COMMON POSITIONING PROBLEMS: The Solutions!

OBJECTIVES:

No matter which modality we are using, no matter whether we are practicing screening or diagnostic mammography, no matter what: We still have to position our patients so that all the breast tissue is demonstrated.

That is always a challenge and all the help that comes our way is useful. Here are some tips regarding positioning dilemmas with some handy remedies. I hope they are helpful.

THE CC PROJECTION: “IF”

A) The nipple is not in profile

If the nipple is not in perfect profile: 1. Elevate the IMF a little higher 2. Lift and pull the breast straight onto the bucky 3. Use both hands to handle the breast 4. (Hint): The nipple points toward the missing tissue

B) The medial Cleavage is not open and visualized

If the medial cleavage is not visualized properly: 1. Position from the medial side 2. Lift and drape opposite breast over the edge of the bucky 3. Do not press the patient’s face against the face protector 4. Place her head beside and beyond the tube

C) The lateral aspect or ‘Tail-of-Spence’ is not demonstrated

If the lateral aspect of the breast is not seen: 1. The Patient’s arm should be relaxed by side 2. Her palm should be supinated with her shoulder externally rotated 3. Control your patient’s posture with your hand around her back on her contra-lateral shoulder 4. She should be relaxed forward bent slightly at the waist 5. Release the breast to the compression with forward and medial orientation of your hand

D) The pectoral shadow is not visible at the chest wall and/or the PNL is not within 1cm of the PNL on the MLO

If the ½ moon of pectoral shadow is not seen at the chest wall of the CC view and/or the PNL is of an inadequate length: 1. Elevate the IMF until the tissue no longer moves easily along the chest wall 2. Identify the edge of the pectoral muscle visible just under the clavicle 3. Loosen the skin over the clavicle so the tissue moves easily 4. Compress parallel to the pectoral edge just under the clavicle 5. Release hand in a forward medial motion

THE MLO PROJECTION: “IF”

A) The pectoral muscle is not demonstrated to or below the level of the nipple

If the pectoral muscle is not seen to the level of the nipple or below: 1. Adjust your tube angle parallel to the obliquity of the patient’s pectoral muscle 2. Move the breast medially and anteriorly from the lateral border until the pectoral pouches out next to the sternum 3. Compress the projection parallel to the pectoral axis along the sternal edge

B) The pectoral muscle is not relaxed and convex in shape

If the pectoral shadow does not appear convexly shaped: 1. DO NOT rest your patient’s arm along the top edge of the bucky 2. Patient’s shoulder should be open, relaxed 3. The corner of the bucky high up and well back in the axilla 4. Patient’s arm should be slightly bent hanging loosely down the back of the bucky 5. Relaxed hand…NO gripping the handle

C) The breast is not ‘up & out’ and/or the retro mammary space is not visualized behind the parenchyma

If the retro mammary space is obscured by parenchyma and the breast is not adequately ‘up & out’: 1. Move the breast from the lateral edge medially 2. Ensure the breast mound moves freely in your grip 3. Support the breast tissue from the inferior border using you entire hand 4. Immobilize the breast tissue on the bucky in the ‘up & out’ position using the edge of your hand to support the pectoral axis along the sternum 5. Release the breast to compression with a distinct out and away motion

D) The Infra-mammary Fold is not clearly seen curving to the abdomen un-obscured by wrinkles, folds or belly

If the IMF is not open and fold free: 1. Support the breast and always release with and up & out motion 2. Have the patient tilt her hips slightly backwards 3. Do not release your hold on the breast until the projection is immobilized by the compression 4. Gently run your thumb and finger down behind the breast along the IMF/belly border to clear folds, wrinkles and tummy

E) Nipple is not in profile

If the nipple shadow is not in perfect profile: 1. Make sure the patient’s feet are directly facing the bucky 2. Control the breast from the mobile lateral border only 3. Immobilize the breast parenchyma parallel to the pectoral muscle until the compression holds the projection 4. (Hint): The nipple points toward the missing tissue

SUMMARY

Mammography is a sensitive, complicated and difficult specialty. All our patients vary as to body habitus, temperament and compliance. It is essential we demonstrate all the tissue, see it clearly and know that all the borders of the breast are verified.

Breast Imaging is an area of DI where we work autonomously much of the time. We are responsible for checking and correcting our own work. I send this article once a year for those who have lost theirs or those who are new to techtalk, I hope they will lend a hand in the arduous task of perfecting your technique and knowledge.

Annie Listens

OBJECTIVES:

Very often technologists contact me with problems, send me wonderful ideas and share their professional lives with me. I am proud and happy to receive these calls; it makes me feel confident, professional and secure in my specialty when I realize how many problems, concerns, joys and triumphs we all share. . I would like to share some of these contacts with you.

Dear Annie,

I read your suggestion to 'Hong Kong' regarding localizing the lesion for a needle location. We also have a good method of finding the lesion in the localization window. We put a small skin marker or 'BB' on the patient's skin in the upper right hand corner of the window and when the image is processed the position can be adjusted by moving the window according to the marker. We use this method for stereo biopsies as well and it works well for the technologists and for the radiologists.

Hope you like this idea and pass it on.

Jane

Dear Jane,

Like it; I think it is brilliant. Thanks for the great idea; I'm sure everyone will love it.

If you require a little more control over the orientation of the image a small addition to the idea could be four small markers at each corner of the window.

Welcome to the 'Einstein Corner',

Annie

Dear Annie,

I am a bit confused as to when to use a grid for the mammogram and when not to. I read somewhere that you don't always need a grid but I don't know if it is better or worse to do so.

Can you give me some information about what the grid does and when it is appropriate to use one?

A bit 'grid-dy' in,

California

Dear Grid-dy,

There is so much information out there it sometimes becomes confusing to us all. When studying for our various certification exams we come across tons of material. All of it is useful but some of it is difficult to place into a useable format.

Grids in mammography are used to absorb scatter radiation and by so doing improve contrast of the image. The vast majority of breast tissue we image is over 4cm thick when compressed and between 25% and 75% mammographically dense; therefore, a grid is almost always used for routine breast imaging.

There are a few notable exceptions to using a grid in mammography. When we are performing magnification views the space between the magnification table and the film receptor absorbs the scatter into the air and prevents it from reaching the film. Therefore a grid is not necessary for magnification radiography of any sort, even breast images. Specimen radiograms should be magnified if possible so a grid is not needed for this type of image. Even is the specimen cannot be magnified for some reason (size, equipment availability, preference, etc.) a grid probably will not be required because the thin, tightly compressed nature of the specimen usually will not produce enough scatter to affect the image. Occasionally, we encounter a patient with emaciated type breast tissue that compresses out completely. In these cases, when the paddle is clicking on the bucky through the breast tissue and there is little dangerous of scatter bouncing through a thick dense object, it is sometimes advantageous to remove the grid. These patients are rare and usually very ill or elderly. By removing the grid we can reduce the mAs and therefore help to eliminate image blur by freezing any tremor, movement or feebleness in these fragile patients.

Grids used in mammography must be of a specific category, regular x-ray grids will not do. Mammography grids must always be reciprocating grids and never stationary type. The reason for this is the grid lines produced by stationary grids will obscure the tiny subtle breast abnormalities we are looking for. The interspaces used in mammographic grids should be made from carbon fiber material because carbon fiber allows more of the primary beam through to the film than the traditional plastic or metal fillers in regular x-ray grids or grid cassettes. A mammographic grid must be a very high ratio grid so as to produce the sharpest image possible. A breast imaging grid must be 4:1 or 5:1, the 8:1 grids used in x-ray will not do.

Signs of a faulty grid on breast images include grid lines of course, but also areas of patchy blur or wavy areas within the image.

I hope this will be some help with the grid dilemmas. We can be easily dazed by information overload in this specialty but it always can be sorted out.

Annie

Dear Annie,

I have had patients demand information and instruction on breast-self-examination. They seem to think that I must teach this information as part of taking their mammogram. Do you have any data on what is my responsibility in this area?

Not a teacher in,

Albany, NY

Dear Albany,

The mammographer’s responsibilities when dealing with her patient are to produce quality images, inform the patient about the test she is having, reduce patient anxiety, take a full patient history and treat the patient with professional dignity. Teaching BSE or any other breast health information is not officially the technologist’s task.

Many breast health centers offer information regarding breast health to their clients. Breast imaging is more than pushing buttons and acquiring images. Our patients think of us as trained, specialized health-care providers who can help them improve their knowledge a propos breast disease, breast health and body awareness. Patient health education reduces patient apprehension, relaxes her, and makes her, generally, a healthier, smarter and more adaptable health-care consumer. All very good for us!

Information in relation to the job we do makes us more relaxed about the quality of our work, more confident when it comes to patient relations, more self-assured when dealing other medical professionals and certainly produces a more poised self confident member of the breast imaging medical team. Also, all very good for us!

So after that long verbal ramble, the bottom line here is if the facility we work for does not insist that patient health education is part of their mandate and therefore, part of your mandate, then, patient health education is technically not part of a mammographer’s direct duty. My opinion however is that we owe our patients all the information we can provide to ensure they are healthier, we are cleverer and our professional lives become easier.

I like to teach,

Annie

Dear Annie,

While studying for my certification exams, I have come across a term that I don’t understand. The text keeps referring to the “ipsilateral” arm, the “ipsilateral” breast etc. I have never heard this word before. Do you know what it means?

Wordless in,

Sydney, Aus

Dear Wordless,

Indeed it is a bit obscure. The word refers to the ‘same side’ as the side you are dealing with. It is the antonym to ‘contra lateral’, the opposite side that you are dealing with.

I trust that clears up what the text is talking about. It is amazing how one misunderstood word can mess us up.

A bit wordy,

Annie

Dear Annie,

I read somewhere that the tube should be angled slightly for the ‘CC’ view. Is that correct and, if so, how much should I angle and which way?

Slightly askew in,

Tokyo, Japan

Dear Askew,

The short answer is no. The tube for the ‘CC’ projection should be directly vertical with the central ray and perpendicular with the floor. However, modified and supplemental versions are very often required to visualize all of the breast tissue. To keep the view as craniocaudal never angle more that 5º or 6º at the most. I have included a few helpful CC tips to help with those difficult CC problems.

Hope this informs and also helps,

Annie

A FEW TERRIFIC CC TIPS!

1. For very small breasts, angle 3-5º laterally and start the bucky a little lower than your eye tells you is correct. Then lift the IMF up along the chest wall until the IMF forms a 90º angle with the chest wall.
2. For breasts that have no medial delineation between right and left (like a bandeau bathing suit top) angle 3-5º medially. When the IMF is positioned correctly (90º angle with the chest wall) the contra lateral breast can be pulled straight away from the side you are imaging with no crossover, no downward drag and no patient discomfort.
3. Another excellent use for the slightly modified medially angled CC is pectoralis carnivatum (a very prominent sternum and rib conjunction) that interferes terribly with the compression paddle on the medial side. Again, angle 3-5º medially and carefully raise the breast until the paddle can clear the sternal and rib skeleton on the medial side. Viola, medial tissue with no skin abrasion, no bruising and very little patient discomfort.
4. Conversely, for the opposite sternum/rib abnormality (pectoralis excavatum) where the sternum is sunken into the chest wall, angle 3-5º laterally and gently lift and separate the medial edge of the breast up and away from the sternum and ribs.

SUMMARY

I always love answering your questions, hearing your comments and getting your wonderful suggestions and ideas. I am reassured by the similarity of our problems, the resemblance of our feelings and the universal support we find in each other. Keep ‘em coming!

Skin Marking Today

OBJECTIVES

Routine identification of the nipple, lesions and pathology with a skin marker in both screen-film and digital mammography on all patients eliminates uncertainty and the necessity for any repeat examinations. Many mammography facilities use these small self-adhesive skin markers to readily identify the nipples, possible abnormal lesions and pathology of all types. Even with the advent of digital mammography nipple markers continue to be beneficial. The markers allow immediate identification of the nipple without adjusting the window and level settings. These markers are placed on the patient before her mammogram and subsequently serve as a reliable and stable landmark on mammograms for the registration of multiple images.

Triangulating a Lesion Viewed in One View Only:

Very often in Mammography there is a suspicious area of concern that can only be appreciated in one view. There are two recognized methods that identify a plane of possibility where the lesion could be located. These methods help to define an area where the lesion is probably located thereby reducing read time.

The two methods typically used today are; the Arc method and the Right angle or Cartesian methods. Both of these methods benefit from the placement of a nipple marker prior to the exam. The Cartesian method has proved to be more accurate for lesions on the periphery of the breast while both methods are helpful for central lesions.

1. Cartesian Method (right angle) (preferred method)

Guidelines:

To locate lesion in 2nd view draw a line through the nipple and perpendicular to chest wall in each view. Locate depth along that line.

This right angle technique works well for central lesions and is a more reliable technique for localizing peripheral lesions seen on only one view. First, the nipple marker is used to help establish a perpendicular nipple pectoral line on both the CC and the MLO views. Then measure from the nipple marker to the area of concern and transfer this measurement to the projection where the lesion is not immediately appreciated (See Diagram1&2 below).

CC= 1cm 2cm 3cm along PNL

MLO= 1cm 2cm 3cm along PNL to chest wall

The value of this technique can be seen in Image A and B where the lesions noted in the CC view at 40mm, 70mm and 95mm are all found at the same distance in the MLO view. This holds true even for the two more peripheral findings.

2. Arc Method

Guidelines:

To locate lesion in 2nd view swing an arc through the lesion from the nipple .Repeat in second view

To utilize this method locate the nipple, or preferably the nipple marker, and measure the distance to the area of concern in the projection where the lesion is noted. In the projection where the lesion is not evident an arc is established at the distance measured in the first projection (Diagram 3 and 4).

This method will work well for central lesions but is not accurate for peripheral lesions of the breast. Image C and D demonstrate this well, as the lesion noted in the retroareolar area in the MLO view at 7mm is found in the CC view at 40mm.

Arc @2.6cm

C. L-CC D. LMLO

In conclusion, the Right angle technique is the more consistent and most precise method. The Arc technique is fairly accurate for central lesions, but can be a pitfall for lesions at the periphery of the breast in the subareolar area, or in the axilla. These quick techniques are generally helpful for a basic approximation.

Using Nipple-To-Lesion Distance Only To Find a Missing Lesion:

Placement of nipple markers can allow accurate measurement of lesions and their distance from the nipple. Findings on mammographic images are generally reported with the o’clock position and distance from the nipple. If a potential lesion can only be identified in one view additional workup is required and every effort needs to be made to determine its location in another projection.

Using the nipple-to-lesion distance can aid in lesion identification. By determining how far back from the nipple the lesion is on one view the approximate location of the lesion can then be ascertained on the other projection. If two views are not sufficient for lesion identification, triangulation of the lesion with additional imaging is then warranted.

Case study

Case Study 1: A 72 year-old female presented for a screening mammogram. Within the superior aspect of the left breast 15cm posterior to the nipple on the MLO view is a 5mm ill-defined mass. To determine a more precise location for the mass the craniocaudal (CC) view is reviewed. In this example the medial aspect of the breast 15cm posterior to the nipple is clean with no masses. Therefore, based on location and its distance from the nipple using the MLO view this lesion is likely in the far posterior and lateral aspect of the breast on the CC view at approximately one to two o’clock where there is the suggestion of a mass. Additional imaging including a standard 90 degree lateral view and spot compression views were performed along with an ultrasound and ultrasound guided biopsy (not shown). The biopsy findings were compatible with infiltrating lobular carcinoma.

Benefits of Routine Nipple Marking in Mammography:

The placement of nipple markers not only provides a high quality examination for the patient, they also aid the radiologist in reading the mammogram by eliminating confusion and saving time. This is true even when dealing with a FFDM system. The time here is saved with less windowing, less leveling and less magnification.

Accurate identification of nipple location on mammograms can be challenging because of variations in image quality and in the nipple projections. This can result in some nipples being nearly invisible on the image. The small radiopaque marker placed on each nipple allows the nipple to be viewed as a reference point on the film for concise nipple-to-lesion distance, helpful in cases with subareolar masses, and in the post-surgical breast with architectural distortion.

Disposable nipple markers make routine nipple marking in mammography possible because they are readily accepted by the patient, easy to use, and cause no significant patient delay.

Using nipple markers helps to eliminate the cost of repeat examinations. In addition to the actual cost for the repeat examination there is the hidden cost of time lost at work for those outpatients who had to return for additional radiographs. Of even greater importance to the patient is the anxiety generated by the report needed for additional imaging which can be eliminated with routine nipple marking.

Case Studies

Subareolar Masses

Nipple markers are particularly helpful in cases with subareolar masses. Depth divides the breast arbitrarily into anterior, middle and posterior thirds, and immediately behind the nipple is the subareolar region.

When a nipple marker is not used it can be difficult to distinguish the nipple from a well-circumscribed mass in the subareolar region. Additional imaging would be required which may invoke unnecessary anxiety for the patient.

Case 1

Case Study 1: A 39 year-old female presents with a history of a tender palpable right breast mass. The mass underwent ultrasound guided core needle biopsy with results compatible with a fibroadenoma. Previously behind the right nipple is one bi-lobed mass versus two separate nodules. (A biopsy clip is noted to be positioned 1.5cm medial to the most medial portion of the lesion.) The fibroadenoma in this case is just beneath the skin surface. The nipple marker is extremely useful to eliminate any uncertainty in identifying the mass from the nipple.

Case 2

Case Study 2: An asymptomatic 72 year-old female presents with a stable 1cm well-circumscribed mass directly behind the left nipple since 2002. The mass is slightly superior on the MLO view. The nipple marker is extremely useful to quickly identify the mass from the nipple.

Suboptimal Exposure

Variations in image quality can make accurate identification of the skin line and of the nipple difficult. The absence of the nipple as a stable landmark in these circumstances generates additional read time for the radiologist. The generally simple registration of medial from lateral on the CC view and superior from inferior on the MLO view is challenged when the nipple and skin line are not visualized. Even with the advent of digital mammography nipple markers continue to be beneficial. The markers allow immediate identification of the nipple without adjusting the window and level settings.

Case 3

Case Study 3: A 74 year-old female presented for a screening mammogram. The skin surface cannot be seen and the use of a nipple marker allows the nipple to be identified.

Post-Surgical-architectural Distortion

In patients with a history of lumpectomy or reconstructive breast surgery there can be significant post-surgical architectural distortion which not only affects the appearance of the breast parenchyma but can also alter the position of the nipple. Without placement of nipple markers during initial and subsequent post-surgical imaging, the nipple may be mistaken for a mass requiring additional imaging.

In these cases, translucent scar markers are also valuable to visualize the scar bed as the surgical trauma heals. The scar bed can easily be mistaken for a new lesion and more critically a new lesion can be dismissed as the scar bed.

Case 4

Case Study 4: A 42 year-old female presents with a history of left lumpectomy for malignancy. She has additional history of reduction surgery performed many years prior to lumpectomy surgery. The nipple in these images is markedly displaced by post-surgical changes identified with a nipple marker.

Case 5

Case Study 5: A 70 year-old female presents with a history of right lumpectomy for malignancy followed by radiation therapy. There is post-surgical deformity in the upper aspect of the breast leading to marked displacement of the nipple identified with a nipple marker.

SUMMARY:

The old saying goes…”the more things change, the more they stay the same”. This is so true for breast imaging. Our specialty is specific, intense and detailed. To identify tiny distortions in wildly varying complicated breast tissue all landmarks are useful. We, as the technologist, are charged with demonstrating all the breast tissue clearly and precisely. Marking the landmarks, lesions and scars help us to recognize what projections are needed to show any and all missing tissue. These inexpensive innocuous little markers help the radiologist to make quick, expert, accurate decisions regarding breast abnormalities.

The breast imaging team’s job is to save lives, make treatment shorter, easier and more affective. Any aids that assist us in that mission are more than welcome.

STRESS AND BURNOUT: Identify, Prevent and Control

OBJECTIVES:

What is burnout? Burnout is a state of emotional and physical exhaustion caused by excessive and prolonged stress. It can occur when you feel overwhelmed and unable to meet constant demands. As the stress continues, you begin to lose the interest or motivation that led you to take on a certain role in the first place. Burnout reduces your productivity and saps your energy, leaving you feeling increasingly hopeless, powerless, cynical, and resentful. The unhappiness burnout causes can eventually threaten your job, your relationships, and your health.

HOW CAN YOU TELL IF YOU’RE BURNING OUT?

Because burnout doesn’t happen overnight — and it’s difficult to fight once you’re in the middle of it — it’s important to recognize the early signs of burnout and head it off. Burnout usually has its roots in stress, so the earlier you recognize the symptoms of stress and address them, the better chance you have of avoiding burnout.

THE SIGNS OF BURNOUT TEND TO BE MORE MENTAL THAN PHYSICAL.

They Can Include Feelings Of:

• Frustration and powerlessness
• Hopelessness
• Being drained of emotional energy
• Detachment, withdrawal, isolation
• Being trapped
• Having failed at what you’re doing
• Irritability
• Sadness
• Cynicism (people act out of selfishness and nothing can be done about it)

If you’re burning out and the burnout expresses itself as irritability, you might find yourself always snapping at people or making snide remarks about them. If the burnout manifests itself as depression, you might want to sleep all the time or always be “too tired” to socialize. You might turn to escapist behaviors such as sex, drinking, drugs, partying, or shopping binges to try to escape from your negative feelings. Your relationships at work and in your personal life may begin to fall apart.

WHAT IS THE DIFFERENCE BETWEEN STRESS AND BURNOUT?

Burnout may be the result of unrelenting stress, but it isn’t the same as too much stress. Stress, by and large, involves too much: too many pressures that demand too much of you physically and psychologically. Stressed people can still imagine, though, that if they can just get everything under control, they’ll feel better. Burnout, on the other hand, is about not enough. Being burned out manifests itself as feeling empty, devoid of motivation, and beyond caring. People experiencing burnout often don’t see any hope of positive change in their situations. If excessive stress is like drowning in responsibilities, burnout is being all dried up. One other difference between stress and burnout: While you’re usually aware of being under a lot of stress, you don’t always notice burnout when it happens. The symptoms of burnout — the hopelessness, the cynicism, the detachment from others — can take months to surface. If someone close to you points out changes in your attitude or behavior that are typical of burnout, listen to that person.

Stress	Burnout
Characterized by over-engagement	Characterized by disengagement
Emotions are over-reactive	Emotions are blunted
Produces urgency and hyperactivity	Produces helplessness and hopelessness
Exhausts physical energy	Exhausts motivation and drive, ideals and hope
Leads to anxiety disorders	Leads to paranoia, detachment, and depression
Causes disintegration	Causes demoralization
Primary damage is physical	Primary damage is emotional
Stress may kill you prematurely, and you won’t have enough time to finish what you started.	Burnout may never kill you, but your life may not seem worth living.

WHAT CAUSES JOB BURNOUT?

Most of us have days when we’re bored to death with what we do at work; when our co-workers and bosses seem irremediably wrong-headed; when the dozen balls we keep in the air aren’t noticed, let alone rewarded; when dragging ourselves into work requires the determination of Hercules; when caring about work seems like a waste of energy; when nothing we do appears to make a difference in a workplace full of bullying supervisors, clueless colleagues, and ungrateful clients. We all have bad days at work. But when every day is a bad day, you’re flirting with burnout.
Most burnout has to do with the workplace, and it’s present in every occupation. Those most at risk may be service professionals, who spend their work lives attending to the needs of others, especially if their work puts them in frequent contact with the dark or tragic side of human experience, or if they’re underpaid, unappreciated, or criticized for matters beyond their control. Remember, workplace burnout isn’t the same as workplace stress. When you’re stressed, you care too much, but when you’re burned out, you don’t see any hope of improvement. You don’t want to get to that point.

THE FOLLOWING SCENARIOS CAN LEAD TO WORKPLACE BURNOUT:

• Setting unrealistic goals for yourself or having them imposed upon you.
• Being expected to be too many things to too many people.
• Working under rules that seem unreasonably coercive or punitive.
• Doing work that frequently causes you to violate your personal values.
• Boredom from doing work that never changes or doesn’t challenge you.
• Feeling trapped for economic reasons by a job that fits any of the scenarios above.

CAN BURNOUT BE PREVENTED OR TREATED?

Because burnout is related to stress, many of the methods effective in countering stress can help prevent burnout as well. For one thing, it’s important to build or maintain a foundation of good physical health, so be sure to eat right, get enough sleep, and make exercise part of your daily routine.

PREVENTING WORKPLACE BURNOUT:

Real burnout as opposed to job related stress is a physiological serious condition that can threaten your health, your lifestyle and your future. It requires drastic change and measures to effectively reverse the process. The most effective way to head off workplace burnout is to quit doing what you’re doing and do something else, whether that means changing jobs or changing careers. But if that isn’t an option for you, there are still things you can do to improve your situation, or at least your state of mind.

Clarify your job description	Ask your supervisor for an updated description of your job duties and responsibilities. You may then be able to point out that some of the things you’re expected to do are not part of your job description and gain a little leverage by showing that you’ve been putting in work over and above the parameters of your job.
Request a transfer	If your workplace is large enough, you might be able to escape a toxic environment by transferring to another department. Talk to your supervisor or court a request from another supervisor.
Ask for new duties	If you’ve been doing the exact same work for a long time, ask to try something new: a different grade level, a different sales territory, a different machine.
Look for a new job	Update your résumé and apply for jobs that are related to but different from what you do now.
Make a career move	Get whatever training you need to make a big move in the same field, such as practicing a new area of law or teaching high school rather than elementary.
Make a career change	If you know you want to work in a different career, start taking steps toward it now, even if it’s one community-college course at a time. Find out what the requirements are for the job you really want and start meeting them little by little.
Get career advice	Consult a career counselor or use the services of an agency that offers vocational services.

BEST DEFENSE AGAINST ALL BURNOUT: BEING WITH OTHER PEOPLE

Although taking time to yourself to relax is important in reducing stress, if you are approaching burnout, it’s also crucial that you cultivate relationships with other people and spend time socializing with them. Poor relationships and isolation can contribute to burnout, but positive relationships can help prevent or reduce its onset.

• Nurture your closest relationships, such as those with your partner, children or friends.

These relationships can help restore energy and alleviate some of the psychological effects of burnout, such as feelings of being underappreciated. Try to put aside what’s burning you out and make the time you spend with loved ones positive and enjoyable.

• Develop casual social relationships, on and off site, with people at your workplace.

“We do all kinds of things, whether it is getting together to play cards or going out to eat. It gives everyone an opportunity to relax and blow off steam,” a teacher wrote to a contributors’ site. Just remember to avoid hanging out with negative-minded people who do nothing but complain.

• Connect with a cause or a community group that is personally meaningful to you.

Joining a religious, social, or support group can give you a place to talk to like-minded people about how to deal with daily stress — and to make new friends. If your line of work has a professional association, you can attend meetings and interact with others coping with the same workplace demands.

• Practice healthy communication.

Express your feelings to others who will listen, understand, and not judge. Burnout involves feelings that fester and grow, so be sure to let your emotions out in healthy, productive ways.

CONCLUSION:

To prevent or recover from burnout, learn to cultivate methods of personal renewal, self-awareness, and connection with others, and don’t be afraid to acknowledge your own needs and find ways to get your needs met.