Monday Jan 23, 2017

After Hitting the Wall, How Do I Bounce Back?

Kimberly Becher, M.D., writes that just three years out of residency she already is experiencing symptoms of burnout, but she has some ideas about how new physicians can cope.

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Tuesday Dec 20, 2016

Can a Sense of Gratitude Make You Happier?

Stressed out? Melissa Hemphill, M.D., writes that keeping a record of the things that bring you joy could make you healthier and happier.

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Wednesday Sep 14, 2016

Death in the Family: It's OK to Let Go

Relatives often turn to physicians with medical questions. Margaux Lazarin, D.O., M.P.H., addresses the difficulty of providing insight and comfort when a family member is dying.

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Tuesday May 31, 2016

Diagnosis Dangerous: What Do You Do When a Patient is Armed, Hostile?

I don't get nervous easily, I don't avoid confrontation, and I usually feel safe in situations where others might not. I do a lot of home visits, and I am not afraid to confront patients if I think they are lying to me. And I don't hesitate to have difficult conversations with patients even when they are angry.

I actually would say I have a track record of making patients angry because I am honest and willing to confront them, especially about narcotics. And like most family doctors, I have had my fair share of threats.

I've had answering service calls from patients who say they will die if I don't refill their benzos, that they will kill themselves if I don't prescribe pain pills. I've had face-to-face threats from patients who say they are going to sue me, report me to the board of medicine and tell everyone I'm a terrible a doctor. (I consider that good publicity most of the time.) Often, this involves yelling and swearing. Through years of dealing with irrational, repetitive drug-seeking behavior, I've developed a thick skin.

But when a patient brings a loaded gun into my office, I feel 100 percent terrified.

Before I go on, I should give some background about my experience with guns. I own guns. I grew up with guns. I don't have a concealed carry permit, and I don't carry a gun on home visits, but I am not frightened by the presence of a gun.

In residency, we had to do a patient education video, and one of my colleagues and I focused ours on gun safety. It explained how to unload and turn on the safety mechanism on different types of handguns.

I live in a part of the United States where guns are part of life. I think every house in my neighborhood has a gun (or lots of them). That is why this is such a difficult topic, and why I was so surprised I was shaken by a patient who came into my exam room with two loaded handguns.

He wasn't pointing them at me and demanding meds. He actually handed them to my nurse so she could do an electrocardiogram. The thing that made it scary was that I didn't feel comfortable around this patient even before he showed up with guns.

As physicians we are in difficult situations all day, making diagnoses, struggling to find the right treatment for a complicated patient, delivering bad news or even saying goodbye. We have to be comfortable with uncertainty, but we make evidence-based decisions and probably look things up more than we need to just to be certain our memory is accurate about a medication dose or length of treatment. We spend hours at home reading and researching yet we still sometimes have to make decisions about people's lives that are not clear, and we reassess and re-evaluate those patients to ensure we've made the right choices. And through all of that we often ignore ourselves, putting the patient first.

After my first visit with this patient -- just a few months before this gun-in-the-exam-room encounter -- I told my office manager that if any patient were ever going to shoot me, I had just met him.

I didn't have anything specific on which to pin that feeling, although multiple people witnessed uncomfortable exchanges between the patient and me, and a few even said they didn't think I should keep taking care of him. But he is complicated, and it's a really long drive to the next primary care doctor. Besides, why should I subject some other doctor to him instead of dealing with him myself?

During a visit with me the week before, he voiced a threat toward a subspecialist to whom I had referred him. I notified that doctor, fully expecting him to dismiss the patient, but it never occurred to me to consider all the reasons I should dismiss him until he presented with two loaded guns.

It was pretty darn clear at that point -- so clear that I felt I had jeopardized the safety of my entire office by not dismissing him sooner.

What came next is my motivation for writing this blog.

I have dismissed other patients for threatening me or my staff. I give them 30 days to find a new medical home and will see them for emergencies. But I didn't want this patient anywhere near the office again. I wanted his dismissal to be effective the moment he walked out the door.

What I found, however, is that I didn't have the ability to make that happen. Law enforcement officers told me I would have had to confront him about the guns, specifically that he was not allowed to have them in my office. I needed to point out that we have a sign on the front door stating no weapons are allowed on the premises, and that he was violating our policy. Then, and only if he refused to take the guns out of the building, did I have the right to keep him out of my office.

It took so long to figure this out that he came back to the office before we had a chance to write our dismissal letter. Fortunately, the receptionist told him she would need to take a message, and he left without any conflict.

When we have doctors getting shot in hospitals and offices around the country -- sometimes by accident -- why am I not allowed to stop a patient from coming into my office with loaded guns?

As a physician, I don't feel I can simply refuse to see patients based on who makes me uncomfortable. I have an obligation to take care of people with violent histories, and I have no moral issue with that. But I am struggling to decide where to draw the line.

I'm not the only physician thinking about safety. During the AAFP's recent National Conference of Constituency Leaders, delegates adopted resolutions that addressed workplace violence. One substitute resolution that was adopted requested that the AAFP help state chapters advocate for legislation that protects physicians from violence. Another one asked the AAFP to oppose legislation that allows guns in civilian clinical settings.

Unfortunately, some states are passing laws that will reduce protection for us and our patients. And that is how I see it: Allowing guns in clinical settings means less protection. I shouldn't have to have a conversation about an inconsistent urine drug screen or board of pharmacy report with a patient holding a gun. And just as I don't want to get shot in my office, I definitely don't want one of my patients to get shot, either.

Starting next year, legislation will make it legal for people in Kansas to carry concealed weapons on college campuses and in health care facilities with no requirement for permits or training. In West Virginia, our state legislature eliminated a concealed carry permit process that included a gun safety class.

I know that after my experience I want my guns in my house where they've always been, and I want no guns in my exam rooms where I sometimes make people mad while I'm alone with them behind a closed door.

Kimberly Becher, M.D., practices at a rural federally qualified health center in Clay County, W.Va.

Wednesday Nov 04, 2015

30-hour Shifts? Only If It Makes Us Better Physicians

When new rules for medical residents were implemented four years ago, the Accreditation Council for Graduate Medical Education limited interns to 16-hour shifts. But at dozens of U.S. hospitals, first-year internal medicine residents are working 30-hour shifts in a study that's taking yet another look at resident work hours.

The 2011 rules were an update to guidelines set in 2003. Each revision has provided more data for accurate assessment of work hours on performance and patient safety. Today's interns -- excluding those in the study -- may work only 16 hours per shift and a total of no more than 80 hours in a week.

From the outside world, where a 40-hour week is considered the norm, this still seems like a lot, especially given that there are only 168 hours in a week. For those physicians who trained before the restrictions went into effect, however, there are significant concerns about the level of experience and education that newer trainees receive.

The original restrictions, put in place in 2003, were intended to combat mental fatigue and trainee errors. Initially, the collected data painted a picture of little or no change, but more recent trends have suggested a subtle decrease in mortality Granted, there are several possible confounders, including increasing use of electronic health records, better access to medical knowledge databases, and improved understanding of disease processes, but the overall trend in mortality for patients cared for by residents appears favorable.

That bodes well for the process, but it’s only one metric. Questions remain about the impact the duty-hour changes have on the knowledge and training of new physicians. United States Medical Licensing Examination scores have remained consistent but there are so many potentially confounding variables that this means little. Many other possible metrics, such as trainee confidence or bedside manner, are also exceedingly difficult to measure accurately.

One of the biggest concerns is the possibility that the restriction of work hours will generate more errors during patient handoffs. For most residents, the greatest chance for forgotten information comes during the transfer of care from one physician to another. We collect reams of data on each patient and order multiple tests that may not be performed until after checkout, making it imperative that we communicate as much pertinent information as possible. Even the most meticulous handoff procedure may miss some details. And more frequent handoffs, which are necessitated by work-hour restrictions, can compound these errors of omission and potentially negate the benefits gained from reducing fatigue. There are several studies looking at handoff procedures and the best way to minimize errors, but so far no one model has prevailed.

The other big concern among duty-hour restriction detractors centers on the decreased exposure to complicated pathology in the early years of training and subsequent deficiencies in education and confidence. As an intern during the initial 80-hour work week rules (2008), I personally saw more pathology on overnight call than during daytime call. I suspect this is because it is more likely that more complex patients will be evaluated and admitted by specialists during daytime hours, but a quick literature search found no specific supporting evidence. Regardless of the reason, there were far more "interesting" cases coming to our service from the ER at 2 a.m. than at 2 p.m.

The system in place at the residency where I trained facilitated the gradual introduction of personal responsibility for admissions. Each intern always had an upper-level resident and an attending faculty member overseeing the admission process. As in all things, some upper-level residents and attendings were better at it than others. The interns took responsibility as we were able, but we were never alone. I understand that this isn’t always the case, and I shudder to think of how many errors I would have made if I were solely responsible for even a simple admission as an intern.

But I also understand that had I not had the opportunity to fail in a controlled setting, I would not be the physician I am today. I would not know the limits of my endurance, or how to push past them to do what must be done. I wouldn’t even know I was capable of doing so. That’s not to say that I feel the restrictions don’t allow this for current trainees, but this experience needs to be incorporated into training, no matter what the duty-hours restrictions call for.

Regardless of your feelings about work hours, or even the profession of medicine as a whole, there is no denying that our job is full of stress. Good stresses and bad stresses, sure, but it's potentially one of the most stressful and demanding callings on both personal and professional levels.

Family physicians literally hold the power of life and death in our hands on a regular basis. We sacrifice time with our families with the hope that the care we provide will allow someone else to spend time with theirs. We spend hours in clinics and hospital wards helping patients learn to help themselves. We help escort new life into the world and, on the same day, hold the hand of the dying as they breathe their last.

In short, we have been given the awesome responsibility of caring for the lives of others, and with that responsibility comes a social contract that we will do so to the best of our ability. That means figuring out the best way to equip doctors in training for as many eventualities as possible, while at the same time preserving their sanity, their health and their compassion.

We must be willing to try new techniques and strategies in the pursuit of that education. Just like the researchers studying work hours at the University of Pennsylvania, we must iterate until we get it right, and be ready for further change when a better way presents itself.

Gerry Tolbert, M.D., is a board-certified family physician who practices in northern Kentucky. A lifelong technophile, his interests include the intersection of medicine and technology. You can follow him on Twitter @DrTolbert.

Wednesday Jun 03, 2015

Give Residents Tools to Turn Tide on Physician Burnout

It wasn't that long ago, during my college days, that I thought burnout referred to a certain lifestyle rather than a severe form of career (and life) dysfunction. Today, however, tales of physician burnout are hard to miss.

In fact, the Academy developed a position paper on the topic last year. And this year, the AAFP posted a blog  about  burnout, as well as an even more sobering editorial about physician suicide.  Burnout also was addressed by Dike Drummond, M.D., in his keynote speech last year during the AAFP's annual meeting, and a closely related topic -- managing stress -- will be the general session topic presented by author Kelly McGonigal, Ph.D., Oct. 1 during the Family Medicine Experience (formerly AAFP Assembly) in Denver. It’s safe to say we all know this is a huge problem.

I think perhaps one of the most fascinating concepts related to burnout is prevention. Many researchers have highlighted the idea that devoting a time to something you are passionate about (research, teaching, etc.) -- really anything that is outside of the daily grind -- can be enough to help prevent burnout. One of the reasons it has taken us so long to come to terms with the fact that we, as physicians, can (and do) get burned out is that most of us went into medicine because it was something we were passionate about. We think of medicine as a calling; therefore, how could we get burned out?

The reality, unfortunately, is that we do. During Drummond's Assembly session last year, he asked each of us in the audience to raise our hand if we, or someone we knew, had experienced symptoms of burnout (loss of enthusiasm for work, feelings of cynicism and a low sense of personal accomplishment). Nearly everyone in the ballroom -- hundreds of family physicians -- raised a hand.

You could argue that was a rather unscientific survey and a relatively small sample size. But there is plenty of evidence that suggests burnout is rampant in our profession. A study presented recently (free registration required) at the American Psychiatric Association's annual meeting found that 70 percent of medical residents met criteria for burnout. The numbers were lower, but still significant for family medicine, with 50 percent of our residents experiencing burnout.

I feel fortunate to work at a community-based academic residency program because we spend more time addressing this topic than the average practice would. Our program has been proactive in teaching residents and students to recognize burnout. Of course, we have the traditional Maslach Burnout Inventory that we discuss with residents, but we also have invited thought leaders on the subject to speak at our residency and to other programs within our health system. Most recently, we heard from Tait Shanafelt, M.D. director of the Mayo Clinic's Department of Medicine Program on Physician Well-being, and colleagues.

We provide residents with resources to not only recognize burnout, but to treat it when they do recognize it. Even more importantly, we try to prevent it.

Physicians have always been pressed for time, and demands in the current health care system may be worse than ever. Therefore, we try to capitalize on 15- to 20-minute segments of time by, for example, utilizing a short reading followed by a period of reflective writing or discussion. We also ask questions that orient residents' attention to challenging or rewarding encounters, such as asking them to recount a time in the past week where they felt particularly helpful (or helpless) or to describe a situation that reminded them why they became a physician. We have found that Balint groups are particularly helpful in setting the stage for these other brief, “on-the-fly” activities.

These exercises in mindfulness about the topic really seem to help accomplish our goals. We have implemented this program during the past few years, and although we have not officially published any findings, we have noted a significant shift in the recognition, and, we believe, prevention of burnout.

I’m fortunate to have variety in my job and also to be involved in research. I think these aspects of my role have buffered me from the burnout epidemic. Still, I keep the issue in the forefront of my mind and remember to enjoy my time away from work, whether it's simply reading a book quietly at home, spending time with family or on a needed vacation.

The millennials have some of this figured out. It’s really about balance, self-awareness and introspection, and as you can see, the resources and tools are not anything groundbreaking. I think we are beginning to recognize just how far-reaching this problem can be, and by empowering our youngest physicians (and really all physicians), we’ll all get there eventually.

Joshua Tessier, D.O., is a faculty physician and coordinator for research and scholarly activity at the Iowa Lutheran Family Medicine Residency and serves as regional assistant dean for Des Moines University at UnityPoint Health – Des Moines. His professional interests include research, medical student education and evidence-based medicine. He enjoys time with his family, cruises, and drum and bugle corps -- all great buffers to burnout.

Wednesday Apr 22, 2015

Balancing Act: There Is More to My Life Than Just Medicine

We are so much more than the sum of our parts. As family physicians, we treat patients who have an amazing variety of problems. There are virtually as many chief complaints in our ledgers as there are patients to go with them. We see headaches and allergies and chest pain and gastroesophageal reflux disease and hypertension and lacerations. And the list goes on.

And much like the variety in our patient populations, we need variety in our lives. Much has been written -- including on this blog -- about physician burnout and work-life balance. Sadly, little is written about the things we do outside the office or hospital. 

Who we are as people was cemented long before we finished residency. Often, our innate love of conversation, creativity, learning or some other skill or interest is what drove us to medical school in the first place. Out of some misbegotten fear of being selfish, we often forgo that one day a week, or even one day a month, during which we take time to do something just for ourselves.

Here I am preparing for the Warrior Dash in Mountain City, Ga. Physicians should follow our own advice more often and make time to take care of ourselves.

I frequently care for patients with anxiety and depression. One of the first questions I ask is, "What do you do for fun?" When I asked a patient that question recently, it dawned on me that rarely do I see that question asked of physicians in articles concerning physician burnout. With all the publicity this topic has garnered -- and so many lives on the line -- no one seems to ask one of the fundamental questions that helps gauge our mental well-being. I fear we don't ask it enough of ourselves, either.

Although concerns about patient care and the business of medicine fill our workday, and family obligations account for much of our time away from work, we still have to make time for our passions.

I enjoy writing. I also enjoy creating many types of art. From movies to paintings to sculpture to woodworking, I like using my hands to create. In some cosmic, karmic balance, it seems to offset so much of the destruction I see both in the clinic and in the world around us. I have friends whose passion drives them to scale tall rock structures and others who find peace in riding a bicycle for miles. You may enjoy knitting or flying or sitting quietly on a rock. The important part is not the activity, but the feeling the activity inspires.

It may sound trite, but we each need to be reminded why we go to work each day. We need to be reminded why we fight to save lives. We need to be reminded to live our own lives. Just as our brains cannot function without glucose, we cannot function properly without fun. Our bodies need to recharge. That's why we eat. Our brains require the same, which is why we sleep. Our spirits, if you will, require the same level of maintenance. Activities that bring us joy serve the same purpose as food or sleep. They allow us to constructively deal with the complex emotions tied to caring for the chronically ill. Pursuing an activity because you want to -- not because you have to -- rekindles the passion and fire we so desperately need when caring for our patients.

The body is more than an eye or a foot. So, too, are we more than physicians. No one is only one thing. Being a doctor is fundamental to who I am, but it is also only one part. I diminish myself when I ignore the other parts. I'm a father. I love spending time with my three daughters. I'm a husband. Spending time with my beautiful, patient wife brings me joy like nothing else. I'm a writer. In both this blog and others, I write about the things I love. I'm a tech geek. Every new gadget purchased brings a sense of wonder that I've felt since I was 5 and used my first computer mouse. I'm a doctor. I thrive on seeing lives changed by improving the health of my community.

Fitting all of these activities into my day-to-day life requires careful time management and purposeful scheduling. Unfortunately, there are only 24 hours in each day, and I need to sleep for a few of those, so I'm limited in the number of things I can do per day. Fortunately for me, there are lots of days each week and even more when looked at in terms of months. It takes a conscious effort to incorporate these small breaks into my life, but they don't lose their flavor through lack of spontaneity. I still enjoy writing or painting just as much when I've planned the time a month in advance as when I get to do it spontaneously. Much as I do with other aspects of my life, I set realistic expectations. That way, when I get extra time to put together a video or play a game with my family, that activity far exceeds my expectations.

No one-size-fits-all method to combat burnout exists. We each have to figure out the balance our life requires and how to get there. For me, were I to remove any one of the things I enjoy, my life would not cease to progress. I wouldn't just lie down and die. But neither would I feel completely whole.

I think Ferris Bueller said it best: "Life moves pretty fast. If you don't stop and look around once in a while, you could miss it."

Gerry Tolbert, M.D., is a board-certified family physician who practices in northern Kentucky. A lifelong technophile, his interests include the intersection of medicine and technology. You can follow him on Twitter @DrTolbert.

Tuesday Dec 23, 2014

'Tis the Season: For Us, Holidays Mix Sacrifice, Blessings

It's holiday time, which means it's time to set the "out of the office" email auto-response, close the laptop and turn off the office lights for two weeks. Except … that's not how our lives really work, is it?

We are family physicians, and although our practice environments differ, this fact unites us. As we take some time off to celebrate with our family and friends, we know that we don't ever entirely turn off as a physician, especially one who has chosen family medicine as a specialty.

DMW Photography

I plan to spend as much time as I can with my husband and daughter during the holidays. But I also will be doing some clinic work, and I have several maternity patients who are due soon.

It can be difficult at times to juggle all of the responsibilities in our lives: our spouses, children, extended family, friends, church, community and -- of course -- our patients. This becomes apparent to many of us during the holidays when others around us who work in different professions take their leave and turn their minds and attention more fully to the festivities.

For me, I have several maternity patients due this holiday season. I don't know if they will deliver on Dec. 24, 26 or 31, but I do know one thing: Whenever it happens, I'll be there.

This may mean that I miss Christmas Eve dinner with my family, or that we have to reschedule a planned gift exchange with relatives. It may mean spending New Year's Day bringing a new life into the world, which I did two years ago.

It has, in years past, meant needing the understanding of parents, siblings and grandparents when I was absent for part of our planned time together because I had to be there for a laboring patient or one who was admitted for a serious illness.

Sometimes it means stepping away from the table when the hospital calls regarding a patient and having the laptop out at times to check lab reports and answer messages via our patient portal.

I will be at work during the day while I have guests visiting this holiday season because my clinic will be open two days each week during that time, and I have notified my guests in advance.

I'm not going to lie; there are times when I resent the constant connection to my phone, but the hospital and my nurse have to be able to reach me. I have sighed -- heavily -- as I hugged my 2-year-old and put on my shoes to go back in to the hospital, even though I was on call the night before and hadn't seen her for more than an hour in two days. And we both cried because she didn't want me to leave.

I have reluctantly told friends we cannot meet them for a weekend away because I am covering maternity call, and my partners are out of town.

We sacrifice a lot of ourselves, of our lives and our family's lives to serve our patients. This can be an overwhelming and exhausting responsibility, but as those of us who have the privilege of our patients' trust know, it is also the greatest gift. Although I will be working during the holidays, I will also be taking time off to refresh and enjoy my family. I will have several days out of the office and away from the daily grind, but I will always have my phone nearby. I will have meals with my family interspersed with meals at the hospital and midnight snacks from the nutrition room while waiting on a baby.

And when I feel like sighing, I will remind myself that I am one of the most fortunate people I know. I have the chance to serve a community, to help bring new life into the world, to comfort my patients and to experience one of the best jobs there is. This is our gift not only this holiday season, but every day, and with this we are so incredibly blessed.

Beth Loney Oller, M.D., practices full-scope family medicine in Stockton, Kan.

Wednesday Oct 08, 2014

Culture Shock: Practice Transitions Impact Our Loved Ones

We all know how difficult residency and the transition to practice can be for physicians. But what often gets overlooked is that this also can be a tough time for our loved ones -- spouses, children, significant others, friends and other family members.

Nearly half of U.S. marriages end in divorce, and the divorce rate is even higher among physicians than it is in the general population. But does it have to be that way?

My wife and I have three children. Because of my packed schedule as a student and a resident, my wife struggled with the feeling that she was "doing it alone" when it came to raising our family. Now that my schedule is more flexible and I am more available, she and I are adapting to changing roles. Not only did residency and entering practice change me as a person, but it changed my family as well, and sometimes it's hard to go back to "normal," or even to define what that is now for us.

Open communication has been the key to ensuring our relationship has stayed healthy. My wife says it has been difficult for her to know how to provide emotional support as I have advanced in my career. Although I am grateful for her support, I know she is sometimes unsure how to help me deal with experiences such as taking on new leadership roles, becoming increasingly accountable to my patients and medical decision-making, and going through a malpractice case.

And she certainly isn't the only one who has found the transition disorienting. As we start practice and get established in our profession, many of us move to a new area. Many take on the added responsibility of buying a house. While we struggle with professional responsibilities, our families often struggle with transitioning to a new place and trying to find a new support network. This can also include new jobs for our loved ones, which can be just as stressful for them as our own transition is for us.

Children, meanwhile, sometimes struggle with attending new schools and trying to make new friends and can feel neglected during this experience if we fail to show them special attention.

Perhaps somewhat counterintuitively, the sudden increase in income that comes with transitioning to practice also can cause significant stress on families. Many of us who traversed the difficult financial times of medical school and residency act as if heavy shackles have been removed and we can now live the lifestyle that we expect physicians to live. But the realities of loan repayment; the need for life, disability, and malpractice insurance plans; the desire to build up a prudent amount of savings; and the need to begin looking toward the financial health of our retirement can put a large dent in those financial expectations. This stress can be alleviated somewhat by open communication about expectations, budgeting and proactively managing finances instead of incurring further debt to change our lifestyle.

The increase in free time that often accompanies this transition can also be problematic. My family expects more of my time now, but I'm also interested in hobbies that I had to put aside during medical training. Devoting ample time to my family and friends is crucial to them and to me, although it can oftentimes mean my other interests have to take a back seat.

My family means everything to me. But I realize that as I have gone through the difficulties and changes inherent in medical training, I have sometimes failed to take into account how these stresses affect them. In my case, healthy communication and appropriate expectations have been the keys to managing these tensions, and I would just offer this advice: As we go through our unique experiences in becoming physicians and establishing our careers, it is crucial that we not neglect those who mean the most to us.

Kyle Jones, M.D., is a faculty member at the University of Utah Family Medicine Residency Program in Salt Lake City. He is the director of primary care at the Neurobehavior HOME Program, a patient-centered medical home for those with developmental disabilities. You can follow him on Twitter @kbjones11.

Wednesday Sep 17, 2014

Choose Well: Helping Patients Act on Their Choices Reminds Us to Do the Same

When my oldest daughter was a baby, she came to work with me almost every day for the first nine months of her life. I co-owned a fledgling private practice then, and it was cheaper and easier to bring her to work with me than to send her to daycare. I loved every moment of bonding with her, and patients actually enjoyed having her there. Once I started leaving her at home with family, patients often asked, "Where is Ella?"

At first, my wife and I were somewhat concerned about possible exposures or infections she might pick up at the office, but these concerns were limited, and the advantages of having her there far outweighed the day-to-day risks. I chose to keep her with me based on multiple factors, including money, time and -- frankly -- safety. Recognizing that there are risks inherent in sending a child to daycare, my wife and I chose to live with any consequences that might arise from Ella being in the practice environment. She survived intact, and I spent several formative months with my daughter without sacrificing patient care.

Helping my patients made going back to work after a short paternity leave bearable. Here I am talking with Tracy Miller, L.P.N., about a patient on my first day back in the office.

Fast forward to today. After the recent arrival of twin girls, we now have three children younger than 2 years old. And with my current job, taking the girls to work isn't an option. That made returning after a brief five days off quite difficult.

I have a relatively straightforward schedule, though, and limited after-hours duties, so I've opted to return to work full time, which will allow my wife to return from maternity leave to her job as a pharmacist part time and give her the chance to spend more time with the girls.

My patients have been excited about the twins. Many even ask to see pictures when they come into the exam room. They've offered congratulations, and my pride swells each time I get to show off my wife and our daughters. Conversation eventually turns to the medical issues at hand, but I'm more than happy to talk about my family for as long as the patient will let me.

That simple act of sharing sets primary care, especially family medicine, apart from other specialties. We take care of multiple family members, often multiple generations, through all stages of life. In essence, we act as part of the family. We expect patients to share the most intimate details of their lives and their health with us, knowing that we must maintain the medical distance required for good judgment. I tend to allow some of my own life to bleed over into the conversation, though. Not intrusively, I hope, but as reciprocity. How can I expect a patient to tell me everything if I'm not willing to share? Building relationships requires work from all parties involved. My patient-physician relationships are stronger when we both share some of ourselves.

Working together to find the least objectionable solutions for illness is the part of the job that makes it more than just a job. I missed that when I wasn't working.

None of that makes leaving Sara at home with the girls any easier. I occasionally worry that I will miss milestones or the small moments that make life so interesting. Each of us chooses where we spend the 24 allotted hours of our day, so I'm not any different than anyone else in that regard. I just hope I'm choosing the right place to spend the time I have. So far, so good. Would I be excited and happy to be at home all day long with my wife and three little girls? Of course. There would likely be some psychiatric diagnosis attached to my personality if I wasn't. However, staying home is not an option, so I will continue with the choices I've made and live with the results.

I won't be home as much, but I am determined to work hard at being both physically and mentally present when I am. I don't turn off my phone (although I probably could), but it takes a backseat to my wife and daughters when they want my attention. It can be a struggle, but it is always worthwhile. We talk a lot about work/life balance in this blog, from what type of practice we have to how many extra activities we can fit into our lives. It can all be summed up, though, with two words -- "choose" and "act."

As physicians, we make thousands of choices each day -- some great, some small. We and the patients under our care live with the consequences of those choices. It's the small amount of control we can exert over our environment. Helping my patients make the best possible choices is, for me, one of the most rewarding parts of being a physician. I happily return to that part of my job each day. It was that part of the job that made returning to work bearable, considering what I was leaving.

Gerry Tolbert, M.D., is a board-certified family physician who practices in northern Kentucky. A lifelong technophile, his interests include the intersection of medicine and technology. You can follow him on Twitter @DrTolbert.

Thursday May 15, 2014

Overcoming the Stigma of Mental Illness in Physicians: My Story

Pamela Wible, M.D., a family physician who is an expert in physician suicide prevention, recently asked other physicians why so many in the profession kill themselves. The answers were plentiful, tragic and not at all surprising.

One physician confessed to having posttraumatic stress disorder after medical school. Another cited constant sleep deprivation. Yet another mentioned the combination of a crushing workload, a difficult boss and payers who are more worried about the bottom line than patient outcomes. That’s just a sample.

When physicians seek assistance for mental health issues like anxiety and depression, it not only helps us, it helps our families, friends and patients.

More than 300 physicians commit suicide every year; that's a higher rate than the national average. Burnout and mental illness have garnered attention both in the mainstream media and medical journals and threaten to exacerbate a growing primary care physician shortage. But despite widespread recognition of this very real problem, a stigma remains among physicians. Thus, many physicians remain reluctant to seek needed care because they think they should be impervious to perceived weakness. However, we cannot properly care for our patients if we have problems that impede our ability to do so.

This is my story of mental illness, and I hope it can help others with similar health issues.

I began having problems with anxiety when I was in high school. It mostly involved social interactions, and I would get nauseated and sometimes have diarrhea. It usually only lasted a short time, and I could overcome it well enough to function. I didn’t recognize any depression during this time, but the anxiety -- combined with the natural angst of adolescence -- may have covered up some signs of illness.

At age 19, I served as part of a church-based mission to Ukraine. My GI symptoms worsened during this time, but I didn’t recognize it as anxiety or depression. I was convinced I had parasites or another infectious process (neither of which is uncommon among Westerners living or traveling in the former Soviet republics). I struggled through it without much medical intervention until I returned home two years later.

My symptoms persisted, especially as I began my premedical studies. I saw an internist about my complaints, and he was convinced that I had giardiasis. I had several negative stool tests, however, and eventually I was told I would just have to learn to live with it.

After getting married and dealing with the increasing financial struggles of a young couple going to school, I ended up having a full-blown panic attack while I was working a night shift at a group home for the mentally ill. This experience, combined with the growing understanding of mental illness I gained while working in that setting, helped me to recognize my problem for what it was: I had generalized anxiety disorder.

I was nervous all the time -- about life, about money, about getting into medical school. I couldn’t control it. I lost sleep sometimes and significantly overslept at other times. I didn’t eat much. My GI symptoms persisted, and I began to realize them as irritable bowel syndrome secondary to my anxiety.

I saw the student wellness physician, who started me on Prozac. The first month was terrible because of the side effects, but I stuck with it, and the medication began to help. I was more productive and felt better than I had in years.

After being accepted into medical school, I thought my anxieties were behind me, so I tapered off of the medication. That was a mistake.

My symptoms returned, and I tried to fight through them. Despite the staunch independence that prevails throughout the medical culture, I eventually realized I couldn’t deal with this on my own. Psychiatric services were provided to medical students, so I started seeing a psychiatrist, who put me on Lexapro.

It didn’t work quite as well as Prozac, but the side effects were less significant, so I stuck with it. For a short time, I also was on clonazepam, but I found that depressed me too much. I started seeing a counselor. I had seen one during my undergrad years but had found it dissatisfying because I didn’t think my problems were legitimized by the therapist. I had a slightly better experience this time around, but still found it difficult to connect with the therapist and believe that she really understood what I was going through.

I am still on Lexapro today, and it works fairly well. I go through peaks and valleys with my symptoms, and I have had some depression in the years since I started residency. I have tried another therapist but still find it hard to connect and let that person in fully.

Thankfully, I can talk about my issues with my wife. As physicians, we have a higher divorce rate than the national average and a higher rate of unhappy relationships, even if we don't divorce. This underscores the importance of being able to share our feelings with someone we trust, no matter who it is, and of seeking counseling when needed. Now I am giving therapy another shot to help me better manage my symptoms.

Fortunately, I have never considered suicide, or even leaving the medical profession. Despite my illness, I still find hope and value in working with my patients and focusing on their needs.

Being a physician is hard. We all know the pitfalls and frustrations of the profession. The harsh reality is that physicians commit suicide more often and have more problems with substance abuse than the rest of the population.

Physicians avoid seeking help for many reasons, not least of which is concern about losing their job or practice. But it's critically important to recognize the problems when they exist and seek help. We are much more likely to cause harm to others and ourselves when we avoid getting help.

The stigma is sometimes difficult to overcome, but seeking proper services not only helps us, it helps our families, our friends and our patients.

I know I'm repeating myself, but I can't say it enough: Please don’t hesitate to seek assistance when you need it.

Kyle Jones, M.D., is a faculty member at the University of Utah Family Medicine Residency Program. He is the director of primary care at the Neurobehavior HOME Program, a patient-centered medical home for those with developmental disabilities. You can follow him on Twitter @kbjones11.

Thursday Feb 13, 2014

Finding Balance at Home, Practice Makes it All Worth the Effort

At the end of last school year, my son's first-grade teacher asked each child in the class what they wanted to be when they grow up. Then she took a photo of each student holding a small chalkboard with his or her answer written on it.

My son's chalkboard said "doctor."

As a full-time family physician and mother of four, sometimes I ask myself if the crazy balancing act our lives have become is all worth it. Would my family be better off if I worked part-time -- or not at all?

Helen Gray, M.D., pictured here with her family, says scheduling and multitasking are key to finding the right balance between home and work.

Little moments like that one let me know I'm doing the right thing. My son has spent time at my practice. He understands that my job -- helping people -- is important, and he sees me as a positive role model.

Of course, there are days when figuring out this work-life puzzle isn't easy. How do you juggle being a mom, wife and physician -- not to mention friend, daughter and more? It's a learning process every day. But at the end of the day, it's manageable.

Our children are 7 years old, 4 1/2 years old, 22 months and 5 months. My timing hasn't always been impeccable. Our first baby arrived during my third year of medical school, and our second was born during my intern year. No. 3 was born during my first year in practice. Baby No. 4, who was a surprise, was born last year during this, my third year of practice.

Although all newborns require some adjustments for families, the arrival of our third child was the most stressful for me. I found out I was pregnant in July, the month before I was supposed to start my job.

I worried about how my employer and new colleagues would react to the new physician who needed extended time off less than a year after being hired.

I worried if I was spending enough time physically at work, seeing my patients, building my practice and being focused on medicine, charts, billing, etc.

I worried about going on leave, away from my new patients, after spending several months building my practice and getting to know those patients.

And I worried if I would have enough time to be a good mom to my three children. The arrival of baby No. 3 gave us a newborn at home, one child in school and one in preschool. And the two older children have full slates of activities: piano, soccer, basketball and swimming for my son and gymnastics and dance for my daughter.

How do I get all my work done and make it to my kids' games, recitals and other events? It's not easy, but I'm not afraid to ask for help. Fortunately, my parents live in town and are willing to help. And my husband, who is a mortgage banker, has a flexible work schedule.

We look at our calendar each week and figure out what has to be done and by whom. You have to know your limits, and sometimes you have to say no -- at work and at home.

That first year out of residency wasn't as crazy as I had feared. My pregnancy went smoothly. I went to my physician frequently, and being on the other side of the patient-physician relationship reminded me what it's like to be the patient. That helped improve my bedside manner. Likewise, my experience as a mom has helped me with my own pediatric patients and in working with new parents. I can relate to different stages of life because of my own experiences, and that has made me a better family physician.

Now with four kids, our days are definitely full. But we all have same 24 hours in a day, so how do you maximize that time? Multi-tasking helps. For example, I plan to breastfeed my youngest child for at least a year. I set aside time to pump every day at work, but I also chart while I pump. And I'm available to staff to answer questions during that time.

There definitely have been moments when I've questioned myself about work -- usually when there is a family event I can't make it to -- but I've never come close to walking away. I'm too invested in medicine. After a rough day, there's always the next day and new opportunities. More often than not, my schedule goes as planned -- or close to it -- and I make it to my kids' activities.

At the end of one particularly hectic day recently, I scrambled across town to get to my son's school program, just in time to see him searching the audience to see if his family was there. The smile on his face when he saw me walk in made it all worth it.

How do you balance your responsibilities to work and home?

Helen Gray, M.D., is an employed family physician in Reno, Nev., working in a hospital-based setting. She also is adjunct faculty with the University of Nevada School of Medicine. You can follow her on Twitter @helengraymd.

Friday Feb 07, 2014

Changing the Trajectory of Burnout in Medicine

Medicine is my second career; my first was musical theater. Like medicine, that career sounds intriguing, glamorous and even sexy. And like medicine, in reality it is all-consuming, gritty and even dirty.

I left my performing career completely burnt out -- emotionally exhausted and detached with a low sense of personal achievement. I'm trying to prevent that in my second career, but it isn't always easy. 

 Heidi Meyer, M.D.

Although the concept of burnout is appreciated by most, its prevalence, definition and impact are not. It is not a diagnosis found in the Diagnostic and Statistical Manual 4 or 5, but it has a specific criteria and even a validated inventory, much like depression. The Maslach Burnout Inventory has actually been given to hundreds of medical students, residents and physicians in what is a considerable body of research.

The data is overwhelming: medicine, as a career, has a singularly high level of burnout -- much higher than other high-stress careers, such as teaching or being a first responder. And it starts early. One study found 76 percent of medical residents have symptoms of burnout. It may be that many physicians start their careers in a state that traditionally would make someone end a career.

This, of course, leads to more part-time health care professionals, a shorter career span, and, quite clearly, higher costs and more medical errors. Yet despite this epidemic of burnout and its negative effect on workforce and patient care, the conversation on this issue has barely begun.

Some may suggest that the revised resident work hours that went into effect in 2003 (has it really been that long?) was the beginning of that conversation, but I would argue otherwise.

Although work hour reforms were spurred by a patient death, preventing burnout was not the goal of limiting hours. The primary goal was to protect patients. The call for shorter work hours was not a new one, but it was only heard when the daughter of an influential person died because of a medical error made by a tired resident.

However, looking at the Institute of Medicine (IOM) report that spurred and informed duty hour reforms, the term "burnout" is used more than 50 times, suggesting that the IOM acknowledged it as a major contributor to patient morbidity and mortality.

What is burnout exactly? Maslach defines it as a high level of emotional exhaustion, a low sense of personal achievement and detachment. Two of the three do not seem to apply to family physicians -- and if they did, most everyone would be burnt out. It's that middle trait -- the low sense of achievement -- that is so ironic.

You are telling me a physician can have a low sense of personal achievement? He or she is a physician for goodness sakes. What more does one need to feel achievement?

But as we all know, we have a job that can feel more like Sisyphus than Galen, and the rock rolls right back down the hill at the end of the day. The perception of achievement is subjective, and it turns out, certain people have traits that make them more likely to burn out when under stress.

A lot of those traits are ones we find in physicians. Yep. Not only are we training our physicians in a way that is likely to burn them out, we select for those traits in medical school admissions. We literally mine for a high-risk pool, expose them to that risk and set them free. It's a bit like giving the opioid risk tool to a bunch of patients, then giving oxycodone to only the highest scorers for seven to 14 years, and then being shocked that you end up with a bunch of addicts.

So what can we do? First of all, we can start looking at the type of students we admit; we already know admissions criteria skew in a way that those most likely to be drawn to -- and be good at --primary care don't even get in the door. But do the criteria skew in a way that selects for burnout?

Ironically, one of the biggest predictors is a high level of empathy. Sad, isn't it? Those who are most invested are the individuals most likely to lose that connection, and in doing so, become likely to leave medicine. Family docs are empathetic -- we have to be. So are we doomed to burn out?

Should med schools look for those with primary care personalities when those traits are a set up to leave the field early?

That brings us to the last point about burnout: it's preventable and reversible. Empathy is predictive, but resiliency is protective and can be learned. Resiliency -- a set of skills that allow us to navigate change with grace -- is something we can teach. Eureka! A solution!

Now all we have to do is require medical schools to add one more course to the already large stack -- one on resilience -- and we will save money, lives and careers.

Anybody know anyone at the Accreditation Council for Graduate Medical Education?

Heidi Meyer, M.D., is an employed integrative family physician at Kaiser Permanente, San Diego. She enjoys yoga; dark chocolate; weekends in Vegas; bonding with her ferocious 9-pound dacshund, Bella; and plotting a drastic overthrow of the house of medicine. You can follow her on Twitter @tweetyturt.

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