Search Results for 'Burnout'

A Country Doctor Reads: What if Burnout Is Less About Work and More About Isolation? (NYT)

This weekend I read a piece in The New York Times that put a slightly different slant on what burnout, in the case of physician burnout, is or is caused by. We have heard theories from being asked to do the wrong thing, like data entry, to “moral injury” to my favorite, “burnout skills“, when you keep trying to do the impossible because people praise you when you pull it off.

Tish Harrison Warren’s piece is a dialog between her and psychiatrist/author Curt Thompson. He focuses on isolation as a driver of burnout:

Assume that if you’re burned out, your brain needs the help of another brain. Your brain is not going to be OK until or unless you have the experience and opportunity of being in the presence of someone else who can begin to ask you the kind of questions that will allow you to name the things that you’re experiencing.

The moment that you start to tell your story vulnerably to someone else, and that person meets you with empathy — without trying to fix your loneliness, without trying to fix your shame — your entire body will begin to change. Not all at once. But you feel distinctly different.

I’m not as lonely in that moment because you are with me. And I sense you sensing me. That’s a neural reality.

I have written about burnout many times. The NYT article made me remember that I once also wrote about missing the doctors lounge and how I once tried to start a slack group among my colleagues. It never really took off but I think the point about isolation feeding burnout is very valid. Back when there were doctors lounges, we would talk with colleagues. Even in the office when I started out we scribbled our chart notes very quickly and then we would have time and space to discuss our cases or other things with our colleagues. Now we are tied to the computers, feeding the big machine that controls each of our lives.

As often before, my thoughts go to a James Taylor song, one about working in isolation to feed a big machine – Millworker:

Then it’s me and my machine

For the rest of the morning

For the rest of the afternoon

And the rest of my life

And, later:

And I have been the fool

To let this manufacturer

Use my body for a tool

But, when all is said and done, I am not burned out, as I say in one of my videos. I work at looking beyond my obstacles and I focus on my patient encounters and my curiosity.

But I wish I wasn’t as isolated as I am, in part simply due to the pandemic. I mean, even medical staff meetings are virtual these days. Like Hollywood Squares…

Burnout? Not Even Close!

I am a 68 year old family physician in rural Maine. This morning I read yet another article about physician burnout, this time in The New York Times. (I’m not linking to it, because they have a “paywall”.)

I did not end up exactly where and how I expected to be at the end of my career, or life in general to be brutally honest. But I am the happiest I have been since the beginning of my journey in medicine.

I have a balance in my life I didn’t have, or even seek, for many years as I juggled patient care, administration, raising a family and pursuing interests that often brought me away from home.

My days in the clinic are a bit shorter than they used to be, but in the past several years I have had to do much more work from home – even more so in the last two. The “half-empty glass” way to look at this is that work has intruded more into my personal life and my home. The “half-full” view is that I can do my computer work when it suits me the best. For one of my clinic positions, I can do charting on an iPad mini in bed, coffe on my nightstand and sleeping dogs at my feet. The clumsier EMR requires a laptop (which in my view can’t be used the way its name might suggest) I sometimes work on in the barn and sometimes on a picnic table in the grass outside.

Ironically, the pandemic has brought me a peace and clarity I probably wouldn’t have achieved otherwise.

I had thought moving back to Caribou for a position with no administrative responsibilities would open up social opportunities I hadn’t allowed myself for the last few years. I expected to become involved with the Swedish community here, connecting more with neighbors and other horse owners, and so on.

But the lockdown forced me to sit more with my own thoughts, my own feelings and memories. It forced me to consider, not for the first time but again, that in this unpredictable life, the only sure thing is that I am me and I am where I am.

When I, as many other people, realized that this pandemic could wipe out countless people including myself, and completely change the living conditions for those who survived, it completely freed me from worrying about the small stuff. Or, rather, from considering the small stuff, because I’m not really a worrier. I just used to run a lot of what-if scenarios through my head. I used to be several steps ahead in my mind and have not only Plan B figured out. I would have backups to my backups.

Now I fully accept the unpredictability of life and that has freed up a lot of mental capacity and even time for me.

I have published three books and my blog has continued to grow. At this writing I have posted every single day for the last three weeks. The more I write, the more ideas I have. And my writing is inspired by my engagement with patients and the thinking about medicine they provoke in me. My clinic work informs my writing and my writing makes me a more curious clinician. I go to work thinking “what interesting things will I see today?”

How could I feel burnout when every clinic day is where I go for writing inspiration?

The pandemic has also, ironically, brought me closer to friends and family. Pre-pandemic, I felt too busy to connect, especially in person, never liked to talk on the phone, and I was not into social media. Now I text, call or chat often with my children. I FaceTime biweekly with my exchange student year brother from 50 years ago. I email and chat with cousins in Sweden and some of their children are in my Facebook feeds.

I am also more connected to my home. I take greater joy in doing the little fix-ups. In years past, my home improvements were on a grander scale. Now I do the little, low key things with just as much pride.

I only leave the property to work in my clinic (my second job is via telemedicine from my kitchen island) and to go shopping. The animals thrive on being all together and mild summer nights we all sleep in the barn with the top doors open. I love falling asleep to the sounds of summer, the snoozing of dogs and the chomping of hay.

I am so content with my life as a country doctor.

Burnout? Not Even Close! (video)

Working Too Hard Doesn’t Cause Burnout. Having to Do the Wrong Thing Does

Physicians are generally highly motivated to treat their patients well, both in terms of clinically well and in a nice manner. When they don’t do that, it isn’t usually because of personality disorders or character flaws, but because their jobs are robbing them of their enthusiasm and compassion.

Sometimes it is our own fault that we get burned out. I realized this ten years ago today (!) when I read Claire Burge’s post about burnout skills. We are, by nature and by training, fixers and problem solvers. Because healthcare these days is so dysfunctional, many of us feel like we should be heroes and do “the impossible” in spite of limited time, resources, support and so on. When we do that, we get external praise or praise ourselves, so we end up doing it again. That can be a vicious cycle of always fighting uphills battles, ultimately at our own expense.

But many times, we risk getting burned out even when we aren’t over-capitalizing our heroism. Sometimes the everyday, totally routine tasks put us at risk for burnout. A lot has been written about moral injury in healthcare as a cause for burnout. I agree that can be a dramatic contributing factor sometimes, but I firmly believe the most fundamental cause of burnout is that we, trained clinicians, diagnosticians and decision makers, are put in the position of public health nurses and data entry operators.

This is a terrible waste of a medical education and a sure way to job dissatisfaction and burnout.

It is frustrating for physicians to hear that everyone in their organization except them should work “at the top of their license”.

Think about it:

A patient is due for their ten year colonoscopy recall. The surgical clinic sends an electronic message asking the primary care physician to make a referral so the insurance will pay. It isn’t enough to respond or forward a “MAKE IT SO” command. No, the physician has to create a non-billable encounter, locate the correct diagnosis code for screening for malignant neoplasms of colon, Z12.11, click however many times it then takes to indicate the provider or clinic and send the order off to the referral coordinator.

Or:

A patient comes in for a sore thumb and is behind on all kinds of screenings and chronic care. Instead of devoting the visit to making the correct diagnosis, bacterial paronychia versus herpetic whitlow, and then treating it correctly, the physician is now held personally responsible for catching the patient up on things that could have been figured out and handled by an unlicensed staffer under the supervision of a public health type nurse working with practice wide protocols.

If there were “efficiency experts” analyzing what we do in healthcare, would they really recommend that the people with the highest degree of education do the most basic functions of data entry and checking off health screening protocols?

I find the priorities of modern primary care bewildering. I personally feel less burned out when I double book sick patients or stay late to take care of a complex new patient than when I am put in a position of bookkeeper. If I wanted to be an accountant or a public health nurse, I would have gone to school for that.

The Counterintuitive Concept of Burnout Skills

One of My Burnout Posts on Today’s KevinMD

“In medicine these days, we seem to do more rescuing difficult situations than mastering an art that inspires and rewards us: The very skills that make us good at our jobs can be the ones that make us burn out.

Doctors are so good at solving problems and handling emergencies that we often fall into the trap of doing more and more of that just because we are able to, even though it’s not always the right thing to do – even though it costs us energy and consumes a little bit of life force every time we do it. And it’s not always the case that we are asked to do this. We are pretty good at putting ourselves in such situations because of what we call our work ethic.”

— Read on www.kevinmd.com/blog/2020/08/4-pitfalls-that-run-through-the-minds-and-daily-realities-of-primary-care-doctors.html

Revisiting the Concept of Burnout Skills

I looked at a free book chapter from Harvard Businesses Review today and saw a striking graph illustrating what we’re up against in primary care today and I remembered a post I wrote eight years ago about burnout skills.

Some things we do, some challenges we overcome, energize us or even feed our souls because of how they resonate with our true selves. Think of mastering something like a challenging hobby. We feel how each success or step forward gives us more energy.

Other things we do are more like rescuing a situation that was starting to fall apart and making a heroic effort to set things right. That might feed our ego, but not really our soul, and it can exhaust us if we do this more than once in a very great while.

In medicine these days, we seem to do more rescuing difficult situations than mastering an art that inspires and rewards us: The very skills that make us good at our jobs can be the ones that make us burn out.

Doctors are so good at solving problems and handling emergencies that we often fall into a trap of doing more and more of that just because we are able to, even though it’s not always the right thing to do – even though it costs us energy and consumes a little bit of life force every time we do it. And it’s not always the case that we are asked to do this. We are pretty good at putting ourselves in such situations because of what we call our work ethic.

The Harvard Business Review piece listed four pitfalls and described two types of leaders, which in our case would be clinical leaders: Leader A and Leader B.

Dr. B is a walking recipe for burnout and Dr. A may be the one whose job feeds his soul, at least to some degree (you still have to like people and medicine):

These four pitfalls run through the minds and daily realities of primary care doctors constantly, I dare say:

Just do more: The future reimbursement model is said to be based on value, loosely speaking. But clinics’ quarterly cash flow is largely determined by patient volume. Doctors have patient quotas, and any quality related incentives or requirements are typically tacked on top of the productivity targets without much infrastructure or time set aside for figuring out how to reach those targets in any kind of systematic way.

Just do it now: We certainly are operating in a constant state of emergency to at least some degree. Particularly the addition of quality targets is done in a not very proactive fashion, but much more reactive, with short term “fixes” that tend to be disjointed, as if we are all trying to make improvements to a moving vehicle while also trying to keep an eye on the road.

Just do it myself: Oh, yes, we have all heard about every staff member practicing to the top of their license, but everyone seems so busy, so how many times a day do we think “It’ll take me longer to get this done if I delegate it to someone else, I’ll have to tell them I need this done, how to do it and then – will I trust that it actually got done?”

Just do it later: Sometimes now is the right time, and sometimes later is the right time. But who decides? Physicians tend to put what the HBR calls “value add” work on the back burner, because changing how we work requires detaching from the short sighted thinking of getting through the piecework of the day. We don’t take enough time to think about what we’re doing and why.

Burnout happens when you work hard without seeing real alignment between your efforts and your goals and values, if you get right down to it. I have read and written much lengthier definitions, but the graph in this article made me shorten mine.

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Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.

BOOKS BY HANS DUVEFELT, MD

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