My New Year’s Prescription for You

From the Editor

I’m not a big believer in New Year’s resolutions. I don’t find New Year’s celebrations particularly energizing, and I’m usually just trying to slog through the coldest and darkest time of the year until I can get back to working in my garden in March. So, I don’t have any particular resolutions this year. But now that Janus is looking forward and I am thinking about what a hard year 2015 has been for everyone, I’ll have a prescription at the end of this column.

The world seems more chaotic than usual, including the weather (today I cut what I think are the last blooming roses of the year on a 70-degree day in mid-December). Fear is rising everywhere it seems, the US political process seems much scarier than usual, and the practice of medicine is getting more and more onerous. The stresses related to medical practice alone, even without living in a crazy time, have mounted over the past decade.

One of the very problematic results of work stress is “burnout,” shorthand for a complex group of various feelings and symptoms. These have been well described in a Studer Group report, Physician Burnout: Preparing for a “Perfect Storm,”¹ (available free on the Internet) and include:

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• Headaches

• Inability to concentrate

• Depression or anxiety

• Irritability

• Chronic complaining or blaming

• Explosions of anger

• Insomnia

• Drug or alcohol abuse

• Loss of passion for work and increasing cynicism

• Emotional disengagement

• (When severe) suicidal thoughts or behaviors

There’s clearly an overlap with the symptoms we generally characterize as relating to depression.

The triggers for burnout have also been well described (see the Studer Group report) and include increasingly intense or heavy workload; pressure related to health care reform and/or technology changes; lack of control over time; inefficient or hostile work environment; lack of support at work or at home; isolation and lack of connection with colleagues; feeling unappreciated and unrewarded; perceiving work policies as unfair; lack of alignment between the physician’s personal value system and the organization’s value system; consistently putting patient care before oneself; grief or guilt because of negative patient outcomes; and financial stress.

Because many psychiatrists still practice solo-likely more than other physicians these days-isolation during practice hours may be either more of a stress or a respite from institutional practice life.

Our University Hospital Chief of Staff recently told me that she has never seen burnout higher than this past year across the entire staff-even among doctors just starting their careers. This is a major national problem. I said I’d be glad to work with her to develop a plan, since it seems no one has found anything that has had a major beneficial impact. Finding workable remedies has become urgent.

A recent online posting from Washington Post reporter Lena H. Sun² illustrates that we have a national crisis percolating around physician burnout. Ms Sun cites a 2014 Mayo Clinic/American Medical Association³ study that found “higher measures on the classic signs of professional burnout” than in a similar 2011 study. More than half the doctors reported being “emotionally exhausted and ineffective.” A similar number reported loss of meaning in their work. The 2011 study found that burnout criteria were met in 45% of doctors compared with 54% in the 2014 study.

Ms Sun also reported that a JAMA analysis revealed that almost a third of residents met positive screening criteria for burnout or met some depression criteria during their training.⁴ One of the factors cited was the diminishing time available for direct patient care and increased computer-based documentation requirements. That problem of course is hardly limited to new physicians. Many of our staff report that as little as 10% of their clinical time is spent in direct patient interaction because of the time required for electronic records.

Another factor contributing to burnout is the challenge of trying to balance work and professional life. This problem has recently received more attention as a source of stress in medicine.

A study on physician burnout and satisfaction with work/life balance with over 7700 respondents found both burnout and low job satisfaction much higher in physicians than in a matched sample of working US adults.⁵ The study also compared results across specialties. The mean burnout rate for all specialties was about 50%. While psychiatrists had a lower burnout rate than about 75% of other specialties, the percent in psychiatry was still in the low 40s. And, while psychiatrists were more satisfied with the work/personal life balance than about 75% of those in other specialties, the satisfaction rate for psychiatrists was only in the low 50s in percent. I guess we should be glad we’re doing better than most doctors, but these findings are not reassuring and actually alarming.

We are the specialists most likely to be consulted by other colleagues when the stress of burnout becomes intolerable. Of course, since there is still tremendous stigma about a physician being sick, and especially being emotionally unwell, we might not be contacted until an individual’s own problems reach a level of clinical urgency. You’ve likely already read our cover story by Linda Gask-a friend and colleague psychiatrist from the UK-who describes not only her own battles with depression, but the impact of our professional culture in which it’s not OK for a doctor to admit one’s own problems. If you haven’t read Dr Gask’s story, go back and read it now.

Few of us are likely to be involved in the development of institutional or systemic programs to address burnout-of which there are very few compared to the need. And, the elephant in the room about various “physician health” or “physician wellness” programs is that most people think these are designed to provide a pathway to get impaired physicians (most commonly assumed to be drug or alcohol abuse related) into treatment against the physician’s wishes. Not many doctors want to feel like they are working against their colleague’s manifest wishes.

Nevertheless, we psychiatrists are best equipped to design and participate in programs to help diminish workplace triggers for burnout. And, even more important, we are well equipped to recognize signs of burnout in ourselves and to do something about it before the burnout impairs our own work or home life. It’s hard work to make changes, because both the medical system and the individual physicians have a hard time admitting how big the burnout problem is. An important aspect of the difficulty lies with the fact that we’re all doctors.

I still remember being in the on-call lounge one night during medical school listening to a group of medical and surgical residents complaining/bragging about how little sleep they got the last time they were on call. I thought these people were nuts. But now I know they weren’t just showing off. They were just doctors.

So, physician, in addition to helping out colleagues in need, heal yourself. Or better yet, try not to let yourself get into a state where the healing is so necessary. That’s my prescription for a happy new year.

References:

1. Studer Group. Physician Burnout: Preparing for a “Perfect Storm.” 2012. https://www.studergroup.com/getmedia/fea54126-168b-4ba3-9866-8f584e4e7fa8/physician_burnout_straight_a_review.pdf.aspx. Accessed December 14, 2015.

2. Sun LH. Burnout increasing among US doctors. The Washington Post. 2015. https://www.washingtonpost.com/news/to-your-health/wp/2015/12/08/burnout-increasing-among-u-s-doctors/. Accessed December 14, 2015.

3. Shanafelt TD, Hasan O, Dyrbye LN, et al. Changes in burnout and satisfaction with work-life balance in physicians and the general US working population between 2011 and 2014. Mayo Clin Proc. 2015; 90:1600-1613.

4. Sun LH. Nearly a third of new doctors at high risk for depression. The Washington Post. 2015. https://www.washingtonpost.com/news/to-your-health/wp/2015/12/08/nearly-a-third-of-new-docs-at-high-risk-for-depression/. Accessed December 14, 2015.

5. Shanafelt TD, Boone S, Tan L, et al. Burnout and satisfaction with work-life balance among US physicians relative to the general US population. Arch Intern Med. 2012;172:1377-1385.