Despite loving my patients, I burned out. I chose my own quality of life over continuing to work with the chronically mentally ill population that I adored. This patient population is frequently shortchanged with their quality of care and I have joined the ranks of people failing them.
This is my experience working in one mental health clinic in the United States. Every clinic runs differently and there are fantastic systems out there. I am so grateful for the amazing clinicians and psychiatrists that continue to dedicate their lives to this population even when they are underpaid and overworked.
We go into medicine to treat patients, yet systems issues can destroy our resilience and prevent us from doing what we love. Instead of facilitating care, dysfunctional systems drive away physicians and make it even harder for patients to get quality treatment.
It's not surprising many clinics aren't well-run given the stresses of funding them. Care for the chronically mentally ill population isn't prioritized and is poorly reimbursed.
My plan was to continue working at the clinic for my entire career. Little by little, clinic policies chipped away at positivity and staff morale was dismal at best. With budget cut after budget cut issues of financial sustainability trumped all else in clinic focus.
Clinic leadership had an incredibly difficult job worrying about financial solvency. Obviously, if your house is on fire you aren't going to start rearranging the furniture. However, when you realize house fires are a new unfortunate norm you need to be proactive; to minimize damage from the fire and also continue to make your house the best it can be.
Our clinic had safety issues that desperately needed to be addressed. For years I tried to address them. I wrote out detailed plans for what needed to be changed, why it needed to be changed, and how to make the changes. The changes I suggested were common sense and cost little to no money.
Leadership agreed to make these safety changes but never carried them out. I began to feel like the system that I was working within didn't have our backs and was too overwhelmed by fundraising to care about "mundane" issues like patient and staff safety.
I started to feel burned out. Defeated and powerless. The patients brought me so much joy, but the system was depleting it. I lost faith in the clinic leadership and could no longer excuse inefficiencies as a byproduct of clinic work. I began to see the inefficiencies as more indicative of leadership incompetence. Our safety was being put in jeopardy and leadership had turned a blind eye.
Lest you think I am exaggerating I will share with you one example:
The kitchen was in the middle of the building with doors on either end. The doors were always propped open and led to the clinic hallways where patients were being seen. The kitchen doors had no security system even though doors with key fobs were already separating the waiting room from other staff and patient care areas.
Every time a birthday was celebrated at the clinic a large pointed carving knife was brought out to slice the cake. This knife would then be washed and left in the kitchen drying rack. This drying rack was right next to the open door and visible to all who walked by. To me, this seemed like an obvious safety concern.
My suggestion was to put a key fob on the kitchen doors to limit patient access. The costs would be minimal given we all already had fobs. After a year of emails from me spelling out my concerns and multiple meeting with various leaders, they agreed to put the fob on the doors. But nothing was ever done... It was not a priority forthem and they didn't care enough to follow through. Finally, the person who originally brought in the knife heard about my concerns and took it back home.
During the same years that I was struggling to get anyone to make changes to improve safety, the clinic reduced the time for patient appointments from 20 to 15 minutes and switched to electronic medical records. Patients in individual therapy were shifted into group treatment. Now no one had the time to listen to and care for our patients.
When a system stops listening to, valuing, and protecting their staff while at the same time shifts all the focus away from treatment to funding; patients and staff feel unheard and marginalized together. We end up walking side by side with our patients, both of us sharing a lack of hope and positivity. We feel powerless together and no longer see a way to improve our environment or a path to a brighter future.
When I left the clinic, it was because I could no longer tolerate a system that wouldn't improve. For me, it meant leaving my patients who I had worked for 9 years to engage. Trusting therapeutic relationships don't always come easily in this population and I treasured that they allowed me to share in their lives.
When I left, my patients lost a physician who cared about them and their quality of life. They lost a human connection when there may be no one else in their lives. I knew they loved chocolate milk, meatballs, and smoking. They also loved to play basketball, wrote raps and poetry, and didn't eat if they were too distracted to go to the soup kitchen. I knew what their early relapse signals were and how to engage them enough to tweak medication in hopes of warding off a hospitalization.
I am not suggesting I am the only one that can do this work but I also recognize this is an area of psychiatric physician shortage. I am replaceable to a clinic focused on finances. Our most psychiatrically challenging and medically complex patient population is slowly being treated predominantly by locums tenens psychiatrists (who don't have the time to build relationships) and mid-level practitioners (often newly graduated who now need to treat highly complex patients on multiple medications with multiple medical conditions).
Despite all this, I think I may have lost more than my patients. I lost part of my career purpose and the passion I had to find a way to engage and treat this population.
For now, I am grateful if I catch a glimpse of one of my beloved patients walking down the street or cross paths with them in town. I know you are alive. I hope you are well cared for. I'm sorry I left you.
These days, the issue of physician burnout is starting to be acknowledged and spoken about. Efforts are underway to identify and address the health care delivery issues contributing to it (hello electronic health records- we are talking about you) without just telling physicians they need to practice more mindfulness to survive. I hope employers start to listen.
A version of this article first appeared here.
Dr. Melissa Welby is a psychiatrist that participates in people’s process of discovery, empowerment, and search for satisfaction and happiness. She treats a variety of illnesses including depression, anxiety & panic attacks, adult ADHD (Attention Deficit / Hyperactivity Disorders), bipolar disorder, OCD (Obsessive-Compulsive Disorder) and borderline personality disorder. She is also the current president of the Connecticut Psychiatric Association.She completed her Internship & Residency at Cambridge Hospital, affiliate of Harvard Medical School, 2000 to 2004. Dr. Melissa Welby is Board Certified in General Psychiatry by the American Board of Psychiatry and Neurology, 2005 to present.