"Ready for dinner"
I’m tired. Really tired. I’ve been seeing patients continuously — one every 15 minutes — for five and sometimes six days a week. The pace is nothing new for me or most primary care doctors. But lately it all feels like a game of Jenga, with patients stacked on top of one another like wooden blocks, ready to come tumbling down.
Sometimes their issues (actually, it’s usually their parents’ issues, since I’m a pediatrician) are straightforward: “He needs a sports physical today or coach won’t let him practice” (even though they had all summer to get it done). And sometimes they’re not: A 4-month-old child is dying from liver failure and desperately needs an organ transplant. But for parents, nothing is mundane, and so I work hard to keep my game face on: Be patient, listen, explain and be prompt and careful in my care.
Like I said, none of this is new. But what’s been different in recent weeks is that all it takes is one irritating parent, one surprise patient, to throw me, to bring down my whole day like those Jenga blocks. I get grouchy and impatient. I’m curt with parents and drag my feet returning phone calls and e-mails to them. And when I do contact them, I know I’m less affable than my usual self.
Sometimes I hit a point where I don’t want to have anything to do with work. I’ll be the last in the office and the first out, leaving charts undone, messages unreturned. And if patients are late, too bad, I’m gone, and they better reschedule or hit the E.R.
Experts define burnout as a combination of emotional exhaustion, depersonalization and feelings of diminished personal accomplishment. This is not unique to doctors. People from all walks of life burn the candle at both ends. But when doctors reach the end of their wick it can have a direct and serious impact on patients.
Neha Sangwan, CEO of the health strategy company Intuitive Intelligence, and a physician herself, best describes the mentality of doctors. “Our training teaches us to override the early warning signals coming from our bodies,” she says. “The mantra of survival that proved beneficial in residency, ‘Eat when you can, sleep when you can, pee when you can,’ slowly erodes at us once we’re in practice. We’re schooled in a culture that values placing our patients before ourselves. We are rewarded culturally by becoming superheroes in crisis, rather than for care and balance in our own lives.”
This is an intense and unpredictable job. From sore throats to gunshot wounds, it’s impossible to know who or what’s coming next. This natural unpredictability often conflicts with our personal lives. Physician and writer Atul Gawande put it best in an essay he wrote several years ago for his book “Complications: A Surgeon’s Notes on an Imperfect Science. ” “Medicine requires the fortitude to take what comes: your schedule may be packed, the hour late, your child waiting for you to pick him up after swimming practice; but if a problem arises you have to do what is necessary.”
Modern healthcare has also contributed to physician burnout. Over the past 30 years, medicine has evolved from a profession where a newly trained doctor could hang a shingle and guarantee his or her future to a highly competitive industry where financial stability and autonomy are less certain. A generation ago, doctors were accountable only to their patients. Now we need to answer to insurance representatives and hospital administrators, many of whom have no direct experience in healthcare but hold power over budgets and reimbursements. It’s that lack of control that has frustrated many doctors and Annals of Internal Medicine left them feeling pessimistic about the future of healthcare.
Burnout has led to depression, substance abuse and suicide among doctors. Those are tragic outcomes, but they’re not limited, of course, to healthcare professionals. What’s worrisome is that burned-out doctors feel and behave very differently toward their patients. A 2002 survey of medical residents showed that 61 percent reported feeling more cynical, 25 percent less humanistic, and 33 percent averse to patients as their year progressed. Such attitudes naturally lead to impatience and insensitivity toward patients.
Worse, studies of residents show that burnout leads to suboptimal care. They reveal that exhausted doctors can be careless in their actions and attitudes, and are likely to commit medication errors. In attending physicians, research into burnout and patient outcomes is sparse. One study, published last January, showed that burned-out doctors had less satisfied patients (probably not that surprising), and that their patients had longer recovery times from their illnesses.
Finally, burnout affects the entire healthcare system. Satisfied doctors are more productive, enhance recruitment of doctors and utilize healthcare resources better. Burned-out doctors call in sick more often, leaving inconvenienced patients, colleagues having to absorb more responsibility, and lost revenue. Physician burnout has not been ignored by the medical community. But like so many issues in modern medicine, it doesn’t get addressed soon enough. Most medical students are quick to adopt the “work hard, play harder” mentality. There’s not a party where the alcohol doesn’t run dry: Binge drinking between exams is a common coping mechanism.
In recent years, wellness groups have sprung up to support doctors struggling with burnout. Dr. Sangwan has been running some herself, having worked with hundreds of physicians (including my wife and me). “The most important thing is getting physicians to shift their thinking to the importance of their own self-care,” she says. Her programs involve teaching physicians about how to meditate, relax, eat better and manage conflicts they may have with colleagues and patients.
That’s important, but many doctors also want more pragmatic solutions. To get there, many of us have begun setting limits. More doctors are turning off their beepers and having nurse triage centers take night calls to handle the many mundane and unnecessary questions that traditionally keep us up at all hours. Now, if you do call, you might be charged a fee. Many doctors have also transferred inpatient care to hospital-based specialists. This eliminates time spent making rounds before and after office hours, a move that has helped decompress the workday. A recent study has shown that these kinds of solutions are indeed giving doctors a much-needed rest themselves, which can only lead to better patient care.
For me, there’s a light at the end of my most recent tunnel. This past weekend, my daughter, 6 months old, started sleeping through the night by herself. My wife and I have scheduled some vacation time together in the fall, and as the hectic, grinding pace of summer checkups winds down, there’s often a lull in pediatric care between the start of school and flu season. My most ill patient, that 4-month-old boy with liver failure, received a transplant and is doing well. Since, as one doctor recently said, “‘First, Do No Harm’ starts with oneself,” I’m going to watch a movie and hope to fall asleep while I’m at it.
More Rahul K. Parikh.