Tag Archives: physician burnout

Reconnecting to Mission, Patients, and Colleagues

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What’s the most personally fulfilling aspect of your work?  In times of uncertainty, threat, and transition, what holds you up?

This past week, I had the privilege of standing alongside giants in the fight against physician burnout.  In a series of presentations at the annual meeting of the American College of Physicians (ACP), we did our best to acknowledge and validate the current state of physician burnout (about half of all physicians in all specialties report at least one symptom), and then present as many strategies to reduce it as time would allow.  We showed how changes in workflow, task distribution, and technology, such as pre-visit labs and scribes, have been shown to improve physician satisfaction, team morale, and patient experience.  My role was to attempt to inspire my fellow internists to claim their individual agency, model a culture of wellness, and advocate for systems change in their home institutions.

The content felt dense but manageable, and the audience appeared engaged.  Our colleagues from all around the country approached us afterward to clarify studies of efficacy and ask about local representatives for advocacy in the ACP.  In the end, I think we achieved our primary objective of having most attendees leave with just a little more hope for our profession than they came in with.

Over the four day conference, however, what consistently grounded me in professional mission and meaning, not only in our own presentation but in others, were the personal stories.  That is how we humans relate to one another, after all—through narratives.  And connecting to mission and colleagues is key to maintaining a healthy and productive workforce, physician or otherwise.

Our attendees participated in two practices that I’ll share here.  Both were “Pair and Share” activities, meant to stimulate reflection both internally and externally.

Who In Your Life Really Changed You?

First we asked our colleagues to think of a patient who changed them, how, and to what end.  I know there have been many patients who changed me, but I always think of one particular woman.  She was middle aged, obese, diabetic, depressed, and severely disabled from osteoarthritis.  She lived alone and had a sparse social network, and her life partner had died unexpectedly a few years before I met her.  At every visit we struggled through the same fundamental challenges of weight loss, glucose control, and pain management.  How could she take her diabetes medications more regularly?  How could we control her pain without having to take opioids every day?  How else could we manage her depression, as some of the medications were raising her blood sugar?  She may have cried at almost every visit; wailing was not uncommon, and once she even vomited from cumulative distress.  Our relationship was good overall.  I overcame my impatience with her non-adherence to the treatment plan as I understood her life situation better.  But for four of the five years we knew each other, I saw few if any indicators that her thought, emotional, and behavior patterns would change.

Then things started to turn around.  She started coming consistently to appointments, no more no-shows.  She got online and found a community center that was accessible by bus.  She connected with a knitting group and started going to art fairs to sell her creations.  She started taking her medications more regularly, and lost enough weight to have her knee replaced.  By the time we parted ways, she had transformed from a weeping victim of circumstance to a woman with agency, self-efficacy, and goals, dammit!  And most of this had nothing to do with me.  I simply had the privilege to witness and support her intrinsic revolution.  From her I learned what perseverance looks like; I learned about hope and self-redemption; I learned that I should never make assumptions about anybody’s future.

Who Supported You in a Time of Vulnerability?

They said do the hardest thing that you know you don’t want to do for a living as your first rotation.  So I chose surgery.  In July of my third year of medical school, my days started around 5:30am and could end the next night at 10pm if my team was busy post call.  Most faculty physicians were kind and wise, or at least non-abusive.  Some, however, not so much.  What buoyed me most through that rotation was always the support and protection of the residents on my team.  I would watch them get abused by our attendings, but that sh*t never rolled downhill when the boss left the room.  I did not fully realize until years later what a gift that was and how much it spoke to the character of these men (they were all men).  This was in the 1990s; verbal abuse of medical students and snide comments about one’s appearance, gender, and just about everything else were simply to be expected.  But my favorite residents always pulled me aside and asked how I was.  They always made sure I felt confident about my role on the team, and they taught me basic skills with conviction and encouragement.  As I was about to insert a patient’s bladder catheter in the operating room, my elder brother in training told me firmly, like he really believed I could do it, “Don’t be afraid, hold it (the penis) like a hose.”

As we did this reflection exercise at the meeting last Wednesday along with our audience, I was so moved by these memories that I looked up one of my old residents that night and sent him a thank you card.  I bet he won’t remember at all who I am, but he will hopefully feel validated that he is in exactly the right position now as program director of a surgery residency.

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Recalling stories like these, and then sharing them with a person who truly listens, receives them generously, and simply helps you hold them (that was the instruction to the group—when it’s your turn to listen just do that, no interruptions, no jumping in), reconnects us to our calling in medicine.  It’s not just about the patients or the science.  It’s about all of the relationships and how we tend them.

We will not solve the immensely complex problem of physician burnout overnight.  It will take a concerted effort at all levels of healthcare, and physicians cannot and will not do it alone.  And it’s not that we are stoic, arrogant, and somehow intrinsically flawed, and thus dissatisfied with our work and leaving the profession in record numbers.  It is a systems problem, no question.  And, while we call our congressional leaders and professional advocacy groups to change policy, while we lobby our hospital administration to hire more support staff and move the printers closer to where we do our work, we can all take a few minutes each day and reconnect to the core meaning and purpose in that work.  Let us all remember a cool story and share it today.

How Not to Engage

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NaBloPoMo 2018: What I’m Learning

My friend Alex* posted about being a nurse and how she loves it despite having to always hold her pee, skip lunch, and get bled on, puked on, peed on, and yelled at, all while missing her family and taking care of yours.  One of her friends, we will call him Greg, commented that until nurses unionize and demand professional respect ‘just like physicians,’ nothing will change.

My impulsive (GRRR!) response:  “Trust me, physicians are struggling, too. I propose that we stand up for one another. Then we’d really be a strong force. And in the end it benefits us all–doctors, nurses, patients, the whole care team and, most importantly, patients. Also, I don’t know of any unions that physicians can join, but there are ones that nurses can: https://nurse.org/articles/pros-and-cons-nursing-unions/”  Okay, I know, saying, “Trust me,” is not a good way to get someone to trust or listen to you.  And my reply was defensive in its origin.  I sincerely believe what I wrote, though, that allied advocacy is an untapped force for good in medicine.  Physicians, patients, nurses, all healthcare professionals—why should we not actively support one another in all of our efforts to achieve a more cohesive, efficient, fair, and collaborative system, one that works better for all of us?  Why can we not embrace our connections and combine our voices to call for change?

Greg replied that basically he does not believe that physicians are “struggling,” and he does not see how we would stand up for one another.  After Alex described that I’m a physician “who will always help the nurses,” he wrote that doctors “can’t be in the business of supporting nurses.”  That we should “be in the business of supporting” ourselves, and “from all the research I’ve ever seen, they’ve continued to do a pretty good job of it.  Good for them.”  He expressed support for physicians’ right to advocate for ourselves.  In each reply, he continued to make his point that nurses should unionize.

I find this thread fascinating.  There are so many ways Greg and I could interpret each other’s replies.  When he talks about demanding respect ‘like physicians’ through unions, what benefits and outcomes does he imagine will follow?  When I say “struggling,” I wonder what he thinks I mean?  Actually he asks me, “How exactly are physicians struggling?”  He goes on to write, “Nurses are nurses and should be for nurses.”  All of his comments and the tone I inferred from them caused me to beg off of the thread.  Too bad, it might have been an interesting conversation—if we could have it in person.  Maybe we can later.

But it motivated me to look up some information to post here, in case anybody wonders ‘how physicians are struggling.’  The answer is burnout, depression, suicide, and leaving work that we love because it simply costs us too much—and I mean costs other than money.

Physician burnout is well described and referenced.

Doctors suffer from burnout in especially high numbers, according to the study, which was designed to offer a representative snapshot of doctors and the general U.S. working population. Nearly half of U.S. physicians – 49 percent – meet the definition for overall burnout, compared with 28 percent of other U.S. workers. More than 54 percent of doctors have at least one symptom of burnout, a more detailed analysis found.

Doctors also register more than one and a half times the general working public’s rates of emotional exhaustion and depersonalization. Working a median 50 hours per week, their satisfaction with work-life balance is far lower than that of others: 36 percent versus 61 percent.

medscape burnout causes 2018

Medscape Survey 2018

There are myriad causes for physician burnout, and most of them lie in the system, not in our inherent lack of resilience or because of some intrinsic defect in our collective character.  The electronic health record has accelerated our dissatisfaction with work.  It does so by creating innumerable clicks to accomplish menial tasks, burdening us with data entry that detracts from actual medical decision making and patient care, and putting a physical barrier between us and our patients, further separating us in relationship.  Burned out and dissatisfied doctors are distracted, less empathetic, and aloof, and we may even make more mistakes.  And when we aren’t well, our patients aren’t well.

A 2015 Mayo Clinic study reported that roughly 40 percent of physicians suffer depression each year and almost 7 percent had considered suicide within the prior 12 months. It is estimated that 300 to 400 doctors take their lives every year.

The pain and suffering those statistics only hint at is bad enough. But they are compounded by findings that burnout corrodes the doctor-patient relationship, resulting in lower levels of patient satisfaction, job satisfaction and productivity, as well as higher levels of medical errors and disruptive behavior.

Burnout is also connected to the decision to switch jobs or leave medicine altogether — an ominous trend as the U.S. experiences a growing doctor shortage.

 

I have not addressed here the challenges that nurses face every day.  My mom is a nurse, and I have worked with nurses my whole career.  I see how they are treated by the system and by patients, and also by us physicians.  And yes, my extracurricular activities focus solely on advocating for physician health and well-being.  Maybe I should learn more about nurse burnout and job satisfaction, and figure out ways to advocate for my nursing friends and colleagues better.

Or maybe it’s too much to ask for groups to stick up for one another.  Maybe Greg is right, and it should be every tribe for itself, let others take care of their own.  Maybe it doesn’t do any good for people to know how and how much doctors “struggle.”  I don’t know.  But I have learned now not to instigate such debates on my friends’ pages on social media.

*Not her real name

 

 

Dr. Jerkface In Context—Healing the Patient-Physician Relationship

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Excuse me, I took an unintended break for Thanksgiving!  Hope you all had a wonderful holiday!

NaBloPoMo 2017: Field Notes from a Life in Medicine

For the past year or so, maybe more, I have increasingly tried to engage my friends in discussion around allied advocacy for physician health and well-being.  Inevitably, however, I’m met with anecdotes from my friends about asshole doctors.  It is a strikingly common experience, I’m sad to report.  And it makes sense:  If a patient has a bad experience with a doctor, ie the doctor behaves badly or the patient feels dismissed, ignored, disrespected, or mistreated, the normal response is to blame the doctor and assume that s/he is an asshole.  In each of these interviews with friends, it took a while for them to come around to the idea that the doctor him/herself may be suffering and therefore not behaving/performing their best.

But the next question is this: Do patients care about doctors’ suffering?  If they knew how the system harms physicians, would they have compassion for us?  What about if they knew how physician burnout and dissatisfaction directly affects their quality of care, all of it negatively?  What would move patients to stand up with and for doctors?  This is my goal for the indefinite future: to help us, patients and physicians, the end users of our medical system, stand up with and for one another, for positive systems change.

Right now I see it as a very personal, grassroots endeavor.  Outside of a one-on-one patient-physician relationship, ‘patients’ and ‘physicians’ in general are abstract groups to us all, and it’s hard to feel compassion for and connection with an abstraction.  “Patients are too demanding, entitled, and ignorant.”  “Doctors are arrogant, dismissive, and profit-driven.”  We carry these overgeneralized internal narratives and others into our encounters, often unknowingly and unintentionally.  Even when we think we see and know the person right in front of us, these underlying assumptions still color our experiences with them.  So whatever conversations we may undertake will take many repetitions to finally reach true mutual understanding.

I have been a member of my church since 1991.  Many others in the community have been there much longer than that.  There are other physicians, and we are all patients, ranging in age from infants to octogenarians.  I have proposed to host a focus group to discuss patient-physician relationship, especially as it relates to the effects of physician burnout on patient care.  The plan is to do it once, with whomever is interested, and see what happens after that.  I picture 10-20 people, patients and physicians alike, seated in a circle.

The objectives will be stated:

  1. Hold an open discussion about people’s experiences in the patient-physician encounter, and explore the context of forces that influence those experiences. Such forces include visit duration, documentation requirements, workflow inefficiencies, patient expectations, insurance status, and clinical setting (hospital, outpatient clinic, etc.).
  2. Participants leave with improved mutual understanding of one another’s experiences in the medical system and more likely to feel empathy and compassion toward their counterparts in the next encounter.

In the long term, I wish for patients and physicians to form a unified platform from which to advocate for policy change.  We, patients and physicians, are the end-users of the healthcare system, the largest combined demographic in the system, and I believe we are the ones who benefit the least from the system.  Health outcomes for American patients are dismal compared other developed countries, despite our exorbitant expernditures.  Physicians kill ourselves at more than twice the rate of the general population.

It’s not enough for medical professional societies to write co-authored, open letters to Congress.  It’s not enough for individual patient constituents to stand up at town halls and berate their representatives.  We must orient ourselves as resistors in series, rather than in parallel.  I think the movement will grow most effectively out of existing connections and relationships, through which we can find shared interests, common goals, and a strong, unified voice for change.

I seek your feedback:

  1. How do you picture this meeting going?
  2. How interested are you in learning about physician burnout and how it affects patients?
  3. If you were invited to such a meeting, what would you think and feel about it?
  4. What would make you more likely to participate?
  5. Would you want to host such a meeting in your community? How would you do it?

Thank you for considering, and see you tomorrow!