Clinician burnout: A hot topic

Lately, clinician burnout has become a hot topic.

Judging by the speed at which Shanafelt et. al.’s study “Burnout and Satisfaction With Work-Life Balance Among US Physicians Relative to the General US Population” has seared through cyberspace, the problem of professional burnout seems to be resonating with large numbers of practicing clinicians, especially those who work in the front lines of primary care medicine.

Why the surge in interest? Because the problem appears to be widespread, perhaps much more so than anyone in the business of medicine realized. And it seems to be most prevalent in specialties involving front line access to care.

Compared with a cohort of 3,442 US adult workers, doctors were more likely to manifest symptoms of burnout and to express dissatisfaction with work-life balance.

Professional burnout negatively influences the quality of medical care and increases the likelihood for medical errors. On a personal level burnout contributes to severed relationships, alcohol abuse and thoughts of suicide. And burned out clinicians are more likely to opt for early retirement.

In a career path that has the potential for meaningful and fulfilling work, why do nearly half of all clinicians report symptoms of burnout? Has this always been the case among medical professionals, or are these latest data straws in the wind?

Perhaps a relative loss of autonomy might be a contributing factor. Fifty years ago most physicians set up private solo practices. As individual entrepreneurs, they set their own hours, charged their own fees and took no orders from third-party payers. All that has changed dramatically. Nowadays, the majority of physicians work as employees in hospitals, clinics or large group practices. Administrators determine their salaries, daily patient load, hours worked, benefits accrued. In short, modern clinicians have experienced a loss of autonomy, a factor which contributes to lack of work satisfaction.

But there might be more to it than that.

Physicians are highly educated workers. Yet compared with high school graduates, individuals with an MD or DO degree have a greater risk for burnout. Interestingly, individuals possessing undergraduate or graduate degrees (including doctorates) other than an MD or DO degree are at lower risk for burnout. Perhaps the relative lack of respect afforded to doctors as a group by society at large might be a contributing factor.

(Lest you think this observation a bit far-fetched, in my defense I offer a bumper sticker which I chanced to encounter just the other day: “Be Kind to a Nurse: After all, someone has to intervene on your behalf to make sure doctors don’t kill you!”)

Most highly educated professionals are not employees in a service-based industry. Clinicians work in stressful environments, caring for folks who are vulnerable, sick and depressed. When problems arise (as they inevitably do), doctors are expected to take things in stride and roll with the punches. Many times they find themselves in precarious situations where the likelihood of getting sued is high. I don’t imagine that tenured university professors fall into the same category.

A more important question is how to deal with the problem of physician burnout. After all, the healthcare system itself stands to suffer immensely with the loss of significant numbers of practicing clinicians already in short supply.

Dr Richard Gunderman offers some wise words to this end:

Only by keeping what matters most at the forefront can we reap a full harvest of professional fulfillment. Burnout is not a disease. It is a symptom. To combat it, we must focus primarily on what underlies it. And here the key is not eradicating the disease but promoting professional wholeness, which flows from a full understanding of the real sources of fulfillment.

In Dr Gunderman’s words: “Medicine represents one of life’s greatest opportunities to become fully human through service to others.”

On that score I think that William Osler and Albert Schweitzer would agree.

Albert Schweitzer in Aspen, Colorado (Life Magazine)

Facing our mistakes

Nowadays, the popular press focuses on medical errors from the perspective of the patient.  Pick up any current patient-focused periodical and you’re apt to find a Doctor So-and-so did me wrong article.  Many times the patient has a valid gripe.

In his recent TED talk Doctors make mistakes: Can we talk about that?, Canadian physician Brian Goldman offers a viewpoint from the opposite camp: How do clinicians react when confronted with the oft-times detrimental effects of errors in clinical judgement?

We know that Sir William Osler made at least one attempt to address this issue head on when he called his residents to the morgue to witness his error in diagnosis.

“Once in a ward class there was a big colored man whom he demonstrated as showing all the classical symptoms of croupous pneumonia. The man came to autopsy later. He had no pneumonia, but a chest full of fluid. Dr. Osler seemed delighted, sent especially for all those in his ward class, showed them what a mistake he had made, how it might have been avoided and how careful they should be not to repeat it. In 30 years of practice since then…I remember that case.”

Over the course of my career I’ve tried to get at such issues by writing about them. I recall one of my early pieces published in the premier issue of Dermanities, Abdominal Pain. Although revisiting it still leaves me feeling a bit queasy, it offers a lesson that I shall never forget.  Or in Doctor Goldman’s words, “Yes, I remember…”

Facing our mistakes is one of the most effective tools that we clinicians have to improve our clinical diagnostic acumen. What a pity that more of us don’t take advantage of it.

Impressionistic Medicine

The Danish impressionistic artist Camille Pissarro lived most of his adult life in France. During his long tenure as a painter, Pissarro gleaned much from Corot, Courbet and Jean-François Millet, forerunners of the Impressionist school. Many other artists worked under his tutelage, Gauguin, Cezanne, and Seurat among them. Eventually, Pissarro came to be regarded as the father of French Impressionism, the only artist to exhibit his work in all seven Impressionistic salons over the last quarter of the 19th century.

More than a mere painter, Pissarro was an anarchist, whose radically egalitarian views found their way into his work. For his subjects Pissarro chose rural peasants, depicting them at work in the fields, as domestic servants, as buyers and sellers in the market place.

In the 1880s, Pissarro assembled a portfolio of 30 pen and ink sketches rendering the horrors of urban capitalism entitled “Turpitudes Sociales” (“Social Disgraces”). He used his art to draw public attention to the injustices inherent in what he saw as an unethical and immoral social order of his day.

Throughout his life Pissarro envisioned a kinder, gentler society, one where people have what they need in order to live a good life — and no more. He put his ethics into practice, opening his home to all visitors, including young hungry artists.

One could not wander through the recent Clark Institute’s Pissarro’s People exhibit without admiring the canvases depicting bucolic scenes peopled with peasants engaged in work and talk. Pissarro’s vision becomes contagious to a visitor immersed in such beauty and grace.

While standing in front of one of his portraits, I — as a practitioner of another form of art, the art of medicine — could not help but think that we clinicians are called to view those patients entrusted to our care as equals in the sense of their humanity, their needs and wants.

Osler summed it up when he wrote: “Dealing as we do with poor suffering humanity, we see the man unmasked, exposed to all the frailties and weaknesses, and you have to keep your heart soft and tender lest you have too great a contempt for your fellow creatures.”

I have learned much from looking at the world through Pissarro’s eyes. Collectively, his canvasses could be considered windows through which one glimpses the art of impressionistic medicine.

Minimal Medicine

Sometimes I wonder whether we as a society have not over-medicalized life. We spend so much of our time browsing health columns, monitoring vital signs, ruminating on our symptoms, consulting our doctors. Many of us have become so health conscious that we balk at deviating from the straight and narrow path. When it comes to our health, we have become risk averse.

Even those of us who spend their days in clinical practice recognize that medicine does not encompass all of life.

Perhaps we need to learn to practice minimal medicine.

These thoughts ran through my head as I read Mark Bittman’s final NYT Minimalist culinary column. Over a span of thirteen years Bittman authored nearly 700 weekly columns for the NYT Dining section. As it turns out, the culinary arts share a good deal with medical practice.

“I discovered that you never cook with someone else without learning something,” Bittman writes. “In every case, there’s a two-way transfer of knowledge. If they know less than you do, you grow from teaching. If more, of course, you grow from learning.”

Bittman’s words bring to mind Sir William Osler’s description of medical teacher and student: “the pupil and the teacher working together on the same lines, only one a little ahead of the other. This is the ideal toward which we should move.” After 25 years of practice, Osler observed, “I have learned … to be a better student, and to be ready to say to my fellow students, ‘I do not know’.”

Osler reckoned that “no man can teach successfully who is not at the same time a student.”

Here’s Bittman musing again: “Usually, I was either taught to make something or I modeled it myself, as best I could. I refused to buy into the notion that there was a ‘correct’ way to prepare a given dish; rather, I tried to understand its spirit and duplicate that, no matter where I was cooking.”

Osler advocated that “the practical shall take the place of didactic teaching.” To acquire the skills necessary to perform medical procedures, students are encouraged to “see one, do one, teach one.” In 1867 the physician Oliver Wendell Holmes argued that the “most essential part of a student’s instruction is obtained … not in the lecture-room, but at the bedside.”

Bittman maintains that, “as Jacques Pépin once said to me, you never cook a recipe the same way twice, even if you try.”

How true. And you never perform a physical examination or surgical procedure in exactly the same way. There are always confounding factors which necessitate workarounds and thinking outside the box.

Medical practice, like cooking, is always a compromise. Like their culinary counterparts, clinicians “almost never have the time, the ideal ingredients or equipment, or all of the skills we’d like.”

“Shop avidly, keep a full refrigerator and pantry,” Bittman advises; “pull things out and get to work.”

Where would the good clinician be without a well-stocked surgery?

“My growing conviction that the meat-heavy American diet and our increasing dependence on prepared and processed foods is detrimental not only to our personal health but to that of the planet has had an impact on my life.”

A nutshell of sound dietary advice, one every practicing clinician should take to heart.

Bittman concludes: “What I see as the continuing attack on good, sound eating and traditional farming in the United States is a political issue.”

What I see as the continuing attack on good sound traditional medical practice has lately become a political issue as well.

The way we practice now

According to current theory, people with ADHD have a relative deficiency of dopamine, an essential neurotransmitter in the brain.  Adequate levels of dopamine are necessary to induce incentive and motivation.  Stimulant medications boost dopamine levels and enhance the ability to stay focused on task.

But in our modern psychopharmacological approach to the treatment of ADHD we have all but forgotten the environment.  more»

The Poetry of the Commonplace

In her recent New York Times column, Compelling Stories, If Not Literature, Dr. Abigail Zuger bemoans the recent outpouring of health-related memoirs. “Few of these efforts rise to the level of great literature,” she writes. “None of these books comes close to succeeding according to the usual standards. The language is clumsy and full of clichés; the dialogue is stiff and unreal; the pacing is way off.”

Dr. Zuger also has something to say about doctors who have taken to writing their own stories: “the great majority are sentimental and predictable, and a few manage to be as pedantic, self-important and annoying as, one ventures, their authors must be in person.” Her conclusion? “Most of these books aren’t great literature either.”

Still, Dr. Zuger confides, she has a soft spot in her heart for such books. In the face of all of her prior criticism, you have to ask yourself why. Is Dr. Zuger merely being sentimental? Or does she identify with the sentiments of her patients and colleagues?

In my opinion, what Dr. Zuger fails to recognize is that the patient’s story, no matter how ineptly told, becomes an integral part of the healing process itself.

Medicine’s great 19th century humanitarian physician William Osler remarked that, dealing as he does with poor suffering humanity, a good doctor has to keep his heart soft and tender, lest he develop too great a contempt for his fellow creatures. Osler reflects on what he terms “the poetry of the commonplace”—the ordinary man, the plain, toil-worn woman, their love and their joys, their sorrow and their griefs.

According to Osler, such tales serve to sustain the weary-worn clinician in his daily work. They also serve to sharpen his compassion for his fellow creatures.

My collection of clinical tales in the art of medicine, Patients Are a Virtue, might not be great literature. Few practicing clinicians and fewer patients will ever read it. Most likely it will eventually be relegated to the dustbin of narrative medical writing. And yet I take heart when I receive that occasional communication from cyberspace, such as a brief e-mail from a doctor in rural western Pennsylvania, who wrote that, after reading my book, he felt energized and renewed in his commitment to his patients. He felt so strongly about it that he purchased additional copies for his colleagues and encouraged them read it as well.

Is every patient and practitioner a poet? Dr. Zuger asks. In his consideration of the poetry of the commonplace, I believe that Dr. Osler would answer her rhetorical question in the affirmative.

The Anatomy of Love

 

“So, how did you meet your wife anyway?”

 

“She was my partner at anatomy lab in medical school.”

 

My friend—an orthopedic surgeon—and I compared notes during a recent undergraduate school reunion.  Three decades is a long time; we had some catching up to do, but we were in no hurry.

 

This is the second instance where I’ve heard a physician comment that he’d met his wife in the anatomy lab at medical school.  The other doctor—a psychiatrist—had morphed into a poet over the course of his career.  One of the pieces that he read from his book mentioned the initial meeting:  an anatomy of love, blossoming in the dissecting room.

 

No matter how scientific our bent, as humans we still gravitate toward our humanity.  We might not be looking for it at the time, but we find love in the most unexpected places.

 

Last fall I traveled to Montreal to speak at a conference hosted at the William Osler Library of the History of Medicine on the campus of McGill University.  That afternoon the librarian in residence escorted our small group into the inner sanctum of the complex:  the room which houses Osler’s personal medical library of 8,000 volumes and several of his personal effects, his ashes among them.

 

The librarian spoke about Osler’s life, offering a series of anecdotal tales of poignant turning points in the great physician’s career.  After completing his academic studies, Osler entered medical practice as both a clinician and teacher.  While serving on the medical faculty at Johns Hopkins Hospital in Baltimore, Osler began work on his massive text “The Principles and Practice of Medicine.”  During this time he also started a courtship with Grace Revere Gross, the widow of Dr. Samuel W. Gross.  Osler had known the Grosses during his former five-year sojourn at the University of Pennsylvania in Philadelphia.

 

Osler was keen to marry, but the widow Gross insisted that he finish his book first.  Osler labored long hours to prepare the work for publication.  He inscribed the first copy to the widow and placed it in her hands with a proposal of marriage.  True to her word, she accepted both the book and Osler’s offer.

 

This was one instance where a great man of medicine first wrote the book that defined clinical practice before moving on to study Gross anatomy:  the anatomy of love.  Only this time it was outside the confines of the dissecting room.

Teaching and Thinking

Common sense in matters medical is rare, and is usually in inverse ratio to the degree of education. —Sir William Osler

Today’s New York Times (13 June 2007) carries an op-ed piece about a conflict of interest that those of us who practice medicine face daily, namely the overwhelming influence that the pharmaceutical industry brings to bear on our prescribing habits.

This comes on the heels of two other recent articles exposing the huge profit some oncologists make by routinely prescribing chemotherapy to some patients despite documented lack of effectiveness.

Much more than mere pillow talk these days, drug companies actually underwrite the cost of much of our continuing medical education. In the past they wined and dined doctors to influence prescribing habits. Nowadays, they underwrite the research that supports the use of their particular drugs, then buy contracted physicians to peddle their influence through continuing medical education materials and seminars.

If that were not egregious enough, the pharmaceutical industry has taken things one step further: they actually define illnesses or disease states to market their drugs more effectively. No where has this been more blatant lately than in the realm of psychotropic drugs. For example, what we used to call shyness is now labeled social phobia, in large part because there is a drug with an indication to treat it: Paxil.

It has come to the point that drug companies dictate so much of a physician’s education from the outset that they have doctors in their back pocket as loyal prescribers for the duration of their careers.

This flies in the face of Sir William Osler’s late 19th century admonition to physicians to be wary in dealing with powders and potions:

“Man has an inborn craving for medicine. Heroic dosing for several generations has given his tissues a thirst for drugs.…the desire to take medicine is one feature which distinguishes man, the animal, from his fellow creatures. It is really one of the most serious difficulties with which we have to contend. Even in minor ailments, which would yield to dieting or to simple home remedies, the doctor’s visit is not thought to be complete without the prescription.…the temptation is to use medicine on every occasion, and I fear we may return to that state of polypharmacy, the emancipation from which has been the sole gift of Hahnemann and his followers to the race. As the public becomes more enlightened, as we get more sense, dosing will be recognized as a very minor function in the practice of medicine.…” (“Teaching and Thinking,” in Aequanimitas, p. 125)

Again Sir William admonishes us: “The battle against polypharmacy, or the use of a large number of drugs (of the action of which we know little, yet we put them into bodies of the action of which we know less), has not been fought to a finish.” (“Medicine in the 19th Century,” Ibid., p. 255) Indeed not—the fight continues. Our ranks have been infiltrated, and we have sold our license to practice medicine for a price.

Osler’s talks and essays eventually appeared in a single volume, Aequanimitas. In the early decades of the last century, this book was given as a gift to many graduates of medical schools in the United States by none other than—who would have guessed it?—the pharmaceutical giant, Eli Lilly.

Teaching Law, Teaching Medicine

In her guest column in today’s New York Times, A Skull Full of Mush (February 20, 2007), University of Wisconsin law professor Ann Althouse opines that the teaching of “law should connect to the real world.”

“The cases we read for class are always based on factual disputes that arose in real life,” Althouse writes. “I’ve spent the last two weeks teaching cases on standing doctrine, which prevents the courts from articulating the law in the abstract and ties the judicial power to resolving concrete controversies between genuine adversaries. If it’s not real enough, it’s not a case.”

In Althouse’s opinion, law professors show the greatest respect for their students if they “teach them what they came to learn: how to think like lawyers.”

Historically, clinical medicine has always been taught at the bedside, through the cases of individual patients. Sir William Osler thought that the art of medical practice could not be learned otherwise.

In my opinion, reading case studies through illness narratives greatly enhances the student’s intellectual grasp of the patient’s condition—from presenting signs and symptoms to differential diagnoses and response to treatments. If we complement our bedside teaching with the illness narrative, we teach students of medicine what they came to learn: how to think like clinicians.