Friday, March 18, 2016

Burning down the house, Part I

A subject all too near and dear to my heart--physician burnout.

I've read a few articles by this U.S.-based doctor, who's made the prevention of doctor burnout and suicide a professional passion of hers:

(Take a minute to get past the morbid laugh at her two med-school boyfriends committing suicide. Go on, get it out of your system.)

There are two main thrusts to the articles and YouTube videos of hers I've looked at. First is that the system of physician health programs in the U.S. sounds horrendously dysfunctional. The regulatory Colleges in Canada are invasive and metastatic bureaucracies in their own right--yes, I describe the College in words normally used to describe cancer--but they aren't quite as awful as what she describes in the U.S.

It's her second major assertion that I'd like to address, namely that "physician burnout" is a blame-the-victim label for abuse.

I actually disagree with both her definition of burnout as well as its causes. Perhaps she's talking about a different entity than what most folks I know would label burnout. If so, fair enough. However, the notion that the problem can be traced back to abuse in med school is a dubious one. Even the most dour and cynical doctors I've ever met (including me, and I'm probably the most dour and cynical one in Canada) are pretty chipper coming out of med school. As awful as residency is, and it fucking well sucks, those who can't handle it will generally take time off and/or switch programs with success. Moreover, starting independent practice entails both a honeymoon period and a good few years of "finding your feet". Can you really then attribute burnout, which manifests years later, to abusive situations encountered in med school? How is it then that relatively few doctors suffer extreme burnout, and some never get it at all (not counting needing vacations--everyone needs time off)? Finally, doctors aren't the only working people that suffer severe burnout. Air traffic controllers famously burn out badly, as do teachers, nurses, and many others. Yes, doctor might be the only job that demands attempting to resurrect the dead and sticking your finger up someone's anus on the same day, but we don't have a monopoly on burnout.

So what is burnout? The chart below summarizes it about as well as anything I've seen.

Accordingly, let's define burnout as a stress-related illness arising from a person's occupation. I made that up, so if Wikipedia says something else, so be it. But make no mistake, burnout is an illness, and its effects can be as disastrous to one's health and family life as heart disease or severe mental illness. In fact, in its advance stages burnout can go hand-in-hand with either.

What makes doctors particularly susceptible to burnout? A lot: the gravity of the work; repeat exposure to people suffering trauma, disability, and death; long and erratic hours, even after residency; the culture of overachievement in medicine; pressure from administrators and bureaucrats, with concomitant deafness to feedback; tedious paperwork that is nevertheless highly time-sensitive, particularly for patients on social assistance; the frequent futility of treating chronic conditions, especially mental illness; unrealistic expectations; the significant time requirements to maintain one's licensure and skills; and others.

Ironically, the serious responsibility accorded is probably not a cause of burnout. Stress is strongly related to a person's perceived control over their life's station, independent of income and other factors. All other things being equal, the conductor feels a lot less stress than the cellist in the back row.

Why should anyone care about doctors burning out, apart from generally wishing good will towards others?
  1. For better or worse, doctors are a scarce resource in the health care system. They take years and many, many taxpayer dollars to train fully. Except in the biggest cities, recruiting a new doctor is often robbing Peter to pay Paul.
  2. A doctor's experience with his or her specific patients is irreplaceable. In any field of medicine with a long-term doctor-patient relationship--family medicine, oncology, pediatrics, psychiatry, internal medicine--the relationship is just as, if not more important than the doctor's clinical skills. Plunking a new doctor into an established practice means thousands of patients starting at square one.
  3. Doctors also fulfill a most important role beyond clinical care: teaching and mentoring their replacements. This is doubly important. Burned-out doctors are much less likely to be interested in teaching. Moreover, even if they do teach, it's quite likely their cynicism or bitterness will trickle down to their trainees. A class of newly graduated doctors with an attitude like mine is not a good thing.
So if we have an idea of what burnout is, and why it's something we should worry about, what can we do to prevent it? Stay tuned.

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