Taking Care of the Physician

This post was originally published on this site
The Checkup

If I am your doctor, or your child’s doctor, is there any reason you should worry about how I’m feeling? About what kind of shape I’m in, physical or emotional?

Maybe you should. A growing body of research shows that physician burnout and depression are linked to medical errors and to the kind of depersonalized care that is often both less effective and less palatable.

“It has been shown in some studies that if the physician is exercising, if the physician is taking care of themself, eating well, sleeping better, they have patients who have better clinical outcomes,” said Dr. Hilary McClafferty, a pediatrician who is an associate professor in the department of medicine at the University of Arizona College of Medicine in Tucson. But the problem may be less the individual doctor’s health habits, and more the medical system that is hurting us all.

There is increasing conversation about “physician wellness” these days, as we look at how young doctors are trained, and at the physical, emotional and spiritual pathways of those who are supposedly (and arduously and extensively) trained to take care of others. Researchers use the Maslach burnout inventory to measure emotional exhaustion and depersonalization and feelings of competence and successful achievement in one’s work; physicians as a group do pretty well when it comes to the sense of personal accomplishment, but they tend toward emotional exhaustion and a sense of depersonalization, which can breed a cynical and dehumanized attitude toward patients.

In pediatrics, we like to think of ourselves as relatively warm and caring, but in pediatric training institutions, burnout rates among residents are 55 to 60 percent, and that’s after all the attempts to regulate and restrict work hours. “I know I have suffered in silence about medical errors, about uncertainty, and I don’t know that we do a very good job of supporting each other,” said Dr. Janet Serwint, a professor emerita of pediatrics at Johns Hopkins University, where she was formerly the director of the pediatric residency program. She has written about an experience in residency in which a child died, she thought because of an error she had made, but there was no place in the busy day to discuss her reaction.

“It’s not that physicians are burned out and so don’t care, it’s that they care deeply,” said Dr. David Schonfeld, a developmental behavioral pediatrician at Children’s Hospital Los Angeles. “You can’t experience compassion fatigue if you’ve not had compassion.”

Medical faculty members have been shown to have burnout rates ranging from 20 to 49 percent. And the hard-won reductions in resident work hours do not seem to have satisfactorily reduced burnout or depression among residents, perhaps because hospitalized patients are sicker on average than they used to be, perhaps because patient loads are higher (if you reduce work hours but don’t increase the number of doctors, well, you can do the math), or perhaps because of the increasing frustrations and time pressures connected to the electronic health record and documentation, which can take up more than half of some doctors’ time, often squeezed in at night or by coming in early.

Another statistic often cited in the physician wellness conversation is the suicide rate. Physicians are at approximately twice the relative risk of suicide compared to people in other professions, Dr. McClafferty said. “Women physicians especially are at a significantly higher risk of completed suicide than matched female controls in other professions,” she said. An estimated 300 to 400 physicians commit suicide every year.

If this were happening in any other high-profile industry, Dr. McClafferty said, “I can’t imagine people wouldn’t be rallying round, saying this is unacceptable, it has to stop.”

There is a clear link between physician depression and medical errors. In one study of pediatric residents at three high-powered training programs, those who were depressed made more than six times as many medication errors as those who were not. This study and others also found that residents experiencing burnout were more likely to perceive that they were making more errors, even if they were not.

We place physicians in situations where they are detecting problems, often connected to social conditions or poverty, Dr. Schonfeld said, but then don’t give them the support they need to address those problems. And we don’t adequately teach the skills in medical training that doctors will need to deal with the realities of taking care of patients. “There are more advanced skill sets, how to deal with conflict, how to deal with negotiation, how to deal with the distress of patients,” he said. “We just send trainees in, the training focuses on medications, pathophysiology, genetics, not the skills they need to be able to deal with those broader issues.”

So we might look to changes in the ways we train residents, not just limiting work hours but looking more closely at what the content of those work hours is like, and at the skills we teach, and at what we do and do not discuss.

“Because of organizational structures and competing responsibilities there’s less time, and physicians are really sad about this, and we need to struggle as a society to make it different,” Dr. Serwint said.

Studies are just beginning to be done of workplace interventions that address such issues as time pressure, workplace chaos, and a doctor’s sense of control, but the evidence supports the idea that it’s more effective to make changes at the level of the institution, rather than just telling the doctors to shape up in the wellness department.

“The solution is not to weed out the ones who don’t care, but to support the large number of physicians who are deeply invested and have the capacity to provide excellent care, but lose that capacity over time,” Dr. Schonfeld said. “Physicians enter medical school deeply committed to the field, they come with the desire to be empathic and compassionate, if we just create a system that nurtures what they come with then we will have less burnout and higher quality care.”

It should not be the doctor’s responsibility to feel that “if I’m just more mindful, if I just exercise more or do it better or more consistently, all will be well, and I shouldn’t be feeling burned out or exhausted,” Dr. McClafferty said.

The fact that nearly half of physicians and over 50 percent of trainees experience burnout at some point “shows that it is not predominantly an individual deficit, but an organizational and system problem,” Dr. Schonfeld said

“If you’re my physician,” Dr. McClafferty said, “I want you to be in good shape mentally, physically and emotionally, so you can be really successful at helping me.”