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Jul 31 2012

Preserving a scarce human resource: Healthy physicians

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Image for Preserving a scarce human resource: Healthy physicians The exhausted and tense man in my office at the Center for Professional Wellbeing hardly fit the role of compassionate caregiver. I listened as he described his attitudes about his work in a busy internal medicine practice. “I was angry, discouraged and unmotivated,” he said. “I saw patients as enemies and all paperwork demands as intrusive.” He looked across the desk at me, eyes flashing. “I worked hard, I passed my Boards and now I have to settle for substandard fees. I have to justify every test. I’m forced to swear that I didn’t lie about procedures I ordered. And on top of it all, I have to deal with hostility from staff, patients and health plan representatives.”

Worse still, this physician went on, peers and practice partners seemed oblivious or indifferent to his suffering. Colleagues always wanted him to see just one more case. If he objected, some even made derogatory remarks suggesting that he didn’t have the “right stuff” to make it as a physician— “Can’t you take the heat?” they’d chide. “That’s what practicing is all about.”

The client described above displays the hallmark characteristics of physician “burnout.”

The physician couldn’t easily describe what aspects of his work were triggers for his anger and exhaustion. He couldn’t begin to imagine how to make his work environment better. He just wanted to leave medicine.

Our job at the Center was to help him rekindle his desire to practice. We showed him this was possible only through the judicious practice of self-care. We helped him learn strategies for “burnout-proofing” his practice. As part of this process, he was asked to become more assertive and stop enabling a system that left him personally depleted. After completing a guided analysis of his current work situation and stressors, this physician even asked for— and got— a medical scribe to help with documentation and paperwork. Today he is practicing with a muchrenewed spirit and with far more enjoyment than he would have dreamed possible.

This article will provide an overview of burnout and describe its devastating effect on medical practitioners’ professional and personal lives. It will define the qualities of a healthy, well-functioning (not burned-out) clinician. It will provide the reader with tools for assessing risk for burnout and describe the often severe consequences of allowing oneself to become burned out. Finally, it will share some strategies for “burnout-proofing” one’s practice environment.

Burnout: An unrelenting problem
Burnout among physicians has reached epidemic proportions since it was first described among human services workers in the 1970s. When physicians experience overload, loss of control (autonomy) and a lack of reward (perceived or real) for their contributions, their risk for emotional exhaustion, otherwise known as the burnout syndrome, is astronomical. When physicians begin the downward spiral into burnout, they no longer contribute with their leadership and motivational energy. Instead, they become needy and unintentionally sap energy away from the group. Worse, this syndrome is highly contagious and can systematically infect a whole practice or clinic by reducing meaningful contact among its individual members.

The burnout process is similar to the process of grieving. Grieving occurs when there is loss or change. Some losses are significant (death of a child, spouse or parent) and result in more profound episodes of grief. Some are negligible (favorite sports team loses a game) and might be experienced as little more than disappointment. Burnout closely mimics the type of grief experienced after a serious loss.

Physicians who suffer burnout typically grieve for the loss of a life dream—no question a significant loss. Most physicians enter practice with the hope of fulfilling a caring, supportive, challenging and rewarding role. They expect reasonable work requests, relative autonomy and a commensurate reward for their efforts. What they get is unrelenting pressure to see more patients in less time, limited control over how medical care is delivered, constant scrutiny and quality “assessments” and increasing demands from patients. The path to burnout begins when these professionals suffer a clash of expectations and recognize the serious mismatch between their actual day-to-day job and their deep-seated internal expectations (Cf.,Maslach and Leiter, 1997. The Truth About Burnout.)

Some evidence suggests that the incidence of burnout is rising among physicians and is striking earlier in their careers. Most recent data see an increase in burnout scores, derived from the MBI (Maslach Burnout Inventory) among residents and new practitioners. These are professionals who, in theory, should be at their most motivated and idealistic stage of practice. Instead, they report that they are increasingly cynical, with burnout percentages of up to 80 percent upon entry to practice.

Burnout: What it looks like
Burnout is characterized by:
  • An erosion of engagement with the job presenting as exhaustion, cynicism and ineffectiveness; and an erosion of positive emotions, particularly loss of enthusiasm and idealism (Maslach & Leiter)

  • The discrepant fit between the person and the job, experiences as personal imbalance and not recognized as unrealistic job demands

  • The betrayal of expectations or the clash between the “spirit” (core passion, values and purpose) and the demands of the work environment

Common “Emotional” symptoms
  • Recurrent sense of sadness

  • Decreased interest in work and personal life

  • Increased incidence of anxiety dreams

  • Recurrent sense of helplessness and hopelessness

  • Decreased control of anger

  • Difficulty in self-motivation

  • Decreased creativity, can’t give anymore

  • Increased fear and terror

  • Increased anticipatory anxiety

  • Increased agitation and sluggishness

  • Severe self-criticism

Common physical symptoms
  • Sleep changes; No resilience from rest

  • Increased physical distress (generalized)

  • Digestive difficulties

  • Decreased immunity to prevalent illnesses

  • Increased “heart-pains” that, upon medical workup are not physiological

Common “transpersonal” or spiritual symptoms
  • Increased hopelessness

  • Withdrawal from community involvement

  • Withdrawal from faith and social relations

  • Difficulty concentrating (including prayer/meditation)

  • Obsession with transgressions and failures

  • Enhanced sense of isolation and loneliness

  • Increased anger at suffering, God, other people

  • Inability to empathize

  • Lessened access to experiencing “making a difference”

  • Anticipating work as exhausting and going home exhausted

  • Nagging feelings (guilt; self-criticism) when treating patients as objects/diseases

Consequences of Burnout
Burnout takes a toll not just on the person experiencing it, but on each person, group and “system” that person interacts with on a daily basis. Spouses of burned-out physicians describe feeling as though they live with a stranger or a robot. Nurses and other subordinates admit to avoiding contact with the burned-out physician to avoid unpleasant outbursts, even when failure to speak up or ask questions may result in errors or less than optimal care. Alternatively, burning-out individuals may withdraw, viewing contact with others as yet another demand on their time. At best, the burned-out physician is a “weak link” who hurts productivity because he or she is unable to contribute fully. At worst, the burned-out individual is a destructive force who threatens practice morale and may even imperil patient care.

Some specific consequences of burnout include:
  • Less ability to perceive the patient is a whole person

  • Less energy to “go the extra mile”

  • Diagnosing quickly out of a belief that such speed will “get me off of the treadmill”

  • Less likely to follow preventive cardiology or healthy habits

  • Anger at how medicine only gives lip service to healthy habits

  • Increased mal-occurrences, errors or mistakes

  • Likelihood to blame the system

  • Greater depression

  • Poorer work and personal relationships

  • Increased tendency to practice defensive medicine due to pessimism-induced litigation fears

  • Less team-oriented; Views each interaction with team members as a drain on time

  • Taking short cuts in care delivery (while hating the pressure that makes short-cuts seem necessary)

  • Lessened ability to dispense hope to patients

  • Earlier retirement, or changing careers

  • Leaving or selling practice

Physicians: Hardwired for burnout?
The U.S. system for educating and training physicians in many ways sets young doctors up for burnout. Modeling by peers and teachers rewards always going “the extra mile” and labeling as weak those who cannot keep pace. Individuals who ask for help are perceived as incompetent or insecure. Peers fear intimacy or constructive feedback, so social tension is high and feedback is low. Perhaps most important, physicians are routinely rewarded for not setting boundaries and failing to say “no.”

The risk appraisal tool below is designed to help clinicians identify their level of risk for burnout. Note how many risk factors are also behaviors traditionally rewarded or praised among physicians.

How to score: Mark a Y or N beside each of the following statements. The greater the number of “Ys,” the higher your risk for burnout. Four or more positives indicate you are at high risk.

Burnout Risk Appraisal
  • You tend to avoid setting and maintaining boundaries

  • You only grudgingly ask for/accept help

  • You often make excuses, such as, “It’s faster to do it myself than to show or tell someone”

  • Given a choice, you always prefer to work alone

  • You do not have a close confident with whom you feel safe discussing problems

  • You tend to blame external factors for problems in your work environment (It’s not me…it’s my nurse, it’s the OR staff, it’s the hospital pharmacy, it’s the insurance company, etc.)

  • Your work relationships are asymmetrical. E.g., you are always giving, but never receive needed assistance/support

  • Your personal identity is tightly bound to your work role or professional identity (Your worth/value is strongly tied to your role as a clinician)

  • You do not value commitments to yourself such as exercise or down time as much as you value the commitments you make to others

  • You often overload yourself and have a difficult time saying “no”

  • You have few opportunities for positive and timely feedback outside of your work role

  • You easily become frustrated, sad or angry when performing your regular work tasks

  • It is harder now for you to easily establish warmth with your peers and/or clients/patients

  • You feel guilty when you “play” or rest

  • You get almost all of your needs met through helping others

  • You continually put others’ needs before or above your own needs

Avoiding burnout: Keep the candle burning
Virtually all medical practitioners working in today’s high-pressure environment are at risk of burnout at some phase of their careers. To prevent burnout, physicians and organizations that employ physicians must work proactively to spread awareness of the problem and encourage attitudes and behaviors that promote health and balance. This is no small task. Nonetheless, it is a wise and necessary investment in one of society’s most precious and scarce human resources: physicians.

Organizations that employ or otherwise rely on physicians (hospitals, surgery centers, medical practices) have a vested interest in spending the time, energy and resources needed to keep doctors well.
As the process of burnout progresses, the affected individual can no longer give to patients or the practice; They are so depleted that they can only guard against their own fatigue. In fact, people who are burning out can negatively impact productivity and morale by sapping energy from the organization. Organizations can guard against this by “burnout proofing” through positive changes to work practices and professional environments. Doing so has an important side benefit of demonstrating to physicians and other clinicians that the organization is committed to preserving medical professionals as whole people. As such, “burnout proofing” is useful as a retention strategy.

What organizations can to do “burnout proof”
Cultivate a work culture that emphasizes and/or makes readily available the following:
  • Unconditional respect for the professional from peers: honest PRAISE

  • Regular timely feedback so corrections/adjustments can be made

  • Collective thinking/problem solving and a collaborative approach to devise and implement solutions

  • Acceptance of transition/change as reality, with visible reinforcement by management

  • Workshops on chaos and transition to help clinicians develop a comfort level with being “out of control”

  • Workshops that acknowledge burnout as a risk of clinical practice, with de-stigmatization of burnout as a primary goal

  • Avenues and/or training for constructive conflict management/dispute settlement

  • Leadership training, including effective mentoring as a skill

  • Parent effectiveness training (problems at home increase stress at work and vice versa)

  • Availability and access to trained independent mediators (from outside the organization)

  • A willingness at the organizational/ management level to acknowledge that the system may create or exacerbate stress not primarily individuals

  • “Juggling” workshops, especially peer-led, that let thriving practitioners share how they balance personal and professional life; Sharing by senior professionals of how they coped with disappointment, dilemmas and stress

  • Availability of curricular (CLE/CME or otherwise) training in stress management

  • General availability of peer support groups and peer coaching

  • Availability of counseling on career fits that do not conform to the workaholic model

  • Periodic creativity exercises and retreats

A physician who is burning out is not weak — he or she is simply human. Acknowledging and de-stigmatizing burnout is an important first step towards addressing risks and building professional environments that support well being and, over the long term, physician satisfaction.

What is patently clear is that the work environment and expectations for the practice of medicine are unrealistic. Demands are often unmanageable and overwhelming. Outside and inside pressures to do more with less deny a sense of control in the role. Reward systems often emphasize productivity and efficacy and clash with humane values. System pressure against physician community-building denies a sense of community, reinforcing the individual “lone wolf” culture modeled during training. Responses to reduce burnout must come from assertive physician wellbeing programs and systems that recognize interdependence to promote lifelong vitality.

 Comments on this article:

I feel for doctors practicing today. There is no way around it. This is a symptom of the pillaging of medicine, and the reduction of doctors to the status of slavery for the system they no longer control. It’s happening in all professions; law, medicine, teaching, religion. It’s no longer the America we grew up in, and it will only get worse, in my humble opinion.

By Dr. Dee on Aug 01, 2012 at 1:28pm

I believe this is an excellent article which in my opinion presents many valid points.  I think it should be made available to all medical students and medical entities in at least North Carolina.  Nearing my 60th year of graduation from medical school, on reading this I immediately recognize many
times from rotating internship through residencies in psychiatry and pathology to years in the practice of anatomic and clinical pathology when it might have been helpful to me.  Despite reasonable interest in and excitement by my practice of pathology, I have often felt it difficult and draining.  I now recognize signs of “burnout” in my career.  While I did practice some of the “antidotes”, I often felt quite alone and variably criticized by those in my sphere.  I thank you for this article.

By Susan E. Bradford, M.D. on Aug 01, 2012 at 2:09pm

This article explains my wife. She has practiced pediatrics for 5 yrs now and is burnt out completely. It’s a shame to see that a majority feels the same way.

By Eric on Aug 01, 2012 at 3:16pm

Burnout is a definite problem. This article does a great job at addressing the importance of burnout but may neglect to mention some other factors.

The first and foremost factor for me is that virtually of all interventional medicine causes suffering. That is one aspect that is not taught in college to premedical students. If someone gets a total hip replacement that patient will endure significant pain and suffering. After the passage of time the patient should be better off. However, the physician is still presented daily with suffering directly caused by that physician that day. We do not get to do procedures just at the beginning of the month. Being exposed daily to not just pain and suffering but pain and suffering caused by the physician builds up.

Another aspect is that physicians used to retire earlier. Our hospital had a mandatory retirement age of 65 until the 1980’s. Doctors also were famous for Wednesday Afternoon Golf. That has vanished.

We work until we drop dead. We work longer hours and the exposure to pain and suffering just continues to build. Most of us cannot afford financially to take off work for relaxing retreats to regroup. To be able to take three months of work off completely would probably reset most of us back to a wonderful state for decades.

We are also terrified of actually getting ill ourselves. If a fellow physician has had a stroke, heart disease or other severe setback and then returns to work the other physicians do not quite look at that doctor with the same degree of confidence. It is bias but real.

Like most problems here in the United States, this will crescendo but then there will be some sort of solution. We need to keep focused on the problem and keep our medical leadership on the national and local levels working hard…just not too hard. We do not want you burning out also!

By Dr P on Aug 01, 2012 at 4:34pm

I am a female Physician Assistant.  I worked in a very busy family medicine practice for 7 years, before changing to a GI practice for the past 3 years.  I was good at and loved family medicine, however I definitely experienced burnout.  When my 2 sons were born, it was much more difficult to balance work and family roles.  Now I am working part-time 3 days per week in a small rural GI practice, and love it.  I am not forced to see as many patients, and I have more time to take care of myself, my family, and my patients.  I feel more efficient, happier and productive.  This article truly hit home for me.  It is a big problem in health care, and I am glad that someone recognizes it.  I am thankful for all the caring, compassionate, dedicated, hardworking health care professionals who give their heart and souls to take care of patients every day.

By Tina Garrett on Aug 01, 2012 at 11:13pm

A good book that helped me in this area was “Don’t Jettison Medicine” by Dr. Patricia Raymond.  Providers must learn how to set healthy boundaries in their careers.

By Tina Garrett on Aug 01, 2012 at 11:17pm

I agree with most of the points in the article.  Many of us recognize burnout but feel powerless to act on it. And medicine is not unique with respect to burnout. The problem is not with individuals but with societal expectations and the system.  Corporate and medical leadership need to understand the issue at hand and act. It is hard believe this will happen.

By SP on Aug 01, 2012 at 11:31pm

Sounds like this is why PAs change practices so often.

*Lack of reward - pay structure, no voice in practice functioning, etc. Looked at as a work horse vs. part of med staff.

*Autonomy - Some are treated as medical students at best. Lack of respect, and inability of SP to have enough confidence in themselves. NO regard for passing NCCPA EVERY 6 years, more CME than any other medical professional.

*Overload - Expected to see as many patients as MDs, held to a hire standard, no say in office structure/staff, etc.

This is my musing as to why PAs move/change practices. Not an attack on anyone.

By tippy on Aug 03, 2012 at 1:42pm

Very nice article.

One thing to consider:  perhaps medical practice as it is now being done is not good for ANYONE.

Too little time, too many patients, lower reimbursement, shorter appointments, more CYA and insurance-dictated activities:  makes my heart clench up just thinking about it.
We can do all the creativity workshops, yoga, and boundary-making we want, but it will still be dysfunctional.

Look at the article on the Ideal Medical Practice in the magazine, The Intelligent Optimist.  This is the kind of work we physicians would love to do.

By Amy on Aug 28, 2012 at 2:00pm

I burnt out in 1988.  All of the above applied to me, but I had no idea what to call it.  When I had my dissociative reaction I had no feelings in my body and the world was like a blur before me.  Nothing mattered anymore.  Fortunately I fell into the hands of a kind physician who knew what I was going through. My brain was like a burned out switchboard with all the wires pulled out. During recovery I had to replace wires I never knew I had, one by one, one day at a time…The process took years, but I eventually returned to medicine through emergency room work.  Future setbacks were not as hard to deal with and I recovered my wits sooner.  I did manage to finally accept patient’s compliments and support.  The water that restored my faith in humanity.  I pray every day and I thank God every moment for my return to sanity.  I have a long way to go but my workaholism is under the guidance of my Lord.

By Antonio Carbonell MD on Aug 28, 2012 at 3:42pm

One more thing. I called burnout the ‘pruning’ of the physician.  We start out as plums into medicine and as we see and feel human suffering in its raw form we start to build impermeable barriers to it and ‘live off our internal juices’ without replenishing them…so we become increasingly dehydrated and eventually shrivel up as a prune.  To restore our original ‘moisture’ we need to crack those barriers… it helps to pray for God to use His masterful 2’ x 4’ beam of awareness… then we can begin to sip on the ‘milk of human kindness’ and accept the moisture of appreciation and gratefulness for our work…Then and only then can we restore our original zest, vitality, vision, and magic of ‘being a doctor’ once again!

By Antonio Carbonell on Aug 28, 2012 at 3:48pm

Really, you must be kidding. Workshops to help physicians “develop a comfort level with being ‘out of control’ ” ? That is telling. The gist of the article seems to be here’s how to get some help sucking it up. What is “it” anyway? The new medical-industrial-government complex? Three’s a crowd.

By Laurie LeMauviel, D.O. on Aug 28, 2012 at 8:13pm

I feel that physician burnout will only get worse.  If I get up in the morning and feel like reading a book, I will run grab a book and read with a smile on my face. If, on the other hand, I am TOLD to read a book, then I may be less excited about my task.  This is what has happened to medicine.  There was a time when the physician had some sort of control of their day, control of the process, and most importantly their relationship with the patient. It was not perfect then, but we, so I am told, has some more control.  Now we are told what to do and are expected to follow every “rule” of paperwork medicine that is in place.  In clinics we spend time in our office pushing paperwork than spending time in the patient room.  I have been out of training for only four years.  I travel around the USA and practice in five states.  I have seen the burnout of physicans around the USA.  I was in a city where all the critical doctors dropped their privs at two hospitals because they did not have the time to keep their office open and provide the level of care they wanted to at the ICU’s. They were all over 50 and were good doctors.  They just could not practice in a healthy way to provide health care to patients.  I love my job, enjoy seeing patients every single day, and can not recall the last time I go up in the morning and said “i can’t do this anymore.”  Why?  I am a locum doctor and have been doing it for 4 years.  I make my shedule, determined the locations, and have the ability to spend all day with family and staff to come up with the best plan of care I can.  I find it very liberating and having little burnout factor.  I am not suggesting that all doctors do what I do.  I am pointing out a very important way that physicians can keep from burning out.  We have to find a way to take back our freedom of practice.  Without the hope that days will be better, we will continue to burn out.  When we begin to hate our job, we begin to get upset that the patient is sick.  It is at that moment that we have failed as a doctor. My fear is that due to the way medicine is going, we will have less power to control our own lives.  This will lead to burned out doctors and the patient’s care may suffer.

By Craig Rosebrock MD on Aug 28, 2012 at 10:05pm

I see overwork not the main cause for this unfortunate phenomenon of burnout physician.
A big chunk of stress is psychological in nature, such as: fear of a lawsuit, even if the physician is not at fault; feeling unsatisfied for doing more business than practicing medicine; tolerating the harassments of the patients, etc. However, the undesired activities of a few physicians sometimes make it hard to defend the majority, who want to practice honestly. We need to change attitude of both, the physicians and the society, to prevent this mental and moral breakdown of physicians and American health care system, respectively. Answering the question “How?” is simple. However, the unanswered million dollar question is “When do we start?” I guess, when we all realize that we’ve reached the precipice.

By M. Zaidi on Aug 30, 2012 at 8:56pm
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