American College of Physicians: Internal Medicine — Doctors for Adults ®

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Thursday, September 20, 2012

Combating 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 3,442 working U.S. 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 less than .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.

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 headline-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).

After taking a year-long hiatus from blogging, Rob Lamberts, MD, ACP Member, returned with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind), where this post originally appeared.

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Auscultation
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Richmond, Va., with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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