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Category: Physicians

Mindful Daily Practice Offers an Antidote to Healthcare Burnout

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By GREG HAMMER, MD

Burnout among healthcare professionals is at an all-time high. Its drivers include longer work hours, the push to see more patients, more scrutiny by administrators, and loss of control over our practice. We seem to spend more time with the electronic medical record and less time face-to-face with our patients.

I have faced burnout personally. My son passed away at the age of 29, which was beyond painful. At the same time, I felt burdened by the growing number and complexity of metrics by which I was judged at work. Days in the operating room and intensive care unit seemed more and more exhausting, and my patience was becoming shorter and shorter. I was fortunate to have had a long-standing meditation practice as well as sabbatical time that I used to decompress and re-evaluate my career. Many of us are not so lucky. More than half of physicians have serious signs of burnout, and more than one physician commits suicide every day.

So many of us feel burned out these days because in our rapidly changing profession we are asked to do more for less and with inadequate resources. We suffer from exhaustion, self-criticism, and worry about what will happen next to our practice, our families, and ourselves. If we want to save our practices, patients, marriages- even our lives, we must acquire personal resilience.

Fortunately, we can increase our resilience and happiness and reverse burnout by embracing a few simple principles—Gratitude, Acceptance, Intention, and Nonjudgment (GAIN)—that we can put into motion in our everyday lives at the hospital, at home, or wherever we are.

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Burned out on Burnout?

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By SANJ KATYAL, MD

If you are like most doctors, you are sick of hearing about burnout. I know I am. There is a big debate on whether burnout is real or whether physicians are suffering from something more sinister like moral injury or human rights violations. That doesn’t matter. In the end, no matter what name we give the problem, the real issue is that physicians are in fact suffering. We are suffering a lot. Some of us—around one physician per day—are forced to alleviate their suffering by taking their own life. Each year, a million patients lose their physicians to suicide. Many more physicians suffer in silence and self-medicate with drugs or alcohol in order to function.

We are losing more physicians each year to early retirement or alternate careers. There are an increasing number of coaches and businesses whose single purpose is to help doctors find their side gigs and transition out of medicine. This loss comes at a time of an already depleted workforce that will contribute to massive physician shortages in the future. Perhaps even more troubling is that those physicians who remain in medicine are often desperate to get out. It is the rare physician these days that recommends a career in medicine to their own children. We now have a brain drain of the brightest students who would rather work on Wall Street than in a hospital. 

As a physician trained in positive psychology, I have been committed to helping other physicians and students improve their well-being. The focus on well-being is a welcome change in medicine.  But is it enough?

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Chronic Disease Drugs are Big Business, Antibiotics are Not

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By HANS DUVEFELT, MD

I have noticed several articles describing how antibiotic development has bankrupted some pharmaceutical companies because there isn’t enough potential profit in a ten day course to treat multi-resistant superbug infections.

Chronic disease treatments, on the other hand, appear to be extremely profitable. A single month’s treatment with the newer diabetes drugs, COPD inhalers or blood thinners costs over $500, which means well over $50,000 over an effective ten year patent for each one of an ever increasing number of chronically ill patients.

Imagine if the same bureaucratic processes insurance companies have created for chronic disease drug coverage existed (I don’t know if they do) for acute prescriptions of superbug antibiotics: It’s Friday afternoon and a septic patient’s culture comes back indicating that the only drug that would work is an expensive one that requires a Prior Authorization. Patients would die and the insurance companies would be better off if time ran out in such bureaucratic battles for survival.

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Doctors Lack Knowledge about Medical Cannabis Use. Their Patients Can Help.

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By DOUGLAS BRUCE, PhD

On January 1, 2020, recreational cannabis use became legal in Illinois. More than 80,000 people in Illinois are registered in the state’s medical cannabis program. Surprisingly, many of their doctors don’t know how to talk with them about their medical cannabis use. 

As a health sciences researcher, I have a recommendation that is both practical and profound: Physicians can learn first-hand from their own patients how and why they use medical cannabis, and the legalization of recreational cannabis may make them more comfortable discussing its usage overall.

Nationwide, physicians too rarely discuss cannabis use with their patients living with chronic conditions, such as chronic pain, cancer, multiple sclerosis, epilepsy, fibromyalgia, and Crohn’s disease—all conditions with symptoms that evidence shows cannabis may effectively treat. Why don’t physicians talk with their patients about cannabis use? Research from states with longer histories of legalized medical cannabis shows that many physicians do not communicate with patients regarding their medical cannabis use for a variety of reasons. 

First, physicians aren’t well trained in cannabis’ medical applications. Unlike the endocrine or cardiovascular systems, the endocannabinoid system—comprised of receptors which bond with the compounds THC and CBD found in cannabis—is not taught in medical school.

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Reference Manuals May Be Facing Obsolescence

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We must ensure their relevance to contemporary patient care

By LONNY REISMAN, MD

It’s 1992 and disruptive technologies of the day are making headlines: AT&T releases the first color videophone; scientists start accessing the World Wide Web; Apple launches the PowerBook Duo.

In healthcare, with less fanfare, a Harvard physician named Dr. Burton “Bud” Rose converts his entire nephrology textbook onto a floppy disk, launching the clinical tool that would ultimately become UpToDate. Instead of flipping through voluminous medical reference texts, such as the Washington Manual, doctors could for the first time input keywords to find the clinical guidance they needed to make better treatment decisions.

The medical community embraced UpToDate’s unique ability to put knowledge at their fingertips. Today more than 1.7 million clinicians around the world use UpToDate to provide evidence-based patient care with confidence. For many, it along with other reference sources has become foundational to providing high quality medical care.

More than just an easy-to-use reference, UpToDate has gone on to improve patient outcomes, according to the Journal of Hospital Medicine.

In the new era of 21st century digital medicine, however, there are opportunities to go further in support of clinicians and patients. Reference tools must be powered by predictive and prescriptive analytics, be personalized to individual patient circumstances, and be integrated into clinician workflow. In some cases, clinicians may be unaware of which questions to ask of a computerized reference manual, or how to incorporate the nuances of an individual patient’s case into the general insights of a reference. Searching for heart failure treatment, for example, may be too broad a query and the resulting recommendations therefore may not provide optimal care for a specific patient’s unique medical circumstances. New digital health solutions that consider patients’ co-illnesses, contraindications, symptomatology, current treatment regimens, and hereditary risks are essential.

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Switching to Outpatient Surgery for Everyone’s Benefit

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By AMY KRAMBECK, MD

The trend toward less invasive procedures, shifting from inpatient to outpatient, has changed the face of surgery. Industry-changing leaps in technology and surgical techniques have allowed us to achieve our treatment goals with smaller incisions, laparoscopy and other “closed” procedures, less bleeding, less pain, and lower complication rates. As a result, patients who used to require days of recovery in the hospital for many common surgeries can now recuperate in their own homes.

Outpatient procedures grew from about 50% to 67% of hospitals’ total surgeries between 1994 and 2016,1,2 and outpatient volume is expected to grow another 15% by 2028,3 with advantages for patients, surgeons, insurers, and hospitals. In my hospital, where bed space is at a premium, my colleagues and I were able to make a significant impact by switching minimally invasive surgery for enlarged prostate, also called benign prostatic hyperplasia (BPH), from inpatient to outpatient.

New Opportunity with an Advanced Technology

BPH affects about half of men in their 50s, with the prevalence increasing with age to include about 90% of men 80 and older.4 As a result, BPH surgery makes up a significant portion of urological procedures in any hospital.

I have been performing BPH surgery for 11 years. There are several options, including transurethral resection of the prostate (TURP) and suprapubic prostatectomy, both of which require hospital stays and bladder irrigation with a catheter due to bleeding. Another less frequently utilized surgical option for BPH is holmium laser enucleation of the prostate (HoLEP). HoLEP causes fewer complications and requires shorter hospitalization.5 Specifically, its postoperative morbidity is the lowest among BPH surgeries.5,6,7  HoLEP has the least bleeding, shortest catheter time, and low rates of urinary tract infection, plus patients are less likely to require additional treatment for BPH as they age compared to other available therapies.5,6,7  

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Rebuilding Trust in our Doctors: An Option for our Broken System

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By AMITA NATHWANI, MA

This week’s impeachment hearings show what a crisis of trust we live in today.  69% of Americans believe the government withholds information from the public, according to recent findings by Pew Research Center.  Just 41 % of Americans trust news organizations.  We even distrust our own health care providers: Only 34% of Americans say they deeply trust their doctor.

One important way doctors can regrow that trust is to become educated about the types of medicine their patients want, including alternative therapies. 

People are seeking new ways to care for their health. For instance, the percentage of U.S. adults doing yoga and mediating—while still a minority– rose dramatically between 2012 and 2017, according to the CDC’s National Center for Health Statistics.  Likewise, the number of Americans taking dietary supplements including vitamins, minerals and natural therapies like turmeric, increased ten percentage points, to 75% in the past decade, according to the Council for Responsible Nutrition.  As Americans increasingly seek out non-pharmaceutical ways to address wellness, they need doctors who can talk to them about such alternatives. 

Unfortunately, this is rare.  As a provider of an holistic approach to health called Ayurvedic Medicine, I often see people who tell me their physician dismissed them when they asked about treatments they’d read about on the internet.  In many cases, clients tell me their doctor has actually chastised them for entertaining an alternative approach to their existing illness.  This leaves them disempowered. They wanted to make choices to improve their own health, but found they were not acknowledged, supported or even understood by the doctor.  

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Academic Medicine and the Peter Principle

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By BEN WHITE, MD

Over four years of medical school, a one-year internship, a four-year radiology residency, a one-year neuroradiology fellowship, and now some time as an attending, one of my consistent takeaways has been how well (and thus how badly) the traditional academic hierarchy conforms to The Peter Principle.

The Peter Principle, formulated by Laurence J Peter in 1969, postulates that an individual’s promotion within an organizational hierarchy is predicated on their performance in their current role rather than their skills/abilities in their intended role. In other words, people are promoted until they are no longer qualified for the position they currently hold, and “managers rise to the level of their incompetence.”

In academic medicine, this is particularly compounded by the conflation of research prowess and administrative skill. Writing papers and even getting grants doesn’t necessarily correlate with the skills necessary to successfully manage humans in a clinical division or department. I don’t think it would be an overstatement to suggest that they may even be inversely correlated. But this is precisely what happens when research is a fiat currency for meaningful academic advancement.

The business world, and particularly the tech giants of Silicon Valley, have widely promoted (and perhaps oversold) their organizational agility, which in many cases has been at least partially attributed to their relatively flat organizational structure: the more hurdles and mid-level managers any idea has to go through, the less likely it is for anything important to get done. A strict hierarchy promotes stability primarily through inertia but consequently strangles change and holds back individual productivity and creativity. The primary function of managers is to preserve their position within management. As Upton Sinclair wrote in The Jungle: “It is difficult to get a man to understand something when his salary depends upon his not understanding it.” (which incidentally is a perfect summary of everything that is wrong in healthcare and politics).

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Everybody Seems to be an Expert, Except Your Family Doctor?

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By HANS DUVEFELT, MD

It’s a funny world we live in. Lots of people make a handsome living, defining their work and setting their own fees and hours with little or no formal education or certification

There are personal and executive coaches, wealth advisers, marketing experts, closet organizers and all kinds of people offering to help us run our lives.

In each of these fields, the expectation is that the provider of such services has his or her own “take” or perspective and offers advice that is individual, unique and as far removed from cookie cutter dogma as possible. Why pay for something generic that lots of people offer everywhere you turn?

So why is it, in this day of paying lip service to “personalized medicine”, genetic mapping, the human biome and psychoneuroimmunology that we expect our healthcare to be standardized and utterly predictable?

And why is it that we are so willing to fragment our care, using convenient care clinics, health apps, specialists who don’t communicate with each other and so on? Does anybody believe it makes sense to have your life coach tell you to have a latte if you feel like it because it makes you happy and your financial adviser scorn you for wasting money, never mind your health coach talking about all those unnecessary calories?

In today’s world, almost all knowledge and information is available, for free, instantly and from anywhere on the planet. But this has not eliminated our need for “experts”. It used to be that we paid experts for knowing the facts, but now we pay them for sorting and making sense of them, because there are too many facts and too much data out there to make anything self explanatory.

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Physicians Should Play a New Role in Reducing Gun Violence

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Julie Rosenbaum
Matthew Ellman

By MATTHEW S. ELLMAN, MD and JULIE R. ROSENBAUM, MD

What if firearm deaths could be reduced by visits to the doctor? More than 35,000 Americans are killed annually by gunfire, about 60% of which are from suicide. The remaining deaths are mostly from accidental injury or homicide. Mass shootings represent only a tiny fraction of that number. 

There’s a lot physicians can do to reduce these numbers. Typically, medical organizations such as the AMA recommend counseling patients on firearm safety.  But there is another way to use medical expertise to help reduce harm from firearms: physicians should evaluate patients interested in purchasing firearms. The idea would be to reduce the number of guns that get into the hands of people who might be a danger to themselves or others due to medical or psychiatric conditions.   This proposal has precedents: physicians currently perform comparable standardized evaluations for licensing when personal or public safety may be at risk, for example, for commercial truck drivers, airplane pilots, and adults planning to adopt a child.  Similar to these models, a subset of physicians would be certified to conduct standardized evaluations as a prerequisite for gun ownership. 

As a primary care physicians with decades of practice experience, we have seen the ravages of gun violence in our patients too many times. A 50-year-old man shot in the spinal cord 30 years ago who is paraplegic and wheelchair-dependent. A 42-year-old woman who sends her teenage son to school every day by Uber because another son was shot to death walking in their neighborhood. A teacher from Sandy Hook who struggles to cope with post-traumatic stress disorder.  

Physicians can contribute their expertise toward determining objective medical impairments impacting safe gun ownership. These include undiagnosed or unstable psychiatric conditions such as suicidal or homicidal states, memory or cognitive impairments, or problems such as very poor vision, all of which may render an individual incapable of safely storing and firing a gun. In this model, the clinical role would be limited in scope. The physician would complete a standardized evaluation and offer recommendations to an appropriate regulatory body; the physician would not be the final decisionmaker regarding licensing.  An appeal process would be assured for those individuals who disagree with the assessment.  

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