The History of Burnout (And Our Maslach Scores)

Margaret: [00:00:00] Welcome back to the podcast. 

Preston: Welcome back to, to How to Be Patient, your favorite second season of the podcast where we tackle psychiatry medicine and occasional existential dread. A little bit more dread this episode than others because we'll be talking about a topic near and dear to our hearts and will Crispy center.

Burnout. Burnout. 

Margaret: Burnout. Who? Who doesn't love it? Who doesn't love little burnout. Yeah. 

Preston: So for the star, our icebreaker today is going to be the most unhinged thing you've ever done while burnt out. 

Oh hmm. Or to try to alleviate burnout. 

Margaret: Um, well, I mean, I think the answer for me is obvious after finishing call last year, and it is the pan supercharge.

Preston: Oh, tell, 

Margaret: tell me more. No, it's unhinged. You heard about this? It's a Panera. Well, allegedly. Well, they're, I wanna 

Preston: know your relationship to them 

Margaret: bad. Well, I can't get them anymore now, so, and I also don't do [00:01:00] 24 hour calls anymore, but when I did do 24 hour calls, I would like, I think I once had like four large supercharged, uh, le lemonades from that St.

Louis that's like a thousand 

Preston: milligrams of caffeine. I think. 

Margaret: It wasn't so good for the old, uh, ticker, but it was, you know, it was what it was. I don't think that's super unhinged though, because I feel like that's high caffeine intake. But 

Preston: yeah, I took, I took a lot of caffeine. I think it's vanilla on the spectrum of onion.

Things done in 

Margaret: vanilla. 

Preston: Well, I'm sure they were lemon flavored. 

Margaret: Okay, well you tell me yours. 

Preston: So, yeah, I guess this was outside of the hospital. Um, I remember I, I was pretty burnt during, in, in medical school and this is when I was still trying to, um, gun for a surgical specialty. So I, I remember, um, being at an American Eagle at the mall, we were like returning some pants and I was looking at all the workers and they were just like folding jeans.[00:02:00] 

And I was like, wow, I'm so jealous of these people folding jeans. So then I went over and I started like pulling like job applications from the, they had like a little sheet like, Hey, we're hiring, like inquire. And I started reading it and I took one with me and I was like, you know, it could be nice, honestly.

Margaret: Did you apply 

Preston: the jeans? No, I never ended up applying. So, so I didn't do anything that unhinged, but I think, I think it was kind of one of the, I I put my toes over the edge, but I didn't jump situations. 

Margaret: Mm-hmm. Mm-hmm. Yeah. 

Preston: And, and I think it, maybe it's a rite of passage, like if you haven't been envious of a, a retail worker at some point in medicine, maybe, uh, maybe you're super, have you never worked in 

Margaret: retail?

Preston: I have, yeah. Okay. So you, you're 

Margaret: aware of the, the levels. 

Preston: It's, I worked at a, a frozen yogurt shop, actually. 

Margaret: Oh, nice. I So did you ever cry in a freezer? 'cause that's also, I used to work at a Chili's. Shout out Chili's. 

Shout out Triple Dipper. I need to stop saying, I'm gonna get yelled [00:03:00] for saying shout out, but I can't, I'm addicted to it.

I'm sorry. 

Preston: I, I saw a TikTok, a guy who he got out of prison. The first place he went was chilies and he got a Triple Dipper 

Margaret: burnout Central. Honestly, Chili's spots I would get better from a Chili's burnout party. 

Preston: Okay, so you were crying in the freezer of a chilies? 

Margaret: Well, I was more just saying generally retail, but like, who of us haven't cried in a bathroom in the hospital multiple times throughout our 

career so far in 

Preston: medicine.

So that doesn't make it different. Let he who has not cried in a hospital bathroom cast the first stone 

Margaret: order. The first Triple Dipper.

Preston: Okay. Well crush it. So. Um, as we kind of get into the definitions of burnout and kind of clinically how it lines up in our lexicon of, of diagnosed mental disorders, discussed mental disorders, and I think pop psychiatry or pop psychology, wherever that falls in there. I want to, to introduce you to the founder of Burnout.[00:04:00] 

So the, the story is gonna start with a guy named, uh, Herbert Freudenberger. 

Margaret: What a name. 

Preston: Yeah. So, um, we're gonna rewind the clock back to Nazi Germany in the forties. He's, he's a 12-year-old Jewish man or boy at the time, living in Germany. And he, uh, managed to escape and come to New York completely alone as a teenager.

Wow. 

So he began working, um, odd jobs and, um, did construction and other things just to survive in New York first. And then eventually he got into education and became interested in psychology. So he actually attended New York University and began working in some of these clinics around New York with some of the most underserved populations.

So he, I think because of his history as a refugee and someone who's been an outcast in their country, he, he gravitated towards these populations. So he's working really long hours in all of these [00:05:00] different clinics, and he noticed this kind of strange phenomenon that was happening with even the most well-meaning workers.

Hmm. 

So he, he, he recognized that it wasn't depression, it wasn't anxiety, but people that really cared and were almost called to medicine and, and altruistic and, and passionate at first about taking care of these populations were becoming jaded. Mm-hmm. And cynical and frustrated. And he kind of recognized this as something that was distinctly different from everything that he'd seen before.

And the way he described it was, it was like they had a flame before the flame of passion or of service was burning. Mm-hmm. But now that had been snuffed out or burnt out. 

Margaret: This is reminding me of the episode that just when we're filming this just came out on the coping skills and that you, there's a bit in it of you talking about how you're feeling currently.

And I was like, 

every [00:06:00] day is mundane in my I'm order like, like I just, everything's the same. It's reminding me of this. 

Preston: Yeah. Yeah. I, so actually I stole that line from the Sopranos. I need to wash that 

Margaret: still. 

Preston: Yeah. One of Charact, that was my promise to you that I would 

Margaret: watch it. 

Preston: He's like, I'm just so tired of the regular of life and that really resonated with me.

So, um, so 

Margaret: it sounds like these people, so he, he used to 

Preston: capture my experience sometimes 

Margaret: lost their spark. 

Preston: He was finding that as, as you, he writes about this term in 1974. So this is kind of right on the edge of the empathy revolution in medicine. I think in one of our earlier episodes, we found a paper in like 1969 that was like, it turns out like relating to a patient's experience can be helpful for the overall care they receive.

Like seems be more empathy. At the bottom we're like, whoa. Revolutionary concept. So anyways, think about acting like a robot would be cool. [00:07:00] Yeah, pay more for it is like you don't, you don't have United Prime, so you don't get empathy with your current coverage plan. 

You just get the AI bot. 

So anyways, term burnout struck.

Other people really in, in high empathy professions. So things like education, social work, and healthcare, um, started to, to grasp onto this and other people took it and ran with it. So this, um, the next name I want to introduce you is Christina Maslow. So she actually, um, took the definition of burnout and started to formalize it into a scale, which is now known as the Maslo Burnout Inventory that was introduced in, um, the mid nineties was the last I saw from A-P-D-F-I downloaded.

And then with her scale, actually, she wanted to take these concepts of burnout and then oriented as this kind [00:08:00] of existential mismatch between someone's values and the institution that they're working for or like the rules that they have to uphold. And that kind of started the groundwork for a discussion around moral injury.

Mm-hmm. 

So. Umberger. He ended up dying in 1999, but about 10 years after that, we really started to pick up with burnout as a mainstream topic. 

Margaret: So like late two 20, 2000 2010s. 

Preston: Yeah. And, and I think that's when I first started hearing about it being brought up. Mm-hmm. So when I say burnout now, kind of like looking at how we define it.

What is your understanding of it as a syndrome? 

Margaret: Um, I guess my understanding of burnout, kind of, I think it exists. Like I, but it, it's not something that I know how to define in terms of our specialty necessarily. Like in terms of like a pathology. Um, maybe because I don't know that it is a pathology, right?

Maybe it's a normative way [00:09:00] of making sense. But in terms of burnout, I feel like. Elements of like this job, I don't find meaning in this job. I don't find purpose in this job. In some ways. Like, it doesn't even have to be that it's an inherently meaningless job. It can be like mm-hmm. Just the number of reps or volume or stress, um, and how unbalanced maybe it is with the rest of your life is kind of what I think up with burnout.

Preston: Yeah. And then, and that's ultimately correct. So if you're ever hearing or or discussing burnout, it's not defined in the DSM, so as the American Psychiatric Association hasn't acknowledged it as a disorder, so we could classify it as a normative reaction, but the World Health Organization, um, classifies it as like a workplace hazard.

Margaret: Yeah, that makes sense. 

Preston: So, um, just as you described, there's kind of three tiers. So mentioning like having frustration with work or meaninglessness kind of falls under this category of personal achievement. So people, so people have low feelings of personal achievement. 

Mm-hmm. 

People will [00:10:00] feel detached from their work.

They'll feel emotionally exhausted. And those are actually the three categories on the MAs lock Burnout inventory. It tries to assess these things that are really almost like philosophical concepts rather than the classic, symptomatic criteria that we adjust, that we like test for. So things like worry.

Mm-hmm. Mood. And then our behaviors. This is really how do you, what is your disposition towards the work that you're doing? I think that that's kind of why it's, it's hard to lump in with the other, um, disorders that we talk about in the DSM. 

Margaret: Yeah, I mean, I think it's also like the cultural component of what is allowed to exist in the DSM or be validated as like, this is something that needs to be treated and we need to have a solution for.

I think that burnout in some ways, like if it, if it's recognized as something that needs treatment, care, or support, then. Well, what are we gonna do with all these healthcare workers? 

Preston: [00:11:00] Yeah. Like if we pathologize it, it it, first of all, some people feel indignant about that because it implies that they are broken in some way, or that they've become sick in some way, rather than it being like a flaw with the system.

So that, that's one reason why people are frustrated with that. I, I think that there's more nuance to it than just that can capture kind of both ends. Um, I think, I think staying positive in a pretty oppressive environment is, can be a, a sign of resilience, but also becoming jaded doesn't necessarily mean that you're weak either.

Yeah. And I think that's where people immediately go with those two things. 

Margaret: It's kind of like a canary in the coal mine type thing too, of like, who feels burnout in different settings. Mm-hmm. Who's, and you know, what do we make of the people that. Are burnt out and like actually seek support for it versus like are burnt out and just kind of soldier through it.

Um, yeah. [00:12:00] Which I think is sort of valued in healthcare to just be able to push through it and hide it at least has been, I think, historically. 

Preston: Mm-hmm. And so one thing that we can do is we can fit burnout into how we conceptualize these other things that we do diagnose. So for anyone who's listening in healthcare and you're trying to say like, how do I put burnout on the differential diagnosis?

I would think about it as one of these like contributing contextual factors for other things we can diagnose. So let's start with moral injury on one side and, and this is an example of when. The easiest example is when you're told to do something that you don't believe in. So if you're a flat earth and you, you have to go out on the street and sell globes to people, which famously you 

Margaret: are.

Preston: Yeah, me and BOB we're out there being be that one 

Margaret: song Taylor Swift left on being forced 

Preston: to preach, uh, spherical earth literature to people. And we absolutely don't believe it. We think it's wrong. We, we think it's amoral to do it, but because of our job we have to. That 

Margaret: mean that mean, whatcha [00:13:00] you calling flat?

Preston: What's, was it, what's a time where you think you were morally injured? 

Margaret: Um, I feel like there have been times where like, working, honestly, you're gonna like, you're gonna call me a gunner for this. But I feel like there have been times in training where I wanted to like have more patience or like be expected to be more thorough and like.

Presenting a case in psychiatry and it wasn't the expectation. And when I would like ask questions because I had gone more in depth maybe on a patient, it was kind of like discouraged, which makes me sound so annoying. Uh, but oh, well, 

Preston: are you sure to saw ego injury? 

Margaret: No. 'cause I was bored was like that, that was a moral injury.

It was also like, oh, you don't need to do all of that for the patient. And I think part of me really valued [00:14:00] what I see now in psychiatry and then was like, no, like I wanna be like my friends in internal medicine or surgery or pediatrics. Not in a, like, 

Preston: you're trying to do what you thought was right by the patient and that was 

Margaret: I you're trying be thorough and know enough to be able to like, make it simpler and get some of the understanding to the patient mm-hmm.

And to like respect the privilege that it is to be like, be a psychiatrist. And so I think that it was mm-hmm. Injuring to me because it was like, oh. Is am I, like, I don't want it to be weird that I want to know these things in our specialty. I don't think it is for the most part, but like I, I've run into enough where I'm like, oh, 

Preston: mm-hmm.

Margaret: Like, I dunno, I want there to be more. 

Preston: Yeah. Um, what about you? So, I I, I have a good example for my sister, actually. She, she's an ICU, uh, care fellow, soon to be, she's gonna be attending in like two months. So shout out to Heidi. But she was telling me a story one time about, um, [00:15:00] a patient that she felt should not have been D-N-R-D-N-I.

Mm. Um, she felt that he didn't have capacity. 

Yeah. 

Um, because he was delirious. But the guy was, um, I guess he was a writer and he had a really high cognitive reserve and he used these big words even as in his delirious state. And he was making comments like, you know, you can't, um. You can't override the autonomy that I have to make my own decisions, you know, and kind of repeating these like, like canned complex phrases.

But then when she tried to engage with him about like, what's happening medically, he couldn't sustain his concentration. He couldn't even repeat back simple things. Mm-hmm. But the way that he was able to kind of articulate that in his disorganized, rambling to him disorganized, but to other people kind of coherent, um, they said that he had capacity and allowed him to make himself dn, RDNI.

Mm-hmm. And then he, he ended up passing, and this was like starkly against what, what Heidi felt [00:16:00] was like a treatable condition. Mm-hmm. I think it was like he just needed a round of dialysis or something and he could have, he could have survived. 

Yeah. Yeah. So, 

so she had to functionally let this person die who she felt like she could save.

And it was because of the decisions of other people. She was a consultant in this case, but 

Margaret: this made me think of an actual one. There was a. I feel like also this is one that a lot of psychiatry residents will be kind of familiar with, or med students who've been on psychiatry, that even being where I am, which is Massachusetts, which has a more robust kind of coverage health system and mental health system in, in a lot of ways compared to other states.

There's still like the issue of state hospital coverage in enough beds for people who have like SSMI er severe mental illness. Um, and what like end of life care for people with like severe, like lifelong schizophrenia where, you know, the medicines we're giving them aren't necessarily helping them.

Sometimes there's also been, you know, comorbid substance use. It's hard [00:17:00] to like maintain health when you're like houseless and you've gone through living life, especially depending on how much like family resource or extended communities they have. And so what I feel like is a common thing in that I experienced and I just like, was kind of horrible.

During residency in my second year in particular was having someone who was in like their like late seventies, had been in the hospital inpatient for a year because they were just waiting on a list for a state hospital. They didn't have like any family to speak of at this point in their life. Their kidneys were not great.

Their, like, they'd had a stroke before they were end stage and like, they weren't on dialysis, but they were like end, like almost there in terms of like, uh, type two diabetes. And their blood pressure was always like a hundred and it was like always high, like 160 over 90 or something like that. But it got to this point for like a month where it was like 200 over like 150 like every couple days.

And there [00:18:00] was like no plan for like, when is this high enough that we're like, medicine needs to intervene because. If you need medicine to intervene, then it's a ligature risk because there's lines and stuff. And so they have to be on medicine, but then they're restrained because this patient was so like, just so in psychosis and none of the meds would touch it.

But it was like, we know like residents would rotate through and like there was a difficulty in the actual situation, but also difficulty in like, who was gonna take ownership in this teaching setting for this patient? And say like, he doesn't really have a guardian who's involved. Like he doesn't have involvement from the state in a like concrete way.

How do we figure out this system so it doesn't, he doesn't get harmed and is protected as much as we can. And also that, so that nighttime nursing and the nighttime call resident doesn't have to be like, his blood pressure's two 20 over whatever. Like, are we just gonna have this person like have a stroke in the, on the inpatient unit like that?

That still bothers me. Obviously that was [00:19:00] one where Yeah, 

Preston: it's just like a revolving door of kicking the can down the road. 

Margaret: Well, I remember asking someone, like leaving something, saying like, coming up, like writing up things like tracking down cardiology, like on the weekend when I was on call and being like, I have this patient during the week.

I have extra time. Let me see if I can get like a concrete plan. And then getting like, like ba like having an attending call me in who had been covering that patient the rest of the time and was like, you shouldn't have done that. Like, that's not like da, like that is like my job to do and, and dah, dah, dah, dah.

And like, mind you, I'd been on that team and so it was like this was also an attending that was like, not going to do this. Uh mm-hmm. 

Preston: So, so you're trying to go above and beyond and then just be being seen as undermining them. 

Margaret: Yeah, and it wasn't even like an understandable undermining, it was like, you just weren't going to do this.

Like, it still makes me both mad and sad and frustrated and [00:20:00] like, ugh, 

Preston: sorry. The one that gets me the most in psychiatry is, um, involuntarily committing people or emergency detentions. And I think like where I really, so I understand what it's necessary and, and if I agree that it's necessary, I think I have a much easier time with it and it still sucks.

And, you know, people kind of let it all out and in a, a verbal barrage on you and all the reasons why, like you're the most evil person ever and hard context. But I. When I'm on call, it's like two in the morning or something. And we don't have attendings in house. We just, we call them from home. I don't know what other programs do.

Yeah. So, so you call the attending, you present and you say, I really think that I can safety plan this person and get them home. And then the, the, the attending basically says, eh, you should, they should come in. 

Mm-hmm. 

And I'm like, but they won't be voluntary. Okay. [00:21:00] Then commit them. You know, and then they just hang up and go back to bed and you're like, that was so easy for you to say, huh?

Yeah. And then, and then you have to go tell this patient who's started off the interview with you, cr crying and sobbing, saying, all I wanna do is go home. Mm-hmm. And I believe they're safe to go home. Mm-hmm. I tried my best to pitch that they're safe to go home to my attending. Mm-hmm. And like, for whatever reason, they don't want to be the last person to touch this hot potato.

Right. Um, or how they see it. And, you know, so the person who's making this, this decision is, is like in bed sleeping, knowing someone else is gonna handle the buck in the morning. And then I have to be like the terrible person. In their eyes doing something I don't believe in. Right. Taking away their rights and committing them to an inpatient psych ward.

Right, right. 

And there are call shift where you do that two, three times. Yeah. You know, at the va and then at our, our county hospital and then at, at our, um, our military hospital too. It's just, it's so demoralizing, Uhhuh, you know, I hate it [00:22:00] so much. Yeah. And I, I try to detach myself from it and say like, I'm not the one making this decision.

It's not my license. I shouldn't care so much. But like, it's, it's in such stark contradiction to everything that like I philosophically and rationally believe in as a person who can under, who to an extent understands justice. Mm-hmm. Like it's, I think that's where I get the most moral injury, I guess.

Yeah. 

Margaret: I think there's a part of psychiatry that is very misunderstood from the outside, not from the patients. Like, I can actually like, take. Quite a bit from patients in terms of like whatever, however they're experiencing me or the clinical situation. Especially in like one year saying, but like it's, I remember I had someone be like, I was working in a children's hospital and like they had a patient I wasn't covering in like the emergency department and they like [00:23:00] were working next to me and I had gone and like had been assigned, this is like my intern year.

Mm-hmm. Assigned one, like a psychiatry patient to cover as like the medicine backup intern, whatever during this. And I came back like an hour later then sign out and was like, there was basically just like security had to be called, it was like first break psychosis. Like this kid got super dysregulated and violent and like had a parent there who was like emotional and crying and it was like late at night.

And so I come over and this other resident is like, I. Oh, well you must have like loved that your psych. And I was like, girl, 

Preston: you gotta be fucking kidding 

Margaret: me. 

Preston: It's like just like, just like how I love appendectomies. 

Margaret: Just like how you love losing someone in the, in like the ICU during surgery. Right? Like girl, what?

I was like girl. So confusing. 

Preston: Imagine it's like someone has a stroke and they have LockedIn syndrome and you're like to the neurologist, you must have loved that. 'cause you're neuro you, 

Margaret: you must love that. 

Preston: Such interesting [00:24:00] neurology, right? 

Margaret: So you know, famously pediatric oncologists love when kids have cancer.

Preston: Like girl. Yeah. Why did you say that? This is so exciting. You have leukemia. 

Oh boy, boy, boy, boy, boy.

I've. It's done a good job covering like our experience with moral injury. Maybe we use this as a chance to debrief a little bit more than we intended, but I, I think the point is moral injury kind of sits outside of burnout, but it's can be something that contributes very directly to burnout and those, those three different categories.

So emotional exhaustion comes from your ability to feel recharged at work, how you feel about going into work. And the, the questions from that MBI will be things like, do you dread going to work? Do you feel exhausted at work? Can you feel recharged after work? And then the second part of it is depersonalization, which is something that I got at earlier.

Like how do you, do you detach yourself from the outcomes of your patients? Mm-hmm. Do you feel like your patients blame you [00:25:00] for things? Do you find yourself viewing your patients as an object rather than an a fellow human? Or do you find yourself not even caring what the outcome of the patient is? And then the last one is personal achievement, which is do you feel like you're making a difference?

Do you think your work is meaningful? And do you think your work is just so, the, the questions are all around that and I, I'm using it as a segue into our responses to that. So Margaret, I had you take the MBI. You did. And what was, what was your reaction to it? 

Margaret: Um, I think that we can talk about our reactions right after this break.

Do, do.

Preston: One thing that's always been challenging about being a lifelong learner is being a lifelong test taker. And I never felt like there was any organized medical resources that I could use for my in-training exams. That is until I discovered Diagnos Psych. 

Margaret: And if you're leaving training like I am, you still [00:26:00] have to be preparing for the test that is the boards.

And now, you know, psych is a medical education resource to help us retain all our knowledge, get better, and get ready for these tests. 

Preston: Yeah. And one thing I really like about the resource is that it has 1500 questions in a Q Bank associated flashcards and categories from epidemiology to biochem, so you can really focus on your weak areas.

Margaret: Ready to take your exam prep to the next level? Go to now, you know, psych.com and enter code. Be patient at checkout for 20% off. That's now you know, psych com

Preston: and we're back with the. Hotly weighted awaited results of our Maslow burnout inventories. 

Margaret: How burn out are you? Can we get some graphics? 

Preston: Are we, are they crispy chicken nuggets? Are they darn pancakes?

Margaret: We're cold at 

Preston: the bottom of a Coleman Grill. 

Margaret: Every healthcare worker's favorite, uh, favorite, favorite pastime? How burn are you? [00:27:00] I mean, well take this survey. I take this out. One survey, my work room. Take 

Preston: this today, by the way, you didn't even give them pizza that out. I printed it out and, and like the residents were scoring very high and then we gave it to the social worker and her score was like four on the whole thing.

Maybe she's just better at coping than we. She was like, she was like, honestly. I'm feeling pretty good. And I was like, what, Andrea? What's going on? And she was like, you should have given this to me. When I was a fifth grade teacher, I was freaking burnt. I was gonna 

Margaret: say, shout out teachers. I was like, awesome teachers.

How burn out are you? 

Preston: If you're a teacher, take the MBI give it to your friends right now and see how high you do and do what you may beat doctors. Yeah. What bragging writes. Of course. Same. That's why everyone does it. 

Margaret: I, Sisyphus is comparing rock size right now. 

Preston: Did you, did you see um, I, I saw a tweet that was like, I think Sisyphus would be much happier, satisfied even if there was a a point system where he could, he could earn a score when he got to the top and [00:28:00] then he could redeem those points for fun stickers to decorate his rock with.

Margaret: Oh, that would kind of work for me, actually. 

Preston: Yeah. I, I mean, I'm just having flash the scenery of the mountain too, having every 

Margaret: episode where we've talked about how you're gonna 

be super chill this year and not track anything about something, and then every clip in the last season of being like, I'm actually running a marathon.

I'm doing a pushup challenge, actually. 

Preston: Oh yeah. We don't need to get into my calorie tracking over the last, oh, I 

Margaret: wasn't, I didn't even bring that up. But you're free. Your chains are broken. 

Preston: Yeah. We're not discussing this now. I'm this, sorry. But I, I've been in a calorie deficit for the last month and I, I quit it last yesterday.

Margaret: My texts. You were like, girl, free yourself. 

Preston: Okay. Stop. Let's stop making them wait and tell 'em what our MBI scores are. 

Margaret: Um, well, there's three parts. 

Preston: Mm-hmm. 

Margaret: Right? So we have to give, give them the context, give them a, a more, a crumb of context for the first. 

Preston: Okay. So the range criterion A is emotional [00:29:00] exhaustion.

How did you do on that one? 

Margaret: Um, I got 18. Okay, 

Preston: so 18 will put you in the moderately emotionally exhausted range. Medium, and then section B depersonalization 

Margaret: 10. 

Preston: So I think that's, is it mild? 

Margaret: Mild depersonalized? Oh, no, 

Preston: sorry. Five or less. Less is low level burnout. So six to 11 on that one. 

Margaret: Is it bad that I was filling this out and I was like, I looked at the scores a little bit after and was like, okay, what kind of dream world are they living?

Preston: No. No, seriously. That's how I felt. So that's also moderately burn out better than 

Margaret: me in healthcare right now. Like I'm a fourth year psychiatrist. 

Preston: And then finally, personal achievement, 

Margaret: um, I got a 40. 

Preston: Oh, so you're not very burnt out in that one. You, you still feel very fulfilled from your work, so, so you're stressed, you're exhausted, you [00:30:00] have some depersonalization, but.

You recoup? Well, so you, you wanna score high in the third one? 

Yeah. 

It's protective against burnout. You don't want you, you wanna do whatever you wanna do. But high in the third category is protective against burnout. 

Margaret: What are your 

Preston: scores? Are you gonna 

Margaret: tell me? I'm a, I'm a depersonalization rising. 

Preston: I'm, yeah.

Margaret: Personal moon, I'm a, I'm an exhaustion Venus. 

Preston: Uh, yeah. I'm a, I'm a an asthmatic and a Capricorn, so my burnout, uh, emotional exhaustion was a 33. So That's high. 

Margaret: Yeah. 

Preston: And, and like I, I knew it going into it, like how I feel like as like some of these thoughts are like embarrassing to say out loud. And then it was like exactly what the burnout questionnaire was asking me about.

Mm-hmm. 

And I, I, I, you kind of feel validated, but also like a little embarrassed I think. Yeah. Um, I scored a, I [00:31:00] think a 22. On the depersonalization one. 

Oh damn. So it was also 

high. And then I think I scored a, like a 36, um, on the, on the last one. Personal achievement. Yeah. So that one was like, okay, that was moderate.

Margaret: Did you ever have to take one of these for your, like, institution in med school or in residency? 

Preston: It wasn't this one in, uh, specific. Um, but yeah, we took some of them, 

Margaret: we had to take one in med school and I remember it would spit out, like at the end it would tell you your results and then give you suggestions.

And it was like, consider exercise and like connecting with friends more. We were like, like 

Preston: it comes across a bit patronizing. I would say. We, so when I first entered residency, we took a questionnaire that was like, it was a risk risk burnout questionnaire 

actually. 

So I remember the questions were. Are you from out of state?

Do you have family in the area? They were like, was this your top residency? Or like, was this one a [00:32:00] choice? Do you find this to be a desirable place to live? Um, and it asked you a bunch of like mental health questions too. Like if you've been diagnosed with depression in the past or other things. And I, I remember like my burnout risk was very high going into it, and I was kind of like, I was offended a little bit.

I was like, okay. 

Margaret: Oh, I'm the best at not Bernie. 

Preston: Yeah. I was like, all right. But then it was totally right. 

Margaret: I get dunked on you. 

Preston: Yeah. Like who has the last laugh now 

Margaret: that online burnout question. 

Preston: Yeah. It got me. And I think it was like for them to assess like, what are our residents risks of burning? Um, so I, I wouldn't, it doesn't mean.

Improve any of these things. And, and like I said, it's, it's more of a syndrome rather than a full-blown disorder. 

Mm-hmm. 

And that's kind of where I want to go next with the conversation, which is, um, the difference between burnout and depression. 

Yeah. And I 

think that's something that a lot of [00:33:00] people in pop psychology use almost synonymously, 

Margaret: right?

Preston: Like, I have a lot of burnout. Yeah. I have depression. Um, 

Margaret: I think one of the questions someone asked is like, related to this on my like Instagram poll thing, which I put with the nervous breakdown book that I found yesterday. Uh, but they asked, how do you know the difference between burnout and just being in the wrong field?

Which is different than what you're saying in terms of like depression. But I think it's just related thing of like, what does this mean? Does it mean something like needing to see a psychiatrist for depression or anxiety or what have you? Does it mean that I'm in the wrong field or in the wrong profession?

Um, so yeah, I think that that delineation is super important. 

Preston: Yeah. And so I I things to answer that question, how do you distinguish between burnout and being in the wrong field? I, I think it, from the outside, it's, it's almost impossible to tell, but a way that you could go about figuring it out is to see what helps [00:34:00] alleviate that burnout.

Hmm. 

So someone who's in the right field, right field, so to speak, or a field that, that would otherwise be fulfilling for them. But because of other extenuating circumstances is burnt out and experiencing the syndrome, uhhuh of emotional exhaustion, depersonalization, and, uh, low personal achievement could have that recharged by a two week vacation or changing jobs or something.

But if none of those things can be alleviated, and it seems to be the nature of the work itself, that would be kind of how you distinguish those things. Mm-hmm. I guess, and so I, I know a lot of like people in psychiatry that felt burnt out at a specific institution or in a certain clinic mm-hmm. Or a certain side of psychiatry, or that's inpatient or outpatient is a classic one.

So I, I think change, like introducing change and then kind of seeing what change was helpful and what change wasn't helpful would be, would be the way I would distinguish between those. And then we, we recall that like, depression is this syndrome [00:35:00] of a lot of behavioral and mood changes. So depression is sadness that is not alleviated by getting out of work.

It doesn't get better no matter what 

matter, 

and it's not tied to a situation. And I think that's the best way to distinguish between burnout and depression. Mm-hmm. So burnout, everything around it is fixated on the work that you're doing and how exhausting that work is, which is why the questionnaire has to do with dreading going to work in the morning, a depressed person and a burnt out person.

Can both dread going to work in the morning, but also that inability to get up still exists for that depressed person on their day off. And it's not to say they're also mutually exclusive. Mm-hmm. There can be burn out people that aren't depressed, there can be depressed people that aren't burn out, and there can be people with burnout who are also depressed.

Margaret: Yeah. And like from that survey that your residents sent you, like having prior episodes of depression or like anxiety disorders is also like a risk factor for mm-hmm. [00:36:00] In some ways developing burnout. I think also, like you were saying with burnout, there's some overlap in this, but like, and hedonia and depression would impact everything sort of the same.

Whereas with this, there may be spillover in terms of like stress management and things like that outside of the job, but it, that that kind of blunting of enjoyment would be more sequestered in the like work and work related part of life. 

Preston: Yeah, absolutely. So. I guess to use my myself as an example here, um, my intern year, I had to be started on antidepressants and I experienced like a depressive episode.

And I think one of the most salient things that told me something was wrong was when I went on vacation. Mm-hmm. And I didn't notice a change. So, um, I, I joined my friend in Park City to go snowboarding. It was like my first vacation of intern year. And old Preston, or normal Preston would be like, very excited to do something like that.

And I was sitting on the ski lift, like going up. [00:37:00] And usually this is a feeling that's like Christmas morning for me, like finally getting into like go skiing. The first, the first run of the season. You know, anyone who does like winter sports kind of knows what I'm talking about. And I felt nothing. I was dreading it.

I was like, everything this is still, I'm just going through the motions here, but I, I just, there's just nothing. When I looked, when I look up at the snow, when I look at my snowboard, the mountains, like I'm just here. 

Yeah. 

And I was, that was pretty unsettling. 

I was like, holy shit. 

This is supposed to be reprieve.

This is this trip that I was planning. I'm in, I'm in this fun part of the town, like part, part of the country, and I'm skiing and I, and I can enjoy this. What's, what's going on? And then I think this year I, I, fortunately I got on medication, I've been doing a lot better and I think I'm experiencing burnout this year.

And I noticed that like I, I have similar frustrations at work, but then when I go to run club on Saturday morning or I go to run my race in LA or something, I, I get excited about that. I enjoy it. I'm having fun. When 

Margaret: you get to film the podcast? 

Preston: Yeah. When [00:38:00] I come here to film, when I do my latte art, you know, it's fun and enjoyable.

Margaret: Yeah. Yeah. So you notice a difference kind of with the meds being, and then like how it was more sequestered to the, like part of your life related to work. 

Preston: Exactly. So I, I'm gonna read to you a couple vignettes and we can kind of talk about the differences between them without being to filter through Preston's personal experience.

So, um, this first one. Dr. Wynn is a third year internal medicine resident. She feels emotionally depleted, avoids emotional conversations with patients, counts the hours until she can go home on vacation. She feels better. She still enjoys weekends with friends. She's not suicidal. She dreads going back to work.

And when she is at work, she's calculated, she's efficient, but more of a checkboxy manner and she doesn't go above and beyond for her patients. 

Margaret: So the question is, is this burnout or is this 

Preston: depression? Yeah. What would this be more consistent with? 

Margaret: [00:39:00] I think it's more consistent with burnout because it is like about how like kind of trying to function in this work environment and more related mm-hmm.

To like patient care rather than having other factor like symptoms of depression and being expansive throughout. 

Preston: Yeah. And, and I think we, we, we kind of highlight the obvious parts of it, which is I. At work, sad, out of work, happy. Mm-hmm. And so she's able to go on vacation and enjoy things, which is what I mentioned I wasn't able to do 

Margaret: for that vignette, though.

I think this also does get at like the, I was struck by the last part of it where you said like, she's not going above and beyond for patience. And I, I just think that's, so part of the burnout equation is the expectation of going above and beyond and doing more and more and more until you're so exhausted that you pass out.

Mm-hmm. That like, in some ways is that part of burnout? Yes, but I would, I think the way I would phrase it with a, like a [00:40:00] patient or someone, or a friend would be like, are you doing for this case? Like, are you doing medicine in a way that aligns with how you want to be practicing medicine in, in, you know, kind of like a, a reasonable like fashion in terms of like what are actual options of how we practice medicine wherever we are.

Yeah. Um, just to say, 'cause I think that that is, part of this is like also the guilt, especially in some fields. Um, in medicine in particular, there's different requirements for each field. Like, no one looks at me and is like, you should be up at 4:00 AM as a psychiatrist, like they would for a surgeon. But I think of my friends in pediatrics and it's like how often they get like, oh, like you're both like a hero and well, you shouldn't want fewer hours, you shouldn't want more pay, you shouldn't want this, that, or the other, or more support in the hospital 'cause you're, we're, we're all doing it for the kids.

And so I, I guess that just like came up for me and thinking about this topic of like [00:41:00] expectations. So 

Preston: the other aspect of burnout is almost like the guilt around not being this evangelical, altruistic human too. 

Yeah. You're 

not allowed to just do the work. You, you should also feel guilty about that on top of everything.

Yes. 

Yeah. I. I feel that too. 

Yeah. 

Um, and, and with the amount of like virtue signaling in medicine, it's just kind of thrown in your face consistently. 

Margaret: Well, I think also, like, I don't know what you're, this is a hot take. Um, so I wonder what you think about it. The fields that require, like, kind of like in this, the current like model of healthcare, right?

Like 

Preston: mm-hmm. 

Margaret: Operations interventions are like prioritized from like a monetary perspective and like prestige historically in medicine has been more in those fields as well when you, whereas like when hasn't been prestige and respect in [00:42:00] modern medicine last like 50 to 60 years for like primary care, pediatrics, psychiatry, like palliative care.

Like these are the fields that are like when we are, I don't know for you, but when I was in med school, it was like, oh, you wanna do psychiatry? Like, good for you. We need people to do that. Like. 

Preston: We need 

Margaret: this. And it's, I could 

Preston: never, I could 

Margaret: never. Yeah. And it's, it's interesting in that it, like these fields all include more emotional labor and it's, it's interesting that that part is undervalued.

And I think that is part of the, like, burnout question for a lot of people is this undervaluing both monetarily and societally of like, what is it that the work, the work we're doing, why can't you, why can't you see 30 patients a day? Mm-hmm. Like, why is that You're just sitting and talking to them. 

Preston: Yeah.

The, the high empathy specialties like, get devalued. 

Margaret: Sorry, that was kind of tangential, but 

Preston: No, I, I think it's, it is a fair take and, and something I hadn't thought too much about that, like, that's a uniting feature between less [00:43:00] prestigious specialties. 

Yeah. 

So this next vignette I have, mm-hmm. Derek, he's a 29-year-old accountant.

He's lost interest in his hobbies. He doesn't feel like eating even when he comes home from a long day at work. He feels worthless. He doesn't wanna socialize or go to the bar with people after he gets off of work. He struggles even executing tasks. And, uh, he starts to fall behind on deadlines. He starts to think that he's a burden to other people and the world would be better without him.

And it doesn't really matter if it's the weekend or if he's working. Everything just feels he heavy and he just wishes he didn't have to exist. 

Margaret: So there's a safety component. Mm-hmm. There's also these kind of physiologic parts of it with like lower appetite, low energy, isolation and motivation. 

Preston: Yeah. And, and we see that his mood doesn't respond to his situational change.

Margaret: Yeah. 

Preston: Which is an important like distinguishing [00:44:00] factor. 

Margaret: Yeah. It, it's, and it's like, I'm just thinking of some of people, like, like you, you talk to people who like have just gotten out of residency or get out of intern year and then their next year's like not as hard, whatever. And they're like. I think it's helpful because we need something that defines these two things.

But I also have had people where it's like they're gone for a week on vacation and they've been so over, like anxious and stressed and overwhelmed from their environment that like the vacation didn't fix it for them. They didn't feel better during that, but when they moved jobs mm-hmm. 

Preston: Or when they 

Margaret: actually finished residency and like had time Yeah.

Like real time off to like, then they did get better like months. Yeah. It's like, is that depression versus burnout? I don't disagree. 

Preston: No. I think it's like, uh, like the dose wasn't high enough, if that makes sense. Yeah. Like, like, um, you know, if that vacation was Tylenol, they, they took, you know, 50 milligrams or they needed to take like a thousand.

Mm-hmm. You know, I, I just, my, my little [00:45:00] two week vacation is, is just not a strong enough dose to wipe out my burnout, 

Margaret: but I think Well, okay. Here's a question I have for you with this. Sorry, I'm going off your script. Mm-hmm. Because I run into this a lot, not with burnout, but with like the perinatal clinic where it's like, or I think all of us run into this where it's like someone's in very difficult circumstances that we can't control as their doctor, but we can possibly help them somewhat with an SSRI.

And I think about burnout with like healthcare workers. Like is it because they have depression, that they're feeling this way? But if you put them in different environments, they wouldn't feel that way. Like it's unfair that they, that they're in this environment, but could we help them in that environment with the medication even if we don't think it's a pathology?

Preston: Yeah. I, I think so. In, in some scenarios it can be helpful. 

Margaret: Yeah. 

Preston: Separate the title of like antidepressant from SSRI there, it can help us [00:46:00] reframe that. So we know that when we give someone serotonin or, or a medication that increases levels of serotonin, it makes them feel agitation to, at a lesser, lesser intensity, makes 'em feel anxiety at a lesser intensity.

So something as simple as like, he like this, this shit sucks. 

Margaret: Period. You know, speak on it. 

Preston: Yeah. Like, and it's gonna make you angry. Like you, you work in, in a job where you're trying to like uphold an oppressive system 

mm-hmm. That 

you don't necessarily agree with. And like your feelings of agitation or frustration and indignation are valid and this medication will help alleviate some of those that you deal with.

Mm-hmm. It's not an antidepressant in the sense that you are depressed, but it's helps you get through the day. I, I think that's how I'd frame it. Yeah. 

Margaret: And I think, you know, to acknowledge like what we're saying is kind of controversial in psychiatry, not super controversial. I think a lot of people know this, but like, I feel like I'll bring it up with my patients.

Like [00:47:00] I will actually harp on this and say like, I think the way you're experiencing like low support and postpartum, let's say especially a postpartum healthcare worker. Mm-hmm. Like you're going and doing this, you're not sleeping. Your like relationship is strained because you're both not sleeping. This is happening.

Like let alone if there's other stuff like grief happening at the same time. Like, are you, do I think you necessarily have a depressive disorder? No. Do I think that there's a chance that an SSRI could help you with this period that is unfair or whatever? Possibly. And I want you to know, I don't think, I don't locate the problem within you, but I do wanna offer you the support if it could be helpful.

Um, yeah. And I think that's important in healthcare too, especially when like, people are made to feel like they should just be able to work 80 hours and, and not blink like. Not me, not, that's not me. 

Preston: I don't flinch, 

Margaret: I don't work 80 hours. 

Preston: So, you know, [00:48:00] in, in summary here, kind of taking a step back and looking at moral injury, which we discussed burnout and depression, I would say that, um, burnout would be the, the saying I'm exhausted 

and moral injury would be I've, I've been betrayed.

Hmm. And then, um, depression would be, um, I'm depressed. 

Yeah. Sorry. 

Margaret: Um, me 

Preston: depress 

Margaret: is that me? It's pre How have you never used one of those in your, in your tiktoks? 

Preston: So I know these are kind of. New conversations on Just Skip. 

Margaret: They're gonna get you in the comments for that. 

Preston: For what? It's me depress No, 

Margaret: no. For when I say something.

There are a couple people in the comments over once in a while, but I'm like, just like saying shit and you don't respond. They're like, 

press and respond. Can we cut that out? Editor? 

Preston: Okay. [00:49:00] Editors, you don't have to cut it out. No. Are responding. Well, 

Margaret: it's real, you know, season two, we're keeping it, we're keeping it real.

Preston: I'm laughing less. Okay. Do dear listeners, if I don't respond tomorrow, it is because my mind is thinking about the next thing I'm gonna say. That's true. And also I hate her. 

Margaret: And also we enemies also, he's coming for my job, um, which is psychiatry. 

Preston: So when we come back, we're gonna kind of go over some of the directions that we hope society goes with burnout and, and our own kind of takes on how to, to fight it.

Welcome back to our Rapid, our rapid Fire Burnout Tips. So Margaret's gonna be starting the timer, and we're gonna tell you as many helpful tips as we can to fight burnout. I and I, I feel like almost underqualified to do this because we we're gonna say 

Margaret: pizza for fun. 

Preston: Well, we have two burnt out residents.

One moderately, one highly. [00:50:00] 

Margaret: Yeah. So 

Preston: who are trying to tell other people how to not be burnt out is it's a bit of a blind leading blind situation. 

Margaret: That's true, that's true. But 

Preston: I will say some things do make it easier. 

Margaret: All right. Let's ping pong back and forth. Do you wanna start or should I start? 

Preston: Um, okay, I'm gonna start blueberry scones.

I make blueberry scones on the weekends. Sometimes those, like one bite of those, that's, that's anti burnout right there. I 

Margaret: love. I FaceTiming my family and hanging out with little kids. This is not for everyone. These are our personal strategies. Take what you will. Yeah. Um, I love just getting to giggle with them 'cause I don't have to talk about anything Smart.

Preston: Um, okay. Venting with colleagues. Real talk. So, um, like scheduling time to like vent about like frus frustrating things or debrief. That helps a lot. And that one is actually evidence-based. So they've done studies where they like, will schedule like debriefs on ICU teams and other things. And [00:51:00] that's been helpful for burnout.

Margaret: Um, I think, I mean I started my TikTok because I was like, I want something that's not at all related to medicine. Not, it wasn't gonna supposed to be a job. Uh, just be like, okay, I'm talking about Taylor Swift, like I'm turning all these other parts of me off and like reclaiming my time. So I do think hobby, creative expression stuff doesn't need to be online.

Uh. Is helpful to take some of that time back, but, and giving yourself time to start enjoying it like that. You probably won't, you might not enjoy the first few times you do it 'cause you're outta practice. 

Preston: And I think more so than just like hobby and creative, uh, outlets, but identity outside of medicine 

Yeah.

Is 

very important I think when you like, especially working, um, in a place where your values may not line up with the things you have to do all the time. If all of your value. Is surrounds you as a doctor. It's just gonna affect you so much more when you have other protective identities against that. So you're like, okay, this, yeah, this doctor part of me [00:52:00] is like, really hurt today, but it's not all of me.

Margaret: At the end of the day, Preston's just a white dude with a podcast mic and that's a protective 

Preston: Yeah. I'm like, I'm just getting slammed on rounds and I'm like, they don't know I'm gonna go home, be a, be a a white man talking into a podcast. They don dunno what 

Margaret: I'm about to do. 

Preston: They dunno how much cre I had to do.

They dunno about 

Margaret: my high value male podcast. 

Preston: Yeah. Like, um, so, and, and I, I would say with those hobbies, like find other goals to pursue. So like one thing that actually helped me a lot with burnout, um, I would say over the last couple months was like training for the marathon, weirdly enough. Mm-hmm.

Because I had something that I was like focusing on looking forward to and progressing with outside of work that didn't really have anything to do with my identity as a doctor. So I'd be like, oh, like I'm getting absolutely grilled at work today. But I'm like, well, I've got my long run this weekend.

Like I need to be, okay. What am I doing to prep for my long run? I can hit these milestones. I'm like doing well on my mileage, like nice. Mm-hmm. Mm-hmm. You know, I'm just like looking forward to leave work to go take care of [00:53:00] this balloon tower Defense was the other thing that was for me when I started getting really efficient at Balloon Tower Defense six.

Margaret: What is that? If you 

Preston: know you, it's, it's a mobile game. Oh, okay. That I just play on my phone. It's, it's honestly insanely addicting. 

Margaret: I saw TikTok earlier today that was like, you don't need a boyfriend, 

you just want a Nintendo switch. Like you just need, like stop letting him hurt your feelings girls. You just need a game.

Uh, and like we're like healthcare workers. You just need to get a game Boy. 

Um, for real though. I agree with you on that. And I think finding places where you can exert control. Ethically, uh, is a good thing. Finding things like that you can improve at, like, I feel like in the hobbies, not for, not to get too perfectionist, but like a lot of us in medicine are type A and in some ways Oh, 

Preston: so do, hold that thought.

Sorry. 

Margaret: I'm gonna kill you. Keep 

Preston: talking. 

Margaret: What? 

Preston: No, keep talking. I'm, I'm just gonna grab something. 

Margaret: What [00:54:00] Preston whatcha doing? If you get that fricking puppet out, I'll kill you. No, it's not the puppet. Okay, fine. Go it. I'll wait. Listeners, I have you here though. I that like having something that you can get better at, that you can control or something in medicine that you actually think you can impact and it can get better.

Um, so not trying to push at the part of your healthcare institution that like 20 other people have tried to change and never changed because there's so much resistance. But something that like no one besides you cares enough about to push against you. What did you get? If you got the Fedor out, I'm also gonna kill you.

This is now I what? 

Preston: This is an honest, honest to God. Harmonica. Alright. 

Margaret: Billy Joel here. I've, 

Preston: I've been, I've been practicing it. 

Margaret: What's here at Billy Joel? 

Preston: So, um, it came, I, I found this in my closet. It came with like a little book on how to play it. But where did you get the book? I dunno, you just came with it where?

No, my dad [00:55:00] gave it to me. 

Oh, that's kind of fun. 

Yeah. Well he never used it. It was new when I opened it. This you just said we're a perfectionist. We need to get better at everything. So bad art every day I may live to regret it. 

Margaret: Oh, that's nice.

Preston: You got a free concert. 

Margaret: That was a, an interesting thing to watch.

Preston: That's all I have to say. The, the journey of like, and I'm not good at this at all by the way. I, I, like anyone who knows anything about harmonica, knows I probably just messed up a bunch of stuff. The first thing you have to do is even like, play one note at a time, which I don't think I can do, but it's a rounds of fun to learn something new and you're like, wow.

Right. I way to [00:56:00] express myself isn't just trying to like be an intelligent, morally perfect servant of, of the medical system. 

Margaret: Does this mean that we're, you know, in the episode, the last episode that came out was like, my friend texted me and was like, I liked that bit where it was like, oh, we said the name of the podcast and you were like Schindler in his list.

And we kept going. I feel like now we've reached the part where it's the name of my. Other accounts, which is bad art, every day we 

Preston: full circle there. Hi. Yeah. How to be patient with bad art every day. 

Margaret: Yeah. Period. And then we're gonna add. With the whole name and then have pets. I'm working on it. I got I I told you I'm getting allergy shots.

Right, so I can get a pet eventually and not react. 

Preston: Oh no you didn't. 

Margaret: So me A year from now 

Preston: is gonna be so lit. It's coming soon. So yeah. Ho, hopefully we're outta time. I'll send 

Margaret: the pond. Yeah. Find 

Preston: them all who are listening. Hopefully some of those are good burnout tips for you. But we want to hear what are your tips for us?

'cause I think we [00:57:00] probably need them more than you do on how you fight burnout. 

Margaret: Do you want a full harmonica episode concert? 

Preston: Yeah. And please take your MBI scale before and after you listen to this podcast and we'll see how much we've helped you. It's anyways. Oh, hi Kat. Um, if you have any other opinions about the show, thank you so much for sticking around in season one.

We are excited to keep going with you guys in season two and we're gonna keep rolling. Uh, we have a lot of your suggestions in our dms and we're kind of forming a list of topics that we wanna roll through, but for both solo episodes and with our guests, 

Margaret: for example, which would you want an as SMR episode?

I think that's still on the table. 

Preston: Yeah. And, and we can roll in the harmonica in the ASMR episode and the puppet show. Scott, Scott accent. 

Margaret: We'll go back to the topic floor and talk about that a little bit. 

Preston: Yeah, I'll use my pelvic floor to play the Harmonica Act. No, God, 

Margaret: press 

Preston: come chat with us and our fun Human content podcast family on IG and TikTok at Human Content Pods.

Or you can contact us directly at How [00:58:00] to be patient pod.com. You can see more from me in Margaret on my YouTube channel at its prerow or on our Instagram, how to Be Patient, which we have our own Instagram page. Now, if you didn't know that. Margaret's also on substack as bad, bad art every day. We respond to all of those intermittently, but you have a how to be patient question.

The how to be patient Instagram page is the best one to go to. 

Margaret: It's like those little rats in the cage where with the intermittent reinforcement, it's, it's, we're intentionally using it. We're not 

forgetting to do things in stressed out. 

Preston: Thank you so much to all of our listeners who take you on take.

Take us in your ears on walks. Take us in your ears. God, what is the No, somebody said that. They were like, I, I bring you guys along on my walks with my dog, but they did not, not say, I 

Margaret: take you in my ears. 

Preston: No, they didn't. That's kind of weird. Yeah. Anyway, thanks for including us on your walk with your dog, wherever you are.

Margaret: Yeah, 

Preston: we're, we're here and I'm just kinda commute, picturing and commutes. 

Margaret: There's been a couple people also who are like, I drive and I listen to this and I'm like, that's so great. Whoa. Don't forget to bully us in [00:59:00] the reviews. Say, yeah, the laughter was just the right amount. This time, make sure, make 

Preston: sure your seat belt's on if you're driving and listening to us right now too.

Very true. 

Margaret: All 

Preston: right. Thanks again for listening. We're your host, Preston Roche and Margaret Duncan. Our executive producers are Preston, Roche, Margaret Duncan, will Flannery, Kristen Flannery, Aaron Corny, Rob Goldman and Shanti Brook. Our editor and engineer is Jason Portis. Our music is Bio Mayor Benz V to learn about our program, disclaimer and ethics policy submission verification, licensing terms, and our HIPAA release terms.

Go to website, how to be patient pod.com or reach out to us directly at how to be patient at human content. Do human content do, sorry, I'm trying to read off the board and Lilac just kicked the entire mouse. 

Margaret: She's like, you're done here, human. How to be patient. Reach out to us how 

Preston: to be patient@humancontent.com with any questions or concerns.

I like, do you have any questions or concerns? She's like, yeah, how patient, how to be patient is a human content [01:00:00] production.