GOT Burnout??

[Stim4me]

http://www.medscape.com/viewarticle/824693

A handful of routine bloggers/haters on this site seem to believe their job is easy..... They are outliners to the data published to date.... Anybody else have burnout out-there? And what are you doing in your practices to address it?? God speed

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[lobelsteve]

http://www.medscape.com/viewarticle/824693

A handful of routine bloggers on this site seem to believe their job is easy..... They are outliners to the data published to date.... Anybody else have burnout out there? And what are you doing in your practices to address it?? God speed

2 yrs ago i went from m-f 7-5 to taking off on wed at noon. Though 2x month i wind up in OR doing something. Stress relief includes SDN, hiking, piddling in garage- chop saw MIG welder, 2 post lift, big compressor.

 

[drusso]

This is extraordinarily high burn-out work. And, staying in it while you're burning out is unsafe for patients.

 

[Stim4me]

This is extraordinarily high burn-out work. And, staying in it while you're burning out is unsafe for patients.

Unfortunately a lot of MDs are feeling burnout and are either: leaving, consolidating, drinking, cheating the system, venting, arguing, supplementing, etc....The best therapy in my book is to accept and learn, hence my blog post...

 

[jonnylingo]

"There is emotional exhaustion, some call it depersonalization, where you try to distance yourself from your patients in order to cope with the workload; cynicism; and feelings of inefficacy, where a person feels that he or she is not accomplishing what they had originally set out to do in their career," he said.

True. When I started 8 years ago, I tried to "feel" my patient's pain in each encounter. Year by year, this empathy has eroded. I feel myself stonewalling my patients emotionally. I know this is not good for patient care. But full openness and empathy is draining.

 

[101N]

This is posted in the public forum so the public - policy makers, hospital admin,
& the folks at Press Ganey - should know that burnout in treating working-aged adults with
chronic non-cancer pain comes not from 'compassion fatigue' but rather from the following three clinical scenarios that we see day in and day out. Here they are:

1. Patients with a history of emotional trauma/hard lives who have poor coping,
little resiliency, an enormous emotional element to their pain (10/10), but a paucity
of objective physical findings. Often these people tend to be under educated, unemployed,
(young medicare/SSDI/Medicaid) with vastly unrealistic expectations for pain relief or
cure, and at the same time in utter denial about how their trauma and emotional state - not injury or
a bad disc - lead them to where they are. Below is an elegant description of this type of patient.
Mentioning psychology to this type of patient inevitably leads to "You just think it's all in my head!"


"Dr. Barsky is trying to conduct a controlled study similar to the ones done in England. Unfortunately,
he has found it difficult to attract volunteers: many patients who have been approached have declined
or are not eligible because they are taking certain medications or are involved in compensation litigation.
Not long after speaking to him, I called Liz Albright, and told her that there were several studies suggesting
significant benefits from cognitive-behavioral therapy. "The distress I have is from my illness, not from social
forces," she replied. Her voice cracked, and she paused for a moment to compose herself. "It's like
being in prison in your body." She would never see someone like Dr. Barsky, she explained. "I won't see any
doctor who questions the legitimacy of what I have."

2. Patients - typically 18-55 - who are expressly seeking narcotics. "Nothing
works but the meds." "I've tried everything!" Their motives are transparent.
If you do the right thing and tell them "Joe, I try to practice evidence based
medicine and there really is no evidence for opioids in the treatment of :
chronic back pain, HA, FMS." They will cuss at you and your staff and berate
you to admin, Press Ganey, and any physician website they can access. Often
times they will go back to their PCPs and complain to them and anyone else
who will listen. They will vilify you as 'abrupt', 'unwilling to listen', 'only spent
5 minutes with me', 'terrible bedside manner', 'immediately jumped to a
conclusion about me', etc. These people are usually really bad liars.

3. Patients with obvious secondary gain that prevents them from ever improving
lest they lose their: disability payments, law suit, SSDI, litigation, etc. Unlike other
specialties, we tend to ask if you have: pending litigation, an SSDI claim, a PIP
claim, have acquired an attorney to defend you etc. If you have the above, you have
a financial incentive to stay sick and in pain. In these cases opioids, injections, serial
IMEs, MRI's, EMGs, etc are a waste of time and money.

And there you have 75 million of the IOM's 100M.

 

[Stim4me]

This is posted in the public forum so the public - policy makers, hospital admin,
& the folks at Press Ganey - should know that burnout in treating working-aged adults with
chronic non-cancer pain comes not from 'compassion fatigue' but rather from the following three clinical scenarios that we see day in and day out. Here they are:

1. Patients with a history of emotional trauma/hard lives who have poor coping,
little resiliency, an enormous emotional element to their pain (10/10), but a paucity
of objective physical findings. Often these people tend to be under educated, unemployed,
(young medicare/SSDI/Medicaid) with vastly unrealistic expectations for pain relief or
cure, and at the same time in utter denial about how their trauma and emotional state - not injury or
a bad disc - lead them to where they are. Below is an elegant description of this type of patient.
Mentioning psychology to this type of patient inevitably leads to "You just think it's all in my head!"


"Dr. Barsky is trying to conduct a controlled study similar to the ones done in England. Unfortunately,
he has found it difficult to attract volunteers: many patients who have been approached have declined
or are not eligible because they are taking certain medications or are involved in compensation litigation.
Not long after speaking to him, I called Liz Albright, and told her that there were several studies suggesting
significant benefits from cognitive-behavioral therapy. "The distress I have is from my illness, not from social
forces," she replied. Her voice cracked, and she paused for a moment to compose herself. "It's like
being in prison in your body." She would never see someone like Dr. Barsky, she explained. "I won't see any
doctor who questions the legitimacy of what I have."

2. Patients - typically 18-55 - who are expressly seeking narcotics. "Nothing
works but the meds." "I've tried everything!" Their motives are transparent.
If you do the right thing and tell them "Joe, I try to practice evidence based
medicine and there really is no evidence for opioids in the treatment of :
chronic back pain, HA, FMS." They will cuss at you and your staff and berate
you to admin, Press Ganey, and any physician website they can access. Often
times they will go back to their PCPs and complain to them and anyone else
who will listen. They will vilify you as 'abrupt', 'unwilling to listen', 'only spent
5 minutes with me', 'terrible bedside manner', 'immediately jumped to a
conclusion about me', etc. These people are usually really bad liars.

3. Patients with obvious secondary gain that prevents them from ever improving
lest they lose their: disability payments, law suit, SSDI, litigation, etc. Unlike other
specialties, we tend to ask if you have: pending litigation, an SSDI claim, a PIP
claim, have acquired an attorney to defend you etc. If you have the above, you have
a financial incentive to stay sick and in pain. In these cases opioids, injections, serial
IMEs, MRI's, EMGs, etc are a waste of time and money.

And there you have 75 million of the IOM's 100M.

so true

 

[emd123]

Here's what I've learned about burnout: Other than your immediate family and friends, no one else cares.

Other specialties don't care (their burnout is always "just as bad or worse!") Patients don't care ("I'm the sick one!") Nurses and staff don't care ("my job sucks too, but you get paid more, so I win") The media certainly doesn't care ("rich whiny doctors"). And the government certainly doesn't care ("Overpaid doctors are the problem").

So it's all fine and good that we commiserate together on here, but let the record show that no one else gives a flying f---.

 

[drusso]

This is posted in the public forum so the public - policy makers, hospital admin,
& the folks at Press Ganey - should know that burnout in treating working-aged adults with
chronic non-cancer pain comes not from 'compassion fatigue' but rather from the following three clinical scenarios that we see day in and day out. Here they are:

1. Patients with a history of emotional trauma/hard lives who have poor coping,
little resiliency, an enormous emotional element to their pain (10/10), but a paucity
of objective physical findings. Often these people tend to be under educated, unemployed,
(young medicare/SSDI/Medicaid) with vastly unrealistic expectations for pain relief or
cure, and at the same time in utter denial about how their trauma and emotional state - not injury or
a bad disc - lead them to where they are. Below is an elegant description of this type of patient.
Mentioning psychology to this type of patient inevitably leads to "You just think it's all in my head!"


"Dr. Barsky is trying to conduct a controlled study similar to the ones done in England. Unfortunately,
he has found it difficult to attract volunteers: many patients who have been approached have declined
or are not eligible because they are taking certain medications or are involved in compensation litigation.
Not long after speaking to him, I called Liz Albright, and told her that there were several studies suggesting
significant benefits from cognitive-behavioral therapy. "The distress I have is from my illness, not from social
forces," she replied. Her voice cracked, and she paused for a moment to compose herself. "It's like
being in prison in your body." She would never see someone like Dr. Barsky, she explained. "I won't see any
doctor who questions the legitimacy of what I have."

2. Patients - typically 18-55 - who are expressly seeking narcotics. "Nothing
works but the meds." "I've tried everything!" Their motives are transparent.
If you do the right thing and tell them "Joe, I try to practice evidence based
medicine and there really is no evidence for opioids in the treatment of :
chronic back pain, HA, FMS." They will cuss at you and your staff and berate
you to admin, Press Ganey, and any physician website they can access. Often
times they will go back to their PCPs and complain to them and anyone else
who will listen. They will vilify you as 'abrupt', 'unwilling to listen', 'only spent
5 minutes with me', 'terrible bedside manner', 'immediately jumped to a
conclusion about me', etc. These people are usually really bad liars.

3. Patients with obvious secondary gain that prevents them from ever improving
lest they lose their: disability payments, law suit, SSDI, litigation, etc. Unlike other
specialties, we tend to ask if you have: pending litigation, an SSDI claim, a PIP
claim, have acquired an attorney to defend you etc. If you have the above, you have
a financial incentive to stay sick and in pain. In these cases opioids, injections, serial
IMEs, MRI's, EMGs, etc are a waste of time and money.

And there you have 75 million of the IOM's 100M.

It is no more realistic to assume you can treat chronic pain in one encounter (at the ER, the PCP's office, etc) than it is assume you can treat any chronic disease in one encounter. The problem is *BOTH* unrealistic expectations from the patient and the health care provider or system. The system does not support INTEGRATED pain care. It is expensive, high resource, high burn-out, labor intensive work. It takes multiple visits, multiple discussions, and multiple trials of various interventions to win the trust of patients and proactively engage them. And, some don't want to be engaged. They are not interested in a healing encounter. Until our broader culture/society accepts a more valid definition of chronic pain (chronic pain is not peripheral nociception), our health care system will be unable to treat the real problem.

 

[emd123]

Until our broader culture/society accepts a more valid definition of chronic pain (chronic pain is not peripheral nociception), our health care system will be unable to treat the real problem.

Questions:

1-What is the more valid definition of chronic pain you're seeking, ie, what is the "real problem"?

2-Do you see this complete change in mindset of our broader culture, as you say, happening anytime soon?

3-If we were able to redefine chronic pain, and change the way our culture views it, how would enable us to better treat the "real problem" as you've described it?

 

[drusso]

Questions:

1-What is the more valid definition of chronic pain you're seeking, ie, what is the "real problem"?

2-Do you see this complete change in mindset of our broader culture, as you say, happening anytime soon?

3-If we were able to redefine chronic pain, and change the way our culture views it, how would enable us to better treat the "real problem" as you've described it?

1) I think that we're converging on an understanding that chronic pain is a RESULT of peripheral sensitization causing, central sensitization, glial cell activation, and yet to be fully characterized limbic system dysregulation.

2) No.

3) It would more closely resemble the way we treat cancer--well delineated treatment plans, coordinated care from PCP, PharmD, Pain MD, PT, Psych, MSW. Patients would understand that a chronic pain diagnosis is a life-long condition to be longitudinally managed with an eye toward preventing and reversing disability.

 

[jesspt]

1) I think that we're converging on an understanding that chronic pain is a RESULT of peripheral sensitization causing, central sensitization, glial cell activation, and yet to be fully characterized limbic system dysregulation.

2) No.

3) It would more closely resemble the way we treat cancer--well delineated treatment plans, coordinated care from PCP, PharmD, Pain MD, PT, Psych, MSW. Patients would understand that a chronic pain diagnosis is a life-long condition to be longitudinally managed with an eye toward preventing and reversing disability.

The cynic in me wonders how many of those patients would choose a treatment approach as highlighted in your 3rd point, and how many would rather keep searching for the next "cure."

 

[Ducttape]

The cynic in me wonders how many of those patients would choose a treatment approach as highlighted in your 3rd point, and how many would rather keep searching for the next "cure."

a select few, since this treatment approach should not, as a standard practice, include opioid therapy. probably noone in the 3 groups that 101N listed.

 

[Stim4me]

1) I think that we're converging on an understanding that chronic pain is a RESULT of peripheral sensitization causing, central sensitization, glial cell activation, and yet to be fully characterized limbic system dysregulation.

2) No.

3) It would more closely resemble the way we treat cancer--well delineated treatment plans, coordinated care from PCP, PharmD, Pain MD, PT, Psych, MSW. Patients would understand that a chronic pain diagnosis is a life-long condition to be longitudinally managed with an eye toward preventing and reversing disability.

We need a "patient care" centered health system not an "affordability" based system, as we are currently heading.
Let the cost of healthcare be addressed with cost controlling methods: interstate commerce, malpractice reform, state control of medicaid block grants, tax relief incentives, hsa accounts, etc...
Society used to hold physicians in high regard, now we are the cause of a failing system. We are the villains...

 

[drusso]

The cynic in me wonders how many of those patients would choose a treatment approach as highlighted in your 3rd point, and how many would rather keep searching for the next "cure."

PCP's are not equipped to manage these patients in the context of all the other preventive, acute care, and chronic disease management they *MUST* do. The burn-out occurs, in part, because the chronic pain, disability, and unmet/unrealistic expectations eclipse all the other clinical concerns and poisons the relationship. Chronic pain and disability have been identified by primary care academic practitioners at *THE NUMBER ONE* deterrent against medical students choosing primary care specialties. Thus, what patients encounter, instead are the now famous ABCD's. The health care system incentives the ABCD's not integrated pain care.

A - Accuse the patient of being crazy.
B - Blame the patient for causing their own problem.
C - Condemn the patiient to therapeutic nihilism.
D - Dump the patient to a comprehensive pain (multi-modal/multi-disciplinary) practice.