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Lifestyles: Say
Goodbye to Burnout
Feeling stressed out? Disillusioned?
Maybe even depressed? You're not alone. And there's
help.
By Shirley
Grace
Can you imagine
practicing as part of a coequal “team” that includes
orderlies and nurses? Where your treatment orders are
relegated to suggestions? Where if you object to a lack
of follow-through you’re asked why you even
care?
And yet, despite all this, you’re still
responsible for patient outcomes?
This is
exactly where psychiatrist Jay Bauer (not his real name)
found himself at a North Carolina hospital from 2000 to
2003. “The doctor has to take all the medical and legal
responsibility, and he’s responsible for how everyone
else performs their jobs, with no authority,” he says.
“I felt like I couldn’t tell them what to do without
getting into trouble. It was an awful trap.”
So
awful, in fact, that he quit — but not before developing
non-Hodgkin’s lymphoma and other serious health problems
that have kept him from practicing to this day.
Extreme? Maybe. But hardly unheard of.
John-Henry Pfifferling, who has counseled hundreds of
burned-out physicians as the founder and director of the
Center for Professional Well-Being, estimates that “80
percent of doctors will go through the burnout process
at some point in their careers.”
But it doesn’t
have to be this way. You can protect yourself. Know the
facts and learn the skills before you begin to wonder if
you still love being a physician.
At
risk, right from the start
As a
physician, you’re more likely than most to have
personality traits that put you at greater risk for
burning out, even as they may make you a better doctor.
Among these:
Idealism — For
most, the decision to become a physician is more of a
calling, based on a strong desire to help people, than a
career choice. “Idealism brings you to caring, and then
you want to achieve all the academic accomplishments,”
says Pfifferling. Unfortunately, many new doctors are
unprepared for the realities of practicing medicine in
the United States.
Perfectionism
— As a doctor, you are inclined to be a
perfectionist — for obvious reasons. Yet this tends to
make you extremely self-critical. In short, good enough
is just not good enough. “We keep trying to emulate an
impossible role,” says Pfifferling. Gynecologist James
Haley of Acworth, Ga., concurs. Having suffered through
his own burnout last year, Haley says his quest for
perfection is the norm among his peers. “There are few
physicians I know that don’t shoot for perfection in
what they do,” he says. “They expect it of themselves
and so does the general public.”
Independence — Physicians tend
to reject offers of support, often feeling they must
project an image of strength and infallibility, says
Pfifferling. “If we show any need for help, then we’re
not good doctors.”
People-pleasing
— An inability to say no is prevalent in
physicians, particularly those in primary care. The
result? You quickly become overburdened and overworked.
Work/life imbalance — The
sustained pressure of practicing medicine often
monopolizes a physician’s attention, leading to a skewed
view of success by confusing professional and personal
achievements. This results in a psychological phenomenon
known as enantiadromia — a sudden, extreme
transformation into an opposite state; in this case,
passion becomes burnout. Swiss psychiatrist Carl Jung
refers to this as “life’s contradictions” — love vs.
hate or thinking vs. feeling. Failing to honor opposite
aspects to being human puts a person at serious risk of
imbalance.
Emotional detachment
— Dealing with suffering and death is a reality
of practicing medicine. Many physicians mistakenly feel
they must distance themselves from their emotions and
always be strong for others. This is unhealthy. “You’re
not supposed to get out of medical school with your
feelings intact,” says family physician Pamela Wible of
Salem, Ore.
“Pedestal-itis” —
Pfifferling concocted this term to describe a common
physician mindset. “They get told, ‘You’re special’ from
pre-med on,” he explains. This ego-stroking is
necessary, as the student can draw strength from the
knowledge that he’s got the chutzpah to make it through
his education, but also debilitating, because requesting
help becomes beyond embarrassing.
Encroaching flames
Other factors that can contribute to burnout
include:
Work stressors — Most
physicians in private practice are working in
volume-based environments, running a daily hamster wheel
of patient encounters to meet revenue demands. Wible,
who set up an atypical solo practice after suffering
serious burnout in 2005, knows how dehumanizing this
scenario can be. She recalls a colleague’s sadly amusing
response to a patient who was miffed at having to remind
the doctor why she was there for a follow-up visit:
“Honey, I’ve seen 2,000 patients since I saw you last. I
can’t remember your name.”
Physical
exhaustion — “When they give all day long, they
get drained,” Pfifferling says. “I was just talking to a
cardiovascular surgeon who’d just done four surgeries
that day — two emergency and two scheduled. He’s very
concerned about the life on that table. When he gets
home, he’s bone-tired, and he may be on call that
night.”
Attending hospital physicians are
particularly at risk for this. Since 2003, residents are
legally prohibited from working more than 80 hours per
week. Yet a survey released by Academic
Medicine in December 2006 shows the unintended
consequence of this restriction: half of attending
physicians are now logging more hours because residents
must clock out when they hit the 80-hour limit. “The
attending doctor is stretched like a rubber band, ready
to break,” says Pfifferling.
Asymmetrical work relationships
— Because medicine is fraught with risk, most
physicians give their patients their full effort. But
like a car slowly leaking oil, your intellectual,
emotional, and physical engine will eventually seize,
and you will have no more to give, unless you are
occasionally replenished.
Information
and cognitive overload — An unrelenting flood
of new clinical and practice management information
inundates you every single day. Overwhelming, to be
sure. Physicians are “supposed to synthesize all this,
and keep up with whatever’s considered cutting edge at
that time,” says Pfifferling. “In the smallest
specialties there are 20 journals. How do you keep up?”
Litigation stress — The average
malpractice suit takes three to nine years to resolve.
And although the chances of a plaintiff winning the suit
is about half that of all other tort cases, the awards
are 16 times higher, averaging about half a million.
Notably, 25 percent of all U.S. doctors get sued
annually; 65 percent will face some sort of malpractice
lawsuit during their careers. Fear of malpractice
partially determined Haley’s decision to bail out of
obstetrics altogether; he now focuses only on
gynecology.
Financial pressure
— Physicians “are the only organization that
cannot by law collectively meet, bargain, and represent
ourselves to protect our rapidly declining
reimbursements,” Haley laments in a recent letter to
Physicians Practice editors. “Insurance
companies have known this for years, and have
continually used it against us with little means of any
recourse on our part. … [Physicians] never thought there
would be such a concern about our financial futures as
it has become.”
The feminine unique
Do women and men experience burnout
differently? Wible thinks so. And studies suggest she
may be right. Wible maintains that the path for a woman
physician differs from that of a man because, generally
speaking, women react to the world in fundamentally
different ways. “Men are really good at turning
[practicing] into a game,” she says. “How many patients
did you see today?”
But women “like to
hang out with their patients more. Call it touchy-feely
or whatever you want, but it’s looked down on in the
medical culture,” she says.
“Minimizing Error,
Maximizing Outcomes,” a three-year study sponsored by
the National Institute of Child Health and Human
Development, shows that female doctors tend to have
patient panels that contain more complex cases, and many
more publicly insured or uninsured patients than male
physicians. Also, female doctors want to spend more time
with their patients. They often find themselves at odds
with the values of the practice in which they work.
“Working in a high-volume atmosphere takes its
toll on women more than men,” says Wible. “It makes it
hard to balance their home and work. Women reach the
empathy burnout stage. They have one foot on either side
of the door. They’re trying to live with their
instincts, and it doesn’t work.”
Burnout
fallout
How do you know when you’re
burning out? You might “act out” by becoming abrasive
with staff and patients or by demonstrating aggressive
anger and rudeness. Or maybe you “act in” with
depression, pessimism, and brooding.
Tragically,
some physicians respond in the most self-destructive
manner possible. As early as 1858, British researchers
noted a higher suicide rate among physicians, compared
to the rest of the population. This holds alarmingly
true today. Male physicians are 70 percent more likely
than other men to kill themselves. For women doctors,
the risk is even greater: the suicide rate is 250
percent to 400 percent higher than that of other women.
(One possible reason for this, among others, is that
physicians’ medical expertise makes them more likely to
succeed.)
More commonly, desperately
stressed-out docs quit medicine or fantasize about
quitting. “I was contemplating going down and getting a
job as a waitress,” recalls Wible. Haley says that had
there been some other field he could’ve switched to that
would allow him to maintain his standard of living when
he was burned out, he may have left.
A
physician in need
But most, it seems,
simply live their lives in quiet desperation. In
December, the American College of Physician Executives
(ACPE) released the results of its survey of 1,200
physicians on their perceptions of physician morale.
Respondents readily admitted to experiencing fatigue
(77.4 percent) and emotional burnout (66.7 percent).
Indeed, six in 10 said they had considered leaving
medicine.
But only about a third acknowledged
experiencing family discord or depression, and fewer
than 5 percent of docs confessed to having had suicidal
thoughts or to abusing drugs or alcohol.
Our
hunch is that these latter figures are higher in reality
than in the ACPE’s survey. But who could blame
physicians for their reluctance to admit they’re deeply
troubled? What doctor, held to a nearly unattainable
standard, would admit she’d turned to four double
scotches (or worse) every night to ease the stressball
in her gut? Not many, especially since license renewal
can come into question for a physician who has sought
treatment for substance abuse or a mental illness, to
say nothing of the professional stigma (and potential
legal consequences) if such treatment, or even the
admission of a past problem, should become public.
The ACPE survey reflects another reason to
believe physician morale is even lower than most doctors
will admit: Respondents were much more likely to suspect
serious problems in their colleagues than to acknowledge
the same problem in themselves. More than 35 percent
suspected peers of substance abuse, for example, but
only 2.9 percent would come clean about their own
problems. In actuality, physicians may not see the
reality in either themselves or others. The real figures
likely fall somewhere in between.
Re-lighting
the fire
Pfifferling insists that there
is hope and help. Much of it comes from within. Here’s
what to do if you’re feeling burned out:
Talk about it. Only one-third
of you share your feelings with other doctors, reports
the ACPE survey; that’s not enough. Do it for your own
good, and that of your patients.
Take
care of your health. Paradoxically, doctors
tend to skip routine healthcare for themselves. About
one-third of physicians have no regular source of care,
states the AMA. Also, most believe that good or bad
health is largely up to chance — fatalism that flies in
the face of preventive health measures. This
laissez-faire perspective causes many
physicians to skip screenings for breast, colon, and
prostate cancer, and many don’t bother to get flu
vaccines. Take time to take care of yourself, but not by
yourself. Doctor, see your doctor.
Get a
hobby. Way back before you became a doctor,
what did you like to do? Sports? Art? Globe-trotting?
Are these still of interest? Whatever “it” is, do it,
and do it regularly.
Educate yourself
about yourself. Yes, you are certainly
well-educated medically, but that’s a pretty narrow
focus. Take some time to learn what’s available to help
you learn about yourself. A seminar. A good self-help
book. Tivo Dr. Phil if that’s what you’d like. But get
inside your own head a little bit.
Gigi Hirsch,
CEO of MD Intellinet, a career-counseling firm for
physicians, says doctors fall into four types:
1. Narrow and deep — Follows a
specific interest (typical of professors);
2. Linear — Wants to rise
through management hierarchy (medical directors);
3. Spiral — Tends to broaden a
sphere of influence (policymakers, advocates); and
4. Transitory — Needs to change
environments regularly (consultants, entrepreneurs).
Which are you? Maybe you’re a composite. That’s
fine, too — it just means you’re an individual, so
celebrate that. In any event, understanding your type
can help clarify your own desires. Hopefully, that can
help you develop a model for your career that’s based on
your true needs, even if it means following an
unconventional path.
Determine a
practice style that works for you. Only you
will truly know what you can handle. Determine what that
is, and stick to it. And there’s no need to be Superman
or Wonder Woman. Say “no” when demands compromise your
plan. Wible tried five or six different practices before
striking out on her own. “They all had their own
dysfunctions. It became clear to me I had to create my
own solution,” she says.
Haley’s burnout
flashpoint last year made him realize he needed to
jettison the stress of doing obstetrics. “I really
wanted to get back to giving women the care they want
and I know they were missing,” he says. “I’ve been open
about nine months. The joy of running a practice has
returned.”
Through his transition, Haley learned
that, for him, nurturing his spiritual self provided a
great deal of comfort. “I just trust God and put it in
his hands,” he says. “That’s how I practice.”
Renew yourself daily. If you’re
running on fumes halfway through the day, how can you
give your patients what they need? Take a few minutes to
recenter yourself, as often as you need it, in a way
that works for you. Meditate. Eat something. Breathe
deeply. Whatever. Just do it. Yes, there’s paperwork to
complete and phone calls to return, and patients to see,
but if you don’t screw your brain back on straight,
you’ll just waste time trying to work while hobbled.
Support others. One of the best
ways to ensure you’re not alone in the world is to reach
out to others. Get involved with a physician support
group, or start your own, even if it’s with just one
friend or associate. Ask for and give clear, honest
feedback. Remember, within every criticism lies a
greater truth. Consider what is being said to you before
reacting emotionally. What can you learn from it? “We
don’t always have to put on the façade that we’re
perfect,” says Pfifferling.
Can you
recover?
Absolutely. Wible’s story
bears testament. In 2005 her world spiraled into what
could’ve been inspiration for a country music ballad: “I
went into this huge depression. I was in bed for about
two months after I left my last job. Then my dog died. I
was in a very negative place.”
Wible felt better
after dragging herself to a self-help seminar, where
“just one weekend of being in a supportive atmosphere
was able to turn the tide of being in 12 years of an
abusive one.”
A few weeks later she decided to
open a different kind of clinic, one she says gathers
the community together and that better reflects her
values and work style. Everything fell into place. “It
was all so effortless,” she says. Haley’s practice model
remained the same, but pared down the scope to what he
really wanted. Bauer says he will be investigating
alternative therapies, overhauling his philosophies on
food, supplements, and such.
“Some can grin and
bear it and turn [practicing medicine] into a scheme,
but it really erodes our humanity. And I don’t think
that’s in alignment with anyone’s value system. When
someone thinks and lives within their values, it all
works. When you’re out of alignment, that’s when the
burnout happens,” says Wible. Do what works for you, she
says, because “really, this is a sacred honor to be able
to practice.”
Shirley Grace, senior writer
for Physicians Practice, holds an MA in
nonfiction writing from The Johns Hopkins University.
Her articles have appeared in numerous publications,
including The Washington Post and Notre
Dame Business magazine. She can be reached at sgrace@physicianspractice.com.
This article originally appeared in the May
2007 issue of Physicians
Practice.
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| Reprinted with permission from Physicians Practice®, America's Leading Practice Management Journal. Copyright © 2007 Physicians Practice. All rights reserved. Republication or redistribution of Physicians Practice content, including by framing, is prohibited without prior written consent. Physicians Practice shall not be liable for any errors or delays in the content, or for any actions taken in reliance thereon. Questions? Call toll-free 800 781 2211 or e-mail info@physicianspractice.com. For more practice management advice and tools, visit www.PhysiciansPractice.com. |
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