Physician Burnout: It’s Time to Take Care of Our Own

Physician Burnout: It’s Time to Take Care of Our Own

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flying cadeuciiDespite highly skilled physicians and advanced technology, the U.S. has not yet figured out how to provide effective affordable health care to everyone. Meanwhile, the health care system is increasingly fractured and stressed—and so are our doctors. Physician burnout impacts nearly half of all seasoned physicians in practice and up to 75% of resident physicians in training1. Over water cooler conversations, as well as in my work as a psychiatrist at the University of North Carolina at Chapel Hill (UNC), I hear more and more physicians report anxiety, stress and emotional exhaustion. Many feel as if they are perpetually swimming upstream; others feel there is no joy or meaning in their work; some want to quit medicine altogether. These good doctors are in crisis in increasingly high numbers — an epidemic that requires immediate attention.

Last year, the UNC School of Medicine launched the Taking Care of Our Own program to address the problem of physician burnout and we have been met with a deluge of physicians asking for help. Burnout, however, is not a diagnosis. It is a constellation of symptoms that include emotional exhaustion, depersonalization and loss of perspective that work is meaningful2. Untreated, burnout syndrome can erode professional behavior at work and healthy relationships at home. This leads to decreased empathy and compassion, poor communication and potentially worse patient outcomes. The personal consequences include disrupted relationships with family and friends, self-medicating with alcohol or other substances, depression and an increased risk of suicide, which is higher among physicians than the general population, in part due to the stigma associated with seeking mental health treatment.

Not a day goes by without my hearing from a physician in distress who has learned about the Taking Care of Our Own program. These conversations have a striking degree of similarity. They typically begin with an apology—a statement about how embarrassing it is to ask for help in dealing with anxiety or depression; or a recent loss; or other emotional stressor that makes it too difficult for the doctor to remain professional and compassionate while managing a demanding workload.

What is Driving Physician Burnout?

The culture of medicine has changed dramatically since I entered medical school more than 20 years ago. Although we worked more hours in the hospital than today’s physicians, there was greater camaraderie and a shared sense of mission and purpose among colleagues. Over the last decade, however, I have observed a growing cynicism and frustration among practicing physicians as they grapple with the complexities and challenges of our struggling healthcare system.

Factors that drive burnout syndrome in today’s environment include overall loss of control and autonomy, along with the ever-growing demands of rigorous computer documentation of all patient care encounters that intensively increase workload and decrease critical face–to-face contact with patients. Other obstacles, such as shortened lengths of stay, increased patient turnover, decreased time for interactions with colleagues and changes in reimbursement also contribute to burnout,. In the younger generation of physicians attitudes have changed, and most resident physicians now expect to have a “balanced life” with idealized ratios of time spent at work versus time with family that may be difficult to reconcile. Despite interventions focused on reducing resident duty hours and sleep deprivation, neither of these factors has been associated with reductions in burnout. New approaches are needed to combat this epidemic and provide appropriate mental health care.

How Do We Take Care of Our Own?

Medicine can be an unforgiving profession. On the one hand, we deal with life and death issues while, on the other, any outward show of distress is often not tolerated and can have grave consequences. Physicians, in general, have good coping skills honed over years of training. They are taught to ignore basic human needs (like hunger and fatigue) and to remain capable, competent and compassionate under highly stressful conditions. As a result of the stigma associated with asking for help for emotional problems, doctors wait too long to seek treatment—often until there is a mental health crisis that may require the psychiatric equivalent of intensive care. Barriers that prevent doctors from seeking mental health treatment include concerns about confidentiality, worries that colleagues will find them inadequate or incompetent or fear that they are failing if they are unable to “handle the stress”. Further compounding the problem is the lack of consistent self-care by many physicians. Resident physicians who consistently work very long hours have trouble finding time for restorative activities that help them emotionally refuel. Peak childbearing years often correlate with residency training, leaving individuals to juggle the demands of residency with the challenge of starting a family.

Taking Care of Our Own offers educational programs about burnout and mental health for resident physicians, and strategies for avoiding and/or addressing it. We work with each clinical department to implement these educational programs and customize material for each clinical specialty, as the demands and stressors vary among the diverse fields of medicine. Residency training directors play an important role when they embrace the need for mental wellness, and give trainees permission to discuss these issues and ask for help. We actively work to remove the stigma associated with seeking care and encourage self-referral. We work with the training directors and other faculty to make necessary changes that greatly increase the odds that the resident physician will be successful. One year into our program, the numbers demonstrate that this has been a winning approach. Rates of referral and demand for services of the program are constantly increasing, now occurring on a daily basis, and have increased 200% in just over 6 months.

The program also provides a mental health evaluation and treatment program for residents and fellows. All physician trainees are eligible to self-refer, although referrals often come from concerned faculty. We have developed a mechanism for triage and referral of resident physicians in need of assessment and treatment to attending faculty throughout our institution. We offer multiple different forms of mental health treatment that include evidence based therapies for burnout, depression and anxiety, and have developed a comprehensive referral base of providers who have experience caring for this patient population.

The Future:

Burnout and physician wellness can no longer be ignored and must be addressed by leadership in academic medicine6. Our initiative is aimed at increasing awareness, providing psychoeducation and offering assessment and treatment in a confidential and supportive setting that is optimized to destigmatize seeking help for emotional distress. The goal is to provide timely, cost effective and efficient care to identify and treat physician mental health issues ensuring improved performance and professionalism. Ultimately, this is good for the doctors, great for the patients and critical for the health care system. We strongly believe that this type of program needs to be offered at all institutions involved in training the next generation of physicians.

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19 Comments on "Physician Burnout: It’s Time to Take Care of Our Own"


Guest
Just another ER Doc
Jul 28, 2014

Until the state board and malpractice carriers stop asking the question “Have you sought psychiatric treatment?” in the same section as “Have you been convicted of a felony?” and treat a positive answer to either question the same, physicians will continue to avoid seeking help until they’ve reached the breaking point.

Guest
Jon Hager, DO
Jul 21, 2014

Ain’t that the truth! The thing that irritates me most is that we (physicians) seem incapable of coming together and demanding fundamental change in the system. We have the legitimacy and the leverage to do this if we ALL agree to it. Instead, we engage in infighting and petty arguments, such as whether membership in ACEP should be opened to non-EM boarded docs…at a time when we should be all-inclusive and united. There is strength in numbers. We can demand change for our profession and for our patients, or we can continue to piss & moan and burn out by the numbers.

Guest
Roger S. Perry, MD, Ph.D, FACEP
Jul 20, 2014

After 40 years of full time emergency medicine practice I have just cut back my hours in the pit, now also know as a Toxic Environment. To me the solution to burn out is not, in psycho-therapy, increasing ones recreational activities, increasing more time with family or friends, etc., the solution lies in ridding our emergency departments of the toxic elements that are poisoning us. I would start with dumping the computer charting and physician computer order entry systems as currently being practiced. I am now being trained in my fourth computer charting system and each one has been more inefficient than the previous. The AMA ACEP and AAEM for a start should develop national standards for computer charting systems that have make efficiency of operation for the physician priority NUMBER ONE. Then lobby the federal government to require these standards for all computer charting systems. In addition our medical societies should get the federal government to rid of the many regulations that erode efficiency in caring for emergency patients. I urge all who read this to contact ACEP, AAEM and even the AMA to make these and other changes a top priority. Cheers, Roger S. Perry, M.D., Ph.D., FACEP

Guest
Joel Sullivan, MD FACEP
Jul 20, 2014

Amen to Dr. Bryant’s above post–perhaps p*ssed off is more appropriate than being burned up or being burned out. The volume of patients has gone up and in the meantime we have to document and enter all orders on a computer. In addition to taking care of the patients, one is now doing the job the unit secretary used to do–you can no longer just check orders on a piece of paper and give it to the secretary to order same. And God forbid if you fail to document the entire ROS , family history, or social history, or don’t address the history in the government specified manner and include all components of same–then you will hear from the billing and chart coders that your documentation has been downgraded to a lower service level–i.e a warning from those who pay you that you are not doing a good job. Such is life and the new nature of EM . Have a nice day–

Guest

I would recommend contacting the Center & Society for Professional Well-Being {CPWB} @ http://www.cpwb.org/ or Tel: (919) 489-9167. Founder & President, Dr. John-Henry Pfifferling, Ph.D., has been addressing burnout issues professionally since ~ 1979. Disclosure: I have no financial interests in the CPWB but I am a 1990 ‘graduate’ of some of the Centers programs, which interventions have been efficacious for me for some 24 years.

Guest
Dave Bryant D.O., FAEEM
Jul 19, 2014

Burnout is different than being burned up. Burnout implies that you are tired of your profession. Many of us are not tired of being doctors. We love our profession. We are tired of having artificial stressors placed on us that have no bearing on the practice of medicine. I love taking care of sick patients and doing so in a chaotic environment. That is why I chose emergency medicine and it energizes me.

However, the practice landscape now looks nothing like it did my first years in practice. Our current sitting president stood up at the beginning of his first term and publicly vilified physicians in order get gain political traction for his health care policy ideas. Since that point, we have become fair game for anyone with an axe to grind. As a result of the increasing corporate structure of hospital systems, physicians are no longer valued in the hospital. We are not even part of the health care system anymore. We have been disenfranchised by CMS, CEOs, ‘physician’ policy makers and and IT. If you dare to speak up against this morass of non-clinical pirates, you are crushed. CMS wants to cut costs and are doing so on the back of those of us who actually care for patients. Perceived satisfaction has replaced clinical excellence as judgement for physician worth. Hospital administrators are grabbing money hand over fist while pressuring physicians to get on board with the new system, or get out all together. If they could find a way to keep the doors of their facilities open without physician involvement, they would do it. The only thing preventing this is that they require our DEA and medical license numbers. The ivory tower type physicians are perfectly happy to push their fantastical ideas of population medicine and lead groups like the AMA and AHA down politically driven pathways. Their policies contradict each other and common sense. Meanwhile, those same ‘physicians’ do not actually dirty their hands with personal patient care. IT has usurped our charts and traditional ordering system and replaced it with a computer based system that now requires us to work harder to see fewer patients. It sounds great in sound bites, but in reality we are left with the functional equivalent of PONG.

The only certainty in life is change. Change does not equate improvement. Physicians used to drive improvements in health care. Now, we are being pushed out in favor of protocols, midlevels and computers. These things brief well to policy makers who do not have first clue regarding the complexities caring for individual patients. Public policy and population studies may deal with masses, but we deal with individuals. If that individual patient has the 1 in a million diagnosis, it is 100% for them. For those of us who care for actual patients, this is what burns us up.

Guest
Joel Hassman, MD
Jul 8, 2014

When physicians tolerated if not embraced the for-profit model of health care driven by insurers and big pharma, they screwed themselves.

Most who comment here with regularity don’t want a dialogue about doing what is right and responsible, as that doesn’t make money, eh?

Which is why I don’t come to this blog much anymore. Misery loves company, and antisocial cretins thrive among the sorrow.

You really want to honestly put a dent in burnout? Physicians need to band together and tell the American people almost in so many words:

“Get the politicians, profit driven assho–s, and technology obsessed idiots out of the health care agendas and let doctors take care of patients”

Yeah, like that is going to happen in my lifetime, and I am over 50!

Should have gone on strike as a collective when the managed care model stomped on us like Gestapo storm troopers!

Joel Hassman, MD
Board Certified Psychiatrist over 20 years, looking forward to leaving the profession by 2018

Guest
bird
Jul 7, 2014

I agree that workplace stress has always been a part of medicine, for that matter every job has its workplace stress. But for medicine the stressors that are present now are not only affecting the doc but also the patient. I feel it stems from knowing the right thing to do and not being able to do it, that really gets at the doc. We all know that there is usually an underlying issue that is driving most medical complaints, stress, obesity, dysfunctional life and if we had to time to delve into these we could probably make a much bigger impact on the health and well being of the patient but in doing so we would end up going out of business because no one pays for that type of work. so instead of talking about their diet we give then lipitor, instead of addressing the weight and why they eat we send them off for a sleep study, and give them meds for knee pain, etc etc etc. so just add that to the list of why we feel stressed.

Guest
Peter1
Jul 7, 2014

I can’t remember when (in my 64 years) that docs have not been complaining about their workplace and/or vocation stresses.

Why are our modern workplace stresses any different for docs than any other worker? Did these docs choose the wrong profession?

I have also talked to lawyers who regret going into law. They would just love to argue the law, but the stress of all the other stuff required to perform their training frustrates them.

Welcome to life. It’s a bitch, then you die.

Guest

We need to provide support and care to our young physicians during residency training and we need to do it now!! While indeed there are a multitude of complex challenges facing the U.S. healthcare system (that absolutely require reform), the training of young doctors goes on, and we need to urgently help this next generation of physicians find ways to survive and thrive.

As described in this piece, our new program at UNC is one small attempt to educate and assist our young doctors as they navigate the difficult terrain.

Guest
Carlos Ortiz
Jul 5, 2014

Reading this is very concerning for us (medical students). I was wondering how can we, as students, prepare for what we are going to face once we enter the working environment? I don’t think medical schools prepare the students mentally for residence, which I think is essential and has to be a must, in order to lesser the effects of physician burnout.

Guest
Jul 4, 2014

For any physician defining the toxic environment is easy – this is just a start:

http://real-psychiatry.blogspot.com/2014/07/a-toxic-work-environment-for-physicians.html

Guest
Jul 4, 2014

What is the nature of the toxin that has infected the workplace? Negativity? Pessimism? Cliques? Until you name the toxin, you can’t do anything about it.

Guest
Jul 4, 2014

Precisely.

Guest

I wholeheartedly agree that the toxic work environment is a primary cause of physician burnout and emotional distress. However, given the nature of residency training, our resident physicians are not in a position to fix the complex problems of healthcare systems nor are they easily able to “up and quit”–even when the work environment is extremely difficult.

Thus, a mental health education and treatment program is one way (albeit a small step) to assist our young physicians on their journey. The goal is to help them survive residency. Our program has been successful in doing this and I would be happy to share more about it with you. And, perhaps some of the residents who receive mental health intervention will be empowered to work to engage in the politics that lead to toxic environments. They may be able to change the culture of medicine in the future.

Guest
Jul 3, 2014

I too am very concerned about “toxic work environments” in the healthcare space, but I’d be very interested in your definition of it. To what extent are physicians themselves contributing causes of it? But, answering that would depend on your definition. If it’s just about impinging on “physician autonomy,” then the answer is “nil,” right?

Been writing about from my (non-MD) POV. Google “REC Blog” (TCHB blocks my URL).