Burnout in Healthcare: How Depersonalization and Dissociation Manifest, and How to Overcome Them

In this episode, we explore the emotional toll of burnout on healthcare professionals with Dr. Jessi Gold, a psychiatrist and Chief Wellness Officer at the University of Tennessee System. Burnout often manifests as depersonalization—a form of emotional detachment that shields clinicians from the relentless trauma they witness. Dr. Gold delves into how this protective mechanism can lead to emotional numbness, distancing healthcare workers from their patients and even themselves. We discuss the concept of alexithymia, where prolonged detachment causes clinicians to lose touch with their own emotions, making it challenging to process trauma or empathize with patients. Dr. Gold offers practical strategies for overcoming burnout, such as early intervention, therapy, setting emotional boundaries, and advocating for systemic change within healthcare institutions. Tune in to learn how reconnecting with the meaning behind their work can help clinicians rediscover a sense of purpose and resilience in their careers. By listening to this episode, you can earn 1 Psychiatry CME Credits. https://www.psychiatrypodcast.com/cme-program Link to blog. https://www.psychiatrypodcast.com/psychiatry-psychotherapy-podcast/episode-226-burnout-and-depersonalization-in-healthcare-with-dr-jessi-gold Link to YouTube video. https://www.youtube.com/watch?v=LDFch7RSSyY

Speaker names marked ? are inferred from speaking time and the show’s known hosts — they are not voice-verified.

• 0:13David Puder?

  All right, welcome back to the podcast. I am joined with Dr. Jesse Gold. She is a psychiatrist, chief wellness officer, and practicing clinician at University of Tennessee. And you've been in practice for, it sounds like about 10 years. Is that right?

• 0:30Speaker 01

  Yeah, if you count residency. I tend to count residency, though. So, yeah.

• 0:34David Puder?

  Yeah, well, I sometimes count the last two years of medical school because it's like you're seeing patients, you know, 80 to 100 hours a week. You should get credit for that, right?

• 0:44Speaker 01

  That's fair, yeah. So I graduated med school in 2014. So I guess, you know, give myself two more years. I'm doing a little more than that then.

• 0:52David Puder?

  Okay, nice. And so you wrote a book recently called How Do You Feel? And if you're on YouTube, you can see a nice little picture of that in her background, and you can see all of her diplomas. And I want to share my initial reactions. I mean, this is a very personal book to you. Tells your story a lot. It also shares a lot of story of clinicians, physicians that you treat. And like, I'm reading it, and I know that you are like the real thing. You know, like you are really in the trenches through COVID and through just, gosh, all of the, like, you see it all. And I know because I was at Loomblin University for a number of years.

• 1:36David Puder?

  I'm actually phasing out of my last role there this week. And I saw a lot of medical students and residents over the years, but it sounds like that's really your focus. Is that right? Physicians, residents, medical students?

• 1:49Speaker 01

  Yeah, I kind of, when I left residency, I saw college students and was the psychiatrist on a college campus. And then really, over COVID, transitioned to primarily seeing faculty, staff, healthcare workers. And that's been kind of the thing I've been really focusing on since. I was always doing it like research and otherwise, but it kind of all came together in that time period.

• 2:11David Puder?

  Yeah. And so I'm thinking about what life is like for you in the trenches, so to speak. And it's like, part of your stories that you share are like so vulnerable. It's almost like uncomfortable to read because it stirs up so many of my own stuff, you know? And I also know you kind of go around and lecture quite a bit to the different departments. So you're kind of like the point of contact person. And so that's like a unique, kind of a unique role. What was, I guess, what was like the biggest surprise for you? Kind of as you ventured out into this role, especially in the midst of COVID,

• 2:53David Puder?

  in the midst of like providers really feeling a level of burnout, a level of anxiety that we haven't felt in a long time?

• 3:00Speaker 01

  So personally, I think I was surprised by how much guilt I had. I know that that's probably confusing a little to people, but you know, we go to school and we're taught to be frontline workers and they pulled us off frontlines because we can do psychiatry behind our computer. And I was spending so much time listening to colleagues and friends and patients talking about their experiences. And I think in trying to make up for the guilt, I overdid it some because I thought, well, if I just saw more patients, like I'd be giving back more and that mattered. Or if I just did more outreach and education virtually to all the departments, like I could make up for the fact that I wasn't on the frontline supporting them.

• 3:44Speaker 01

  So I think listening to them triggered something like that in me where I thought, like, my way of giving back, my way of helping in this really hard time period was to do everything I possibly could to support their mental health. You know, from a clinician perspective, what really has always surprised me is how long it takes us to get help. So I think a lot of the people who show up in my office are pretty bad by the time they show up. I mean, I'm a psychiatrist, so I get that there's some skew to that, like, because people come to psychiatry when they want medication. But inherently...

• 4:22Speaker 01

  We wait a really long time because we're doing our job, taking care of other people and prioritizing them over ourselves and also have so much stigma and so much concern about getting care that it really delays us getting help. And a lot of the time, by the time somebody's like in my office, I'm just like, oh, man, I wish you came months earlier.

• 4:45David Puder?

  Years sometimes, right?

• 4:47Speaker 01

  Yeah, years earlier. And it's really disappointing, I think, especially like working in the profession and knowing what mental health is and knowing the biology and knowing all of that stuff. It doesn't really fight the stigma that still exists, particularly in our profession, but also this like belief that if you are a hero, if you are helping, you shouldn't need help. Like, that's a weakness in some way.

• 5:13David Puder?

  Yeah, I, I think, of course, we need our own therapy. We need our own, you know, team around us to be able to, to be able to continue to perform. And, but even the way I say that, it's like, to be able to perform, right? Like, there's something in that. And that's the kind of stuff that like came to my mind as I was reading and kind of listening to what you, what you've been talking about. It's kind of like this idea of like, we have it in our mind as professionals, like, we are here to perform. Like, we are human doers. We're not human beings. We're like, like, like, sick days, for example. Tell me about sick days. What is sick days like for physicians?

• 5:55Speaker 01

  Oh, man. I mean, so there's this concept called presenteeism, which is basically the opposite of absenteeism, meaning we show up all the time, right? So absenteeism, we like, measure days for people to say, how is sickness affecting the workplace? No one's measuring presenteeism because we're there, right? And so for physicians, for other people in healthcare, we learn really early on not to do that for lots of reasons. One, burden is a big word that always comes to mind for me, but I think our system, without redundancy, is really set up to make it so if you take time off, someone else has to come cover you and you learn like- You don't want to be that person who's asking for help from a colleague or a coworker. And so you really don't want to do it.

• 6:40Speaker 01

  And then the other burden is to patients, right? So as an outpatient psychiatrist, if I cancel a day, all those patients don't get care. And they probably won't get care for another month or so because it's not like they could magically fit into my busy schedule. And so I often will look at my day before I decide if I'm sick enough, you know? And I think you see modeled for you, people coming in with things that like you just like, this is a really bad physical illness. Like, I don't understand how you're allowed in a workplace where you can make someone else sick because you have patients, but you just like the stories I've heard as a clinician, but also just like in the ethos of our sort of medical culture of people like putting

• 7:24Speaker 01

  in an IV and dragging it because they're throwing up at work and just like being really proud of themselves for coming anyway. Or like, oh, I got in a car accident on the way to work. I didn't go to the ER. I did my whole shift and then I went to the ER. Or lots of stories of women miscarrying on the job or basically waiting until they have their water break to, you know, start taking maternity. And you're like, these are really intense sort of high bars for taking time off. And, you know, where does mental health even fit on that? Because our scale is like, are you in labor and or actively hemorrhaging? Then maybe we'll listen.

• 8:09David Puder?

  Yeah, yeah. It's, it's like, uh, it kind of reminds me of the culture I had in like sport. I played sport and I rode in college and it was like one of the, one of the top programs in the US. And it's like you, there are no sick days. Like you are showing up and

• 8:29David Puder?

  I remember just the one time I actually got so sick that I couldn't show up. Like I had such incredible guilt, you know? But then I remember being told by the doctor, like, no, you could actually die if you went and you rode in the next week, you know, like you need to not row. And I just felt like this relief, like all of a sudden, like, okay, fine. I can like finally rest, right?

• 8:55Speaker 01

  Yeah, because I might die. So that's, that's a real thing.

• 8:59David Puder?

  Yeah, it's like, it's like you could, you know, you could actually kill yourself. I remember him saying, and I was like, oh, okay, maybe I can't show up.

• 9:09Speaker 01

  Do you remember seeing in med school, like, somebody showing up like, and people thinking it was super cool? Because I think when I look back, like, I can picture people above me in training, like residents passing out in a surgery, just like kind of stepping away, having a banana and like coming right back in and like the whole team praising them for it and me thinking like, that's really cool. I should do that. Like I, I need to be that cool because everybody else seems to think that's cool. And like years later, in sort of reflecting and also seeing folks as patients, I'm like, what a messed up thing to think, but that's what you're told to think, you know?

• 9:50David Puder?

  Yeah, it's kind of, especially on the, I think whenever there's, whenever you're closer to death, right? So I did, I did some research on like psychological safety and connection and stuff like that. And one of the things that I noticed was psychological safety is the worst in places that the death is the highest, right? And I think that's because there's a little, it's almost like that sort of like war vibe, right? Where it's like, no, we are literally in war and like you being a part of this team is saving lives and therefore like your feelings, your personal wellness is like totally, totally secondary to the mission.

• 10:33David Puder?

  And.

• 10:35David Puder?

  You know, it's, yeah, I think that there has been that culture and I think it's probably not going to go away, you know, like completely.

• 10:44Speaker 01

  I don't think so either. I mean, a lot of those things like we see younger folks coming up and being more aware of mental health and being more aware of themselves and sort of work-life balance in general and kind of saying this is absurd, why is this a thing? But until the system has better ways to do coverage and redundancy, until there's less of like that burden on you, especially in residency, I don't really know how you can be told like to show up like only when you feel perfect or something like I just think we just don't have a system like that. And so you kind of have to learn to deal with the way that the system is if you want to stay in it, at least for now.

• 11:27David Puder?

  Yeah. And I, okay. So I would, I would say it's not even that they have enough people to cover. It's like they almost like under cover nowadays. Like I had this nurse that worked in an OR and they would on a regular basis have like a lower than a hundred percent staffing on purpose, just to, just to save some money or just to, you know, and then someone would no show sick. And so now like the whole system is stretched very thin and everyone's stressed out. And it didn't seem like the people up the chain really cared

• 12:05David Puder?

  at all. And so I, I feel, I fear with the, you know, the constant drive to for profit and commercialization of big healthcare networks, like this is not going away. This may get worse, it may get, it may get worse, you know?

• 12:22Speaker 01

  Yeah, you know, I, I like to hope that they have some more awareness of some of this stuff because COVID shoved it in their face. But I have a lot of belief that they also would like to think that COVID was like a fairy that came down from the clouds and made things bad and went back up to the clouds. So we're all good now, like as if when it's over, whatever, when you declare it done. And people are fine. It just is what it is. You're back to that. And so, you know, and part of my impetus, honestly, to like, write the book and start having these conversations again is I'm like, no, they're not. Like, we weren't fine before. We're not going to magically be fine now. But, you know, I don't disagree with you that like, there's a lot of urge for the system to just like, kind of,

• 13:06Speaker 01

  mold back, like if you stretched it and it was like, I'm all right, time to go back to the way it was. We're not changing. And so, it's really frustrating when we're measured in dollars and not kind of like who we are as people.

• 13:23David Puder?

  Yeah, yeah. Okay. So like, yeah, tell me, tell me the motivation you have to write. And I think for you, writing, it seems like is like, it's like, it's like, almost like, um, therapeutic, you know, it has therapeutic value.

• 13:36Speaker 01

  Yeah.

• 13:36David Puder?

  And I, and I want more of my audience to write, you know, so if you're like a long term listener, and you're writing your book, let me know. And I want to, I want to hear about it, you know, but, um, okay. So yeah, tell me, tell me a little bit about the motivation and.

• 13:49Speaker 01

  Yeah. I mean, so I started writing in med school, exactly like you said, like I had big feelings and we weren't supposed to have big feelings and I needed a place for them. And I started writing about them. I didn't necessarily intend for it always to go out or anything like that. But the biggest time I had an experience in med school where, I was basically tricked into doing cardiac massage on a person who was already dead, like physically pumping their heart. And I really didn't know that I was like a early third year med student. And it was really hard for me when I figured out what happened and then sort of saw how jealous the other med student was, but like, also, nobody was saying like, what an interesting teaching experience. How was that like for you? Or like, anything like that. And so.

• 14:32David Puder?

  Wait, wait, wait, slow down. So you were tricked into it? Like, what do you mean tricked?

• 14:37Speaker 01

  Yeah. So like, you know, that's a, it's a, it's a quick summary statement, but really, I was in the case for like 30 minutes, a trauma that guys like, completely open and they're trying to fix what's going on. And about 30 minutes or so in, they're like, hey, med student, meaning me. Can't scrub in and I'm like watching this. I have no idea what's going on. I have no idea even what any of these people are doing. And I'm like, okay, so I go scrub in and then I come into the case and they tell me to like, put my hands like an alligator and like pump the heart in my hands. And then kept yelling at me for like not doing it right. And then at the same time also had me jab epinephrine into the heart

• 15:19Speaker 01

  and stuff. And I'm sitting there and I'm like, what is like, what is going on here? Like, I've never done even like CPR regularly on a person yet. Like I have yet to do that. This seems extreme. And I didn't realize like the person was really already dead until like the anesthesiologist was like, hey, like, what's going on over there? Is it time? Like basically kind of like, are we done with this experiment yet? And then, you know, he said that the surgeon said, you know, time of death. And then the anesthesiologist was like, I had a feeling, I had a feeling when you called the med student in.

• 15:59Speaker 01

  And I was like, like, I was like, this was like a sick, like,

• 16:04David Puder?

  Really awful.

• 16:05Speaker 01

  To teach me or something. And you know, in med school, I, I knew I wasn't going to be a surgeon, but I, you know, you have to try your best on all those rotations and learn what you can learn. And it rocked me, did not feel good.

• 16:20David Puder?

  It's like a little, it's almost like it feels a little bit like psychopathic, you know, to, to have to jump in there and do something that is utterly futile. But you don't know it at the time, but they're doing it because they want you to have this experience or something. And I like the experience so that maybe if it wasn't a death, like maybe you'd be able to help. But then it's like, but this was a person's like sacred life and like you're being kind of called into this action. In the midst of like, a really tragic moment. So yeah, I can see why that would be really, it would, it's almost like a moral injury of sorts.

• 16:57Speaker 01

  Mm hmm. And I felt like ill physically, but like even trying to do it in the first place, like while I'm getting yelled at for not jabbing the right way, like, and I'm just like sitting there and I'm like, what, I don't think I'm the right person for this. And I, my head's just like, can you say no? No, you can't say no, you know? And afterwards, I went to talk to the dean, just being like, this happened, I don't think that was right. And, and you know, she was, she was very validating and supportive, but was also like, yeah, that guy, he does that. We keep talking to him, but he keeps doing that. And I'm not sure that us talking to him is gonna make a difference.

• 17:38Speaker 01

  And I'm sitting there just kind of being like, oh, okay, I guess that my experience is now common. So they're, they're done with it. But you know, that took me to writing because I was so mad and so frustrated and felt so like helpless.

• 17:53David Puder?

  Yeah.

• 17:54Speaker 01

  And you know, I wrote a piece and sent it to my med school mentor and she was like, one, first, I'm really sorry that that happened. But second, like, this could really help other people if you would feel comfortable doing something with it. And, you know, I took some of the curse words out and a lot of the anger and ended up uh, writing a piece for Annals of Internal Medicine about it.

• 18:16David Puder?

  Wow.

• 18:17Speaker 01

  And that experience, you know, and writing it taught me a lot about how we can get our voice like in a different way, you know, like they, they can try to silence you or not be able to support you. But like, you can still help and teach and educate around your experience, even if you're a student, you know?

• 18:35David Puder?

  So, so what if you're, you're, you're like a student or you're a resident and you're hearing this? And you're saying to yourself like, red flag, red flag, like if I were to tell my story. Like, I would, I may lose my license, like, or I might not be able to get through residency or medical school, like, maybe the dean would have an issue, it's gonna make the university look wrong, you know, and stuff like that. What would you say to that person?

• 18:56Speaker 01

  I mean, I'm a big believer in, like, your story is your story and tell it when you're ready, you know, I think I felt like I had to and I felt called to do it, but my ability to talk about myself and to talk about my own mental health has evolved over time. Like, when I was a med student, I wasn't talking about the fact that I take meds. When I was a resident, I didn't even really talk about that. I just did that more recently, like, in 2020, because I realized I had never talked about it. And I thought I processed all of these things enough that I could feel comfortable doing it. I felt secure enough in my job that I could feel comfortable doing it. So I think there's a right place and right time for sort of what you feel like sharing. Like, at that time, I wasn't actively

• 19:38Speaker 01

  criticizing the program. I was using it more as like a, I don't think anybody even thinks about that being like a not great teaching skill because I didn't even see a code. So I'm not even ready for this mentally at all. And nobody acknowledged my emotions in the whole thing. And so, you know, I think sometimes I'll tell people to, like, if you feel like you need to share and somebody's gonna hold it against you on the next step of your application process or something like applying to residency, if you feel like it's true to you and that's what you want to talk about, you probably don't want to be somewhere that will judge you for that, you know. You might not be able to change, like, where you are from med school, but if you're applying and you want to disclose on your application, or you want to write a more vulnerable essay, you know, I can't

• 20:22Speaker 01

  tell you that a program's not gonna discriminate against you for it. And they aren't supposed to openly, obviously, and I can't tell you that they won't, but I can tell you, if you want to share, and that's important to you, and a program doesn't take you for that, you probably wouldn't have fit in that program anyway. And that's sort of my spiel, common belief on that.

• 20:42David Puder?

  Yeah, I once had a medical student who was, did some work with me, applied and didn't match. And I looked at the personal statement, and it was very disclosing, but in a way that as a psychiatrist reading it, I knew that it was not processed effectively. And so I would, I would say the caveat to that may be If you're trying to get into residency, like there is like, this is my maybe internal stigma on this, and maybe you're right about like, okay, but maybe that, maybe all of those programs wouldn't be good, but this guy wanted to be a psychiatrist. But I would just say as a caveat, maybe like, if you've been through something traumatic,

• 21:27David Puder?

  before you write about it, maybe do some of your own work, like in therapy, to kind of make sure that this is, you know, just because like, you don't want to be talking about a trauma on the, during an interview, where the psychiatrist knows like, you have not processed this trauma at all. And I don't, I don't know, do you have any thoughts on that?

• 21:46Speaker 01

  Yeah, so when you self-disclose, other people self-disclose too. So that's also important. So if you haven't processed, like, you're gonna get 30 stories that trigger you, right? And so for me, if I'm gonna talk about something, I mean, when I decided to talk about meds, I talked to my therapist about why I wanted to do that and what was going on for like, six months before that. This book, I had processed the time period, went back and wrote about the time period, then reprocessed it in writing, but also in talking to the same therapist, right? And so there are lots of layers of writing that can help. And it's part of why, like, I would suggest to you, if you're like our person who might want to do it, that you use a pen and paper for a while, because if you type it, you're

• 22:28Speaker 01

  like, much more likely to just like, decide it's a piece you want to share with the world, and it's already there, so you might as well. But if you write it on paper, like, you can, you won't edit it as much, you'll kind of just write your feelings. If you decide later that there's something there that you want to process, and then, you know, make into a piece, like, it's totally fine, but, you know, it gives you the space to do that. I think what you're talking about psychiatry is particularly interesting, because I remember, you know, doing applications and hearing people, judging people for the stuff they wrote in their application, and thinking like, oh, man, like, if psychiatrists do this, what's it like in a surgical residency program, like, in, you know, reading this stuff?

• 23:11Speaker 01

  And I was thinking, well, maybe we're just doing that because we think we understand what it means. If somebody writes something and you can tell that they just got out of a program and they're not fully like stable and the stress of residency might be too much for them, you might be concerned that they wouldn't be able to stay in residency. And like, we sort of look at it almost like they're patients. I know that, and we're like, not supposed to, but I feel like we almost go, ah, I'm not sure.

• 23:38David Puder?

  But then I think as a program director, you know, once you're a program director for a while, and I've never been a program director, but I feel like I understand them because I've, I've seen this is, you want people that are going to show up to work and work hard and not cause you issues and not complain too much. And so if you get applications where it's like, okay, this person's really smart, but they're going to be an issue for me, you may pass it up, which is why when I write letters of recommendation for students that do projects with me, I always comment on like, this person is highly conscientious and they work hard and they don't complain and they, you know, so it's like, there's this ideal, and I guess I'm talking about our own stigma against this, you know, which is like,

• 24:19David Puder?

  it's, it's like, yeah, we're, at this point in your career, you are at a privileged position, and I'm at a privileged position because we can talk about it and like,

• 24:30David Puder?

  like, are we going to be dinged by a board to, to mention that we were in therapy or, you know, like, probably not in the same way that, you know, like, there may be more judgment on us earlier in the process.

• 24:45Speaker 01

  Yeah, and you have much less power and say in that point in the process too. Like, I think if I was in a workplace that was going to hold against me that I felt like talking about meds, I probably would start looking for a new job. And, and I don't know that, you know, you can't do that as a resident and you sure can't do that, like, i- in all places for all people and there's privilege to that. But, you know, I think we do grow in our ability to say some of this stuff because we have more power and like, our existence has proven a point. And, you know, I think licensing is a big thing that has evolved over time and has become an advocacy issue that a lot of organizations have taken up. So it has improved in a lot of ways to. Not having all the illegal questions that it previously did, like sort of just like,

• 25:30Speaker 01

  have you ever gone to therapy, you know, and these things that people felt like they needed to lie about? Um, but still we move states and not all states are the same. And still there's so much lore that even if your state was perfect and a lot of them have changed to be much better. I think you could find an attending who would tell you some really, really bad story and scare you away from it.

• 25:54David Puder?

  Hmm.

• 25:56David Puder?

  Yeah, on the, on the board issue, um, like I've, I've had professionals that I've known, been through board complaints, various things, and it's like one of the most stressful things that I've seen professionals go through.

• 26:07Speaker 01

  Yep.

• 26:08David Puder?

  You know, and it's like, they continue to work in the midst of that, in the midst of that stress. And that's like, you know, or like legal things. It's like, it's like on top of all the stresses that we deal with as professionals. It's like now you're in a session thinking about like, oh, I'm about to be sued or this board is coming after me. And, um, yeah, it can be really, really stressful. And so, like, yeah, it's just, it's, it's, it can be, it can feel like an adversarial system. Where what we want to do is just take care of people the best we can.

• 26:48David Puder?

  Yeah. Any, anymore, is that something you've seen?

• 26:51Speaker 01

  Yeah. I mean, I think that's why, you know, when I talk about people waiting to come DC and a lot of that comes into play, right? I think they're like, well, they told me if I got help, I'm going to lose my license. So I'm not going to get help until I absolutely need to, because I might hurt someone. And then there's a legal problem and that's more complicated. So I'll get help now. Right? And so all of those things go into people's heads when they're thinking about getting care. I think I get asked probably more than a lot of fields in what we do, like to not document. You know, like we, could you just paper note, write this, or could you write no notes? I'm like, I can't do that. Like, you know, could you charge a different insurance code? Because if you prescribe a med like bupropion,

• 27:35Speaker 01

  it can also be used for smoking cessation. So can you say that I'm, I'm trying to quit smoking instead? And you're like, uh, okay, interesting equivalency, but, um, you know, or they'll ask for.

• 27:48Speaker 01

  Like some time off paperwork that doesn't say a mental health thing. And so I think it's, I mean, I think it's so hard.

• 27:57David Puder?

  Yeah.

• 27:57Speaker 01

  And it impacts our decision making and, you know, even how much we pay attention to our own health and mental health, because we just don't have a lot of outlets to do that.

• 28:08David Puder?

  Oh, yeah. And I'm, I'm totally like, I'm, I'm, I try mostly to, to appease the, uh, the, the people asking these requests, you know? It's like, can you document the minimum? Yes, I can absolutely document the minimum. Can you not put that you're a psychiatrist? I'm like, well, they could look up my name, but I'm also an assistant professor of internal medicine. So I will just put that at the bottom next to my name. Okay. I will skip the other parts. And, you know, it's like all these little like things which, you know, and I also educate patients when they're taking time off work. Like, look, you don't need to tell your employer why you're taking time off. You don't need to tell them this is for mental health.

• 28:52David Puder?

  Like, so I don't know. I, I feel like the stigma is real and like, it's not just all in our mind, you know, that it's real.

• 29:01Speaker 01

  Oh, to, I mean, totally. I mean, I think, you know, the stuff that you're saying too, like I've done some of that to be as, as helpful as possible too. Like, could you not write that or can you not go into detail on that? And I'm very mindful of my notes in general and not putting too much in them and just doing the bare minimum as much as possible. But inherently, I still have to code a thing to send it to insurance or I still, you know, have to write a note of some sort for the same reason. And I think, you know, some resident clinics and med student clinics went back to paper charts and stuff like that for that reason. And sometimes I wonder, like, I get it. But sometimes I'm like, are we furthering stigma by saying like, if you see a psychiatrist, they're, they should be using paper charts.

• 29:46Speaker 01

  But I think there's like this, is it stigma or is it privacy thing? And I think both are true. Like, there is some stigma to it, but I also think we have a right to have privacy about the things that we're dealing with. And we don't owe it to people to tell them. And they don't need like proclamations of our mental well being.

• 30:06David Puder?

  Yeah.

• 30:08David Puder?

  Yeah, I um, I, I think the, probably the worst field for this is actually flying planes.

• 30:18David Puder?

  I had a listener reach out to me and just go through like all the details on that. I don't know if you know, but it's so much more invasive. And the people who are kind of like overseeing it, like, and the demand for like details is so much more invasive than it is. And from what I've seen from doc, like doctors and stuff, so. It's, it's not just our field, but our field, um, yeah, it's tough. I've also talked to a few lawyers over, over my years and they say that psychiatry boards tend to be less brutal compared to psychology boards. Psychology boards can be even more invasive, you know? So, yeah, anyways.

• 31:01Speaker 01

  Which I've always found interesting too, because not all of us, but many of us choose to do this because of our own lived experiences. And it's encouraged that we get treatment, like it's encouraged that we go to therapy as part of training or something. And then you're like, and then you're going to be asked on licensing if you've ever gone to therapy. And it's very counterintuitive in that sense.

• 31:22David Puder?

  Right, right, yeah. Yeah, that, that feels very invasive to me. Like if they're like, have, are you currently, or have you been in therapy in the past? Have you ever been in a psychiatric hospital? It's like, um, is this really like necessary? I don't want to lie, right?

• 31:41Speaker 01

  Yeah.

• 31:41David Puder?

  Yeah, so, okay, so, so you got motivated because the writing was like a release. It was a way for you to kind of have a voice, express some of your anger, frustration, work through conflicts. And it sounds like you're really now, you're like, you're like doing the thing for yourself. But that, or you're doing the thing for other people that you almost like needed done for yourself as well, you know? There's, it's like. It sounds really meaningful, but also exhausting.

• 32:13Speaker 01

  I appreciate that assessment. I mean, I think a lot of what I've done as I've gotten older and been able to like forge my own path as much as I can has been to sort of center things on meaning and mission and not just CV and resume. Like, I mean, if you look at my CV, you might go, well, you've still done all of that stuff. And all of that is true. But once I figured out that I could still do that stuff and do stuff that I liked at the same time, I've had just as much success as an academic doing the work that I care about centered on the mission that I care about. And the book's very much like that, you know, the population I care a lot about, working through what it would have been like

• 32:56Speaker 01

  to tell my younger self, some of this stuff I think is totally true. Like, I understand myself in a very self reflective way that I definitely did not in college and I definitely did not in med school. And I maybe got a little better in residency. But, you know, I think a lot of stuff for me has come from doing the work on me and feeling comfortable then sharing it with other people for the purpose of maybe them feeling less alone, but also going, oh, like, I've got some stuff to work on, too. And, you know, acknowledging our limitations as human beings, which I have to do on a regular basis and often forget. And, you know, we're all work in progress. Like, if you said, Jesse, like,

• 33:39Speaker 01

  you talk about being burnt out. Do you think you'll get burnt out again? And I'd say, yes. Like, I wouldn't go, no. But I think when I was younger, I thought that somebody who's successful and somebody who's talented and gonna be a leader doesn't do that, that they can juggle everything and be fine. Like, there's no failing. There's no need for a break. There's no sickness, right? And I think over time, I've learned, like, it's just, like, this is not fair and not true. And in so many ways, not helpful to think like that. And I, and now I'm much more realistic about the impact of life on work and work on life and me, you know?

• 34:25David Puder?

  Yeah. So, yeah, talk about, in burnout, so there's three domains, personal accomplishment.

• 34:33David Puder?

  Emotional exhaustion, depersonalization. I think that depersonalization is the, it's kind of an interesting one to look at. What does that domain mean? How does it show up? What do you see? How's it shown up in yourself?

• 34:48Speaker 01

  Yeah, so depersonalization in so many ways in healthcare is what we learn to do to tolerate the stuff that we hear. So we are told to basically like, remove ourselves in some way from the words that we're hearing and the empathy that we feel and be more disconnected from the person, patient in front of us. But the problem is when you are burnt out, you do it to such an extreme level that you're doing it all the time, but you're also going, ugh, another, like, you basically, they, they call it like, treating patients like objects. It's just kind of like, another, another one, another one, another one, not, look at the human in front of me and the things that human is dealing with and how can I help that human? It's like, another human that I feel disconnected from.

• 35:32Speaker 01

  And I think that that goes into our, all of our areas of life and we kind of are less empathetic in general, like, less connected to the things that we're doing. And for me, I'm a big, I mean, I went to, into psychiatry because I like people's stories and I like how I could see a hundred people with depression and maybe they had the same medicine at the end, but the reason that they came in and the things going on in their life actually mattered. And I've always been a story person and a people person. And for me, it showed up when I would catch myself, like, missing parts of things people

• 36:13Speaker 01

  were saying when talking to me as patients and I'd come back into the conversation and worry that I just missed something important because I was somewhere else for a bit because I just didn't feel like I was connecting enough. You know, the story at the very beginning of the book is probably like, the worst example of that for me, which was like, I forgot that I met a patient before. And I know people listening who might do other fields or even our field could say, that's not a big deal. But to me, like, if I've met you and you told me all of the things that you've never told anyone else and I'm aware that my job is to create a safe space for you to feel like you can do that again.

• 36:56Speaker 01

  Redoing my entire intro spiel that I do for a new patient and you saying, but Dr. Gold, I met you already is like, pretty heartbreaking for me, you know?

• 37:07David Puder?

  I felt that. I felt, I felt how uncomfortable that was for you. I felt, yeah. And I also triggered memories of my own experience of like,

• 37:19David Puder?

  yeah, so I think, I think there's something about that, kind of like the not remembering, like where it's like, within dissociation, like we don't lay down narrative memories. And so to be with a person, it's like, if you yourself are slightly dissociated from just the composite of stresses and burdens, it could be hard to kind of remember in the same way. Fongi, who I interviewed on mentalization, had a really helpful statement to me about this that kind of like, changed the way I, I handle when I like miss gaps of like, hearing things.

• 37:59David Puder?

  He said, it's very normal, actually, to have gaps in mentalizing the other person. And so what he does now, without any shame for himself, it sounds like, is he just rewinds to where he last left off and say, can you pick up at that point? And just say that again for me? And I also, I wonder if like, when they're, when they said that chunk of information, were they dissociated? Because if they're dissociated, like our mirror neurons, like the most empathic thing for us to do is to actually dissociate as well, right? Because like our mirror, our brains pick up what other people's brains are picking up. So it's like, empathy actually would be for us to not be able to recall

• 38:44David Puder?

  or build a narrative, in the same way that they in their trauma, maybe were not able to bear, bear the burden of holding that as a narrative. But yeah, I don't know, I'm just.

• 38:57Speaker 01

  It's all really, I mean, it's interesting. I remember saying in group supervision around one of my psychotherapy patients in residency, like, every time I see this patient, I think I'm gonna fall asleep. Like, I've never felt like this before. Like, he's not boring. Something's wrong with me in these settings. And my supervisor said something very similar to what you said, like, that you're probably protecting yourself from the stuff that he's saying, just like he's protecting himself in some capacity, you know? Like, my reaction as an empath was to like, just kind of avoid, like, to try to, like, go to sleep and not hear it, or something. And it was very hard for me, because I'm like, oh, I've had patients

• 39:41Speaker 01

  come in and say they had, like, a therapist fall asleep on them. I don't want to be that person, you know?

• 39:45David Puder?

  Right. Right. I think, I think two things. One is, when the patient's talking, if you're, if you're, if you feel like you're falling asleep, you know, my internal reflection would be like, okay, did I get enough sleep last night? I remember when I had kids, and they were young, and they were keeping me up, or, you know, when they're sick and they keep me up, it's like, the next day, it's so hard, right? It's like, but if it's not me, and my fatigue level, then it's like, okay, yeah, it's like, what is it about? Is this person dissociative in the midst of talking? I remember one patient that it was like, yeah, I've had a really hard time staying awake. And she was on heavy opiates, and I

• 40:30David Puder?

  think to the level that she could barely stay awake. So it was, it was like, the medication was dissociating her. But I think for you, it's like, you, oh, your shame of feeling sleepy is also very prevalent there, which I wonder, how much are you picking up on their shame? Like, is that your shame, or is that their shame?

• 40:52Speaker 01

  Yeah.

• 40:53David Puder?

  You know, people in the midst of telling traumas feel shame even when they shouldn't. And so sometimes we feel their shame. And so I think it sometimes makes sense, or guilt, you know? So to be curious, like, if that's, how much of this is ours versus theirs? Is always a good sort of reflection. What were you thinking there? I saw you.

• 41:16Speaker 01

  Yeah, no, I think it's I think it's so interesting because psychiatry is so fun like this, you know, like, I think so many other specialties would just be like, I guess I was tired, you know, and I think it's such a cool thing that we like, think about the ways that it could be that, and that could definitely be the answer. But in the same respect, like, what if the way that I was feeling is related to the way that they're feeling? And what is that? And what is it bringing up in me? And that might be important for what it means to them. And I think that conversation makes us so much better at what we do in these settings, because if we're not in tune with our own reactions and emotions, we're probably missing something that the patient's saying. And I think that's one of the cooler things

• 42:00Speaker 01

  about psychiatry, because like, we actually need to understand our emotions to do our jobs well. And other groups that I see as patients, I feel like a lot of times can push them down to do their jobs well, you know?

• 42:13David Puder?

  Right. Yeah, it's like, it's, it's, it's also the difficult part. Because the, the treatment is actually being in touch with their own emotions, right? And, and that can be really hard to be in touch with their own emotions. If, if the, the weight of everything is feels too much. Yeah. Yeah. So, and then I remember, in one part of the book, you mentioned how your therapist gave you this like sheet of happy things to do or something. And I was like, internally, I was like, oh, I would hate that if my therapist did that. But it sounds like you actually liked it.

• 42:48Speaker 01

  It depends on my mood. So sometimes, so my therapist knows I don't like stuff like what I would define as woo woo, like, things that like, you're gonna try to tell me to do that I've tried and I don't like, and it's just gonna make me mad. And so a lot of times when she suggests stuff, because we've been through it a lot, I do think that she's probably thought about what it means to me to suggest that stuff. And so I do try to do some of the things she suggests. But a lot of times, I'm like, that's the dumbest thing I've ever heard. I mean, simple things like, when I walked my dog. I used to always listen to music and or a podcast, speaking of podcasts.

• 43:29Speaker 01

  And I would just be out like doing that. And she was like, have you ever done it in silence? And I was like, why would I do that? Like, that's a horrible idea, you know? And it took me a while to realize like she was just trying to get me to take some time for me. That wasn't also distracted by noise and music and other people, even though that stuff can be comforting in its own way. But sometimes like she'll suggest stuff and I just start laughing and I'm like, you know who you're talking to? Like, that's just not gonna happen. Try something else, you know?

• 43:59David Puder?

  Yeah, it's like the, I feel like when physician wellness started, it was like, you need here, we're gonna have like an extra yoga or an extra resilience training, right? How do you feel about those things?

• 44:14Speaker 01

  You know, it's really funny, like being that person who gets called to do the lectures on this stuff for groups, because I'm sort of like a personification of that, like the checkbox, the thing they have to do additionally to be well. And so I often call that out because I think it's important for them to know that I'm totally aware that like this, I am the Band-Aid. You know, I think it's a way to do something, but not fix the problem. Some in a lot of situations, a lot of accreditation boards have something about wellness and teaching about wellness. And as a result, they have to do something and that sometimes is like very simple. I think we miss the mark a lot on the idea of gratitude. Like, people love free stuff, but they also would like a raise.

• 44:58Speaker 01

  Or people would like love free stuff, but they actually want you to like give them kudos in the right way, you know? And I think with nurses especially, we're so bad at that. Like Nurses Week gifts are like the funniest things I ever get sent on social media. They're like empty plastic bags, but they're filled with love. And you're like, what does that even mean? You know, you're like, who thought this was an idea? There was one on TikTok where somebody got one of those like hammers to get out of a car in an emergency to break the glass. And she's like, I'm not really sure what, like, why we got this. Like, this is not. Not helpful, right? I used to get a bunch of burnt out people and you're like giving them hammers. Like, I just don't understand that either. You're like, this is like the dumbest thing I've ever heard.

• 45:40Speaker 01

  But, you know, I, I have strong opinions on that because I also like am in that space where those end up being the solutions a lot of the time. Because people don't invest in it. And I also know that the word resiliency is really hard for people because it has been co-opted almost.

• 45:56David Puder?

  Yeah.

• 45:57Speaker 01

  To me, and we're not fixing the system, you fix you. And I don't really think that's what it means. I think in a lot of ways, it's like, the system is really broken. How do we help you thrive anyway? But we framed it very much like because of how the pendulum has swung on these conversations. Like, mm, we're not going to fix the problems in healthcare. Here's a resiliency class. You do it, you know? And people are like, like, it's not me, it's you. And they're right.

• 46:24David Puder?

  Yeah. I mean, I, I looked at this one meta-analysis that was like on physician burnout. And the most effective treatments are actually changing the system, not changing the physician. It's like, no, yoga, like, for the physician is not what they need. They need like a better support. They need less busyness. They need less, you know, they need a, a, a more, you know, a system that actually is there to facilitate them doing their job at a higher level, right?

• 46:53Speaker 01

  Support staff, you know, all of that stuff's obviously more money, but it is actually the way to help. Instead of giving people, I don't know, lifesavers because they're lifesavers.

• 47:03David Puder?

  Oh my gosh, you're so funny.

• 47:08David Puder?

  Oh, man. And I, I don't know, like, I, I remember in one of the books, you were like, during COVID, you weren't an essential worker. And I always felt like, um, despite being on Zoom, like, of course I'm an essential worker. Like, I don't know, like, was that a message you got? Was I, was I somehow like?

• 47:29Speaker 01

  It was like my brain taking in the idea of being sent home and not having to be physically there and at the same time, all of the other people being physically there. And then kind of feeling like mental health. I mean, obviously, we're doing essential things, but was not viewed in the same way because nobody was like, those people at home are really helping us. They're like, not in the hospital. What are they doing? They're not helping, you know? And so I think that message I got was being sent home and then also not talked about. So, you know, I think one of the first articles in popular press about mental health of

• 48:08Speaker 01

  mental health care workers was probably like a year into the pandemic prompted by me ranting on Twitter about something and a bunch of therapists sort of like commenting back. And I think that is where like this idea of like what's essential, like I just think we weren't even in people's thought processes, like, you know, very obviously ER docs, very obviously folks in ICU, very obviously like people who are, you know, doing triage and things like that. But I felt very much like I'm literally holding them up, but nobody else can see it and I'm not in the hospital, so I must not be as important.

• 48:50David Puder?

  Yeah, no, I think it's an awful feeling and I think, of course, you're important. And I think, of course, you know, like, there's so much meaning, but then to not be sort of valued by the system in the same way is, is, is, it's like, do we, and I sometimes think about this, like, do we ascribe our meaning from the, our supervisors or the people up the chain in the hospital hierarchy? Or do we ascribe our meaning from the patients that we help? And then, but sometimes it's like, I don't know, Dr. Tarr used to tell me this and I didn't really fully understand it until I had been practicing a number of years, but like, it can be very lonely. You can feel a lot of loneliness and weariness after the work that we do.

• 49:31David Puder?

  Like, if you're doing it well, he would describe like, yeah, I think by and large therapists, mental health professionals, they're more weary, they're more lonely than the average person because they're very present for other people. And we need our own refueling. We need our own spaces, you know? And I'm like also conscious, like, I'm talking with you and like, there's stories I want to tell you, but I can't right now because I'm on a podcast. And there are stories that are so graphic and so horrible. And potentially also would, you know, it's like, there's no way of telling it without the person that told me it knowing that that's from them.

• 50:13David Puder?

  And I want to like, you know, keep the sacredness of that shared thing, you know, not from being a public thing. It's like, you know, there's that stuff that goes through my mind as we're talking. It's like, you know, we are, we're scratching the surface, right? Of like, what this means. And if you're listening in and you're not a mental health professional and you're not in the trenches, like, you may be like, what are they really talking about? Like, what is this burden that they're carrying? And it's like, um, yeah.

• 50:45Speaker 01

  I saw somewhere, someone on social posted, like, should you be concerned if your therapist goes to therapy, like, something like that? And all of the responses were like, spend a day in our job, like, just one day and see if you think that we should be just tolerating that without it affecting us and that we would be better at our jobs if we just didn't, you know? And I think I would always want a therapist who saw a therapist because I think it's healthy. It admits that like, we also are humans that need the space and time and support. And I would rather that than somebody who pretended our job didn't affect them, which people do. And it, you know, when I think about choosing psychiatry as a field, I'm not on my feet

• 51:26Speaker 01

  all day, I'm not on call all the time, but I am hearing stuff that's hard. And I've had to learn to cope in some capacity with it, but sometimes it's harder than others. Like, the world is more complicated at some point, or I'm not fully myself from whatever's going on in my life, whatever. You bring that in as much as you try not to, and then sometimes that stuff affects you a lot more.

• 51:49David Puder?

  Yeah, and I try to normalize that over and over again on this podcast. And I would say some of the, some of the best emails I get are people that are like, I'm a mental health professional and I started listening to you five years ago. And then I started my own therapy and I've been in therapy for five, five years. And like, I'm totally in a different place than I used to be. And I, you know, give you 3% of that improvement now. It's like, it's like those, those, those types of messages make my day. I'm sure you get some of those as well.

• 52:20Speaker 01

  Yeah, I mean, for me, like, one email after a talk that says, like, thank you for normalizing that I'm gonna go get help now. Or thank you for putting words to what I didn't know was burnout. I'm gonna go get help now is exactly why I do it. You know, I didn't write the book for me. I wrote the book in hopes that that happens for someone, you know, where they go, oh, our stories matter. Our, our healthcare matters. Our people who do this work matter.

• 52:48David Puder?

  I want, I want to get back to the, kind of the distractedness that I think we face, right? It's so easy to distract ourselves. I just had a, a patient, just tell me, just this morning before our session. Our session, I think I can honestly say the, for the last 15 years, I have not been able to sit quietly in my own mind. I constantly feel like I'm reacting.

• 53:13Speaker 01

  Yeah.

• 53:17Speaker 01

  I mean, it's probably why I'm not very good at silence. You know, like, I think silence is scary because then I'm with whatever I'm thinking about. I think it's probably like that for everybody. But I think what I've been, what I think about in silence is probably stuff I chose not to.

• 53:35David Puder?

  Yeah.

• 53:37David Puder?

  Yeah, I, um, I go rowing, like, probably four times a week. So I go out there on the water and, um,

• 53:46David Puder?

  I inevitably have a moment of silence. But sometimes I'm watching YouTube videos right up to the moment I get on the boat. You know, or a podcast.

• 53:58Speaker 01

  Yeah.

• 54:00David Puder?

  But hey, I think we could go on forever, but I know you have a patient to get to. Any final thoughts?

• 54:05Speaker 01

  It's actual personal therapy, actually.

• 54:07David Puder?

  Oh, really? Oh, good for you.

• 54:09Speaker 01

  That's where, that's like, you know, trying to shove that into my day as much as possible is really hard, but it's actually personal therapy. So I try to make space for it, even if it's between meetings, you know, because it's really important to me.

• 54:21David Puder?

  Wow, well, I was like, thinking we'd go on for another hour, but we'll have to leave people with the ability to find you on Instagram. What's your handle?

• 54:32Speaker 01

  At Dr. Jesse Gold, Jesse spelled J E S S I.

• 54:36David Puder?

  And then your book is called How Do You Feel? Which is like, like, kind of like, not the trite, you know, answer that you want, or it's like a real deep, how do you feel? Like, how do you really feel, right? And then, you know, we should not disavow that we have our own experiences as professionals, but we should really, you know, allow us the same compassion that we give to our patients, that we should allow ourselves to have the full range of human experience and to do the deeper work that allows us to continue to have a heart to do the work that we do with our patients. So that's what I took away.

• 55:19Speaker 01

  Yeah, I hope so. I hope everybody feels like that. And thanks for validating that for them.

• 55:24David Puder?

  All right. Have a great day. We'll leave it there.