May 2016 editorial
PHYSICIAN BURNOUT--updated version
Medicine: “Oh, Physician, How do I stress you? Let me count the ways:”
- 11-13 years of intense training under immersion in the “Superman” medical culture
- Sleep deprivation/interruption
- Emotional impact of treating serious illness, death, or chronic disability
- Pressure to work while pregnant/sick/chronically ill
- Malpractice lawsuits
- Financial debt
- EHR/ data entry
- Federal mandates
- Insurance hassles
- Pay for Performance programs and surveys
- Repetitive work
- Pressure to see large volumes of patients
- Loss of autonomy due to protocols/insurance restrictions/formularies/provider network restrictions etc..
Can you think of more? I would love to get responses to share. (firstname.lastname@example.org)
Physician burnout is characterised by 3 features: exhaustion not relieved by rest, depersonalization (cynicism), and a sense of worthlessness of one’s work. Physicians are set up to experience burnout because of numerous factors, including the culture and demands of medical training, financial stress, the challenges of caring for people with very serious illnesses, having to navigate a crazy medical non-system, isolation and loss of autonomy. More of us are more burned out than we realize.
The Maslach Burnout Inventory is a questionnaire developed by Dr. Maslach to measure and diagnose burn out. The full questionnaire is available on their website, Mind Garden:
It asks you to rate your feelings on a scale of 0-6 for issues such as feeling emotionally drained, feeling impersonal towards patients, and feeling that your work is valuable. I found a free copy online and found the results surprising. I think more of us are burned out than we realize.
The physician merry-go-round is an all encompassing ride that never slows down. The quest to get into medical school is competitive, arduous and requires great personal sacrifice. Once you get your excellent GPA, excel on the MCAT and get accepted to medical school, the work has just begun. In college at least you were competing against a large range of students, (some of whom didn’t even like science), but in medical school you are graded against the cream of the crop. Excellent becomes good, and good becomes average, and don’t even think about being satisfied with average. The ideal medical student is eager, brilliant, studied and upbeat. She presents thoughtful, thorough, well researched patient presentations and accepts criticisms with a smile. He stays up late reading about isovaleric acidemia and still gets up early enough to finish rounds by 7 am. Never tired, always alert, and most of all...never makes serious mistakes.
I did my internship at UCSD medical center where the neurology rotation took place off campus, at the naval base, and this made me nervous. I was enjoying my internship at UCSD, but the frequent interrogations and the teaching style of putting interns on the spot was stressful. I chose pediatrics because I liked to take time to think through a problem before committing myself. I prefered to writing to speaking, and for me, answering questions under pressure in front of an audience was hard. I could barely cope with the competitiveness and the expectations of perfection in a “friendly academic institution”, and I knew for sure I would die in a military environment. The day came, and upon arrival at the Naval base I was a wreck. I assumed I could be yelled at, or be asked to salute, and I didn’t even know how. I didn’t know what to expect, but I was right about one thing: navy training was a whole different world.
The instructors were kind and patient, and genuinely seemed to enjoy explaining things. There was no pressure to see patients in a hurry and everyone was friendly and enjoyed a good joke. The teaching staff delighted in our good work, and patiently helped us with our weak areas. We took a lunch break. It was my best month of internship. In my experience, academia was more militaristic than the military.
Getting pregnant upon entry into internship was not exactly planned, but things happen…
For women, the stresses that go along with bearing children or postponing having children are borne along with the challenges of medical training.
In residency the hours are long….but despite long hours many residents “moonlight” because the pay is so good. I recall doing 24 hour shift covering the nursery of the local hospital on the side, because I needed the money to be able to pay the bills.
After sacrificing my twenties to the rigors of medicine, I believed there would be a real reward at the end. I thought I would get to coast, and finally enjoy the fruits of all that hard labor. My first job in Fort Bragg had me on call every third night, and the job fell apart after a year. I worked with no pay for for a few months until I joined Eureka Pediatrics. Job security is no longer a given in medicine.
Dike Drummond MD is the current “guru” on physician burnout. His website, “The Happy MD” shows a rugged suntanned and smiling middle aged man who I assume is Dr. Drummond but could easily be an Eddie Bauer model (now there’s an alternate career idea!) looking relaxed and happy. After a major crash and burn episode of burnout, he solved his problem by switching from family medicine to running a variety of coaching and training programs. Perfectly positioned to recognize the widespread problems of physician burnout, and created a program and website to help. Check it out.
Physician burnout is a real thing. We are not robots. During medical training it was drilled into us that we should be super human--we should be able to stay up all night working and not miss a beat. We should be able to work long days and not only fail to complain--but enjoy it. We should always know the right answer, come up with the best differential and never miss a diagnosis. Certainly, never make a mistake, because mistakes can cost someone their health or life (no stress there). However, we are not Norse Gods or super people from kryptonite; we are human beings made of flesh and blood who have fragile neural networks that cannot help but react to pressure and stress. Our brains and bodies react to sleep deprivation, sleep interruption, and insomnia. We tire after working long hours. Our emotions go wonky when we make a mistake or a patient dies. Our brains get overloaded when bombarded with an overwhelming number of obligations, mandates and expectations. One of our neurologists can probably better explain how the prefrontal cortex responds to chronically elevated cortisol levels, but I am not here to discuss neurobiology, I hope to put out a wake up call to aid in recognizing and obtaining help for burnout.
- www.sciedu.ca/jha Journal of Hospital Administration 2015, Vol. 4, No. 1 REVIEWS Physician Burnout and Occupational Stress: An inconvenient truth with unintended consequences