See, Hear, Feel

EP97: Dr. Benjamin Doolittle on the inner life, burnout, and wonder

January 17, 2024 Professor Christine J Ko, MD / Dr. Benjamin Doolittle Season 1 Episode 97
See, Hear, Feel
EP97: Dr. Benjamin Doolittle on the inner life, burnout, and wonder
Show Notes Transcript

Dr. Doolittle has a Master's in Divinity as well as an MD, and his research spans hepatitis, HIV, and wellness and burnout. He'll often ask his trainees, "How is your spirit?" It was a pleasure to talk to him about the intersection of medicine and spirituality, the inner life, how it might relate to burnout, insights on how to stave off burnout, and the connection among curiosity, wonder, and love. Dr. Benjamin Doolittle, MaDiv MD is a Professor of Medicine, Pediatrics, and Divinity, the Director of the Internal Medicine-Pediatrics Residency Program, Medical Director of the Faculty-Resident Continuity Clinic, and a Professor of Religion and Health at Yale University. He has special expertise in addition, hepatitis C, HIV, and primary care. His research focuses on the intersection of medicine and spirituality, wellness, and burnout. Dr. Doolittle is an ordained minister and serves at New Haven’s Pilgrim Congregational Church. He is quoted as saying, “The medicine is easy, but everything else is hard,” and, “Faith offers…mystery, wonder, love – which are not illogical, but are not logical either.” More on Dr. Doolittle as well as an article on bio-psycho-social-spiritual training for trainees.

[00:00:00] Christine Ko: Welcome back to SEE HEAR FEEL. Today, I'm very excited to have a conversation with Dr. Benjamin Doolittle. Dr. Benjamin Doolittle has a Master's of Divinity and an MD, and he's a Professor of Medicine, Pediatrics, and Divinity; the Director of the Internal Medicine- Pediatrics residency program; Medical Director of the faculty-resident continuity clinic; and a Professor of Religion and Health at Yale University. He has special expertise in hepatitis C, HIV and primary care in terms of research. Separately, his research focuses on the intersection of medicine and spirituality, wellness, and burnout. Dr. Doolittle is an ordained minister and serves at New Haven's Pilgrim Congregational Church. He is quoted as saying, "The medicine is easy, but everything else is hard." And, "Faith offers mystery, wonder, love, which are not illogical, but are not logical either". I'll put links to two articles related to Dr. Doolittle in the show notes.

[00:01:01] Welcome to Ben. 

[00:01:03] Benjamin Doolitle: Hey, hello there. Thanks for having me. 

[00:01:06] Christine Ko: Would you first share a personal anecdote? 

[00:01:09] Benjamin Doolitle: I just came back from England where I was a visiting scholar at Cambridge University and then also St. Andrew's. I went there for all of these intellectual reasons, right? There's all the academicy stuff and a couple lectures and stuff like that.

[00:01:27] But at Cambridge, they have these chapel services open to the public, these evening services in the Anglican tradition. At least two or three times a week, I would go to these services. And, it was a spiritual awakening for me. I was there to do all this intellectual stuff, and I had a bunch of papers and a book project and all this stuff, but to sit in these dark chapels with psalms being sung, surrounded by candlelight was so deeply moving that the takeaway from this experience, was a reawakened gift of the inner life.

[00:02:09] Christine Ko: That brings me to my next question because it sounds like you were on your leave from Yale, but still doing work related to your job as a physician, and then you found this spiritual, evensong practice. So can you talk a little bit about the intersection of medicine and spirituality?

[00:02:28] Benjamin Doolitle: The practice of medicine for physicians is so challenging, right? We know burnout is about 50 percent, and it's been stable for 20 years. It's been unchanged. So there's this inner life, that's so important for us to cultivate. Our patients struggle with their own inner struggles that are beyond their physical illnesses. The hard part, I think, is how do we alleviate suffering? Or doubt? Or anxiety? Or worry? And some would argue, That's not medicine's job. Our medicine, our job is to fix the sick body. I don't know, I think our patients come to us for more than that. I think right underneath the surface of medicine are deep interior questions that are ultimately spiritual questions. 

[00:03:21] Christine Ko: I just spoke with Dr. Jeremy Howick about empathic communication and other things, and one of the things he emphasized is that the mind and body are not actually separate. This is related to good care.

[00:03:34] Benjamin Doolitle: In the same breath, I think it's very fair to say, Hey, I went to medical school. I'm not a pastor or a counselor or a psychologist or a spiritual director. I'm not any of those things. I'm a doctor. That is completely legitimate. I totally agree with that. We cannot ask of our physicians more than what we've been trained to do. I just find that we should all at the same breath recognize that what we're doing is really complicated and we probably need a lot of help to do it right.

[00:04:06] If we don't have some kind of inner life that's real for us, it's really hard to sit across from a patient. You'll notice I'm very careful not to use the word religion or spirituality, right? I'm using this, the word inner life. I like that phrase better because both words, religion and spirituality have this maybe pejorative load to them, a lot of baggage attached to both of those words. So I like the idea of a of an inner life. I'm really interested in the inner life of physicians because of this idea that death is a professional colleague and doubt is what we confront every time we don't know what that rash is or what the patient's symptoms mean. And along with doubt comes an existential anxiety, right? Of, what can I offer? What can I do for this patient? Who am I in the world? Those questions, they're not ethical questions or humanist questions. They're spiritual. These are spiritual foundational questions.

[00:05:02] It brings me back to the recent experience of sitting in these ancient religious services that were outside of my tradition. If we define religion as a set of communal beliefs and practices, let's say, spirituality might be a more internal belief system that may be uncoupled from traditions. If we define it like that, it makes me think where spirituality is very weak is it's ultimately this isolated solo endeavor. It's tends to be an isolated solo endeavor where we never use it the way we want to. And maybe in this post modern, post religious world, we're hungry for something meaningful that makes sense to us. And this is where I think religious disciplines are actually very liberating and very deepening. Every time I leave the gym, I'm always so happy that I went there and exercised my body. And whenever I leave a religious worship service, I am glad that I exercised a part of my inner life. And I wonder if the answer is not so much to be spiritual. The answer is to incorporate religious disciplines, like we show up the way we show up for a tennis match or a yoga class or show up for dinner with our friends. Part of being fully human is to incorporate disciplines of the inner life. What do you think about that?

[00:06:31] Christine Ko: I like it. What you said just now touches on mindfulness, being present, showing up fully present.

[00:06:39] Benjamin Doolitle: Being a physician is a lonely role. The challenges we face and the anxiety and all that, like it's so beautiful and hard at the same time.

[00:06:48] Christine Ko: Yeah, you said something else about a physician's existential angst related to, is what I'm doing for this patient or that patient or all of my patients really making a difference? That kind of thing. And also, you mentioned how over the last 20 years, burnout has been about half of physicians and it's been stable.

[00:07:07] Although, and not to contradict you, but I think burnout is a little worse now. 

[00:07:12] Benjamin Doolitle: Yeah, it could be. Yeah.

[00:07:13] Christine Ko: I have a theory that existential angst is really what leads to burnout, not really actually the amount of work that we have to do, although sometimes the work is overwhelming.

[00:07:24] Benjamin Doolitle: Yeah, I think you're right, right? The disconnect between what we perceive our role to be and what the tasks that we are asked to do. Yeah, there's a big disconnect there. Burnout has an actual definition. It was this pretty interesting psychologist out of the 1970s, her name was Christina Maslach, and she realized that there was something that was different than depression, different from anxiety, that was purely work related. She defined burnout. It's a great ,word, right? We instantly know what it is. The way she defined it is that there were three things. One was emotional exhaustion, which is this idea that you're not just tired at the end of the day, but your tank is empty, right? There's no emotional reserve. The second thing is depersonalization or where you see the patient as an object. And then the third domain is lack of accomplishment. So like you feel like, a sense of futility, like what's it all good for? And those three domains hang together pretty tightly, but they're distinct. 

[00:08:20] We do know that burnout tends to be stable. We know that if you're burned out as a med student, you're more likely to be burned out as a resident. If you're burned out as a resident, you're more likely to have burnout as an attending, and that it's connected to all these other things, which are really hard: increased errors and struggling marriages and all that.

[00:08:39] Initially the language around burnout was that it was my fault and your fault, right? That you and I weren't meditating enough, and we weren't eating enough vegetables, and all that. And then it quickly became a system issue, the rise of all the chief wellness officers, and if we can devise systems to reduce our clicks per hour, that will solve all the problems. I think the pendulum is swinging back where clearly there are systemic issues that need to be addressed and workload and collegiality and all that stuff. But also, I think, there are clearly intrinsic challenges that we have to address, inner life type issues. Being goal directed, left brained analytical, perfectionist, driven... those very things that make us successful physicians, right? Those are the things that get us into medical school and get us into residency and then help us get a good job and get promoted and all that. But it does seem to be those very traits that are also maybe what leads us into burnout or anxiety and all that kind of stuff. Our strengths are also our challenges. 

[00:09:41] Christine Ko: Absolutely. It's just like in a relationship where what initially attracted you becomes a thing that like really actually is the downfall. I didn't realize that burnout is not really like a different population being affected at different times? it tends to be the ones who are affected in training are the ones who continue on to be burned out physicans? So it's like you're affected early on and you just never get past it? 

[00:10:03] Benjamin Doolitle: Within reason, and honestly, we don't really know. We're collecting data now. 

[00:10:09] Christine Ko: In your experience, separate from research, is there a way to keep people from being burned out? 

[00:10:15] Benjamin Doolitle: I was very curious about that very question. A group of us asked that question. We found happy physicians and asked them, Hey, why are you so happy? We did it among primary care physicians. Actually, that was the first project. The first was primary care physicians. Then we did emergency department physicians, and we did residents. We've done different populations. One was a group of people living in wheelchairs. They suffered spinal cord injuries. Another was a group of palliative care physicians who care for children with HIV in South Africa. And there was a group of Pakistani physicians. Oh, and then one of my favorite projects, people who sing in a choir. But the method was essentially the same, which is we find people who are not burned out. They meet criteria for not being burned out. And then we have various satisfaction scales, satisfaction with your life, satisfaction with your job. And if they meet criteria for satisfaction, then we enroll them and interview them. And the qualitative studies have been really fascinating. We've done more than 200 interviews of these different pockets. Essentially a few things have been common among all of these different people who were thriving, who are not burned out.

[00:11:34] One is a strong internal sense of purpose or a strong value. So value, purpose. No one's in it for the money, the prestige, the whatever. Most everybody had some degree of autonomy. They were super busy people. They did not have great work life balance. Very interesting, right? We talk about work life balance. These folks didn't have work life balance. But they did meaningful things. And they had some control. Except for the residents. The residents, they had no control. Residents, instead of control, they felt like they were well supported by their program leadership. That was the one kind of value that was swapped out. Value and purpose. Some kind of autonomy. A love of medicine. They just loved medicine. They loved medicine, and they love their patients, the relationship with the patients.

[00:12:22] And then the other one... Physicians who were thriving, all of them had some rich overlapping circles of social network. Not just one social connection, rich, overlapping kind of stuff. And that was a very loud signal. And as we've been doing these interviews, I became very interested in personality type. Are there certain people who just love the social connection, and is that why they're not burned out and why they're satisfied? And it doesn't seem to be. The other thing that was fascinating of all these studies were the folks who were living in wheelchairs, they all had spinal cord injuries. So they knew what it was like to walk and now they were not walking. And they described, and to be fair, this was a group it was a peer mentoring group called "more than walking". The folks living in wheelchairs would describe how they needed to have purpose, and they needed to contribute by being a peer mentor, but they also needed to ask for help, that they recognized the need for others and to ask for help. Boy, that's a very profound lesson, too, right? And maybe we docs could learn something from that, a little bit of vulnerability, a little bit of reliance on other people, a little bit of asking for help. 

[00:13:41] Christine Ko: Knowing what you know about burnout, with those themes of purpose and but then some differences like for residents, for example, they don't have autonomy really necessarily as residents, but so then they need support. Are there some simple things that you actively do to create wellness?

[00:13:58] Benjamin Doolitle: I think we have to show up for our bodies and our spirits and our minds, right? So we go to the gym. We exercise, we go to sleep, all that stuff. We must show up for our inner life, through reflection, introspection, worship, exercising our wonder and awe. And then we must show up for our mind and deepen our skills and our intellect. Maybe when through the grind of life, if those three things get out of balance, that's when we suffer our existential crisis or our burnout. And so it does make sense to pay attention to those three things in a very intentional way.

[00:14:37] Christine Ko: I love it. I love it. You mentioned wonder, and it's in your quote that faith offers mystery, wonder, and love. Can you touch on that a little bit? 

[00:14:47] Benjamin Doolitle: This is one place where science and religion meet. Where they meet is in mystery and wonder, right? We don't know so much. And there is a sense of awe when we ponder the complexity and the beauty and the suffering of our patients and of ourselves, medically. There is mystery and wonder and awe in that. The next step from mystery and wonder is love. We are connected to this great beyond, and we're connected to each other. And that connection is love. And at the end of the day, we can nurture mystery and wonder and love the way we would nurture a garden. Where science and religion maybe meet, our response to that is love I believe.

[00:15:39] Christine Ko: I like it. It's beautiful. Do you have any final thoughts? 

[00:15:42] Benjamin Doolitle: Beyond mystery and wonder and love? 

[00:15:46] The step before mystery and wonder and love, I think, is curiosity. I think it starts with curiosity and leads to mystery and ends in love. 

[00:16:00] Christine Ko: Thank you. Thank you so much for doing this. Thank you for your time. 

[00:16:04] Benjamin Doolitle: Yeah, it was lovely to meet you and thank you for asking me.