Physician Wellness / Burnout Prevention

[sunlioness]

Does anyone know of any resources for educating myself on this topic? I just find it very distressing that in the setting of a severe physician shortage how many docs are leaving medicine. That people have built careers, put food on their table, and their kids through school helping docs leave medicine. But sometimes? I really want to leave medicine too. It just seems such a huge problem and one I would like to help solve, I'm just not sure how to start educating myself and obtain relevant experience. Anyone have any resources?

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[wannabie]

I came across this article/blog post. Maybe it'll be a bit helpful? http://www.idealmedicalcare.org/blog/physician-suicide-101-secrets-lies-solutions/

I started a support group in my area and it seems to be a good way to take some action against burnout.

 

[wolfvgang22]

I was thinking the same thing, sunlioness. Last summer I started resenting my less compliant patients a lot and developed many symptoms of mild depression and then anxiety with non-cardiac chest pain. That got my attention!
I found this site helpful. It has footnote links to a Cochrane Review on burnout treatment and several other references at the bottom. I'm open to more information also! A good book on the topic would be great.

I think the section regarding "General Advice for Patients" from the above article was good, and I'm starting to do some of it, it's helped. I'm gradually learning to say "no" better, learning to figure out what's important and what's not (everybody thinks everything they want me to do is important RIGHT NOW), started a new zen-like hobby (woodworking), started trying to get more exercise, say "**** it" and take one day every 6 weeks in addition to usual days off of for Mental Health Maintenance, and generally take things less seriously. I'm starting to put much more of the onus on getting better on the patients, no matter how much some of them want me to cure them while they make minimal to no effort to improve.

"The more relaxed you are, the better you are at everything: the better you are with your loved ones, the better you are with your enemies, the better you are at your job, the better you are with yourself." - Bill Murray

 

[notdeadyet]

This has all the makings of an awesome thread...

 

[Shikima]

Sunlioness - you've got this thread to start with!

Personally speaking I've been struggling with burnout for quite some time myself. I like wolfvgang, I've started taking more time out for myself and looking for alternatives to clinical work in making up the lost time. I've noticed by having a better/different lifestyle overall and I feel much better. I'm also putting more ownness upon the Pt's in clinic for determining their self-care -- I had 3 good interactions today because I directly confronted them rather than taking the passive approach.

 

[sunlioness]

Yeah, I've read that article and many like it. That's so great that you started a support group. I am trying to get involved in our Physician Wellness Committee here. But unfortunately they can't let me on the committee until someone leaves it. End of this year at the earliest, I've been told.

I just have a lot of thoughts around this area. It bothers me how often burnout is presented as an individual problem rather than a systemic ones. Burned out physicians are encouraged to practice mindfulness, seek counseling, work on work-life balance, or to consider leaving the field. There's nothing at all wrong with these things. And I do think some people are more prone to burnout while others are likely more resilient. But I think framing it as an individual issue ignores the systemic pressures that contribute to the problem. I'd rather fix that. I just keep coming back to what an ED physician I met at a conference told me, "In one hour's time, I can save one person's life who comes in with something serious. Or I can see 15 people with bull**** complaints. I get so much more satisfaction from the former. But if I'm not doing the latter, my hospital comes down on me. So I'm getting out.".

Or how about this scenario. You're a primary care doc in a health system. Your salary is 100% RVU based with 10% withheld until you've demonstrated meeting certain incentives. A patient comes in who hasn't been seen in a while because he has a symptom he's worried about. You have 15 minutes with him. Upon opening the encounter, you are are deluged with Best Practice Alerts, telling you that in order to meet Meaningful Use criteria you need to counsel this patient on smoking cessation, screen him for depression, and give him his flu shot. You try to accomplish all this in 15 minutes. On the way out, your patient is given a Press Ganey survey. He fills it out with average reviews, "Dr. So-and-So didn't even look at me. She just stared at the computer. She didn't listen. I went in there to talk about X and all she did was tell me I needed to quit smoking and ask if I was thinking about killing myself.". Yourn salary is now docked for failing to meet your patient satisfaction incentive.

Yeah. Mindfulness will fix all of that. It just seems that in a society where we are facing a crisis of physician shortage and poor access to health services, why do we seem to be bent on making it harder than it needs to be to be a doctor? The examples of this are nearly endless.

 

[nitemagi]

I've blogged on this a bit.

I particularly like the work by Christine Moutier (great psychiatrist now with NFSP), modeling burnout on a model of reservoir/depletion.
http://www.ncbi.nlm.nih.gov/pubmed/18270280

Really I think the dynamic exists in all relationships, where we invest energy with an expectation of someone doing something in return. We put energy into a project with the expectation the other person will agree. We treat patients with the expectation that they'll accept the treatment. When we overextend or do more than they do, we get strained and eventually burn out.

So the trick, in that model, is to
1. replenish through doing things that nourish you (refill your reservoir)
2. Don't work harder than your patients. Which means tempering expectations.
3. Extend yourself selectively. If they work hard, then you work hard.
4. Don't see failure as an indication to work harder.

Of course this doesn't address systems that are all stress/pressure based that don't make it possible to do all the expectations put out there. I agree that's a system problem, and we have to then either leave the system, change the system, or change our expectations of the system (which can feel like apathy).

In the Nesse evolutionary model for depression, we shut down when we have a goal that can't be achieved, and can't be given up. We shut down to conserve energy. We want to hibernate. With the direction that medicine is going, it makes sense that we're setting up unachievable goals, and the only solution feels like leaving the system and dropping the goals.

 

[F0nzie]

Interesting to try and understand the link between physician burnout (sort of a loosely defined term) and suicide. I have felt burned out, sleep deprived, malnourished, sad, and angry in medicine but not once have I had thoughts of suicide.

Which makes me wonder if it's easier for doctors to talk about burnout vs. clinical depression. I believe the state medical boards require that you report if you have a mental illness. Which may (amongst other reasons) be a barrier to receiving treatment.

As physicians we have a high suicide rate compared to other professions. However despite psych having some of the highest job satisfaction don't we also have one of the highest suicide rates when compared to other specialties in medicine?

 

[deleted307836]

Sorry for the off topic question, but does anyone have reliable statistics on the number/percent of physicians leaving medicine (other than retirement)?

 

[Armadillos]

Obviously covering your pager when on call is one thing, but I think an important thing in modern life is to set up your electronic life carefully. You need to do it in a way so that your not interrupting your monday night football enjoyment to read some email about a trivial issue that you then spend the next 10 minutes troubleshooting in your mind. This can be as simple as leaving your phone in a different room so you can't instinctively check it every few minutes w/o realizing it

 

[Doctor Bagel]

Which makes me wonder if it's easier for doctors to talk about burnout vs. clinical depression. I believe the state medical boards require that you report if you have a mental illness. Which may (amongst other reasons) be a barrier to receiving treatment.

This is not true in my state. We're asked if we had a medical condition (psychiatric or otherwise) that has interfered with our ability to work. Very different than just having a diagnosis. I did get a hospital credentialing form once for a moonlighting job that I asked if I had any medical (including psychiatric) condition ever -- I guess they wanted to know about my sprained ankle two years ago and my seasonal allergies. I found that a bit overly intrusive. That sense of intrusion by others into our lives might play a role in some of this burnout in that we have a sense that if we screw up at any point things are over. Not entirely true, but I think it's a common feeling in our field.

She's a bit odd, but I do like what Pamela Wible has to say about burnout and about physician suicide. As noted above, the pressures in routine physician jobs to see a ton of patients in a short period of time coupled with increasing documentation and bureaucratic pressures isn't sustainable.

I went to the American Psychoanalytic conference this year, and Glen Gabbard made a brief comment on a session on masochism that masochism is rampant in our profession. Entirely non surprising but interesting to hear. I think that could explain some of our burnout in that we put ourselves into situations that really aren't good for us. Of course our system is also broken, although we might have more choices than we tell ourselves we have.

Now I'm waiting for the flood of comments about how great it is to be a doctor and about how we should just buck up or whatever because that's how these things always play out. We're our own worst enemies.

 

[nitemagi]

It is great to be a doctor. But we tie our expected payback/rewards as 1. Prestige, 2. Monetary Compensation, 3. Effectiveness in changing/improving others (which includes gratitude). If we exert effort and get less of those or none of those, then we can feel frustrated, powerless, hopeless, etc. I believe much of the bureaucracy ends up making doctors feel less effective (in psychiatry the reliance on psychopharm as the sole hammer-nail tool as well), and when we don't feel effective then #3 drops off.

 

[sunlioness]

I'm waiting for those comments too, Doc Bagel. Sometimes I wonder if almost like a kind of Stockholm Syndrome when people start making those comments. The ones I usually see are, "If you can't handle the pressures and responsibilities, this field is obviously not for you and you should get out.". And yeah, like I said. Some people are likely more resilient than others and deal with it better. And if there were an overabundance of doctors, then yeah, maybe telling people to get out if they can't hack it is reasonable, if not necessarily compassionate. But that's not the case. Again, Crisis Doctor Shortage. We need to be finding ways to make it workable for people who were once passionate about wanting to help people be able to hang onto that. I mean what was that study, I just saw linked somewhere? 40% of practicing physicians across specialties said they'd like to get out. In fields like Emergency, it's over half. Some of those people will get out and good for them. Bad for access to healthcare. Some of those people won't get out and will continue to practice while largely checked out. Bad for them. Bad for their patients. (And sure, some might take some time off, get some counseling, shuffle some things around and come back rejuvenated. But do you want to bank on that?)

The two states I'm licensed in don't ask about mental health diagnoses either. They do the vague "are you aware of any condition, physical or mental, that would prevent you from safely practicing medicine?". I don't have a problem with that. But there can be other barriers to getting treatment. Like health insurance policies that only consider your employer's providers to be in-network.

And yeah, Fonzie. I've never felt suicidal either. I mean there have been times when I have had some pretty intense escapist fantasies, but never to that extreme. So I am sure that mental health issues are relevant and that some of it might be due to clinical depression. But it's not the complete picture. Kinda like the patient who presents with depressive symptoms who lives with an abusive spouse s/he's financially dependent on and has no other supports. They might meet criteria for a major depressive episode. An SSRI might help take the edge off. But if that's all you focus on, you're missing a big chunk of the picture.

 

[splik]

As a marxist I agree with the criticisms about burnout interventions directed at individuals. This is a deliberate strategy that obfuscates the genuine causes of dissatisfaction in the work place and instead locates the problem within the individual. Suddenly the problem is not increasing job insecurity (let's not kid ourselves, this is the reality of medicine today), being blamed for things beyond your control, the demands for higher productivity and seeing more patients than you feel comfortable with, and the pernicious trend for patients to become customers where the customer is always right (including when they want xanax, adderall, and suboxone cocktail), the problem is you.

There is a lot of research outside of medicine that shows that interventions for workplace stress that focus on treating individuals with counseling, CBT, mindfulness etc are woefully ineffective at reducing absenteeism or symptoms of depression or anxiety. On the otherhand interventions designed by organizational psychologists who recommend institutional changes have been shown to be successful. This requires institutions to acknowledge there is a problem and be willing to address this. The Karasek-model shows that satisfaction in the work place, as well as stress (and various complications including diabetes, obesity, hypertension, cardiovascular disease) are tied the levels of autonomy and demands that workers have. So people in high autonomy low demand jobs do the best in terms of health and wellbeing, whereas jobs with low autonomy and high demand do the worst. This is especially because people in those jobs are essentially held to account or expected to do things over which they have little control over. As physicians, lack of autonomy is a particularly demoralizing factor because we work for so long and hard in positions (med school, residency etc) often getting **** on and treated poorly and either paying for the "privilege" or getting paid a paltry sum, only to find at the end that autonomy for many is illusory. This is particularly as larger organizations have made it less financially solvent for physicians to work solo. Although psychiatry has been affected a little less as healthcare reform marches onwards it is going to become harder for people to work in solo or small group practices. I am hopeful that more physicians will see why they need to unionize in order to have a greater control in their fates.

It is certainly true that there are particular traits such as perfectionism, rumination, and so on that can exacerbate difficulties and put one at risk for burn out but addressing these alone or even primarily is misguided.

 

[wolfvgang22]

That sense of intrusion by others into our lives might play a role in some of this burnout in that we have a sense that if we screw up at any point things are over. Not entirely true, but I think it's a common feeling in our field.

Maybe not entirely true, but close enough that it doesn't matter to me.

 

[doctorpilgrim]

Christina Maslach has done lot of work on Burnout in organizational setting. Bureaucracy promotes learned helplessness, depersonalisation, stress on productivity causes exhaustion and loss of personal accomplishment. I agree with sunlioness that larger issue is structural, individual treatment and prevention can only do so much. Because the continuing onslaught on our profession will raise the struggle to next level. Sadly this is a losing battle.

 

[Doctor Bagel]

Maybe not entirely true, but close enough that it doesn't matter to me.

Oh yeah, I agree. It's not all paranoia.

On reality versus perceptions, there's a lot of reality in the fact that there's less money, and we're increasingly under the control of these big hospital systems, insurance companies and maybe the government. But I feel like we also get stuck in certain defeated positions making us feel more powerless than we are -- at least that matches up with what I've seen with other people and with myself, especially in thinking about what I should do after I leave training. So sometimes we as individuals close doors and increase our own suffering, but the system is also really screwed up and increasingly demoralizing for physicians.

I think nitemagi's statement above about patients outcomes is a huge one. We're pushed to work in settings where we can't really provide good care, which is demoralizing. Cynically, I feel like some of the push to increase access to care means people get care on paper but don't really get meaningful care (even if this care is compliant with "meaningful use" -- god, I hate that phrase).

Not a novel thought, but our training structure has a play a role in burnout, too. We're told to put up with so much early on with the promise that it'll be worth it in the end. Considering how long we delay gratification, things afterward have to be pretty damn awesome, which they usually aren't.

 

[oldanddone]

I'm loving this thread. And I'm loving a post that starts 'as a marxist' with some good old systems analysis and especially loving the amount of 'likes' it got. Whew. There's relief there too for me that there are others out there who have knowledge to share from a critical perspective on what is wrong headed about the 'total quality management' approach that is infecting medicine. Already has infected the 'private sector' and the field of education. And also medicine. Medicine maybe had power and prestige to not have to worry....propped up no doubt by privilege on the backs of others but something to be said for the autonomy that once was. Rather than attack such autonomy I would have liked to see it spread to others. But sometimes I think the popular press and the payer pressures on colleges etc go along too much the other way as seeing autonomy as a bad thing and to be taken away. Sure there is financial incentive for those who have always had power on the backs of workers to take away the means of production and the control of autonomy. But the popular perspective of increasing 'safety' this way by reigning in 'unsafe autonomous' professionals and instead making them employees who are overly policed is really distressing. The beurocratization is distressing. I keep thinking of how long we have known about the pitfalls of beurocratization since weber and the early sociologists etc. And how it ties in with dictatorships and dystopia. And yet. People and being human is what gets compromised. Sometimes I think of how hard nosed training and colleges are. With no broad analysis. No sense of what ideology they are ultimately supporting. And how in other areas of work and life there would be a good case for discrimination based on mental health stigma. Way too ideologically ignorant and hard nosed. I think of how feminism and other grassroots movements have critiqued the medical model of individual pathologic ingredients. And how none of that is taken up in colleges. They are there apparently in order for us to be autonomous and self regulating. Where is the awareness around self regulation economy and power from foucault and feminists and others. Where is a thoughtful sense of self regulation from a professional perspective that is meant to value humanity health and autonomy.

So glad to see this thread

 

[DD214_DOC]

Put the responsibilty back where it belongs -- on the patient. Educate them, sure, but don't beat your head into a wall. Don't infantalize patients and hold their hand.

I had a big conflict with the policy of a clinic I previously worked in. If a patient no-showed, the policy was that we call them -- preferably during their appointment time -- to ask why they were not there and to offer to schedule a make-up appointment. We had to attempt and document at least 3 separate calls before we could say we, "could not reach them". I refused to do this. They're adults, and they know how to pick up a phone and reschedule.

 

[sunlioness]

Put the responsibilty back where it belongs -- on the patient. Educate them, sure, but don't beat your head into a wall. Don't infantalize patients and hold their hand.

I had a big conflict with the policy of a clinic I previously worked in. If a patient no-showed, the policy was that we call them -- preferably during their appointment time -- to ask why they were not there and to offer to schedule a make-up appointment. We had to attempt and document at least 3 separate calls before we could say we, "could not reach them". I refused to do this. They're adults, and they know how to pick up a phone and reschedule.

Three separate calls? Yikes. When I had my own practice, I used to try to call people who didn't show. I don't do that anymore, but I do bill. If someone comes back later and says, "I'm so sorry, but my spouse was in the hospital and I totally forgot to call" I'll reverse the charge, but yeah, generally I agree with you. We're 100% RVU and no shows hurt.

 

[wolfvgang22]

Put the responsibilty back where it belongs -- on the patient. Educate them, sure, but don't beat your head into a wall. Don't infantalize patients and hold their hand.

I had a big conflict with the policy of a clinic I previously worked in. If a patient no-showed, the policy was that we call them -- preferably during their appointment time -- to ask why they were not there and to offer to schedule a make-up appointment. We had to attempt and document at least 3 separate calls before we could say we, "could not reach them". I refused to do this. They're adults, and they know how to pick up a phone and reschedule.

Yeah, the VA makes me do the 3 call thing. Usually nobody answers, or I hear "The Cricket number you have called is no longer in service."

 

[Shikima]

Three separate calls? Yikes. When I had my own practice, I used to try to call people who didn't show. I don't do that anymore, but I do bill. If someone comes back later and says, "I'm so sorry, but my spouse was in the hospital and I totally forgot to call" I'll reverse the charge, but yeah, generally I agree with you. We're 100% RVU and no shows hurt.

I considered this in my PP, but decided against it realizing that I was expending more energy than they were. I just bill for the no show now.

 

[keifernny2]

There is no reason that reschedule calls can't be automated by admin staff or nursing staff. It is a complete waste of time for physicians to be making them.

 

[wolfvgang22]

Cynicism aside, I do find that when I talk to a patient on the telephone the patient is much more likely to actually reschedule or show up than when the patient talks to a nurse or admin staff. I think it's less my elite skill as a persuader and more a function of of the fact that patient's rarely get calls from actual physicians.

 

[doctorpilgrim]

I work on the physician wellness committee of our Medical group. Physicians and providers are resentful of being referred to it and rightfully so. Whereas our job is to educate and advocate for them, I routinely see the management use it as a tool to get providers to fall in line. Every month I used to go bat for my colleagues, did prevention surveys, suggested changes which would inevitably be shot down by a physician no less because they would cost some money. I think most of us are good and well equipped to deal with clinical issues, it is the managements constant manipulation, lack of authority to handle our responsibility, constantly being held accountable for things beyond our control by patients, management, insurance, government and public that plays a major role in burnout. If the prevalence of burnout was 1 to 5 percent then maybe we could do something change ourselves. When it is 1 in 3 or more, then the only hope is changing the structural issues.Medical groups in my experience are the worst as our own colleagues constantly plan and scheme to beat us down. May be things will need to get worse before the public opinion or system wakes up to it.

 

[Shikima]

I work on the physician wellness committee of our Medical group. Physicians and providers are resentful of being referred to it and rightfully so. Whereas our job is to educate and advocate for them, I routinely see the management use it as a tool to get providers to fall in line. Every month I used to go bat for my colleagues, did prevention surveys, suggested changes which would inevitably be shot down by a physician no less because they would cost some money. I think most of us are good and well equipped to deal with clinical issues, it is the managements constant manipulation, lack of authority to handle our responsibility, constantly being held accountable for things beyond our control by patients, management, insurance, government and public that plays a major role in burnout. If the prevalence of burnout was 1 to 5 percent then maybe we could do something change ourselves. When it is 1 in 3 or more, then the only hope is changing the structural issues.Medical groups in my experience are the worst as our own colleagues constantly plan and scheme to beat us down. May be things will need to get worse before the public opinion or system wakes up to it.

You could equate it to being forced into punitive psychotherapy for the purposes of social control. I've seen a number of nurses, SWs and other ancillary personnel show up in my clinic for this reason.

 

[oldanddone]

I understand that kind of process. I'm not sure it should even be called psychotherapy when something is too proscriptive and has too much of an endgame. For instance would couples therapy be therapy if the goal is for both to end up doing exactly what the more powerful and paying partner wants? No. Not psychotherapy. Maybe 'corporate re education camp'. Not true healing.

 

[Shikima]

I understand that kind of process. I'm not sure it should even be called psychotherapy when something is too proscriptive and has too much of an endgame. For instance would couples therapy be therapy if the goal is for both to end up doing exactly what the more powerful and paying partner wants? No. Not psychotherapy. Maybe 'corporate re education camp'. Not true healing.

I'm picturing the detention camp from 'Red Dawn' (the original, not the crappy remake).