Home >> ALL ISSUES >> 2018 Issues >> Frontline dispatches from the burnout battle

Frontline dispatches from the burnout battle

image_pdfCreate PDF
Karen Titus

June 2018—Bryan Bohman, MD, doesn’t spend his days wandering the Bay Area handing out buttons that read “Lift people, not the bottom line.” But don’t rule this out as a possibility someday, either.

Dr. Bohman, chief medical officer, University Healthcare Alliance, and clinical professor of anesthesiology and perioperative and pain medicine, Stanford Health Care, is campaigning against physician burnout. Yes, it threatens the quality of medical care, he says, and yes, it’s expensive. But he and others with an interest in the topic are learning, from experience as well as from emerging research, that the most important bottom line rests with physicians themselves. Like modern-day apostles, they are beginning to spread the word, even if not everyone wants to hear it: Physician well-being matters.

While the concepts of mental health days and self-care have wiggled their way into popular culture, campuses, and even some businesses, medicine is playing catch-up, says Luke Perkocha, MD, MBA, a pathologist with The Permanente Medical Group, Northern California. “People don’t understand what burnout is,” says Dr. Perkocha, who is also a member of the group’s physician health and wellness committee. It’s not caused by long hours or hard work. “It’s a kind of cynicism and lethargy that occurs when people become disillusioned with what they’re doing. They feel like they’re not accomplishing anything, that they’re ineffective as physicians, or that they work in an environment that is unsupportive or incongruent with their values.”

Even when they do know the definition, physicians often react by practicing the art of cognitive dissonance. That’s certainly true for pathologists, says Jim Hernandez, MD, MS, associate professor of laboratory medicine and pathology, Mayo Clinic (in Arizona) School of Medicine and Science. A frequent speaker on this topic, he sees interest from quite a few colleagues as he travels throughout the country. But, he says, “I don’t think a lot of pathologists are aware of how difficult this is for the profession, and the high prevalence.”

As Dr. Perkocha puts it, “There’s that wonderful, all-purpose defense mechanism of denial.”

Numbers tell the tale

Medicine has never been for the faint of heart. Stress becomes normalized in medical school, when physicians become experts in—among other things—denial and delayed gratification. So when faced with symptoms of burnout in practice, the natural response might be to summon up one’s inner Patton and say, Toughen up! If I just hold on a little bit longer, there’s light at the end of the tunnel.

Perhaps that used to be the case. “Obviously we train for many years and are willing to work hard,” says Dr. Bohman. “But what’s been asked of us in the past decade is superhuman effort.”

Dr. David Hoak of Incyte Diagnostics is leading the effort in his practice to address burnout, and says he’s grateful to his group for participating. “Just the fact that we’re thinking about it and talking about it provides some help,” he says.

Dr. David Hoak of Incyte Diagnostics is leading the effort in his practice to address burnout, and says he’s grateful to his group for participating. “Just the fact that we’re thinking about it and talking about it provides some help,” he says. [Photo: Hannah Max]

Ten years ago, as chief of the medical staff at Stanford Hospital, he witnessed a rise in physician distress, due in part to the piling on of quality and productivity metrics, patient satisfaction surveys, and regulatory requirements. Stanford was also setting up its electronic health record, he recalls. Taken together, he says, “You realize, that’s a lot of additional ‘asks’ of folks—without additional support.”

In other fields, human resources might be expected to step in with help. Not so in medicine, he says, “partly because physicians never acted like they wanted that sort of thing.” And while employee satisfaction surveys were done annually, there was no equivalent survey of physicians.

Though Stanford boasts a strong program for helping physicians with substance abuse and behavior problems, Dr. Bohman characterizes it as too little, too late. “It occurred to me that we should be paying more attention to the physicians who are struggling under some of these burdens, to keep them from going down the road of burning out or potentially exhibiting negative behaviors.”

Stanford took the usual next steps—forming a task force, creating a wellness committee—but unlike a legislative committee, where bills are sent to die (as the old joke goes), Dr. Bohman says he and like-minded colleagues wanted answers that would lead to action. “We started finding out what was going on in our organization.”

A lot, as it turned out. It wasn’t a pretty picture. And Stanford wasn’t alone.

In 2013 the committee conducted its first physician wellness survey, breaking away from traditional questionnaires that focused on the health system and patient referrals. The data turned out to be eye-opening. The burnout rate among physicians was 24 percent. Around the same time, a leading figure in physician burnout research, Tait Shanafelt, MD, then with Mayo Clinic’s Division of Hematology, found in a national survey that 54.4 percent of physicians reported at least one symptom of burnout, and that rates were rising. A similar survey done three years earlier showed 45.5 percent of physicians reported at least one symptom of burnout. And satisfaction with work-life balance had dropped, from 48.5 percent to 40.9 percent.

Nor were Stanford physicians getting better. A follow-up survey in 2016 showed the burnout rate rose to 39 percent, while the personal fulfillment rate dropped from 24 percent to 14 percent.

Pathologists have their own numbers to cogitate. A Medscape survey from 2015 puts the specialty on fairly happy ground compared with other specialties. In the category of physicians who are burned out, depressed, or both, pathologists (along with rheumatologists) weighed in at 42 percent.

Is that good? Out of 29 specialties, neurology “led” the pack at 55 percent, followed by critical care at 54 percent. Burnout rates were lowest in plastic surgery, at 32 percent, just ahead of dermatology (34 percent) and orthopedics (36 percent).

When it came to being happiest at work, pathologists ranked third (34 percent) among specialties (behind ophthalmology, 37 percent, and plastic surgery, 35 percent). The unhappiest groups were cardiology and internal medicine, both of which brought up the rear at 21 percent.

Outside of work, pathologists were also fairly happy—48 percent reported out-of-office satisfaction, along with radiologists and critical care physicians. (Allergists and immunologists were the happiest when they left the office, at 61 percent, while cardiologists were the least happy, at 40 percent.)

Does this mean pathologists are fine?

“So we’re better compared to other specialties,” concedes Dr. Hernandez. “But that’s still a lot of pathologists.” Just as troubling is the gender gap—45 percent of women pathologists are affected by burnout/depression, versus about 33 percent of men, he notes.

Dr. Hernandez thinks about it this way: As he walks through his lab and talks with his colleagues, he’s mindful that even if he can’t see it directly, about a third of them are burned out. “And this is a pretty good place to work!” he says.

Worries of their own

In some respects pathologists may seem to have it easier than some of their clinical colleagues (as the Medscape survey might indicate). Pathologists have a built-in stress reliever in how they practice their profession, Dr. Hernandez says. Colleagues show cases to one another, and immediate decision-making is confined primarily to frozen sections and blood banking.

They also don’t regularly interact with patients, often a source of stress for many specialties. On the other hand, says Dr. Perkocha, their interpersonal conflicts and satisfaction are determined by fellow physicians. “So the medical group becomes more important, and there are a lot of dysfunctional medical groups out there,” he says. “That can be a tremendous amount of frustration and burnout.”

The subtle interplay between practice and personality also weighs on pathology. Compared with other specialties, says David Hoak, MD, pathologist and former president, Incyte Diagnostics, Bellevue, Wash., the stress that pathologists experience relates to fear of making a misdiagnosis. “That’s always kind of lingering,” he says. “I think it affects some pathologists more than others.”

“The expectation is we’ll always have the right answer,” he adds, which can bring more stress. “It may also prevent us from being more open about emotional things. It is hard for us to get up in front of a tumor board and say, ‘I don’t know what this case is.’ That’s not a very comfortable place to be.”

When clinicians make mistakes, says Dr. Perkocha, they often do so within a gray zone: Was that heart murmur really there? But the findings of a slide don’t change. “If you miss them today, and someone else finds them tomorrow, or next year, they were always there,” says Dr. Perkocha. One could argue that only in retrospect are mistakes made obvious (Pickett’s Charge notwithstanding), but while pathologists are sued at lower rates than many of their clinical colleagues, “mistakes are often more apparent in pathology,” he says.

Dr. Perkocha

Dr. Perkocha

Pathologists by definition tend to be inquisitive and conscientious, Mayo’s Dr. Hernandez says. Left unchecked, these attributes hurtle toward perfectionism. Acknowledging and learning from a mistake translates into excellence. The flip side is dysfunction. When fear of making a mistake causes paralyzing indecisiveness, then it’s time to seek help, says Dr. Hernandez, who calls himself a recovering perfectionist. Pathologists might take a hint from baseball’s star closers. “You have to move on,” he says, “and not perseverate about past errors.” There’s also little point, he says, in obsessing about extremely rare disorders in the differential diagnosis.

Dr. Hoak cites another type of anxiety, one he links to pathologists’ place in the health care hierarchy. “We’re always servants to the hospital, and servants to the clinicians, and servants to the patients.” That leads to a quandary when trying to tackle each day’s workload. Do I start on this new breast biopsy, or do I start on the case that I was working on yesterday? “I know somebody is going to call me about some case, but I don’t know which one,” he says. If emergency physicians are trying to triage patients, then pathologists are trying to triage cases.

Looking for solutions

Compared with Dr. Shanafelt’s national figures, the Stanford physicians looked relatively cheerful, an organization full of sunny Mary Richardses in a world of Lou Grants. Dr. Bohman feared Stanford leadership would respond in that vein: Hey, you’re better than average—what are you crying about? His worries were unfounded. “That wasn’t their response,” he recalls. Instead, they said, ‘That’s not acceptable. We need to do something about it.’”

The task force recommended setting up a Well MD center, which was a five-year commitment from the school of medicine and Stanford’s two hospitals. Dr. Shanafelt was hired to oversee the center, replacing Dr. Bohman, who was serving as interim director. “He’s been here less than a year, but he’s already doing great work,” Dr. Bohman says.

CAP TODAY
X