Overcoming exhaustion

The ‘window mirror’ approach to patient care: What we can learn from it

I knew I was in full-blown burnout from years of working as a psychiatrist for the local public health department. I was one of the few psychiatric clinicians accepting any (or no) insurance for many miles.


I woke up to my cat licking my eyelids. I had fallen asleep at the top of the stairs, tangled in my shirt, which was half off and stuck around my neck. The last thing I could remember was hours before, coming home from clinic so exhausted I crawled up the carpeted stairs, pulling my shirt off to change—and had apparently fallen asleep before I could finish. I woke up three hours later.

There were so many moments leading up to this event, and yet no single episode stood out as the inciting issue. I knew I was in full-blown burnout from years of working as a psychiatrist for the local public health department. I was one of the few psychiatric clinicians accepting any (or no) insurance for many miles. I had a waitlist for new patients that had extended out to six months for new evaluations.

Because the clinic base turned no patients away, I was completely unable to “close” my clinic to seeing new patients, so follow-up visits spanned from three to four months out, with only my lunchtime hours available (in which I scheduled when needed) for patients in urgent crises. And in a public health department providing psychiatric care for five local Federally Qualified Health Center clinics serving the underserved, everyone seemed to be in active crisis.

Experiencing exhaustion

I worked through lunch hours. I pulled food out of my home refrigerator multiple times for patients when the food pantries were empty. I drank so much coffee on a daily basis that I started to have gastrointestinal discomfort. It was alleviated only with food, but I barely had time to eat. Looking back on those years in service, it is so obvious to any reader why I was experiencing a core exhaustion. But for me, at the time I just focused on one problem, one patient, and then the next, just trying to get through the day. I had no idea why I had gained so much weight and was so fatigued.

Coincidentally, my (then) number one workup for etiology of symptoms (other than for depression) was fatigue. I had an inordinate number of initial evaluations for fatigue. One patient, with full medical workup and multiple failed medications, came in wearing a T-shirt with brightly printed patterns of a popular caffeinated soda. I asked her how much of the beverage she was drinking. It turned out that she was ingesting two to three liters a day. I had been changing her psychiatric medications for months due to potential GI side effects.

I had asked previously about caffeine intake, and she had denied it on each occasion, reporting it had not occurred to her that this was significant enough to mention. This type of interaction occurred so many times, it was not identifying information for the patient. It became a common element of understanding the workup for fatigue in my early years of practice.

The irony of both my patients’ and my own “blind spots” to this contributor to our underlying condition was not lost, even on me at the time. Multiple patients reported drinking two to three full pots of black coffee throughout the day, yet they insisted that had nothing to do with difficulty falling asleep and were very upset they could not have increases in their sleep medication.

Similarities in myself

Soon after, I started to take steps to address my fatigue. I limited the number of patients I would see, eliminated the “add-on” appointments and left the clinic every day at 5 p.m. regardless of how many times the EHR or Wi-Fi restarted. I started taking notes on paper whenever the medical records system was down, which happened multiple times per day.

Some days, I would leave piles of paper notes to be scanned to patient records while my colleagues struggled to re-enter notes that were lost on stalling computer systems. While they were doing that, I was going to Zumba, physically and metaphorically dancing to let go of stress. The idea caught on, and soon a group of physicians would leave stacks of paper notes to be scanned into patient records at the end of the day. I stopped trying to solve all of the problems of a broken health care system, and I gained the gift of time.

I incorporated these changes, and the number of malaise/fatigue patients I was given for evaluation reduced dramatically.

Similarly, when I had relationship challenges, the very issues I was facing would show up in patient care with my patients. When I was struggling to find my voice in an intimate relationship, countless patients, regardless of gender or orientation, would speak about feeling unseen and unheard. Soon after this issue was resolved for me personally, the number of patients with this as a primary challenge reduced as well.

Years later, as I started to progress professionally, I saw more and more patients, whom I had been working with for years, start to break barriers beyond what might be expected of their demographic. At the same time, I was breaking barriers in my own career. I worked with college students who were accepted into medical school, soon to be first-generation physicians. Similarly, my career in medicine was expanding.

‘Window mirror’ medicine

In my experience, we have a lens of perception bias as well as an unexplainable magnetizing force (such as the Baader-Meinhof Phenomenon) in which our patients often mirror what we, as physicians, also face. One sees this in day-to-day life when we buy a new car. Soon after purchase, it seems that very car is everywhere—without changing any aspect of one’s lifestyle or driving patterns. This phenomenon has parallels to the “window mirror” approach to practicing medicine, which was proposed in the journal Open Medicine in 2008 and describes a patient care model in which the needs of the patient and the physician are each considered and both parties empathize with and care for one another.

Such an approach to patient care would help us create and maintain more of a human-to-human connection with our patients. With countless studies reporting the increasing shortages of physicians, and extensive burnout for those still in practice, perhaps a unidirectional outpouring of service to our patients is not working.

Maintaining an inherent natural bidirectional connection with intrinsic shared values of care in partnership with our patients might not only be the key to a greater connection with our patients—it might also be the key to improving our connection with ourselves. For me, sharing my humanity with my patients was the key factor that made all the difference in my practice of medicine, and more importantly, in myself.

Editor’s note: The views expressed in this article are the author’s own and do not necessarily represent the views of The DO or the AOA.

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