‍How Physician Burnout is Taught in School (part 2 of 2)

December 29, 2019

In my previous article, I talked about how medical school and residency develop and enhance the mindset that increases the risk for physician burnout.  I referred to the process as being W-H-I-P-P-E-D. Now, let’s break down the seven main components.

 

Working Excessively

Graduating from Morehouse College was exciting and scary at the same time because I knew I had to step up my game for medical school at Washington University. Being ranked the #3 medical school at that time would require nothing less than my “A” game. At first, the transition wasn’t too bad because “Wash U” had a simple pass or fail system regarding all of the course the first year. In theory, this should encourage students to work together and support each other, eliminating the cut-throat attitude. And it worked, as I network with various groups, helping each other pass tests and learn the material.

Then came year number two.

Being cut-throat was an understatement. Those who I thought had my back splintered off to form the power groups of the class. They shared resources that no others had, supporting each other all hours of the day and night and making sure they were the best of the best at all costs. Fortunately, I Retained a core group of physicians, who are among my best friends to this day,but it opened my eyes to a new level of competition.  

It was either sink or swim because the same number of students who started year one would not be the same number who graduated. If you didn’t make the cut, you were left behind, naturally forcing you to study harder, worklonger, stay up later.  Now, those who are in medical school have a certain level of discipline and work ethics that get them there in the first place; however, the competitive nature of it kicks it into overdrive.

Fast forward to the burned-out physician who has to meet weekly, monthly, quarterly or yearly quota of patients that need to be seen.Add in all of the extra government regulations that have to be documented to get the proper patient compensation.  Andwhere does this all of this documentation go? It goes into the electronic medical records that can be so complex it can take weeks or months to understand the basics and yes, you have to study in overdrive to learn that as well.

To work excessively is bred within us as a survival factor,from the early days of staying in medical school and maintaining your job,income, and status as a full-time clinician.

Higher Standards of Living

I remember the final months of my residency at Emory University and having conversations with the other seniors in my class. We Dreamed of the life we’d have, the houses we would buy, the toys we would drive around, each being a status symbol of a physician. Have the biggest house,fanciest car and most luxurious lifestyle. Not all were like this and some of my friends had the discipline of delayed gratification to eliminate debt, save and get the spoils of their success later in their lives. I wish I hung outwith them more!

These status symbols are like a reward that’s dangled in front of us, a carrot on a stick, and we go for the bait. After years of long hours and hard work, I had the mindset that I wanted to get rewarded for efforts, like many of my other colleagues. There is nothing wrong with this;however, there is the mindset of maintaining ourselves in a certain light and havinga status that visually appears appealing, telling the world that we made it. The problem, however, is going overboard. Did I need to go from a small 1000 foot, two-bedroom apartment to a  five-bedroom, 4000 square foot house?

Nope!

However, as I interviewed at my final place after residency,this is what I saw from all of the other physicians in the group so that’s what I gravitated toward. The reality is, it comes at a cost: a bigger mortgage,deeper credit card debt and the desire for even bigger and better things. Itcan eventually get to a point where many physicians may actually live paycheck to paycheck because of overspending and a lack of discipline.  

Even if a newly graduated resident has absolute discipline financially, there is still a problem.

 

According to the 2019 findings from the Weatherby Healthcare MedicalSchool report, two-thirds of respondents are still carrying medical school debt, with 80% of the group having over $100,000 and the other 20% having over$250,000.

Imagine the stress of having 6-figures of debt. Having that linger in the back of the physician’s mind naturally triggers them to put in longer hours and work harder to alleviate the problem faster. It’s not a great situation to be in when you have the stress of financial debt, leading the physician even closer to burnout.

 

Independent Work Effort

Back in the late 1990s, there was a push to integrate generalized training with the subspecialties. Otherward, as an Obstetrician-Gynecologist,I would have six months of my internships dedicated to non Ob-Gyn fields such as pediatrics, family practice and adult medicine. Because of the way therotation worked with my eleven other classmates, I didn’t even DO anything related to my field until six months after I started my internship!

I remember my first call night as a physician in July 1996, working in the Grady Hospital ER zone known as “asthma-detention.” Basically, you would get any patients that came in with asthma issues and ALL non-trauma patients from the prisons, no matter what the problem was. I started at 7 pm and thezone was empty (realizing months later this was no accident because the president who had signed out, handing the next shift over to me was finishing his 30-day shift and knew what the hell he was doing!).

By 7 am the next morning, I remember signing out, handing it over to the oncoming intern, “I can tell you about these 30 patients, the other 15 I don’t know anything about and have a good shift! My goodness, I got so overwhelmed and stressed with the sheer volume of patients. Yes, I got a little support from some of the other docs in the ER but they had their own zones tomanage, so I quickly realized I was on my own. When I arrived back at the ER that night to do my second shift, I got a sign out of like 40 patients in the unit, so I knew it would be a long 30 days.

What we learned, with a lot of trial and error and quick thinking, was how to safely and quickly clear that unit out, fondly known as“treat em and street em.” The whole point is the mindset of working solo, not asking for help, was a pride thing for us. We were the new guys on the block,not wanting to look weak in front of the senior residents and attendings, so we learned how to work hard, keep our mouths shut and not ask for help.

So, what does this have to do with the current physician burnout that we see today? There are probably many more physicians, more than 50% who are clinically burned out and they simply won’t ask for help. They have the mindset that standing strong and not asking for help is the thing to do and doing or thinking otherwise is a sign of weakness. Not pulling your weight in residency during your shift would get you serious repercussions from your colleagues.It’s that mindset that contributes to those physicians who really do need to reach out for help before they go over the cliff by failing to do so.  



From the findings presented at the 2018 annual meeting of the American Psychiatric Association (APA), one doctor commits suicide in the US. every day – the highest suicide rate of any profession.
This is more than twice that of the general population. They often have untreated or undertreated depression or other mental illness, says study researcher Deepika Tanwar, MD.  It’s arate that surpasses those in the military.  

How do we help those physicians who need it if they feel they are invincible and can handle anything?

 

Physical Invincibility

So, what did the 30 days of my time in the ER do for me? I Thought I was invincible and handle anything thrown my way. Invincible is the young intern who can stay up all night and triage more than 60 people without a minute of sleep. Invincible is me as a clinician staying up all night,delivering 3-4 babies and then seeing more than 40 people the next day. That’s the mindset that naturally develops, especially when you are a young intern, likeme, eager to prove your worth and value to the team.

My next rotation after the ER was pediatrics, and in the first week, our team had to cover an extremely high-risk delivery.

Quads.

Yes, a mom was getting a cesarean section to deliver her four children, my team was there, and I was excited! I remember when the attending asked me if I would like to help manage one of them in the NICU since they were premature, I didn’t just say yes; I said I would help manage all four!

When I look back, that was a moment when trying to be invincible like the incredible hulk wasn’t in my best interest. After four weeks of following their vitals, tests, imaging studies, complications, I think I saw anything and everything. Being overwhelmed with everything, literally made me turn green. I remember the palpitations, heart racing in anticipation of test results and physically dragging myself home after every shift, physically exhausted.

The problem that many other physicians face, as I did, is now you have created an expectation of being “the man,” the person who can handle the load and stress of a big volume of work. Trying to back off of the insane workload physicians create for themselves creates a certain “expectation” among your colleagues and implication to employers that there is the problem. When a physician is practicing at an excessively high volume, it comes with higher compensation, but also brings them closer to physical burnout. So, you may ask,“well, couldn’t they just work less?” If it were that simple, I have no doubt many physicians would do it, but what if that high level of work generated a higher standard of living requiring the additional income. What if your boss saw that air of invincibility and they would rather let you sweat it out and not invest in the cost of getting you a partner or more help in the office?  I experienced this during one of my jobs, seeing over 40 people a day, rotating with one other physician anddoing over 60 deliveries a month for four months straight without even a simple phone call from the administrators to ask, “do you need help?”

Having that mindset of physical invincibility is a duel-edged sword that can help you through those nights when you are overwhelmed, but cuts you deep when you try to get rid of it.

 

Pursuing Perfection in All We Do

After six months of being in primary care rotations, I was eager to get into doing stuff in my chosen field. If I wanted to take care of the elderly or young babies, I would have gone into those residencies. I wanted to deliver babies, do complex gynecologic surgery and take care of women in various stages of their lives. So, getting to my first core rotation in obstetrics was exciting and scary at the same time. Hell, some of my colleagues had already delivered dozens of babies, performed cesarean sections and assisted with hysterectomies, but I hadn’t done one at that time. Thus, doing my first cesarean section with the chief resident was something I was looking forward to.

However, I don’t think the chief had the same feeling!

Today, a cesarean section takes me an average of 30 minutes todo, from start to finish.  That first one,23 years ago, took 2 hours AND it was the patient’s first surgery. She had no scar tissue, was very low risk, and should have been a cakewalk at a maximum of an hour. Why did it take so long? Because nobody in the department really knew me. I was in other departments for six months and was way behind, so I had a chip on my shoulder, not only to catch up but to exceed the skills of my colleagues who had a head start. I was meticulous in everything I did during that c-section because I wanted to show that I was competent in what I do.

This personality trait is one seen in many physicians who develop and excel at it for many reasons. One, as stated above, is to have therespect of our colleagues. There is an expectation, especially among surgical disciplines like Ob-Gyn, that perfection is a big key, not just for the physician to physician satisfaction, but for patient satisfaction. Let’s think about cesarean sections for example. Do you think the patient really cares about how the physician masterfully closed the uterus back up, put all the tissue and muscle layers together? Or, do they care about how their incision looks? Ithink for that reason alone, I probably took 30 minutes to close my first one!

However, having that air of perfectionism can and does contribute to physician burnout.  The stress of having to be right or do everything “just so” leads to perfection. Especially in my field, I’m not taking care of one life but two. That challenge alone drives me, and many others, to provide optimum care. Being in that extremely stressful situation can lead to adverse situations personally and professionally. For example, the physician who yells at the staff and belittles them because the chart wasn’t prepared right. Clinicians who order an abundance of unnecessary tests because they want to rule out everything, driven by a fear of a lawsuit if something significant is missed. These professional consequences of professionalism lead to increased stress, physical ailments such as heart disease and mental breakdown including, but not limited to depression, anxiety and suicide.  

 

 

Emotional Disconnect

Making it to the third year of medical school was a huge transition for me. Going from studying medical conditions on the pages of textbooks to being face to face with them is an emotionally rewarding experience. Bringing life into the world and holding a newborn for the first time is an experience like no other. It’s a big reason why I chose my field.  However, with the blessings of life comes the sadness of death. Yes, I’m sure most medical students have had a close family member pass away; however, when it’s your patient and you were involved with their care before they pass, it’s a different experience.Everything may have been done, and death was just an inevitability but there still may be the feeling that if you have done just a little more, you might have saved them.

We, as physicians to be, are taught both consciously and subconsciously to be emotionally disconnected because it’s a coping mechanism.By having that emotional disconnect, it allows us to provide distance and be able to serve the patient more objectively. This disconnect can allow us to serve the patient more effectively from a medical standpoint, avoiding excessive tests, minimizing prolonged suffering and honing the ability to make decisions based on their needs, not our own. However, when the bridge between the patient and clinician emotionally becomes too large to cross, much is lost.  

We know this disconnect starts in medical school because of an instrument created in 2001.  The Jefferson Scale of Physician Empathy was created originally for medical students and physicians, being used as a gauge to track progress over the educational years. In 2007, a cross-sectional study was performed and the results revealed some unnerving data. The scores of this short 20 item test showed that there was a decrease in empathy as students went through medical school. So, medical school, in trying to help the clinician improve patient care and satisfaction, can actually develop the platform for more emotional disconnect to come.  

 

Depersonalization and Maintaining that Necessary Physician-Patient Distance

So, imagine if the Jefferson Scale scores are decreasing during medical school, which has a stress level that pales in comparison to clinicians who have been practicing 5, 10, even 20 years. How does that affect physician burnout? Less empathy for the patients, leading to decreased quality of patient care, increased frustration with the patients, clinic employees and the medical field as a whole can trigger deeper levels of depression and burnout. Add the stress of excessive working, having an independent mindset, financial instability, unsustainable levels of perfection and invincibility can all lead to even a greater disconnect between ourselves and the patients.

There is a decreased ability to understand the patient’s concerns and needs, and it becomes more about us than them. In time, the total collapse of emotional connection can be seen in physicians just trying to get through their day, seeing patients as numbers in the chart, another 20-minutes segment to get through, and checking off the codes to get the compensation for our time. In time, the gap may become too much to overcome, leaving a physician who has lost all emotional attachment for patients.

 

 

Taking The Next Steps

These are seven factors that are consciously and subconsciously taught to us as clinicians during our training in medical school and residency. While many of them are necessary to optimize our education, work production and efficiency, more often than not, the boundaries of these factors are crossed, leading to the physician becoming less than optimal from a professional, personal, emotional and physical standpoint.

It’s my hope and desire that you recognize these traits within.  The first step to acknowledging and accepting that there is a problem goes a long way towards reversing the physician burnout rates.  Doing this is awin, win, win situation.

Physicians win.

Patients win.

Medicine as a whole wins.

Until next time, take care and be well!

Regards,

Terence Young, MD

a.k.a. The Doctorpreneur

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