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Monday Jan 23, 2017

After Hitting the Wall, How Do I Bounce Back?

I've been out of residency less than three years. Throughout my training, I heard patients talk about other physicians and say things like, "She was different when I first saw her," or, "He used to take more time with me. He just doesn't seem the same as he did a few years ago."  

Most of the time, I didn't know the physicians my patients were talking about. But regardless of my personal knowledge of the physician in question, my answer was always the same: "They are probably really busy and just feel overwhelmed." And each time I worried a little more that one day, I would be the doctor who seemed different to her patients. 

Two weeks ago, my fear became reality, but I've since found some ways to address it.

I used to run a lot. There is a concept that runners call "hitting the wall." Everybody understands what it means -- you have done so much, and you can do no more -- but the moment you actually hit the wall is unforgettable. You truly have nothing left to give, and no adrenaline or discipline can overcome the fatigue.  

Two weeks, ago I hit the wall. But I wasn't in my running shoes. I was at work. The term one of my colleagues used was "compassion fatigue."  

Our work as physicians isn't primarily physical, anyone wearing a Fitbit can tell you that. It is the mental overload, the endless work we have to do that is unrelated to the actual patients in our offices.

The priority should be the patient in the exam room, and for some time each day, it is. But the bulk of our work takes place outside the exam room, doing things we enjoy far less than being in that room with the patient. We went to medical school to be in that room, and we chose family medicine because we absolutely love being in exam rooms listening to patients tell their stories.  

Increasingly, physicians are choosing to work in employed settings. The AAFP conducts surveys to track these data on employment settings and even what types of procedures are performed or diseases are managed to ensure the Academy is serving its membership and providing appropriate resources and CME. I've heard criticism from older doctors that younger doctors, like me, don't want to run our own businesses; we just want to go to work and get a paycheck. That stance has repeatedly annoyed me. I chose my federally qualified health center setting primarily because I wanted to see uninsured patients and have access to a 340B contract pharmacy for their medications.

There is also the reality that it takes staff to navigate meaningful use, quality metrics and incentive-based payments from all the insurance companies, which has made it increasingly challenging to own one's practice.

But not until I had a couple of years under my belt did I also have the insight to speak to the downfalls of being an employed physician.

I spent two years pouring my heart into my patients. I agreed to be overbooked to see any patient of mine who walked in requesting a same-day or sick visit, regardless of how busy I already was. I accumulated 31 homebound patients. Not a day passes that I don't hear from a family member, caretaker or home health nurse regarding one of my homebound patients, and sometimes I get calls from quite a few. I was working long hours, working though lunch to see more patients, going on home visits during lunch or after office hours.  

My last scheduled appointment is early in the afternoon, but I often was seeing patients up to two hours later because of overbooking and home visits.

But I was happy, and I wasn't complaining. And my nurse was happy, but what I didn't once think about was the fact that all my work meant she was getting paid overtime.

As an employed physician, I don't do payroll or review time sheets. I don't even know what people in the office make per hour. So here I am thinking that I'm just killing it, building a large patient panel, running quality metric reports, coming up with strategies to improve measures and outcomes.

Then just like that, I hit the wall.  

Hard.

Why? Administration came down hard and said no overtime for my nurse. None. Disciplinary action would result from any more overtime.

At the same time, everyone else in the office decided they couldn't talk to any of my patients -- that all calls had to be dealt with directly by me or my nurse because they couldn't complete their work within their scheduled work hours, either. Some things had to change.  

After I got past being so angry I couldn't even start to formulate a survival plan, I started to rationally think through how I could do all this work while allowing my nurse to have a hard stop every day. And I realized I couldn't.

Maybe my frustration had nothing to do with the actual administration vs. nurse situation. It may have been rooted in my epiphany that what I want to do every day is not possible. I had built a patient population with what are apparently unrealistic expectations. I can't agree to see all of my patients who walk in acutely ill. Someone else will have to, or my nurse won't get to clock out for lunch. I will cut down my homebound patient panel and refuse to accept new ones.

This is not how I envisioned medicine, and it's not how I imagined working as an employed physician would be. I am in one of the most supportive employed physician settings I've heard of. I have longer visit times than most physicians, I can change my schedule on short notice to accommodate my family's needs, and I take zero call.

Yet I wasn't spared from the wall.

Being a doctor now feels like an impossible feat. Not once does a patient walk out the door that I don't think of some quality measure, lab order or discussion I was supposed to have to satisfy an insurance or agency metric that I just didn't have time to do.

I'm depressed, and I'm burned out. And I'm less than three years out of residency.

This is not good for our patients or for the future of medicine. Granted, I'm not representative of everyone, but too many will relate to my story.

I'm sure people will have suggestions for how things could be done differently in my particular office. Clearly, additional staff would alleviate some issues, but in the end, none of the above details matter because too many physicians are becoming less happy and more miserable.

Suicide statistics are alarming, and many of us have lost a colleague. Too many of us are one step away from hitting that wall, and the only people who truly understand are those who have been there. I hope that as more of us talk about it, just like with any unspoken trauma, doctors will be more comfortable reaching out for help.  

Although the buzzword is burnout, the real problem is depression. Two years ago at the National Conference of Constituency Leaders (NCCL), a new physician delegate broke into tears talking about the time she hit the wall. She didn't use those exact words, but in retrospect, that is exactly what she was trying to convey to those of us drafting resolutions. A year later at the same event, she spoke about how support from other new physician delegates at her first NCCL had not only helped her in her practice back home but had motivated her to get involved at a higher policy-making level to work on issues that are beating us down as physicians.

Particularly as new physicians, NCCL is our home, our place of refuge. We all have a connection, and regardless of the long hours or the stress of residency, we have camaraderie with our fellow residency classmates because we all endured it together.

To the overwhelmed, depressed, already-tired-of-medicine new physicians out there, NCCL is your throwback to the call room. Come and find someone who knows exactly how you feel, and more importantly, hear from those who have found concrete solutions in their practices, because there will plenty of those, as well. This year's event is scheduled for April 27-29 in Kansas City, Mo.

In the meantime, there are other ways to communicate with your family medicine colleagues, including the AAFP's online communities, which include the Academy's member interest groups.  

The Academy has made improving member well-being a high priority. Last fall, a track on well-being was offered at the AAFP's Family Medicine Experience. The AAFP also plans to roll out expanded resources with the goal of improving family physician well-being and decreasing the burden of physician burnout later this year.

In addition, the Academy recognizes there are far too many barriers to providing high quality care and it continues to work to alleviate the system issues involved.

For me, my personal plan also includes saying no, often, to things that get in the way of me sitting in the exam room -- or a patient's living room -- listening to patients tell me their stories.

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

Comments:

Thank you for bringing light to an all too covered over issue--what we expect for our patients is what we ourselves must do first. FIRST DO NO HARM--has to apply to ourselves!! It is a treacherous balancing act between doing "just one more" and actually enjoying the LIVING of each moment. Finding balance first, resting, eating--actually not holding our bladders--and leaving that stethoscope with all it's connections in the office at the close of the day. Even if that means not meeting that productivity, PHQ bonus....my life and my family means more than that!

Posted by Lori McFann on January 23, 2017 at 06:03 PM CST #

Great job, Kim. I'm also 3 years out and just hit that wall too. All because a family crisis came out of the blue and added an anvil to my already precarious juggling act. I now realize the danger of pushing one's limits until there is no room to deal with one more thing - the straw or tree limb that breaks the camel's back so to speak. I think we all are at risk for making this fatal error. The combination of an over-achieving nature with limitless drive and boundless ambition married to empathy, compassion, and a can-do spirit can be very self-destructive. Having learned this lesson, I am taking strides to fix it - cutting back on new patients, reducing nursing home rounding, and limiting unnecessary extracurricular busy-work. Hence, I haven't written one of these Fresh Perspective blog articles in a while, but now you have inspired me to do so! There I go again taking on one more thing, but heck, I can handle it! Afterall, I live for the thrill of the balancing act and the sense of relief when each juggled item is finally put to rest in its perfect place at the end of a hectic and rewarding day. Best wishes on succeeding at your own balancing act!

Posted by Kurt Bravata M.D. on January 24, 2017 at 12:05 AM CST #

The buzzword is burnout, the real problem is exploitation. Either say “no” and find an exit or find meaning in the suffering (Man’s Search for Meaning – V. Frankl)... or depress. Understand and accept your choices. I'm hoping that medical leadership will be more focused on how to say no and find healthier exits. The alternative is to promote resources to facilitate more cheerfulness and efficiencies to deal the exploitation.

Posted by Randall Oates, MD on January 24, 2017 at 01:49 PM CST #

This hit home, exactly what I'm going through. It is saying no to even little things - like today I was discharging a NH pt before clinic and the nurse had a question on a pt that wasn't mine and I'm not on call. I respectfully said no that she would need to ask on call, and that I'm working on boundaries. This is hard for me to say no but if I'm going to stay in practice I have to get better at it to survive much less thrive. I am also just 2.5 years out in a rural practice... Feeling tired. Thank you for this perspective.

Posted by Sara Olmanson on January 25, 2017 at 01:44 PM CST #

At my 3year post residency anniversary I lost my mind. Tired of feeling exploited I said no. And opened my own practice (in business for 2 whole weeks now) and I can't stop smiling. hopefully in 3 years I'll still this happy

Posted by CB on January 25, 2017 at 09:32 PM CST #

One of my first bosses (who I thought would share some key values with me, as the clinic was a RHC in an HPSA) advised me one day "Don't ever ask a patient if they have any more questions. If they are due for flu shots, have them return another day so we can charge for two visits. If a patient goes on and on, stand up, go to the door, put your hand on the doorknob, so they know you are done with them."

The hair rose up on the back if my neck; I left the job after a year.

Another job had advertised specifically for primary care doctors, but it turned out to be because insurance companies had threatened not to renew contracts unless the urgent care clinics provided PCPs for patients to establish care with. One week in, a colleague clued me in that management had no intention of providing a dedicated nurse to help me to provide preventive medicine like annual exams and colonoscopy referrals. He winked and said "See a few primary care patients each week, but you can make a lot more money if you see lots of urgent care patients. If a patient has a cold, write a prescription so they think they should always come in for colds. You can really rake it in that way."

I gave my notice then, 2.5 yrs after completing residency, and opened my own bare-bones modest practice 5 miles away in a town that hadn't had a doctor in over 20 years. I knew it would be a lot less money (it has been: 45-55k per year, for the last 18 years) but we schedule only 8-15 patients per day, I see my own hospital patients, make house calls, and fully participate in leadership (for no pay) at the community hospital.

Many other employed young docs have come and gone since then, lured on by bigger paychecks or a promise of less hassles. Those who bought homes on the real estate bubble have been unhappily trapped in their jobs because their houses are "under water." My little practice has turned out to be a durable model: low overhead, plenty of time with patients, and we discriminate in favor of the super-elderly and veterens (a decision I made after hearing that other area practices were not accepting new patients who were seniors or veterens.) Going to work is a bit of a love-fest almost every day.

Patients demanded that I stop renting office space and put the money into paying down a mortgage on a nice old bungalow four blocks from my house. I often walk or ride my bike to work.

Now we have a Family Medicine Residency in our community. Most of them will end up as employed physicians, but they all know that another option exists, that it can be done. When they hit the wall, they talk to me.
:-)

Posted by Dotty B. Walken, MD on January 26, 2017 at 03:12 AM CST #

At a recent leadership meeting burnout was either the #1 or #2 topic when you freely associated with your colleagues in between lectures and seminars, the "water-cooler" talks in the lunch break room. Yet, I was surprised to see that this was not even on any of the formal topics for the lecturers, other than a casual reference by a keynote speaker that the Triple Aim is now also the Quadruple Aim, including physician experience as the new one.

It's kind of like single coverage - we all wants it, agreed on it, but no one who's among the shakers and movers list wants to talk about it in the open. Burnout is like porn - you can't describe it but know it (the wall) when you see it. By the time you actually feel it - it's too late sometimes (suicides). For that reason, you can't rely on the healthcare "system," which nowadays are reducing FP's to a metric cruncher to tell you so.

It used to be so much of the "culture" of healthcare. After all, that's what had attracted 90% of us in the beginning. A family friend, a son of a chairman of anesthesiology at the Mayo Clinics in Rochester, Minnesota, once showed me a picture of his mom. She was a nurse. It was a picture of her back, in a white gown in a BW photo, pushing a patient in a wheelchair down an archaic corridor out of the hospital. That was his (and her) pride. It was all about the patient leaving, knowingly healthy now.

Now we have the opposite forces. Healthcare "markets" have replaced "culture," and hospitals are more concerned about rolling out the red carpets with limo valet pull up service, bringing them in to the front lobby with emerald high glass-walled ceilings. The sicker you are, the more we want you here. No one knows how much it costs, albeit the tax-payers, or the debt burden for generations to come. If shame is looking at yourself in the mirror, for me this fits the definition to the tee.

There's a part of me that says this is "the way it is." Part of me says that history has shown that this won't last. From my observations of the past two decades in medicine I will share with you this - that our leaders of the past 30 years just "do." They have bioinformatics as their leverage. They have made a lot of money. The transition is very intentional and not because of any bad / unwanted random occurrences. It was planned decades ahead, with the epicenter of change being the hospitals (from the hospitalist movement in the 90's to the biggest merger and consolidations in US history that is happening now with hospitals buying up the ambulatory practices). It cannot happen without regulatory approval. It cannot happen without the medical profession taking a bite out of the bait. The failure rate overall for many "systems" is 70% (pretty much any industry standard here).

Posted by Michael N., MD on January 27, 2017 at 11:44 AM CST #

If the previous generation just "do," it is my hope that the next generations will just "decide." You'll have that chance. I hope along with it is wisdom before hand. I also hope that "decide" will also unite the profession in full agreement.

Lastly, a part of the component of professionalism is "collegiality," and I'll share with you something anecdotal recently. I left an organization after 18 years. It's very big, number one in customer base and every metric you can imagine. At the exit interview, the department chair asked me - "what's the matter, you are not satisfied with our competitive pay?" They are, second only to county, the highest paid organization that's private. I sighed, and took a long look at him. After decades of unconditional loyalty for the organization and sacrifice for the patients, I silently said to the wall behind him - "you really don't know me, do you."

Then I composed myself after 30 seconds. I thought about my toiling colleagues that I'll leave behind. I wanted him to take some message back to his boss, the regional medical director.

First, I said, "I'm burn-out." I wasn't really. Genetics has made me fit like a marathon runner in a system that's designed to wear you out. I thank my parents for that.

Then I ended with, "It's my personality that I really want to help people."

They can take away your minds, but you heart will ever give up. Listen to it and follow your passion and you'll be fine. You are a great person just for sharing, among the minority who won't be silenced. Thanks for representing us.

Posted by Michael N., MD on January 27, 2017 at 11:45 AM CST #

I agree that what is labelled "burnout" is realistic fatigue from a traditionally abusive system of training and (now practicing) which exploits physicians' competitiveness, ambition, perfectionism and compassion. No amount of screening for "resilience" or "wellness program" is going to fix the broken system. WE must fix the system, and it will not happen until we insist on it.

There are options like Direct Primary Care, which preserve your autonomy and your love of caring for patients, and have the highest quality and cost effective metrics. Most new grads don't realize its an option or have the training to start a practice. We are being mass produced for employment positions. This does nothing to help the suicide rate or primary care shortage. More docs are leaving clinical practice for administrative positions, retiring early, or living miserably.

My heart goes out to new grads who face staggering debt and few options for repayment without jumping on the hamster wheel of employed practice.

Healthcare reform should not just be invested in more mid-levels, but in caring for the education, establishment, and retention, of DPC docs. Regulation needs to support that DPC is NOT insurance, and require transparency of pricing, and pave the way for membership fees to apply toward high deductibles.

This would be a win-win-win-win for patient, physician, insurance plans, and GNP.

Posted by Michele C Parker on February 09, 2017 at 01:08 PM CST #

Thank you, Dr. Becher, for this brutally honest post.

However, when you say "the Academy has made improving member well-being a high priority," I could not disagree with you more. Despite the happy talk, the AAFP has DONE nothing to address the epidemic of burnout that is destroying our specialty. The Academy is committed to advancing the agendas of CMS and the large insurers; the damage that is being done to our membership seems completely acceptable to our leadership.

I don't see any evidence that things will change anytime soon.

Posted by R Stuart on February 21, 2017 at 12:17 PM CST #

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