Burn-out

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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).

15 thoughts on “Burn-out”

  1. It’s a tough job because you make it so . Every once in a while , you have to stop and listen to the music .

  2. Ophra has a vendetta against you? That àlone makes me respect you. I can tell that most of my doctors are burned out when I’m asking questions based on something I’ve learned on the internet. It makes me feel really sad. Personally one bad day isn’t going to turn away from anyone. But if it is a regular pattern, or if it is someone I don’t know well it will make me wary of that person.

  3. The Oprah thing is a running joke in the blog for years. She’s a fun person to use as a foil. She has NEVER ONCE LEFT A COMMENT. I think she is just being petty.Regarding the “bad day,” I am saying that if I miss the subtle signs of meningitis in a baby or if I’ve got a lot on my mind and don’t give enough effort in my care, I can harm them or even kill them. It may not be true that I would be ruined, but I am very much aware of this possibility and do everything I can to not cut corners. This causes fatigue after 18 years, and I often wish for a life without such unending pressure to perform at the top of my game. I know it’s impossible to be perfect, but I sure as heck want to get as close to it as I can each day.I am better at dealing with all of this than many docs, as I am pretty good at leaving the past behind. I don’t stay up at night wondering if I forgot to do something. I have to just leave what I did in the past and trust things will work out. If things go bad, I will deal with it when that happens. Otherwise I just clear my mind from what’s been done. I have colleagues who burn out quickly because they can’t ever put their work down. Primary care is not the place for an obsessive-compulsive.

  4. I may make my job tougher than it need be, but I tried to show that it is stressful by definition. I do take time off, listen to music, play the guitar, exercise, write, and spend time with family at home. The point of this post is to give people some perspective on why docs get stressed and sometimes act in ways that otherwise are hard to understand. The unfortunate reality is that the main way to make my job less tough would be to not care as much as I do about doing it well.

  5. The motto given to my churches tech team by a former programming minister who was a trauma surgeon is ” On a good day nobody remembers we are here. On a bad day…well, nobody died.” A very good perspective for us. It speaks volumes about his reality. I can’t imagine living under that kind of pressure. On a few occasion I have been on the receiving end of a bad call by a doctor. Everyone makes mistakes. If we make a mistake in the tech booth, we feel terrible and defeated. If you make a mistake, or even if you go by the latest guideline and it turns out badly, I don’t really hold it against you. At some point we all have to embrace our flawed humanity.

  6. The interesting/depressing thing about your very accurate list is that only a couple items are inherently part of the job of practicing medicine. Most of them are demands placed on docs by outsiders, generally for the purpose of making a buck off our laborBeing a good physician is stressful enough in and of itself (but enormously satisfying); these additional chores are what can take all the joy out of it.
    These are exactly the type things that one would expect a functioning professional society to address aggressively. Instead, the ones we have in primary care are committed to making things worse.

  7. It’s such a catch-22… I can so relate. I absolutely love the fact that I am trusted with people’s lives and their stories…. but some days I do come home with not that much more left to give to my own family.
    During a particularly difficult time at an unethical volume-driven practice, I took some stress leave, which led to a decison to resign. While I was so relieved to be out of the toxic environment of this avaricious clinic, I was ridicuously obsessing over the patients I had left behind, especially the complicated and chronic-care ones….. that I even considered apologising for resigning and asking for my job back! My husband called it the medical version of the Stockhom effect, haha! Thankfully i have now moved on and am working at a great practice now.

    But yes, I still have my 10 pet peeves list, almost identical to yours (!!!). But whenever I reflect on it, and consider the life of a corporate exec, or even taking some time out and being a full-time mum for a while… I know I would never be able to turn the doctoring part of me off. I’m convinced it becomes engrained into the fabric of our identities. Once a doctor, always a doctor 🙂

  8. I am so burned out for the very same reasons. It’s sad that I actually contemplate going back to work for Walmart instead of doing what I used to love. I will be closely watching your direct care access model over the next year.

  9. Dr. Rob,
    I am a second year medical student in Oregon and am currently working with a classmate to bring some of the issues you discuss to light at our school and in our community, early and often. I want you to know that these blogs are incredibly inspiring to me, which is surprising even to myself considering that I’m entering a field full of burn-out, suicide, stress, pressure, etc. However, I am young and idealistic and still very excited to save the world (or at least make a positive difference in the lives of my patients). Your blog inspires me because it proves there are doctors out there still who are not so jaded they forget to think about their patients’ emotional and spiritual well-beings… or their own. I am lucky enough to be entering a changing field – a work in progress that is bettered by “drop-outs” like you. We need more transparency surrounding the discontent that is rampant in healthcare – it encourages incoming physicians to educate themselves and really evaluate now what they want for their careers. Please: continue to write, continue to dissent, continue to find creative solutions. You are helping more than your patients.

  10. Thank you. One of the best things about being a doctor is that I do get encouraged by people far more than most professions. Comments like yours are encouraging to me both as a writer and as a physician trying to do something about a broken situation. I do hope things are vastly different (in a good way) when you get out of your training. Do I recommend this job? For people like me and, I suspect, you, there is no other choice worth considering.

  11. I disagree, of course. The job is incredibly rewarding and fits my own skills like none other could. It’s the business part that got me down, and I am changing that.

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