Tips to Avoid Burnout in Psychiatry (Outpatient, mostly)

Summary

Psychofarm Podcast — "Tips to Avoid Burnout in Psychiatry (Outpatient, mostly)"

Date: March 24, 2026
Hosts: Dr. Gregory Malzberg (“A”) & Dr. Fu (“B”)

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Episode Overview

This episode of the Psychofarm Podcast tackles the pervasive issue of burnout among outpatient psychiatrists. Drawing on personal experience, clinical insight, and practical philosophy, Dr. Malzberg and Dr. Fu discuss why burnout is so common in their field, share hard-won tips for protecting one’s wellbeing, and reflect on boundary-setting, workflow optimization, and the emotional labor of psychiatric practice. Though aimed at outpatient psychiatrists, many tips are broadly applicable to all clinicians and therapists.

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Key Discussion Points & Insights

Opening: The Myth of Glamorous Schedules & Residency Stress

• The hosts joke about online misconceptions, such as inpatient psychiatrists going home at 2pm, and acknowledge the grueling nature of outpatient psychiatry.
• Dr. Fu points out: “Third year of residency is across the nation, the most stressful year.” (01:43)
• Dr. Malzberg counters with, “For me, first and second year were by far the worst. I like third year.” (02:12)
• Residency stress is program-dependent but universally tough.

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I. Practical Strategies to Prevent Burnout

1. Time Protection & Session Boundaries

(05:12–13:05)

• Strict Start/End Times:
  • Dr. Malzberg is “super strict about the time that I start. ...I never start late and I never start early. ...I end at 20 minutes [for a 30-minute block],” ensuring all work—including documentation—is completed within the session window.
    • Quote: “In that 30 minute block, I am done.” (06:24)
• Include Documentation in the Session:
  • Both hosts agree all encounter tasks should be finished in-session. Dr. Fu notes: “You can be psychotherapeutic while documenting.”
• Key Pearl: Never start early. Use any waiting time as vital rest.

2. Efficient Documentation

(09:26)

• Tip: Use a silent keyboard and mouse to avoid distraction and maintain rapport during note-taking.
  • Quote: “Get a silent mouse and keyboard. ...Patients always know when you’re documenting. ...You gotta be open about it." (09:52)
• Be explicit about documentation, and keep focus on patient care.

3. Task Lists & “Inbox Zero” Philosophy

(11:06)

• Dr. Malzberg keeps a notepad of tasks and commits to clearing it daily.
  • Quote: “I have a rule that by the end of the day I need to have all those things finished...don’t leave work until that task list is complete.” (11:34)
• Avoid letting administrative work snowball.

4. “All Care Occurs in the Session”

(13:05–16:05)

• Set expectations that discussion, forms, and medication changes all require an appointment.
  • “I set the expectation early that all of our care, if we're going to figure out something to do together, we need to schedule an appointment.” (13:29)
• If urgent, use reserved “emergency” blocks—not overtime—to see patients.
  • “I always have at least two 30-minute blocks that I keep protected...If it doesn't get filled, I finish my checklist.” (15:18)

5. Managing Emails & Messaging

(16:05–22:38)

• Expectation Setting:
  • Use email/text only for logistics, not clinical discussions.
  • Example strategy: Respond with "sent" or "noted" for nonclinical communications. For clinical inquiries: "Let's discuss at the next appointment."
    • Quote: “98% of my emails are sent. ...I set expectations very early that the use of text and email is not for clinical purposes, it's for rescheduling.” (18:03)
• Boundaries:
  • “If you train them very early on, that email is not how we communicate, they'll learn.” (21:02)
  • Recognize limits in certain practices but strive for the ideal.

6. Enforcing Rules & Psychological Frames

(23:22–27:51)

• Boundaries are critical:
  • “Rules and boundaries are really important. ...There is actually a freedom to operating within a system of rules.” (23:22)
• Kind vs. Wicked Learning Environments:
  • Providing clear, predictable treatment frameworks (“kind environments”) reduces patient and clinician anxiety.
• Don’t “rules-lawyer” yourself:
  • Adhering to well-established professional boundaries protects yourself and patients.

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II. Philosophical Themes & Emotional Wellbeing

1. Find Safe Outlets for Emotions

(28:26–35:18)

• Necessity of Trusted Supervision/Peer Support:
  • Dr. Fu: “If we don’t communicate our emotions and experience them, then they're going to turn into something else. ...Find people ... that you can safely communicate your emotions to.” (29:19)
  • Dr. Malzberg’s anecdote: Supervisors who helped him “process things and helped me to better formulate what was going on in my emotions.” (31:36)
• Technical Containment:
  • Not just venting, but having your experience “perceived and reflected back” (32:38).

2. Differentiate Complaining from Processing

(35:18–36:19)

• Set “complaining time” (scheduled venting) to offload tension, and recognize when it’s helpful vs. when it’s just rumination.

3. Give Up Your Power—Know Your Limits

(36:57–40:34)

• Accept Limitations:
  • “We don’t actually have that much ability to change outcomes. ...Most of what happens ... is determined by actions of people who are not you.” (36:58)
• Avoid overextending; honest appraisal protects your energy and honesty with patients.

4. Get a Life: Nourish Yourself Outside of Work

(41:20–46:08)

• Don’t let your job consume you:
  • “You need to have your ordinary life, right? ...So it's very easy to lose sight of that when there are dollars on the horizon or patient outcomes on the horizon..." (41:24)
• Schedule fulfilling activities:
  • Alone, with one person, and with a group—“it’s a protective factor.” (44:22)
• Protect vacations and downtime:
  • “Turn your notifications off ... make it so that you’re not getting bombarded with work at times that you’re not supposed to be at work.” (45:04)

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III. When All Else Fails: Structural & Career Recommendations

(46:08–53:35)

1. Seek Supervision or Professional Support

• Not all supervisors are helpful; find those who invite reflection on both clinical and emotional experience.

2. Change Jobs if Necessary

• Sometimes, the system is irreparably flawed for you: “There are some jobs ... it's impossible not to burn out. ...Get a new job.” (49:44)
• Ensure the “deal” is reciprocal: you should be getting back at least as much as you put in.

3. Therapy for Clinicians

• Personal psychotherapy can help when burnout persists.

4. Recognizing Burnout

(51:01–53:03)

• Symptoms: Frustration, negative thoughts about work, irritability, detachment, feeling unable to recharge even after breaks.
• Test: If a long vacation doesn’t refresh you, it may be time for big changes.

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Notable Quotes & Memorable Moments

• “It’s not your fault, but it’s your responsibility.” (Dr. Fu, 04:47)
• “Never start early. ...Even if you do nothing, waiting around for a few minutes ... that’s important rest time for you.” (Dr. Fu, 07:12)
• “All care occurs in the session.” (Repeated theme, throughout)
• “If you train them very early on, that email is not how we communicate, they'll learn.” (Dr. Malzberg, 21:02)
• “Rules are important because there is actually a freedom to operating within a system of rules.” (Dr. Fu, 23:22)
• “Get a life.” (Dr. Fu, 41:20)

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Recommended Timestamps for Key Segments

• 05:12 — Time protection and strict boundaries
• 13:05 — All care occurs in the session
• 16:05 — Managing emails and patient messaging
• 23:22 — Importance of boundaries and learning environments
• 28:26 — Processing emotions & mentorship
• 41:20 — “Get a Life” and scheduling life outside work
• 49:44 — When to seek a new job
• 51:01 — Recognizing signs of burnout

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Summary Flow

The hosts explicitly weave practical, administrative, and philosophical content, mixing dry humor with candid admissions of struggle. Their tone is collegial, gently irreverent but deeply invested in clinical integrity and personal sustainability. References to operant conditioning, residency heartbreak, and the parallel between psychotherapy and professional support make the episode relatable for any mental health provider.

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Listener Takeaway:
Burnout in (outpatient) psychiatry is common and dangerous, but can be powerfully mitigated through rigorous boundaries, efficient workflow, honest communication, and soul-nourishing life outside of medicine. Find your people, define your limits, hold the therapeutic frame—and never be afraid to make big changes or seek help when you need it.

Transcript

[A]

Welcome to the Psychopharm Podcast. This podcast is for education and entertainment. It certainly is not medical or psychiatric advice, diagnosis or treatment. Listening does not create a doctor patient relationship with me or Dr. Fu. If you're a patient, certainly don't change your treatment plan because of something you hear in the show. If you're a clinician, do not use this podcast as a reference or substitute for your own training, judgment, thinking and up to date sources. Opinions are our own and don't necessarily reflect any employer or affiliated organization and may even be detached from reality.

[B]

Good morning, Dr. Masberg. Good morning.

[A]

How's it going?

[B]

Oh, you know, sometimes I'm wondering whether I should have done inpatient psychiatry because if you believe things are posted on the Internet, I could be going home at 2 o' clock every day.

[A]

I know. I'm always surprised when I see what people are saying online that like it's like a three hour gig according to Reddit.

[B]

I actually think that is definitely possible sometimes. But personally I was pretty sure I didn't want to do inpatient because of the nature of that. I didn't want to kind of just meet people and send them off. I wanted to and my feelings actually help people. Not that inpatient doesn't help people. That's not what I'm saying. But there is a cost. I think there's another post recently talking about how little autonomy or how much work there is in outpatient psychiatry. Not sure if you saw that.

[A]

No. Before you go into the work in the outpatient for inpatient, if you're risk tolerant, I, I, I, I think there's more and more lawsuits happening. As we kind of mentioned with ChatGPT, it's getting easier to write lawsuit thingies. And yeah, I wouldn't want to be inpatient right now. That's my, my opinion. But yes, yes, outpatient is I have seen posts on in terms of the

[B]

stress and burnout occurring in outpatient because it's pretty grueling. You know, I think there's a reason why the third year of residency is across the nation, the most stressful year. And if you are a resident in PGY three year and you're listening to this right now, this is the worst you're going to feel in residency statistically or rather based on, you know, teaching wisdom. So don't worry, you'll start to feel better soon.

[A]

And if you're in first year, for me, first and second year were by far the worst. I like third year.

[B]

Really? Okay.

[A]

I feel like third year is the is where you Knowledge actually matters. I. I feel like you can get away with first and second year with knowing absolutely no psychiatry.

[B]

Program dependent. Dr. Mal.

[A]

That's program dependent. I. Yeah, lots of, lots of comments there that you can't get into.

[B]

Yeah. Anyway, this is all related to our topic today because what we'd like to do is we'd like to talk a little bit about burnout. Right. And how to sort of prevent or at least manage your burnout in outpatient psychiatry. Though I suppose a lot of things that we talk about can be modified or applied to other areas of practice within psychiatry, mental health, and as a psychotherapist too.

[A]

Yeah. I want to, you know, let's start with being practical. I also find I've supervise a lot of people who come in with burnout or, you know, just work fatigue. And a lot of times the people just want this, you know, this one simple trick. And it's very much more of a change in philosophical approach, I think. But there are. Hopefully we'll give you a few little tricks as well.

[B]

You know, this is another digression, but it sort of makes me think about an observation I have about patients comparing to patients. There are all kinds of patients that have the same diagnosis in terms of axis 1, but the more personality impairment a patient has, the worst a prognosis. You can see this in research and this is pretty obvious clinically. You know, you have the same patient coming in, one patient will be 80% better in three months and the other one will be the same or worse. And I think, I think that if you look at that patient's life, the patient who is not getting better, the patient with personality impairment, it's like there's a million little decisions throughout their life, obviously because they've had a very rough childhood most of the time where they weren't able to learn how to make the right decisions and meet the right people. But there's like a million little decisions that add up and just makes things so much worse. And that's similar in your practice of medicine. It's the little things. It's a million little decisions that add up. And so you have to start making little changes, little by little in order to anything better. If you're in a situation where you're being burned out, though, sometimes a big change is good too.

[A]

So, Dr. Fu, what you're saying is if patients aren't getting better, it's their fault, and if practitioners are burnt out, it's their fault? Is that is. Did I capture.

[B]

You know, everyone will always say in response to that. So I'll use one of my mantras. It's not your fault, but it's your responsibility. That's how.

[A]

Yeah, I've seen that in reference. That's a good line to use like, you know, mental illness is not your fault, but it is, it is your responsibility.

[B]

Yeah, unfortunately. Okay, what should we start with? Top tips on how to prevent burnout.

[A]

First is I think approaching the frame. So I think the thing we should start with is time protection. Do you want me to give us a start?

[B]

Yeah, you should.

[A]

Now, it's weird. I seem like a stickler when I talk about this stuff. I am super strict about the time that I start. I am at most the most I've been late in probably the last six months. To appointment is like 15 seconds. So I never start late and I never start early. There's like a 15, 30 second window that I consider trying to get to the appointment. And never starting early is something that's. It might seem counterintuitive because you're like, oh, I'm here early. I can get a start early. You know, then I can maybe get the appointment done five minutes early. But I communicate to the patient very, very strictly this is our start time. And then the same as that, I end at 20 minutes. So I know there's a 30 minute block of appointment. I consider that 30 minute block the full time. I have to finish the encounter. And what is the encounter? The encounter is talking with the patient, giving all my recommendations, writing my notes and finalizing, you know, you. I'm a big fan of sending emails and resources and things. So pulling together the resources and sending the resources to the patient. So in that 30 minute block, I am done. Like I'll, I'll, I'll have no more work to do. Of course there will be patients that I have.

[B]

Let's be clear. You are including documentation and script, sending absolutely everything. Absolutely. Very good. Me too.

[A]

So I really use those 10 minutes and I finish absolutely everything. I consider like it's very, very rare that I'm not completely done with the patient at the end of that 30 minute block.

[B]

Yeah. Now, you know this is going to mean in Today's World in 2026, it is going to mean that for med management, you have to document during the session. Do you document during the session?

[A]

I don't. I have AI scribes.

[B]

Same thing. You gotta have a scribe, you gotta use AI and me, I document during the session. I'm sorry. You can be psychotherapeutic while documenting. You just have to get used to it and know what you're doing. And you, I think in today's world have to do this in outpatient, where 30 minutes is somewhat considered a luxury. Now, in terms of per patient time, you're gonna have to be efficient. Never start early. I absolutely agree. I always tried to start on time. And depending on your particular practice area and type of clinic, you may not be able to match Dr. Malsberg's excellent timeliness. You know, if you're within five minutes, you're doing really well. But I used to start early, even just a couple of years ago, and that was a mistake because it doesn't actually help you, I think. And even if on one individual case, you end up spending a little bit more time or effort, in the end, you're going to burn out. You're going to be expending too much time on yourself. Even if you do nothing, waiting around for a few minutes for the next session to start, that's important rest time for you, the clinician. So keep that in mind. I totally agree on time protection. Yeah.

[A]

Now, a few, you know, practical tips in terms of things we talked about. As I mentioned, I wrap up my appointments at 20 minutes. Now. I let the patients know. At, you know, certain patients, you'll kind of get a flow for how long the appointments will be. But for patients that you know are going to go long at the 15 minute mark, I give. If they're in the middle of something really heated, no matter what they're in the middle, I'll pop in and say, hey, just, just a reminder, we got five minutes left. Whatever you set the expectation is, will determine how the patient interprets how, you know, if you set an expectation that you're supposed to meet for an hour and then you cut them off at 30 minutes, they're going to be like, what the heck? Like this, this guy's, you know, he's a pill pusher. If you set the expectations early, the appointments are 20 minutes. When they go and end at 20 minutes, the patient leaves. Happy now? Second number. Second pearl. For practical tips, you mentioned that you document during your appointment. Get a silent mouse and keyboard.

[B]

That's right.

[A]

I have the Logitech MK295. So the patient doesn't know that I'm typing and clicking during the appointment. And it's not because I'm not scrolling on the Internet or anything, but I'm able to take notes, make notes for what I need to do at the end of the appointment. Pull together resources, and it's not intrusive into the appointment. So get a silent mouse and keyboard. That's a patient.

[B]

Always know when you're documenting. And I think we gotta be open about it. In fact, I'll even sometimes say, give me a moment, I wanna write that down. I don't think people mind if you document. I think what they mind is if you're doing things that really aren't about their treatment. And so what's important as we communicate is about their treatment. It really should try not to do other people's documentation like with the patient. That makes no sense. Right. But yeah, I agree. You got to pick a end point and you want to be consistent with that endpoint. Being explicit about it is good, but simply practicing it on a regular basis and your patients get to know you, you get to know them, they'll begin to know. And what you mentioned in terms of things heated, this is not always going to be possible. There are some patients who are more disregulated. But your job is also to regulate the patients. And there, there are certain techniques that you can do for that. But that's mostly psychotherapy training. This stuff that we're talking about, about the frame and timing, you know, it's been tried and true for psychotherapy, if you've had any training. This is old news to you and it makes sense, right? Originally, before Clopronazine, all outpatient psychiatry treatment and even inpatient psychiatry was psychotherapeutic, not based on medications. So, you know, learn from, learn from the old ages.

[A]

Just a small plug to leave a review if you can. Leave a review will help other clinicians find our show and will let us keep making it. If you're on Apple podcasts, open the show page, scroll to ratings and review. If you like this, tap five stars. If you're not sure what to put for the review, just say, hi, Dr. Fu. And if you're on Reddit or YouTube, leave a comment. Dr. Foo reads absolutely every single one. Let's get back to the show. Yeah, one, one last little, you know, tidbit that's relevant here. And I can't go into like a full system for how you, you know, organize all the tasks you need to do, but at all times. I have a little notepad, the classic you put a little square, you put the task that you need to get done. And what I, I have a rule that by the end of the day I need to have all those things finished that I, I learned that from a mentor in that like have, have a task list and don't leave work until that task list is complete. I found that I got burnt out because what I would happen was I wouldn't finish my task list and then it would build up and I would get stressed because I would be thinking about all these things that I needed to do. I have a task list that I run throughout the day. You know, let's say I need to do a prior off and I'm not able to get it done in that 30 minute chunk. In that I put a square, I put prior off and I get it done before the end of the day. And I never let, I'm making it sound like I'm a star here. Starting within 30 seconds and I never let my task list. I'm exaggerating a little bit for effect, but I try to get my task list done before.

[B]

You gotta make the attempt. Right. And if you're already going hours after closing time with documentation and work, it's not going to be feasible to get everything done, you know, within 10 minutes of close in one week. Right. Small changes and it takes time. Anything worth doing takes time, you know, and you may need outside help to troubleshoot your workflow if you're in a dire situation. I've helped people with that before to good effect.

[A]

One last point. If, if, you know, you find that you're constantly going over, set early expectations with your patients and the intake, say, you know, my intake is an hour, my follow ups are 20 minutes. Yeah. All right, let's move on to our next big topic for avoiding burnout. And that's that all care occurs in the session. Yeah. Do you want me to take the start?

[B]

Yes, sure.

[A]

So when patients need forms filled out, when patients send emails about questions about medications, you know, patients have an emergency, I set the expectation early that all of our care, if they want, if we're going to figure out something to do together, we need to schedule an appointment. A big part about this, a big additional thing to this is. And we'll talk about emails. I think in our next point. In emails, patients will send questions. They'll send like, hey, I don't think I actually want to start the Lexapro. Can we try gabapentin? I set the standard for emails. I say all the time, let's discuss it. Next appointment. So just set the expectation with patients that whenever we're going to do some work together, whenever something needs to get filled out, whenever we're talking about side effects or whatever, we're going to do it in that 20 minute chunk.

[B]

Yeah. You know, this is something that you Kind of have to be flexible with because many clinicians don't get to set their own rules at the practice and you kind of have to roll the punches. But if you sort of aim towards an ideal world where all non emergency things of substance are managed within some kind of appointment time, that is going to be majorly helpful if you can just get as close as you can to that platonic ideal based on your practice.

[A]

Yeah. And everything that we're talking about here is a platonic ideal. And what happens in reality is that I'm able to follow it for 90% of patients and I have the expectation of myself that I'll follow it. And then 10% are just unavoidable things that I, you know.

[B]

Yeah, I can.

[A]

Yeah.

[B]

I mean even if there is something urgent, don't try to set out, put out that fire unless it's a true emergency. Say let's get you into the schedule as soon as we can, if that's appropriate.

[A]

And there's patients who email all the time. And I'll just repeat, let's discuss it next appointment. Let's keep care decisions in an appointment. One tidbit, as you say, like, you know, a lot of people don't have control over their schedules and things, but if you're private practice, build emergency appointments into your calendar. I always have at least two 30 minute blocks that I keep protected that I keep for, you know, patient sends an email, needs to be seen shortly. I don't panic because it's not like oh, now I gotta stay till 7:30. I throw it into one of those emergency slots. I think that's so helpful for people who have their own practice is build in. I have two emergency appointment blocks, like 30 minute. You can call it admin time or whatever. If it doesn't get filled, I finish my checklist. But it is helpful so I don't panic when someone has a problem because I know I can get them in.

[B]

Now messaging and emails is perhaps the bane of the modern physician's existence. And open notes too. Now that's a contentious topic, maybe for patients rights advocates, but I do think that this sort of change in technology and how people interface with physicians is going to push good physicians out of the field and cause burnout and the rest of the. In the ideal world, I don't think there should be any direct messaging. I actually think that worsens care. It feels like it's great to be able to just message someone all you want, but that's actually quite a divergence from the traditional model of Care and it's kind of like imaging. Right. If you could have access to an MRI anytime, that would mean unnecessary imaging that would cause panic and anxiety and keep you from sticking with one set of findings. Right. Getting more information or contact with the doctor is not necessarily a good thing for treatment is my global statement here. So the ideal world, in my opinion, the best setup is that you do have some kind of a first frontline staff, whether as a clerk, receptionist, nurse, social worker, somebody should be frontline in order to manage messages. That's ideal. But of course many practices can't work that way. So I'll let you handle the rest of advice when it comes to how you manage messages and emails.

[A]

Yeah, we're having, we're having the opposite. Because here I'm like, yeah, that's a, that's a great point and is a useless point. Yes, I, the practice I work at now, I have to have text available. So we use that spruce. So patients have. All patients get access to my phone number at the beginning.

[B]

If you run a cash practice, by the way, I think you should charge per contact. But anyway, go on.

[A]

And this is, this is a insurance based practice. I of course wanted to check out of this. They don't have my personal cell, but they do have the work. I hate that. I wish I could check out. But you know, as you said, like, we have to adapt to reality. I can't throw a stink and say I refuse to do this. I'm not going to be hireable if I do that. So here's my. I, I established, I developed an approach to email and then I just applied it to text messaging. I set expectations very early that the use of text and email is not for clinical purposes, it's for rescheduling. I also established super early on that I am not a friendly emailer. I 98% of my emails are sent. It's just the word sent. I don't even take the time to capitalize the S on sent or it's noted, period. That's the vast majority of my emails are one word. I set expectations early. If patients send me giant blocks of texts of my partner did this and now I'm feeling this way, I say, let's discuss next appointment. So here's the thing I want you to take away. The expectations you send will change how the patient responds to the content of the email. I established very early that email and messaging is not how we work together, it's not how we contact. So if you send me something, I'm going to Give you a bare minimum response. And I, I communicate this. If a patient is constantly sending emails. Well, I, I guess I'll get to that in a second. But I make it very clear that this is my style of texting and patients don't get offended by it. If you. Very early on, you know, Dr. Fu, thank you so much for your wonderful message. I really appreciate that you took the time to write it. Let's fig the patient will think of it as like training. Like you're training them to send emails, you're training them that it's, this is how we, how we work together. So I train my patients in a sense that, like, email is not going to be a way that we communicate.

[B]

Yeah. And why do we do that? Right. Again, no one is going to meaningfully recover or get better from email and texting. I'm sorry, that is not a standard or acceptable treatment modality. And the more we sort of lean into encouraging, even implicit by being overly interesting or validating on our emails, that mode of communication, instead of setting appointments, meeting face to face and talking, I think the more we do a disservice to people because it may feel good, it may feel helpful, but that's not a standard mode of treatment. It's really extra time now for practical matters that are necessary, like if I've made a mistake on a prescription, that's absolutely something, you know, we want to know about. And your system should have a setup where that can be managed. But for anything of substance that isn't related to some kind of a clerical or EMR error, you got to do that in an appointment.

[A]

Yeah. And this, this was something. Every person I've supervised, when they say they're too, like they're over, they're, you know, work until 8pm or whatever. I, I go through their emails and I'm like, this is way too much. This is way too much. This is way too friendly. You don't need to say, hey, great to hear you. How was your vacation? It's just, it's not the time. So, you know, again, the key thing here is against that. Majority of my emails are sent noted or noted. Let's discuss it next visit. I also establish very early if patients, you know, let's say we started gabapentin. And then they say, I make it a point to discuss everything that's important, but if they have questions, I say, let's schedule an appointment. If there's, you know, anything that can't be answered in, in one sentence, I prioritize saying, like, let's schedule an appointment. And I, I found that patients learned very, very quickly that like, oh, this email's not just not gonna communicate. If I, if I wanted to learn something or start a medication, I need to, to have an appointment so that I get very few emails. Now, of course I do get some. But if you train, it's like, you know, people do what they think is appropriate. So if you train them very early on, that email is not how we communicate. They'll learn.

[B]

I don't know if people are going to appreciate the term train, but yes, it's your responsibility as the clinician to set the frame and to keep the frame. It's part of the frame.

[A]

Me and my partner are getting a dog, so I've been learning about operant conditioning.

[B]

Yeah.

[A]

So I apologize for the word train. I just read a book, Dogs on the Mind. How to. How to train dogs. So

[B]

that's true. We're all mammals anyway.

[A]

This leads me to another big point for avoiding burnout. Talk about everything in the appointment. If a patient sends a long email or we email, it sends me a bunch of emails that we're going to talk about it. The patient has the expectation that you don't just bombard me with a ton of things and then the next appointment will be, hey, how are you doing? We're going to talk about it. And if the patient's sending intrusive emails, I've gotten more and more comfortable with saying like, you know, talking about it. This is not how I really work. Why do we think we're kind of having this? Talk about patients who are sending me emails, talk about the content of the emails, talk about better ways of dealing with things. So set expectations early. It makes a big difference.

[B]

Yeah, I mean, rules and boundaries are really important. It may initially feel good to have a lot of apparent freedom that there are no rules. Makes me think of that sketch from. I think you should leave. That may not be a reference that most people get, but rules are important because there is actually a freedom to operating within a system of rules. And it's actually anxiety provoking to be operating within a system that doesn't have rules. This is related to Robin Hogarth talked about two concepts, kind versus wicked learning environments. And I think this is a very important thing to keep in mind as you enforce and keep boundaries and frames. You know, a kind environment is a predictable environment. This is where the rules are very clear, there is reliable feedback from the system and patterns are predictable. And repeat. This is like a chessboard or a checkerboard Right. It's a fixed system, stable outcomes. You can learn about it and be right about your predictions in the future. A wicked learning environment, on the other hand, is where information is incomplete or hidden. What happens as a result of your actions is delayed, inconsistent or absent. And your outcomes are maybe shaped arbitrarily by biases or heuristics. Now why is this important? Well, I think that a lot of difficulties in life and personality and development come from wicked environments in the developmental environment. Right. If you grow up in a inconsistent environment like that, then you don't learn confidence and trust in yourself in the world. And of course you're going to be used to dealing with systems like that. So an important part of our treatment of patients as clinicians is to provide a kind learning environment within our treatment modality. And the other side of that coin is what we opened this episode with, that you have to be not burned out to give good care. So it serves both things and that's a huge reason of why it's so important.

[A]

Yeah, I love, I love this talk about, you know, this applies both to patients environment in terms of what they're experiencing with us. And I'm. This also immediately makes me think of the wicked environment of being a resident. I, I like the work you do. You don't get, you switch different attendings and you get different yelled at for different things and you get no positive feedback. And it's very unclear. But the, I think the point you're trying to get across is with patience, establish your rules, have it so that they know that if they do this, this is going to occur. And those expectations are very comforting. They're protective. They make it so that if they do send a long email, they know what they're going to get in return. If they are late, they know they're going to have to talk about it. What the rules are is less important as knowing what the consequences are. And I think we talked a little bit about that in the frame and that the important thing is knowing what's going to happen if I do something right or do something wrong.

[B]

Yeah. That being said, I wouldn't try the rules lawyer self either in the sense that you, you shouldn't violate a principal rule or standard of practice because you think it's for the greater good. You know, read your state board, medical board's disciplinary hearings or outcomes and you're going to find so many situations where someone lost a license for good or bad reason because they thought they were doing something for the greater good initially you don't know what is going to come in the future and little decisions add up or can cause a butterfly effect that you're not seeing right now just because you think it's the right thing today. So that's why the rules are important. You have some time tested principles, you keep on those and work within that system. That's my strong advice. Without getting into more details about how things can get wobbly, not having boundaries, risks, all kinds of violations, ethical, clinical, keep to your set of rules and principles.

[A]

Maybe, maybe we should use this time maybe to move from the practical, you know, frame based things for helping burnout and move to the more, more philosophical things that we want to talk about.

[B]

I think it's a good idea. So you know, that's. So we've been talking like about within practice stuff, but I suppose there's something that. I don't know how to put it. Philosophical is pretty good, I suppose. Or maybe it's about approach or attitude. And it's not just within the practice, but some of it is outside of the workspace.

[A]

Yeah. So the, the first one actually want, want you to kick us off you. When we were, we were messaging about this, you said communicate the emotions. Can, can you talk more about what you meant by that?

[B]

Yeah, I mean this is something that we get from psychotherapy theory.

[A]

Right.

[B]

Which is really a matter of human theory in the end, how we work as human beings with consciousness. We have kind of a lonely job, especially in outpatient psychiatry where there's less of a team. And you're going to encounter all kinds of emotions, positive and negative, and you're going to have to communicate those to somebody. You're gonna have to turn those emotions into words. And what makes it difficult is that we need to keep patient confidentiality. We can't give particulars about specific cases.

[A]

Right.

[B]

But if we don't communicate our emotions and experience them, then they're going to turn into something else. Stress, anxiety, tension or actions. And so one of the global principles I have is that you should find people in your life that you can safely communicate your emotions to. And what's safe is that your emotions are simply heard and recognized as they're not undermined or ignored. You don't need to be told necessarily that your emotions are 100% correct. It's simply recognizing that, that they're there. These kinds of interactions with other people. You should feel reasonably good about having expressed your emotions. And you might not have this resource in your life. Not everybody has this, unfortunately. And if that's the case, One of the only other avenues would be supervision, a peer discussion or support group for clinicians, or of course, emotion focused talk therapy, psychotherapy.

[A]

Yeah, I'm gonna talk about some of my experiences with what you're saying. So in residency I found I, I didn't relate to a lot of my co residents and, and you mentioned communicating emotions when we, you know, we were. We would do group therapy together and when I would talk with a lot of, not everyone, obviously, but a few of my co workers, I, I found it actually increased my stress. I felt like there were things that we just didn't see things the same way and I didn't relate to the problems that they were having. There were aspects of patient care that I was really struggling with that it wasn't helpful because they were, you know, I can think of one in particular who was. All they wanted to do was make sure that they only worked from nine to four and anything that was inconvenient to them in terms of like getting out at 4pm that was like the world's worst thing. And, and what I learned there is that complaining wasn't a helpful thing. Like if I, if I was just complaining about the different emotions I was having or problems, it wasn't productive. I like, it just got. It increased my anxiety and it made me feel worse.

[B]

Overall.

[A]

What really changed was when I found two particular mentors, Dr. Israelovich and Dr. Q. They were people who were able to take what I was experiencing and help me to make sense of it and help me to better understand the problems that I was having. It made me feel less alone during these supervisions. I remember it was so I would walk in frantic, where it was like, this is a problem. I'm worried about this. I don't know what to do about this. And I would walk out being like, I got this, I can handle this. And oftentimes it's not like we were solving problems. There was just something about talking with a trusted mentor that made me feel like I was processing things and helped me to better formulate what was going on in my emotions. So the advice I always would give was find a mentor or a supervisor who's been through these things and can help make sense of them with you.

[B]

It's really lovely anecdote, I think, and it highlights sort of what I refer to as technical containment, which I think is the core of all talk therapies and of parenting for young children and of just talking to your patients. You know, there is a difference between ruminations and complaining, right? And communicating and experiencing emotions to another person who is able to perceive your inner world. The latter is what we're trying to get. Get as close to as possible. You know, is talk therapy of that quality or mentorship of that quality, accessible to all people? I don't think that's realistic. That's an ideal again. Right. So, you know, practically many people will have to get this kind of experience through their community and their family to the best of their ability. But for the clinicians who can find it, it, try to find it. And also try your best to remember that this is something you practice yourself as a clinician. What is technical containment? It is when you perceive the inner emotional experience of another person, you receive it, digest it yourself, and you communicate back to them in some fashion that you've done so that you've perceived them. That's all. You're not giving information, you're not changing anything. That in itself is important.

[A]

Yeah. And that's, you know, I think the. Another catchphrase of kind of what we're saying here is find your people. There's going to be people who kind of do that naturally and, and you feel understood and people that when you go to them with your problems, they make you feel, like you said, understood. So now that I'm out of residency, you know, I, I have sought out. When I find someone who thinks like I do, who experiences similar problems, shout out to. To Ben and Ron. You know, just make little text groups of, of things that you can kind of talk about problems and say, hey, I'm experiencing this. And, and when you find your people, you'll feel heard, you'll feel understood. Yeah. So, you know, like the people that understand you and that can help make sense of your problems, that hold on to them. Like, like, like foster those relationships. Yeah.

[B]

And be that person for somebody else too. Right. Like I said, because of the necessity of patient confidentiality in this field. This is not a field where you can just go out and blab about what you're doing for work to everybody. So you will have to find some more specialized venues in order to process, so to speak. Yeah.

[A]

Now the flip side of this is kind of talking about complaining. There are some, some complaining is helpful. I, I've also learned for myself of, like, there's sometimes that I'm complaining and I can hear my head. It's like, this is not anything. This is just you talking. And, you know, the solution I've now created is I come home and my partner, I sit down on the couch and for 10 minutes I get all my complaints out. This person was mean to me.

[B]

The.

[A]

The food was cold, this thing happened, and then I'm done. So just to say, like, there's kind

[B]

of a classical CBT technique scheduled worrying. We're complaining, right?

[A]

Yeah, Just dumping the problems. So, you know, find out what you need to, you know, and. And put a cap on the stuff that, you know, isn't deep emotional processing. And, and to your point, the thing that helps is my partner knows that she's just supposed to sit there and go, huh, oh, that's terrible. Oh, poor you. And then we move on. And we don't. We don't need to, you know, like, it's not the time when I'm, you know, it's like, didn't your father do this? No, it's not. It's just like, I'm just getting this all stuff out.

[B]

That's right. Before you do any analysis, this talking in a psychotherapy frame. Now, as a clinician, before you do any analysis, okay. Before you do any interpretation, before you do any confrontation. Contain, contain, contain. Demonstrate to the patient that you have actually heard and experienced something like what they have gone through within themselves, emotionally, psychologically. Okay? So the second global piece of advice that I often give to prevent burnout. I don't know if this really comes across in the tagline I like to use, but I say, give up your power. Give up your power. What do I mean by that?

[A]

Similar to your don't work too hard.

[B]

I. But, yes, that's another one. That one maybe is closer to the frame. Don't work too hard, but give up your power. Okay, what do I mean? You know, we're powerful people in the sense that we hold a very special social role where we hear and do things that most people never hear or do for other people. So it's also easy, I think, to get an outsized feeling of how much power we have. We don't actually have that much ability to change outcomes. We're a small piece of this system, this machine, and most of what happens with patients is determined by actions of people who are not you, whether that's the patient or people in the patient's life or the social system they're within. We need to really be clear about what our duties are, what we're capable of changing, and especially what we're not capable of changing. We cannot really control or prevent bad outcomes. We're going to see suffering, we're going to want to change it, and we're not going to be able to change it. That's life and being able to understand the boundaries of that is a hugely important thing, I think for the inner experience of the clinician.

[A]

Yeah. This is such a big one. The thing that really helped me, I feel like sometimes you'll say that the best way to figure these things out is to have experience and to know it. But really figuring out what my role was helped me to, as you mentioned, give up my power. My goal isn't to make everyone the self actualized and the peak of personal function. So knowing the limitations of what you can do is really protective because you know, as you're saying, like it gives you the freedom to actually provide the best care to everyone because you're not overextending yourselves in ways that aren't productive for the patient. So I, I really like this one. I think it's such a helpful thing that, you know, knowing that your role, like there's just limitations to what you can do.

[B]

Yeah. And you know, if you're clear about that and honest about it, I think it helps with the patient care too. Right. You really gotta know what the general effect size of SSRI is. You shouldn't oversell it. Right. Because if you oversell it, you're going to give people the false impression that this is a powerful medication that's going to change your problems. It's the same thing. Know the limits of your powers and what you're responsible for and what you're not responsible for and give people a reasonable sense of that at the beginning and then we'll know how to proceed together based on that.

[A]

Yeah. And you know, your give up your power and the don't work too hard. These aren't saying like be lazy. These aren't saying don't, don't work hard. It's more of an understanding of our limitations. And by understanding what you can and can't do, you provide honest care and you're less susceptible to getting enmeshed or getting wrapped up in some enactment that is probably going to hurt the patient. So these things are not the short

[B]

and the long game. Right. You know, we can't just think about today. Same thing with the medications. Don't just think about what's going to be happening in the next six weeks. Think about side effects that could happen over the lifetime. And similarly, the way you do your practice today, you know, can't just be about the next six months or the next week for this particular patient. You have to think about how are you going to maintain yourself as a good functioning clinician over the rest of your career.

[A]

Yeah. In your notes. And maybe you said it again, but understanding that, you know there's going to be suffering that you can't, there's nothing you can do about. And part of our role is learning to accept that there's not anything that we can do about that suffering. So it's, it's not all your stuff to take on.

[B]

It's going to feel bad. Don't get me wrong. You're not going to be able to do much about that besides talk about it. But talking is important. Emotions are important, even if they're painful. The final element of what I tend to advise, this is probably the easiest one to do in a way. So I, I often start with this one. But it's get a life. Get a life.

[A]

What does that mean? We gotta clip this. How to avoid burnout. Just get a life.

[B]

Yeah, get a life. Well, you know, you can't just be your job. There are workaholics. Some people, they dislike that. They're gonna be that way until, you know, they can't work anymore or even they'll. They'll just work up until they pass away. I, I don't recommend that, even for those people. But most people are not like those people. You should not let your professional identity consume your life. You need to have your ordinary life, right? What you do outside of work, the reason that you're working just simply to live. And so it's very easy to lose sight of that when there are dollars on the horizon or patient outcomes on the horizon, or your professional identity that you feel that you want to guard and protect because of all the work you've put in for it. But you gotta live your ordinary life. So if you're not doing it, I, I think you gotta schedule these things into your weekly schedule. It helps to schedule things because if you simply say, I'm going to do more of this or that, it's not going to work. This is similar to the Smart Goals concept for cbt. So are you exercising? Are you engaging in your hobbies, both hobbies that you do alone with a partner or in a group? Are you eating healthily and correctly or very unhealthily? How are you doing in terms of intimacy, both with friends and in your romantic life? And how are you doing with things like religion, spirituality, and other social large group activities? These are the same things that we should be checking on and talking about and encouraging with our patients. Right. It's not just a medication we throw at people. This is something that we should at least check in on by simply asking about these things, we highlight their importance and we can't neglect it for ourselves either. Have to get life.

[A]

Yeah. And this, you know, this reminds me of my one, one of my siblings just had a kid and they said the second they became apparent, like work just dropped in priority like crazy. And all of a sudden it was just incredibly easy for them. You know, when someone said, hey, I need, I need a meeting scheduled tomorrow to just say, you know, unfortunately I'm not available, you know, maybe in two weeks. And their work didn't suffer for it. They're just because, you know, I think it's so important to have protected that you protect your personal time and, and view it. Let's say you are a workaholic and you do think your work is the most important thing. View it through the lens of in order for you to be the best you at work, you need to be able to disconnect and have time where you're doing other things. So a part of getting a life is protecting your personal life. If you work for someone, they're going to always want you to take on more appointments. They're always going to want to, to fill your. To fill your appointment slots. Protect yourself, you know, prioritize the other things in your life.

[B]

Yeah, you can get very concrete about if you need to. I actually tell residents before third year and also before they're first attending here, I recommend in advance that you schedule at least one of each activity every week. An activity that you enjoy and feel fulfilled. After that you do by yourself. Something that you enjoy and feel fulfilled after with one other person and something that you enjoy and feel fulfilled after with a group. Do I even do this? Not necessarily, especially as things get busy. But again, it's a platonic ideal and I would say in my opinion, no science behind this. It's a protective factor. Something that's a little insurance for you, keeps you from being too wrapped up.

[A]

Absolutely. Maybe something related to this that's connected. Another recommendation I make is in regards to vacation. When I take vacation early on when I first started, I was tempted to not turn on my email the automatic reminder. And if I would get messages to be able to take care of something, the person who was supposed to be the covering physician, whoever the covering physician I would be, I would email them quickly and be like, hey, I can take care of this. I actually recommend when you take time off and you take vacation, protect that time. Turn your notifications off, use the covering positions, really protect that time and don't let Work intrude on it. And this is true both after work and on vacation. But essentially like make it so that you're not getting bombarded with work at times that you're not supposed to be at work. So, so, you know, put on those vacation reminders, tell people you're on vacation, protect that time.

[B]

Yeah, it's really, really important. And this not only applies to patient facing care. You know, I remember in my first year doing a bunch of medical record review for the medical board on Christmas in a cabin in the woods. Okay, not going to do that again. You got to make sure that you look at your own timelines, you look at your own work and you set the rules for yourself about when you're going to work and when you're not going to work. Otherwise it will pervade your life and in my opinion, you'll burn out. Yeah. So we've talked about a bunch of general recommendations. You know, they could perhaps be implemented individually, maybe sometimes they can't. I feel like if you can't implement this stuff into your current practice and you're feeling burnt out, there are I think, three major solutions. One major solution, this is not in any particular order, it's getting supervision, postgraduate supervision, coaching, mentoring, even if you have to pay for it, you find the right person, it can make a pretty considerable difference. But get your money's worth. Don't overpay. That's what I think the second one might be. You have to get a new job. I'm sorry, there are just some jobs, whether it's a matter of the system that's in or because of the particular management or the coworker workers or anything. Some jobs are just not going to be suited for you. It may be a perfectly fine job for somebody else, but you are your own person. Then you got to find what works for you. And the third one is just the ham fisted recommendation that all psychiatrists and mental health people give is the psychotherapy, but if it's actually properly done, one that's gonna help

[A]

going through each of those ones. In regards to supervision, what I'll say is there's huge differences between different supervisors I had in residency. There were supervisors who it was, you ask the clinical question, you get the clinical answer and that's it. The ones that I found the most helpful, it was like this blend of therapy and supervision, like this supervisor would ask me questions about. It wasn't just answering clinical questions as much as it was my own emotions to patients as much as it was how, how I was feeling. About things, you know, the discussing my aspects of my own life. So find a supervisor that like to me it felt like I was. It was like a therapeutic thing to go to supervision and it was more than therapy.

[B]

But it is true that there's a lot of parallels and many of the same techniques are used. But I think a good supervision invites with open ended questioning and self reflection. For the clinician being supervised. If that's not present, it's going to be a little bit limited in utility. And frankly you might even be able to get it from a large length model AI. That's not how good supervision works. What you're describing I think is great supervision and it is a fundamental part of working in the mental health field. We have to be able to self reflect if we're going to be able to help patients do the same. Yeah.

[A]

And I tend to find most of those people have some psychoanalytic training. The ones that do the supervision I'm describing.

[B]

There's a concept called the parallel process even where in a psychodynamic or psychoanalytic supervision, what happens within a patient therapist interaction will begin to replicate itself within the supervision session. And you have to manage that. So it's no surprise. But it's still technically non attack therapy because the goal is not to get the supervisee different from their own personal life or mental problems. Right. The goal and the frame is about improving yourself as a clinician. So that's why it's not psychotherapy.

[A]

Absolutely. Your second recommendation for getting a new job. There are some work environments that I think it's impossible not to burn out. If you just have impossible number of patient appointments, if you have no expectation for vacation, all those things. It's impossible for you to live a fulfilled life. So get a new job. I do think is not the work environment is so important and your expectations and supervision provided.

[B]

Yeah, globally I would say think about what you're contributing and think about what you're getting back. A job that does not give back at least equivalent to what you put into it, that's not a good job.

[A]

Right.

[B]

Neither do I think there should be too many jobs where you put in very little and get a lot back. But especially in a free market system, if, if you out of obligation, feelings of guilt, depressive feelings, keep yourself in a job that is basically a bad deal for any worker. You are preventing the system from correcting itself and producing better jobs for other people. So keep that in mind you depressives out there.

[A]

Absolutely. I think, you know, I think we're Getting close to wrapping up, but maybe we should talk about when to recognize that you're burnt out.

[B]

Okay. Yeah, probably should have started for that.

[A]

Sorry folks, when I'm burnt out, one thing that I first you have to like learn your own emotional blueprint on things. When I'm starting to get really frustrated by cases, when I find that I'm just complaining to my partner all the time and it starts bleeding into, you know, not just my little 10 minute complaint time, but no matter what we're doing, you know, I'm playing ping pong and then it reminds me of, you know, this one difficult co worker and I essentially what happens is it starts to kind of bleed into other things. And what I find is oftentimes all it need, that's when I need a vacation. There's so many times that I get into these bad head spaces and it's like all these patients are so tough and my boss is a jerk and my co workers are a jerk and then I go on vacation at the end it's like, oh, I can handle this. So, and we talked about having colleagues and supervisors but, but listening to, you know, if people start to pick up that you're not feeling like yourself. There's so many times that really all I need is, is a break and some, and some disconnect time and I am able to recharge.

[B]

I don't think I, I mean clinically, let's put it that way, it's going to look like adjustment disorder because that's pretty much the standard stress response of a human being to a bad situation. When there is not a really severe medically identifiable disorder that's pretty much burnout. Right. So general overwhelming feelings, negative thoughts and feelings about your work or your situation and you know, recurrent thoughts about that, fatigue, irritability, certainly feeling helpless, detached. These are all standard signs. And if you have the right partners and friends in your life, simply asking them whether you've seen more unhappy or irritable can be helpful. Especially if you're in such a state where your ability to self reflect is being impaired by your stress. Yeah.

[A]

And I think, you know, my advice is if after a, well long enough vacation, like you know, more than five days, if I still feel the exact same way, then I start to reconsider if it's burnout or, you know, I do need to change that job or I, I do need to really make a big change in my life. Because to me the big question is, is this burnout? And that once I'm refreshed I'll feel differently. Or is this a sign that I need to make real change in my life? So, yeah, my, you know, little.

[B]

And I suppose it's worth mentioning that the things that you do should be helping your overall functioning. It can't just be an escape. Right. There's difference between an escape and something that is. And that's going to apply to any breaks, hobbies, activities, vacation. And also the group of people that you commiserate with or communicate with, as you mentioned. Right. Simply complaining or talking about things negativistically, it's not necessarily helpful. Sometimes it can be. You just gotta look at your individual situation and how what you are doing is helping or not helping you. What's leading you forward? What's holding you back? Yeah.

[A]

Awesome. Should we wrap it up?

[B]

I suppose so. I hope this is of some kind of help. I feel like the things that aren't psychopharmacology are a little less interesting to people, but we'll see what people think and maybe in the comments, anything that we haven't mentioned that you found helpful in your life for recognizing or addressing or preventing burnout?

[A]

Yeah, I think that'd be really cool if people. People shared because it's always helpful. You know, little tidbits are helpful.

[B]

That's right. All right, until next time.

[A]

All right, thanks for listening. If you want to support the show, check out my very practical antidepressant course. If you want to check that out, go to Psycho Farm. If you prefer to read, you can go to Amazon.com you can just search my name, Gregory G R E G O R Y Malzberg. M A L Z B E R G and the book is Psycho Farms Guide to Treating Depression. It's a nice, easy, readable, practical guide to medications for depression.