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Burnout

It happened again.  I was talking to a particularly sick patient recently who related another bad experience with a specialist.

“He came in and started spouting that he was busy saving someone’s life in the ER, and then he didn’t listen to what I had to say,” she told me.  ”I know that he’s a good doctor and all, but he was a real jerk!”

This was a specialist that I hold in particular high esteem for his medical skill, so I was a little surprised and told her so.

“I think he holds himself in pretty high esteem, if you ask me,” she replied, still angry.

“Yes,” I agreed, “he probably does.  It’s kind of hard to find a doctor who doesn’t.”

She laughed and we went on to figure out her plan.

This encounter made me wonder: was this behavior typical of this physician (something I’ve never heard about from him), or was there something else going on?  I thought about the recent study which showed doctors are significantly more likely than people of other professions to suffer from burn-out.

Compared with a probability-based sample of 3442 working US adults, physicians were more likely to have symptoms of burnout (37.9% vs 27.8%) and to be dissatisfied with work-life balance (40.2% vs 23.2%) (P < .001 for both).

This is consistent with other data I’ve seen indicating higher rates of depression, alcoholism, and suicide for physicians compared to the general public.  On first glance it would seem that physicians would have lower rates of problems associated with self-esteem, as the medical profession is still held in high esteem by the public, is full of opportunities to “do good” for others, and (in my experience) is one in which people are quick to express their appreciation for simply doing the job as it should be done.  Yet this study not only showed burn-out, but a feeling of self-doubt few would associate with my profession.

Analyzing questionnaires sent to more than 7,000 doctors, researchers found that almost half complained of being emotionally exhausted, feeling detached from their patients and work or suffering from a low sense of accomplishment. (From NY Times Health Blog)

Yet my own experience with my own emotions in medicine, as well as my experience with other physicians, suggests that half of the physicians in the survey are probably lying.  Being a doctor is certainly a great privilege, but it is also an enormous tax on the emotions.  Since I haven’t done other jobs I can’t compare, but there are many days I find myself wishing I had a job I could just do and then just leave at the office.  The changes in health care over the 18 years I’ve practiced have increased that frustration and fatigue, causing me to catch myself pining for the “good old days.”  Ugh.

It is interesting that the study showed the highest rates of burn-out in the “front line” professions, such as family medicine, internal medicine, and emergency medicine.  So what is it in my job that makes me feel symptoms of burn out?  Here’s my top ten list:

1.  The pressure to see a high volume of patients – because I am paid by volume, I am constantly pressured to spend less time with my patients.  This makes me feel like I’m not doing a good job on anyone.

2.  The fact that good work is penalized – When I do explain things, call people, or just act friendly toward my patients I am rewarded with a lower salary.  I constantly have to choose between doing good and getting paid, and that’s really lousy.

3.  The piles of paperwork – This has grown steadily over time, and is barely reimbursed at all.  The time I spend doing paperwork either takes away from my productive time with patients, time with my family, or my own personal time to take care of Rob.

4.  The ridiculous rules – Complying with coding requirements for documentation, with “meaningful use rules,” and with increasingly invasive rules around prescribing controlled drugs makes me nauseated.  Not only are these rules complicated and confusing, but noncompliance (intentional or not) to them could make me lose my license or worse.

5.  Dr. Oz and his cronies – I single out Oz only because of his overall influence (and to get back at Oprah for her vendetta against me), but the increasing invasion of medical information with self-serving balderdash is both annoying and destructive.  I don’t want to explain why all fatigue is not thyroid, or why gluten is not a toxin, yet I must do so to be able to care for my patients.

6.  The Evening News – The love affair the networks (CNN and company included) have with the “latest study” is enough to make me consider experimentation in television/baseball bat mating.  Every day there is a study showing that what was helpful last month will now kill you.  It’s all headling grabbing for money, and I spend an increasing amount of my time dealing with it.

7.  Drug seekers – Fueled by codependent doctors who can’t say no to requests for controlled substances, far too much of my day is spent explaining why Percocet is not a good choice for chronic pain, and daily Xanax will just make things worse.  A huge percentage of my phone messages are about these medications and I would gladly stop prescribing them altogether if they didn’t help some of my patients as much as they do.

8.  Politics and medicine – I’ve already said enough on this issue.  Unfortunately, the politicians are supposed to fix this mess, and that’s a pretty depressing reality.

9.  The constant weight of responsibility – Over the past 18 years I have never had time away from the reality of this.  It isn’t gone when I go home, and it doesn’t disappear when I go on vacation.  I can do 18 years of good work, but I can never coast.  The next exam room may be that child with subtle meningitis, or the person seriously considering suicide.  It’s in the fine print of the job, and I accept that, but it gets pretty heavy over time.

10.  Knowing that it can all crash any moment – If I miss one case of meningitis, don’t address the depression properly, or simply have a bad day, I can see my reputation ruined.  Any day could be “that day” when my life can become 100 times harder.  Despite a career of doing good, one bad day can put me in the spotlight as a “bad doctor.”

So do I want you to feel sorry for me?  Please no.  But I do want people, especially those who regularly put doctors in their crosshairs, to remember that this is a really, really tough job.  Yes, it’s a privilege, but sometimes the pressures can turn the nicest doc into a jerk, the most careful clinician into a quack, and the most caring person cold.

Some of the things on my list are just part of the job, regardless of the system, while others are caused by the ills of society and our ridiculous system.  We need to fix what we can for both doctors and patients.  We also need to understand that we are all humans (despite repeated evidence to the contrary).

Rob Lamberts, MD, is a primary care physician practicing somewhere in the southeastern United States. He blogs regularly at More Musings (of a Distractible Kind)where this post first appeared. For some strange reason, he is often stopped by strangers on the street who mistake him for former Atlanta Braves star John Smoltz and ask “Hey, are you John Smoltz?” He is not John Smoltz. He is not a former major league baseball player.  He is a primary care physician.

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5 replies »

  1. I am just curious of the readers who come to this site with regularity: Do you really think this country as a whole is better now than it was 4 years ago, based on the people you interact with on a regular basis as much as yourself? Hell, I would ask are you better of now than you were 8 years ago, in the beginning of Bush Jr the second round?

    I’m not, because the pathetic state of both these “parties” we are forced to chose between is just disgusting to have to fathom. Politicians do not give a stool sample about anyone outside their group of blind loyalists and special interests, and why does the general public continue to think otherwise to this day? Because we allow anyone who has homo sapien DNA who is allegedly a legitimate US citizen the right to vote, irregardless if they have a genuine capacity to understand and comprehend what they are voting for in the first place.

    And now we allow these narcissistic, antisocial, and clueless “representatives” the “right” to set laws that will dictate what, when, who, and why you will allegedly receive health care as it stands now.

    This doctor above talks about burnout and what we should do, well, when will doctors as a whole actually show those of us who do have gonads and care about the state of hell, er, health care and as a sizeable collective take a stand against all these non providers who are shitting on what health care is truly about?

    Yeah, that time passed when managed care took the biggest dump known to man and basically told doctors to go to hell, physicians have no say in what are the standards and needs of the profession.

    Eerily, has elements of how Nazi Germany basically condemned the Jewish population to death, just no one really believed it could be done, until it almost was. I really don’t care who thinks this analogy is way out of line, just remember Nancy Pelosi telling us all to let the law be passed without reading it first, which she did at the end of the day. And it doesn’t matter whether Romney or Obama has the winning margin come November 7, just that these two clueless humans have been the spokesmen for this country that health care is determined by people who do not spend one freakin’ moment in the health care arena.

    It is not about burnout in colleagues who care, it is solar flare out. Silence really is death in matters like this, no one has the gonads to say it and stand up to the destruction of care!

  2. Completely identify with the “assembly line” comment above. Another reason to abhor business model applications to medicine.

    Just don’t expect politicians to understand the problem. Especially the democrat ones who think this country is better off as a whole since Obummer took office. Oh yeah, another validation to them for PPACA.

  3. I work in a private setting where volume of patients is largely set by the physicians. The problem is a choice between volume (which adds revenue) and care quality (which hurts revenue). Having a system that rewards quality with lower reimbursement is the root of the problem, not administration. I don’t see how administration leads to 7 of these. Most of them are implicit in the pressures of being a physician (PCP, in my instance), or are caused by how the US HC system is set up.

  4. Seven out of ten of your points is due to poor administration. That occurs at multiple levels and I would say that administrators and administrative systems in medicine are the best example of how NOT to administer a successful business. Let’s face it – the type of administration that you describe here can only work in a system that has essentially eliminated any enlightened approach and means of escape. Anyone can say “crank out more widgets.” The irony is that you are not recognized as a knowledge worker (according to Drucker’s definition) you are being treated like an assembly line worker from the 1950s. Administrators these days apparently so ignorant that they don’t know the difference.

    The piles of paperwork and crushing workload all have the implicit agenda of keeping at least 40% of us so burned out that we can’t resist ridiculous administrators.

  5. It really can be summed up with one simple question of colleagues as of now: would you recommend to a younger person considering a career in medicine to pursue it?

    I wouldn’t for the three reasons, in order, I chose it for me back in the late 1970’s: I wanted to help people, I wanted autonomy, and I wanted to make a decent living.

    You think I help people today? Not being constantly second guessed, told what I should be providing in choices, and at least up to now just reading about how others are being sued for not being God and preventing morbidity and mortality from happening, when it fact they do and will continue to do so.

    Autonomy, well, anyone who is conscious and attentive, you tell me how much autonomy any doctor in any specialty has as of 2012.

    Money, and note how it was worded, “decent living”, is not an option if it makes you compromise on the way you provide care. And this rote rebuttal by the usual suspects to “just go concierge” is just demeaning and insulting to those of us who genuinely want to offer care to anyone who is honestly, receptively interested in treatment. I have been working in both community health programs as well as part time private practice settings concurrently for most of my career, and I have been nickeled, dimed, now Jacksoned and soon to be Franklined to a point where if I hit Lotto tomorrow, I really doubt I would even give 3 months notice to people, and that should be the standard if leaving a practice.

    So, Dr Lamberts talks of needing to fix what we can for providers and patients, well, it starts with the basics, and PPACA is not going to help either side as it is now. And insurers as status quo, well, again, no fix there. And this endless push to just prescribe like pez, not an option for improvement. Finally, telling patients that illness or death is the reality at hand as presented, you think this culture can handle the truth? CAN YA?!

    No one wants to handle the real debate about Medicare: False hopes and false expectations do not help society. Again, you all think we as a whole will live to 85 and beyond, but, on who’s cost? That dialogue will not happen at this week’s convention, nor any of the three presidential debates, and not even at most dinner tables across this country by honest and invested citizens, for fear of backlash that makes 70mph winds of a hurricane feel like standing in front of a fan before facing the onslaught of our older population.

    Hey, don’t believe me, just look around you at the Mall, the MVA, Wal Mart, the post office, maybe even at the doctor’s office! Your choice of the slice of Americana a la 2012!

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