would have helped a lot?

Claire: When I hit crisis point, what I really needed was first of all time off. Which I didn’t do. I probably needed some intense therapy at that particular point. My therapy came later on in my journey, but I think it would have been really helpful at that particular point in time. But then, once you’ve kind of got through that initial stage, you then have to start thinking about your work. And as we discussed, you can’t go back into the fire and not get burnt again.

Either what you have to do is to make some changes within your current role or think about changing your role. And for a lot have us in the NHS at the moment, leaving your job might not be the right thing to do. You might have a training contract, for instance, and be tied into that post for a set number of months or years.

You might not financially be able to leave your job. This is real life, unfortunately. And the thing that really matters is having some sort of control and autonomy. There was a study that was done in non-medics group of burntout professionals who all went off sick with burnout. And the only thing that made a difference at two years as to whether or not they were back at work was having that sense of control and autonomy.

That’s how important it is to burnout recovery. But you’re absolutely right. We cannot control the bigger things. We cannot control the systemic pressures that we’re under. So where do you get that from? And it’s about working out where you can get that, and go for low hanging fruit. I think essentially, is my advice at this point.

So, “What can you realistically control? Where can you be boundaried?” You mentioned boundaries earlier. And how important that is? What about the work that you’re doing? Can you negotiate something with occupational health? You know, can you have mentor duties? Shorter working days? Could you go part-time? Those are all options available to you in terms of how you work.

And then there’s this concept of this thing called job crafting. I don’t know if you’ve heard of it, Rachel. But it’s basically where you take the job that you currently have. And you try to mold it and shape it into something that really works for you. Now, it’s not about changing it beyond your job description. One of the problems I think with it is obviously, that you have to make those changes. It’s not something that your employer does. And I think for people who are burned out, that can sometimes be a big ask.

Particularly when you’re in a vulnerable space. And the danger is that you take on too much. But I’d encourage people to think about what it is about their job that they really enjoy. And what are your values? You know, what are the things that get you going? Why did you do the job in the first place? And when you think about what it is that you really enjoy. Is there a way that you can incorporate doing more of that into your day-to-day work without changing your job beyond its description?

And in doing that, you can gain a sense of control and autonomy, because you’re you are the one making those changes. So for instance, if you really enjoy teaching, is there a way that you could factor a little bit more of that into your job plan? If it’s forming relationships with your patients, is there a way that you can facilitate that in your day to day work, and in your interactions?

Obviously, a lot of these changes might be difficult, and you might not be able to to fully do them in the way that you want to. Because of the pressure with the job, you still have to get the job done, unfortunately, regardless of where or how you work. But sometimes just some little tweaks and little changes is enough to keep you healthy when you go back. And I think the other thing, just to add to that is that burnout, recovery does take a long time.

And not to get frustrated with the process. Some studies say you never recover, some say 10 years, they’re most commonly quoted figures is one to three years. And that’s generally what what I say as well. So if you go back to work, and you’re still not quite right, don’t beat yourself up, it takes a very long time to get over burnout and to start to feel to feel better as well, even with those changes. So your normal, if you’re in that position at the moment, you it is entirely normal to be feeling like that.

Rachel: You’re absolutely right. And it’s normal to struggle when you go back to work. And I was reflecting on what you said. You know, everybody that I know that has had burnout in the past that has recovered has completely changed the way that they do life completely. They become much more boundaried, both at home and at work. You’ll say “Do you want to come out tonight? And they’re like, actually, “No, I can’t because I’ve been out that night. And I know that I can’t cope. And I know that I really need to do this and that.” And at work. They’re like, “Nope, this is what I will say yes to and is what I won’t.” And people really respect them for that. I must say, they completely reset the way they do their life.

And it’s interesting. I was smiling when you mentioned job crafting. Literally out of this podcast about to go and host a panel discussion at the factor medical leadership and management conference about job crafting. There’s lots of evidence. In fact, that will probably be out just before this one, actually. And so if you’re listening, and you want to listen to that, go and listen to that.

But there’s lots of evidence that job crafting actually helps increase engagement. That’s how you feel about your job. And then that, in turn, reduces levels of stress and burnout. And I coached lots of doctors for careers and things like that. And I do remember one person, one GP, she was really, really struggling. And the only change that she made was that she realized she loved teaching, but she had been put as clinical governance lead in the practice.

And when she changed her role. Got a colleague who loved that sort of thing to do. That she did what she loved. Suddenly all seems a lot more easier. And she was much much happier. And then she was able to craft out a role in medical education and then really push into that. So “Oh, absolutely, job crossing isn’t just about completely changing a role, it can just be about, like you said, if you know that you really enjoy patient contact, then you maybe request to be part of the patient participation group.”

That means that you get a little bit more of the stuff that really gives you that that purpose, and maybe lose some of the other stuff. It’s quite interesting. And I think control and autonomy is so so important.

One thing I noticed amongst people that have been out is that they think they’ve got no choice. They feel that they’ve got no choice in life, they’ve got no choice in work. And you always have a choice, even if the choice is to leave or to stay. That is still a choice. And we always encourage people to use the Zone of Power.

The Zone of Power [is] very simple. It’s a circle on a piece of paper. The Zone of Power shows you what you’re in control of, and what you’re not in control of. And just write down everything in your life you’re not in control of outside your circle. Write down everything that you are in control of inside the circle. And the work out, “What is there inside the circle that you could do that you’re not doing already to change stuff?”

And just another quick story, I was talking to another person who was coaching GPS. She said, she had this coachee, who was really nearing burnout. They really wanted to drop some sessions, because they knew that was the only way they were going to be able to cope with they had small children as well. And they said, “Well, have you asked if you can drop the sessions?” And the person said, “No, they’re just not going to let me I know, I think I’m just gonna have to leave.”

The coaches we’re facing, “Well, would you not even ask?” We should not even ask if the alternative is that you leave? Could you not ask? Ask for the outrageous. And she saw this person a few months later. And they said, “Well,” I just asked. I thought, well, I’ve got nothing to lose. I asked them they said yes.” And quite often people will say yes.

I would say, “Ask for the outrageous.” “What is the worst that someone can do? They can say No.” Then you know what your choices are, at least you know what your choices are. And I think so many times, we just go with what other people want us to do, rather than working out what we want to do. And again, I’ll put the Thrive week planner tool in the show notes that you can download and plan your ideal week and compare that to your current we can then work out. Actually, “What does need to change?”, “What needs to shift?” So I think, there is quite a lot of autonomy that we could take hold of that we don’t.

Claire: Yeah, I absolutely agree. And I really identified though, with what you said, which is that quite often people with burnout feel like they don’t have a choice, or that your choices are very didactic and black and white. It’s one route or the other route. And actually, there’s lots of options available to you. And you mentioned coaching, I think that’s where coaching comes into its own because you can explore the options available to you with the guidance of someone who was removed from that situation, as if you’ve got access to a coach. Absolutely. I highly recommend that people do that as well at that particular point in their burnout recovery.

Rachel: Yeah, and ​​I know that there are many, many places around the country that have coaching schemes for free, either an NHS Leadership Academy or training hubs, things like that. So just find out what you can get.

Claire, in a minute, I’m gonna ask you for your top three tips to prevent burning out again, when you’ve already had a burnout. But in the meantime, if people wanted to get ahold of you, how can they get ahold of you or find out about what you do?

Claire: So I’m most active over on Instagram, where I’m at drclaireashley. I also have a Facebook group called The Burnout Doctor. Anyone is welcome to come and join that. I also have a website, www.drclaireashley.com. And my subscription box website. I run a subscription box for Knackers Medics. It’s called Do Yourself No Harm. And that’s www.doyourselfnoharm.com.

Rachel: Right. Thank you. So if anyone wants to contact Claire, then do contact her by those links in the show notes. So Claire, what would be your top three tips?

Claire: Yeah. So these are my top three tips to prevent burnout from happening to you. Again, the first one is you must develop some sort of reflective practice. Ideally, journaling is probably the best way to do this, whereby you monitor your stress levels, and your thoughts, your feelings, your behaviors, your emotions, so that you can recognize if you’re starting to slide again. Because I did this myself, I recognized that I was sliding back into burnout last year, and I could get help sooner rather than later. If I hadn’t had that practice, I wouldn’t have known.

The next thing is, you have to go and do some work on your values and engage in values based decision making to prevent yourself from burning out again. And by that, I mean your values are kind of your guiding principles and the things that are important to you. The things that give you fire in your belly, and burnout changes your values.

Typically, after burnout, people tend to value their health more, but it’s like any cataclysmic life events, like a bereavement or starting a family. Your priorities will change. Your values will change after those those things happen. And it’s really important you know what your post burnout values are, so that you can then use that to guide every decision you make about your future career and the way you want to live your life. And if you don’t do that work, then you don’t have those guiding principles and you’re likely to make mistakes, unfortunately.

Then the first thing is, you have to put yourself first. You have to let go of that guilt and that shame. You can’t pour from an empty cup. And as healthcare professionals, we tend to put other people’s needs first. But the truth is that you can’t look after other people, if you don’t look after yourself. First, start looking after yourself. That means being boundaried at work. That means taking time to engage in evidence based practices that will allow you to manage your stress. Like for instance, during regular physical activity, making sure that you’re prioritizing your sleep. Doing all the stuff that we know as medics to stay well.

Start doing that now. Put yourself as number one. Life is short. No one on their deathbed ever says, “I really wish I’d worked harder” or “I wish I’d let the NHS flog me more.” What are you going to regret more?

At the end of your life, making a change or allowing yourself to stay burnt out and stay miserable, put yourself first. And I know it’s really hard for people that put the other people first continually. But if you want to serve other people, you have to be in the right place to do that.

Rachel: Thank you. I think that’s so important, that if you do struggle to put yourself first, by not putting yourself first you are not serving other people you because you will not be around for them not be available. And my three tips would be number one, ask for the outrageous however you can. Yeah, catch the story in your head, like what are you telling yourself?

And then number two, get help. Get help as soon as you can. Even if it’s just a sense check that story in your head, “You know, I’m feeling like this. What do you think?”, “Have you noticed anything?”, “Is this normal?”, from a neutral party [and] maybe not from your direct colleagues. Because they are maybe likely to be as burnt out as you are?

Well, Claire, thank you so much for being here. That’s been such an interesting chat. And I think there’s probably some really useful stuff there for people. I have to get you back at another time to talk further about this. And good luck. Sounds like you’re sort of really on a keel now, which means that you will just notice those changes earlier. So you hopefully won’t go back into burnout fingers crossed.

Claire: Fingers crossed. I feel like I’ve been very well supported, luckily. I’ve made a lot of changes. I have a lot more awareness now about my stress levels. So, hopefully I’ll be able to sustain things going forward. And thank you very much for having me. It’s been an absolute pleasure talking to you today.

Rachel: Speak again soon. Thanks. Bye.

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