Physician burnout article

[karayaa]

http://commonhealth.wbur.org/2013/10/why-i-left-medicine-a-burnt-out-doctors-decision-to-quit
Not trying to be alarmist or scare anyone - but - please everyone be introspective and realistic. Shadow as much as possible and talk to doctors about this. Just don't blithely ignore it and assume it'll never happen to you.

---

Members don't see this ad.

 

[Lya]

I think the question is about how we as future physicians can demand and pursue better work environments with more autonomy, less time pressure, less chaos, and aligned values with administrators'. Cleveland Clinic and Mayo Clinic might be some of few areas that value the quality of hospital environments for physicians, but for others with the established hospital culture, how can we make a shift without being perceived as complaining, weak professionals?

Being burned out is just one small piece of larger problems we see in our healthcare system. We can also delve into the inefficiency, uncertainty, bureaucracy, and so on. Rather than being succumbed to the system and avoiding the medicine as a career, I wonder how we can gather supports from scattered physicians who already quitted and other practicing physicians with the symptoms of being burned out, together pursue the system we desire, and make the whole system physician-led, patient-centered, and administrator-supported.


I might be too optimistic, though.

 

[Mr Avante]

👎sleep:

 

[astronautmd]

Before opening the link I knew this was about a female physician.

 

[AlexMack12]

I find this topic extremely interesting. In undergrad I did a senior community healthy project on depression and suicide among healthcare professionals. According to the American Foundation for Suicide Prevention, the rate of suicide among female physicians is 400% higher and for male physicians, 150% higher, than their non physician counterparts (which reflects that more males than females complete suicide in the general population. Among physicians, the rates are more equal, which shows there's actually not more gender bias when talking about suicide among physicians).

Though this article touches upon a number of factors contributing to burnout, all of which I'm sure exist, it doesn't touch upon one of the biggest contributors to completed suicide- untreated depression and burnout. Physicians and other healthcare providers have higher rates of such mental health issues yet traditionally underutilize counseling services and other professional help due to stigma (I.e., what kind of a doctor am I to need help, what will peers think, etc).

Dealing with death and disability, politics, administration, and other demands of a career in medicine will never be easy. The key is acknowledging burnout and depression in this population and changing attitudes about mental health issues and their treatment. Feeling burned out, sad, and depressed? Get help. You, your families and friends, and patients will be glad you did.

 

[Lya]

Dealing with death and disability, politics, administration, and other demands of a career in medicine will never be easy. The key is acknowledging burnout and depression in this population and changing attitudes about mental health issues and their treatment. Feeling burned out, sad, and depressed? Get help. You, your families and friends, and patients will be glad you did.

There's a chapter about this in one of Gawande's books. Just adding to what you said:

Getting help is one thing, but returning to work is another thing. The doctor will be perceived very differently and will struggle to come back to work because of the system. It makes sense that the physician won't be allowed to work, during some time, to his or her full capacity and responsibility, since the system wants to ensure the physician's quality of practice. But the damage has been already done, and the time it takes to go back to "normal" practice can be years, let alone being allowed to come back to the same hospital.

Retiring early is still common among such physicians even after getting help.

 

[AlexMack12]

There's a chapter about this in one of Gawande's books. Just adding to what you said:

Getting help is one thing, but returning to work is another thing. The doctor will be perceived very differently and will struggle to come back to work because of the system. It makes sense that the physician won't be allowed to work, during some time, to his or her full capacity and responsibility, since the system wants to ensure the physician's quality of practice. But the damage has been already done, and the time it takes to go back to "normal" practice can be years, let alone being allowed to come back to the same hospital.

Retiring early is still common among such physicians even after getting help.

Well it might be a different story if a physician is involuntarily hospitalized on a psychiatric unit due to concerns about safety for self or others- yes, in that case, the physician must disclose that they received inpatient treatment and will need to be cleared by a psychiatrist before returning to work. However, at that point, the person has spiraled down pretty far and is probably at the point of suicide.

I'm talking about encouraging people to seek help way, way, way earlier in the downward slide that is untreated depression. There's absolutely no obligation to disclose personal health records or treatments when a condition has not caused impairment to self or others. The whole problem is that people wait- and this is when issues become tougher to solve, jobs may be impacted, etc. It's a lot easier to get help when the onset of stress is felt than when someone is so desperate that suicide seems like the only option.

 

[NickNaylor]

I think the question is about how we as future physicians can demand and pursue better work environments with more autonomy, less time pressure, less chaos, and aligned values with administrators'. Cleveland Clinic and Mayo Clinic might be some of few areas that value the quality of hospital environments for physicians, but for others with the established hospital culture, how can we make a shift without being perceived as complaining, weak professionals?

Being burned out is just one small piece of larger problems we see in our healthcare system. We can also delve into the inefficiency, uncertainty, bureaucracy, and so on. Rather than being succumbed to the system and avoiding the medicine as a career, I wonder how we can gather supports from scattered physicians who already quitted and other practicing physicians with the symptoms of being burned out, together pursue the system we desire, and make the whole system physician-led, patient-centered, and administrator-supported.


I might be too optimistic, though.

None of the bolded is going to happen. "More autonomy" is not going to happen - medicine is becoming more and more evidence-based. In other words, there will be data that shows that if you have a patient with problem A the first best step is test X unless the patient has alarming systems, in which case you should proceed immediately to procedure M. Now, this is good in some sense because we have real data that demonstrates how to best help patients. That's obviously a great thing. As a provider, though, your job slowly becomes reduced to simply memorizing a bunch of algorithms and accurately interpreting your clinical and lab findings. This is less true at a place like a tertiary center because the cases are more difficult and complex, but the above is the reality for your average, run-of-the-mill community physician as I have seen it. That's not to say that it's not enjoyable. But the cowboy days of medicine are likely over at this point. You will be trained under an evidence-based model that will be hard to say no to.

"Less time pressure" is absolutely not going to happen. Medicine is now big business, and as hospitals expand there's going to be more and more corporate pressure to increase volume as much as possible for little or no increase in compensation. In private practice this is less of an issue as you can decide what you want with respect to scheduling patients, but if you intend to work for a large hospital-based practice you probably won't have that freedom. Even in private practice I've spoken with multiple docs that say they have worked to become "more efficient" (aka cram more patients in), some of whom did exactly what you mentioned their first years of practice. Maybe it's greed, maybe it's just efficient use of resources - who knows.

I'm not even sure what "aligned with administrators" means.

The physician in the article brings up some good points and gives a somewhat interesting perspective, but she frankly just sounds like she has a borderline paranoia and/or absolutely no confidence in herself. I've never worked with a physician that was that concerned about the issues she mentions. They're absolutely concerns, but she seems to amplify them to the extreme.

 

[DubVille]

I think the question is about how we as future physicians can demand and pursue better work environments with more autonomy, less time pressure, less chaos, and aligned values with administrators'. Cleveland Clinic and Mayo Clinic might be some of few areas that value the quality of hospital environments for physicians, but for others with the established hospital culture, how can we make a shift without being perceived as complaining, weak professionals?

Being burned out is just one small piece of larger problems we see in our healthcare system. We can also delve into the inefficiency, uncertainty, bureaucracy, and so on. Rather than being succumbed to the system and avoiding the medicine as a career, I wonder how we can gather supports from scattered physicians who already quitted and other practicing physicians with the symptoms of being burned out, together pursue the system we desire, and make the whole system physician-led, patient-centered, and administrator-supported.


I might be too optimistic, though.

I'm curious to know why you believe CCF to be a panencea for practicing medicine? As a student and rotating resident it was one of the most toxic environments I have ever seen. Perhaps life for an attending is different, but most residents and attendings I worked with in the hospital were miserable.

 

[circulus vitios]

"Oh, you hate your job? Oh my god, well why didn't you say so? You know there's a support group for that. It's called EVERYBODY. They meet at the bar!"

 

[yehhhboiii]

I'm curious to know why you believe CCF to be a panencea for practicing medicine? As a student and rotating resident it was one of the most toxic environments I have ever seen. Perhaps life for an attending is different, but most residents and attendings I worked with in the hospital were miserable.

do you mind expanding on this?
when i hear cleveland clinic i think patient centered medical care where doctors with different specialties work together very closely with improved outcomes
maybe that's just propaganda

 

[Lya]

None of the bolded is going to happen. "More autonomy" is not going to happen - medicine is becoming more and more evidence-based. In other words, there will be data that shows that if you have a patient with problem A the first best step is test X unless the patient has alarming systems, in which case you should proceed immediately to procedure M. Now, this is good in some sense because we have real data that demonstrates how to best help patients. That's obviously a great thing. As a provider, though, your job slowly becomes reduced to simply memorizing a bunch of algorithms and accurately interpreting your clinical and lab findings. This is less true at a place like a tertiary center because the cases are more difficult and complex, but the above is the reality for your average, run-of-the-mill community physician as I have seen it. That's not to say that it's not enjoyable. But the cowboy days of medicine are likely over at this point. You will be trained under an evidence-based model that will be hard to say no to.

"Less time pressure" is absolutely not going to happen. Medicine is now big business, and as hospitals expand there's going to be more and more corporate pressure to increase volume as much as possible for little or no increase in compensation. In private practice this is less of an issue as you can decide what you want with respect to scheduling patients, but if you intend to work for a large hospital-based practice you probably won't have that freedom. Even in private practice I've spoken with multiple docs that say they have worked to become "more efficient" (aka cram more patients in), some of whom did exactly what you mentioned their first years of practice. Maybe it's greed, maybe it's just efficient use of resources - who knows.

I'm not even sure what "aligned with administrators" means.

The physician in the article brings up some good points and gives a somewhat interesting perspective, but she frankly just sounds like she has a borderline paranoia and/or absolutely no confidence in herself. I've never worked with a physician that was that concerned about the issues she mentions. They're absolutely concerns, but she seems to amplify them to the extreme.

Makes sense.

Many would agree with and support the evidence-based approach (aside from some complex cases that don't have solid evidences yet), so that might not be a serious concern. Standardized protocols could help lower the medical errors as well.

About the time pressure, I fully agree. It echoes what I have read in the past about the emphasis in efficiency. I remember an OB/GYN saying she has to see 40 patients a day, ~7 minutes per patient.


I have a question, though: Are having a good work environment (manageable pressure, evidence-based, support systems for physicians, patient-doctor interactions valued, administrators supporting physicians, etc.) and pursuing the efficient, cost-effective hospital model mutually exclusive?


I understand that CareMore is one of those cheaper-than-average, more efficient models out there, and they are a highly team-based, managed care group. Since they are very coordinated, I am not sure if the physician burnout is common in this model, but some efficient hospitals seem to have better systems for both physicians and patients than other similarly efficient hospitals.


Also, in your opinion, how would you draw a line between amplifying concerns/complaining and genuinely bringing up the concern? It varies by individuals, but it just seems like some hospital settings have little or no voice from physicians. It might not be a serious concern, but I was just curious.

 

[Lya]

I'm curious to know why you believe CCF to be a panencea for practicing medicine? As a student and rotating resident it was one of the most toxic environments I have ever seen. Perhaps life for an attending is different, but most residents and attendings I worked with in the hospital were miserable.

do you mind expanding on this?
when i hear cleveland clinic i think patient centered medical care where doctors with different specialties work together very closely with improved outcomes
maybe that's just propaganda

I'm actually interested in this as well. Can you elaborate more on this?

My view on CCF is entirely based on the Internet articles, so I could have been misinformed. From what I have read, administrators seem very supportive towards physicians compared to typical hospitals.

 

[DubVille]

Let me start by saying that many residency and fellowship departments were very happy and supportive (during my exposure). That said, in my time spent there I would say they generally are pretty "hard" on their residents. Overworked, fairly condescending, pushing the 80 hours to the brink, and not the most friendly learning environment.

Warning the following is an anecdote: One of the residents I worked with as an MS4 now in a different residency program at CCF used to be in a competitive surgical specialty (at CCF). She got pregnant and had some complications leading to increased time off. Her fellow residents had to pick up the slack and one of her colleagues committed suicide. Upon her return she was partially implicated and blamed for the tragedy because she "forced" the extra work onto the other residents. She was miserable and transferred into a completely different specialty. She was now about to finish and was doing great in her new field. I realize this is very one sided and anecdotal, but she was now a well liked resident in her new program and from my brief exposure to her she didn't seem to have an axe to grind (she strongly recommended I apply to CCF in her current program). During my other months I witnessed/was exposed to much less serious/egregious mistreatment.

The clinic has a strange relationship with Cleveland. It is pretty much the only thing that brings people into the city from other parts of the country/world and employs a ton of people in the city. However, the ED is a complete joke for such a s center (ED in that area would cause red numbers) it isn't a level 1 center. There is no real trauma service in the hospital (again not a level one trauma center, and trauma patients don't always have insurance or $$$). The hospital is in an arms race between Case Western gobbling up all the hospitals in the area. Once it becomes a clinic hospital the ED/hospitalists tries to force out private practice docs and will consult CCF specialists (even if the patient has a relationship with another specialist that comes to the hospital). I witnessed that several times, at satellite campuses.

An MRI, lap chole, appendectomy, etc done at a CCF facility will cost far more than any other independent hospital in the city. Why? They are the clinic and now own half of the hospitals in Cleveland so they have the upper hand against insurance negotiations. As a doctor that sounds great since you get to keep more $$$, but it isn't true. Most docs that work at CCF are salaried with added benefits for billing, but it doesn't really add up.

Say surgeon A is doing a lap chole in room A. He is private practice and will be reimbursed $600 (completely made up number) for the procedure and post-op visits. CCF guy is in the adjacent room and is reimbursed $2000 (completely made up number) because his rate is based off of CCF's contract. However, he doesn't really see much of that as he is salaried and it goes into CCF's coffers. Perhaps if he stays busy enough he will get some $ back for his production. Bottom line is it increases costs. I don't know how things will change with ACA starting up.

To CCF's credit they do some amazing research, publish a great journal, and are advancing healthcare possibilities. They are also a great place to send rare/difficult cases as they have nearly infinite resources and many world renowned physicians at the main campus.

I actually would go to CCF for residency or fellowship training if I new the culture of the individual residency. You would have great research opportunities and see the most interesting/rare cases. It is an interesting model that is highly fellow driven, with teams specializing in line placements, code teams, etc. The place is a business and I actually don't begrudge it despite what I wrote above, but I certainly felt as though the majority of docs were revenue generating peons for the corporation. Honestly though, that is the way docs are viewed in any hospital system. Healthcare is a business and I have no problem with people making money.

If you have any other info feel free to correct me. I was a student/resident while there and a student for 2 years in the Cleveland area, so a lot of my experiences are based on me being very "green" to field.

 

[PTPoeny]

There's absolutely no obligation to disclose personal health records or treatments when a condition has not caused impairment to self or others.

This isn't necessarily true. Many (most? all?) State medical boards ask if you have been diagnosed or treated for any mental health issues in the last x years, where x ranges from 3-9. Some of the states specifically ask about impairing/disabling/harmful conditions, but others specifically ask about everything. Lying or nondisclosure is a good way to lose your license.

 

[NickNaylor]

I have a question, though: Are having a good work environment (manageable pressure, evidence-based, support systems for physicians, patient-doctor interactions valued, administrators supporting physicians, etc.) and pursuing the efficient, cost-effective hospital model mutually exclusive?

Also, in your opinion, how would you draw a line between amplifying concerns/complaining and genuinely bringing up the concern? It varies by individuals, but it just seems like some hospital settings have little or no voice from physicians. It might not be a serious concern, but I was just curious.

No, I don't think these things are mutually exclusive. The problem, as I see it, is often in competing interests. The primary goal of a huge multisite hospital "non-profit" is not necessarily to provide excellent patient care - financials and "the bottom line" become much more important. Insurance providers have their own motives and goals and affect management in certain ways. Administrators are similar. In theory all of these things should be oriented towards the goal of providing the best patient care possible, but in practice this is often not the case. It's not that patients are being deliberately neglected or harmed - it's just that things operate in such a way as to make processes inefficient and frustrating for both providers and patients.

Hospital settings have little/no voice for physicians because hospitals are simply corporations by another name. Don't be fooled by the non-profit label or the line of work. That doesn't mean that all hospitals are evil (likewise, not all corporations are evil), only that you should rid yourself of the notion that hospitals are saint-like institutions that do all of this wonderful, excellent good for the community. Those are the exception rather than the rule - at least based on my experience. The individuals in "the system" are generally well-intentioned, genuinely good people trying to do what they can to help others out. Unfortunately, as a collective manifested as "the system" there is so much inertia that an individual's ability to do anything substantive in the way of making real changes is extremely difficult. You have to make it your mission, and while someone needs to do those things, for most people there are too many other things ahead in the line of priorities to devote sufficient time to do anything they might otherwise do.