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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.


I know how to help: let's increase the number of mouse clicks and field changes family docs do every day, increase the number of patients they should see every day, institute PCMH, and make payment predicated on outcomes in non-compliant patients. If none of that works, how about increasing the amount of government regulation and tightening up on "the two midnight rule." In short, "the beatings will continue until morale improves."

Posted by walter beverly on February 10, 2014 at 02:00 PM CST #

I agree with Beverly. Burnout is increasing because of increasing external stressors driven by the government and the insurance industry. Learned helplessness is what is causing burnout, not the type of people who choose to become physicians. In this case Caesar was wrong. The fault, dear Heidi, is not in ourselves, but in our Obamacare.

Posted by Keith Dinklage M.D. on February 11, 2014 at 07:17 AM CST #

When I finished residency in 1996, I was burned out. I worked locums and eventually joined an excellent medical staff and was struck by the high rate of burn out I was seeing in many places in our country...in 1996. There are skills of resiliency that can be studied, understood and hopefully help improve the satisfaction and longevity of what we do. Just as there is no one model of a family doc, there is not a single solution to this problem, but there is a single starting place that is recognition and ownership of the problem. The external pressures that have increased in the past twenty years are painful to recognize, but in and of themselves are not the cause of burnout. Burnout in the form of alcoholism, family breakdown and drug abuse in the medical profession was a problem when patients paid in chickens and cash and there were few specialists. We must work to improve the system in its own right, but this is a seperate issue from the origins of burnout. Dr. Meyer, you have begun an epic journey and I will be happy to contribute.

Posted by Michael Lambke, MD on February 12, 2014 at 08:37 AM CST #

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