20 July 2018
Dear Interested Readers,
Burnout: It’s Variable Impact on Providers and Patients
I read obituaries habitually. It is a habit that I acquired from my wife who inherited it from her Irish father. She refers to the obits as the “Irish sportspages.” I am always drawn to the obits of the very young and of physicians. Both categories are easily found on most days. It is a sad fact that it is easy to discern the cause of death for most of the younger people on the “Remembered” pages. They die in accidents, of cancer, or of overdoses. A few of the younger people that I find in the obits died in the line of duty as police officers, firefighters, or in military service.
The obits of the physicians are usually longer and occasionally show a picture from practice. There is often a comment about how caring and devoted to patients the doctor was and all of the contributions made to science and the community. There was a perfect example of these points this week in the Boston Globe and New York Times. Dr. Alan Rabson, an influential cancer physician and scientist, died at age 92. He had not retired from his duties at the NIH until 2015 when he must have been 88 or 89. I had never heard of him, but as I read on I learned enough to appreciate his contributions, and be inspired by his reported attitude about patient care and the reason he chose to practice medicine.
In addition to his scientific and administrative achievements, colleagues say, what made Dr. Rabson stand out were his kindness, his empathy, his geniality and his willingness to help anyone with a cancer diagnosis who was seeking advice or a referral to an oncologist.
Near the end of the article his son, who is also a physician, commented on his father’s source of motivation.
…there were those phone calls and emails from people seeking help.
“Every evening he would be on the phone” talking to desperate patients, the son said. … Dr. Rabson told him, “This is why I went into medicine — to help people.”
It is the rare healthcare professional, whether they be a physician, advanced practice clinician, psychologist, nurse, clinical aid, administrator, manager, or even senior executive who has not said exactly the same thing that Dr. Rabson said at some point in their experience. I have always felt that one of the reasons why some clinicians cringe when we talk about the need to be more “patient centered” is that being “patient centered” was always their objective. To be able to help people, to be prepared to live a patient centered life is why they endured all those nights on call in the hospital in their twenties while their friends were partying and traveling the world. I had no problem avoiding all of the downsides of the psychedelic, free love sixties and early seventies. Like so many young clinicians of the era I was on the wards, in the clinics, and in the emergency room taking care of the casualties of the day. I never remember anyone questioning the commitment to delivering the best of patient care to anyone who came to us. We rarely talked about our stress and sacrifices, but if we did, we talked about them as if they were badges of honor and the equivalents of the Purple Hearts and Bronze Stars awarded to those who sacrificed in battle. What happened?
To answer my own question, I think that there was a shift in attitude that was perhaps the first step toward real and positive change. Burnout existed then. We just acted like it did not. Just as it was impossible to address issues like PTSD, the injustices from racism in our society, the continuing horror of domestic abuse, or the whole spectrum of crimes against women, until we begin to admit its widespread existence, document its prevalence, and start a focused conversation about how to manage and ameliorate or eradicate it, we can not remove the impact of “burnout” from practice on clinicians or the collateral impact on patients. We must admit that it exists, and that many of us are suffering from it to some degree.
As with many disorders, for “burnout” there is substantial variation in presentation, host defenses, host vulnerabilities, and the combination and frequency of exacerbating events. We are not all the same. We are not all exposed to the same stresses, and we do not respond identically when we we are similarly challenged. We do not have the same internal or external defenses so it is no surprise that awareness, pain, and symptoms of professional dysfunction range from unmeasurable to catastrophic among professionals working in the same place at the same time, who on the surface appear to be the same. I am reminded of two realities when I think about the impact of burnout on clinicians and patients. The first is the old aphorism, “Except for the grace of God, there go I.” The second is the natural experiment involving the exposure of the 1969 Holy Cross football to hepatitis A that demonstrated the variation in host vulnerability of an apparently similar population to a common exposure.
If you do not know the story, it is worth a brief comment because it makes the point that is critical to understanding the way forward with burnout. Through a combination of “never events,” almost 100 very fit athletes got equal doses of water laced with hepatitis A virus from a contaminated source at a break in practice on a hot August afternoon. Over the next several weeks there was a rolling presentation of symptoms in at least two thirds of the team that led to losses in games against theoretically weaker opponents, Harvard and Dartmouth. Finally when the cause was recognized, the remainder of the season was cancelled. Looking at the players as a population, some were virtually asymptomatic, but had measurable changes in their liver function tests, some had mild symptoms, and some, about a third, became very ill. There was also variation in recovery.
We all are aware that some of us are genetically, or constitutionally better prepared to defend ourselves against a variety of illnesses even when we are all “healthy.” Our experience varies because of factors that are beyond our control. A hostile environment, or unreasonable demands in the workplace have a differential impact on their victims. What I can shrug off may be fatal for you, not because I am better or necessarily stronger, but just because of factors beyond the control of either of us. Perhaps that is why our forebears put so much emphasis on fate or the “will of God.”
These thoughts were on my mind this week as I continued to read Lost Connections:Uncovering The Real Causes of Depression–And The Unexpected Solutions, by Johann Hari. I mentioned the author and his controversial book briefly in the posting on Tuesday of this week. As I said in that post, Hari contends that there are at least seven reasons for depression and anxiety beyond the genetic and biochemical explanations that have guided our treatment over the last thirty years since Prozac was approved in 1987. Those other reasons make a lot of sense from the point of view of almost anyone’s experience in the age of globalization, population mobility, increasing consumerism, and the shift from a real world to a digital word of business and human interaction. The unifying concept for his seven alternative explanations is “lost connections” which in itself reminds me of those fearful moments when my Internet connection is suddenly interrupted as I am writing one of these notes, or the way I felt back in my practice days when “the system” went down, and I was forced to practice without the data I depended upon coming from our EPIC EMR.
For ready reference those lost connections that Hari postulates are:
- Disconnection from Meaningful Work
- Disconnection from Other People
- Disconnection from Meaningful Values
- Disconnection from Childhood Trauma
- Disconnection from Status and Respect
- Disconnection from the Natural World
- Disconnection from a Hopeful or Secure Future
An interested reader who is very concerned about burnout and has begun to directly focus on the questions it raises by talking to healthcare professionals sent me an email this week that further underlined for me the natural “variation” in the experience of burnout. The note also suggests that many of us are afraid of the repercussions in our professional relationships if we confess, complain, or even try to positively approach this “third rail” issue.
Hi Gene,
I just read your Tuesday letter and wanted to tell you what I’m learning about burnout so far. I’m only just beginning, so this may sound simplistic at this point.
From what people have told me so far, burnout seems to depend on the following, not necessarily in this order (and by the way, not one person so far has used the term ‘burnout’ to describe stress, although when asked about the applicability of this word, they agree it applies):
- whether or not they work fixed hours
- whether or not administrators “have their back” and support them
- whether their bosses understand and appreciate the quality–not just the quantity–of their work
- whether (and how much) they are afraid of being sued
- whether they work in pursuit of their own larger goals (i.e., do they keep their ‘eyes on the prize’ however they define it?)
- whether they really are doing what they love…
I haven’t spoken with anyone so far who has mentioned the EHR as a cause of dissatisfaction or burnout, or paperwork (although a couple have said they don’t like doing ‘mundane’ work). That doesn’t mean I won’t–it just means I haven’t yet.
Administrators are often in a different world from the clinicians working in the trenches (one pointed out that administrators need to work in the trenches, too), as you also have pointed out.
Clinicians tell me that sometimes they push back to get the quality of their work to be taken as seriously as the quantity (and this is where their very real fear of lawsuits comes in, as well as their desire to do their best for each patient). But often they don’t push back because they fear reprisals.
This is certainly a tough nut. Maybe the way to reduce what we call ‘burnout’ is to address the underlying issues that are associated with it: fear; inattentiveness; and the failure of parties to listen to each other, talk to each other, and figure out how to make the changes that providers say are needed to help them do their best work…
My first thought was, “She is talking about “lost connections.” Before I could respond, a second email arrived from the same Interested Reader,
I spoke too soon. I talked with someone today who explicitly pointed to the EMR as a real source of diminished joy and explained why in some detail.
This time I was quick to answer:
I was surprised by your first note, but figured that the other issues were even more important or there was some variation in your sampling. I do think the issue is much bigger than just clunky EMRs and dysfunctional work flows. It may be that there are many levels. The systems failures may be surface issues that augment the deeper realities that separate us from the foundations of job satisfaction.
I took your previous note seriously and it got me thinking. I am going to … reference your comment in Friday’s posting if that is ok.
I do believe that there is a significant amount of intersection between the reader’s list of causes for burnout and the issues of disconnections hypothesized by Hari to be the variable origins of depression and anxiety in the majority of people. Hari points out in his careful discussion of each type of disconnection that several can occur at the same time, multiplying their impact in combination. If one has many good connections at home or among friends, and other sources of strength outside the workplace it may be possible to handle disrespect at work, or a “soul sucking job” as one of my daughters-in-law once described her role as a medical assistant that took calls from anxious and angry patients who came off as “demanding.” We label those patients whose needs stress us.
This subject of burnout deserves much more exploration and discussion before we “jump to conclusions” and begin advocating for the first solutions that come to mind. Despite that warning to myself I do have my own working hypothesis which feels like it may bridge the list from the Interested Reader to Hari’s concept of “lost connections.” It may explain why the heat from the little flame of stress that has always been a part of practice has been turned up to the point that everyone is sweating. What has changed is that most practices are now financially stressed or fear that their current success is vulnerable. The medical record is no longer a document about the patient’s problems, history, and treatment, that coordinates care between clinicians. It is now a financial instrument that seeks to maximize the revenue of the practice and determines the income of the individual. The time devoted to the record as an instrument of finance is taken from the time for connections with the patient and productive interactions with colleagues. The image that many patients now have of their caregivers is not a smiling face and a helping hand, but rather an image of the clinician’s back while the person they once faced is looking at a computer screen and occasionally looking over their shoulder to ask a question that can be recorded in an effort to move the encounter from a level three to a level four. You may disagree. It’s just a hypothesis, and probably not the whole story, but there is some truth to it even though it is hard to talk about.
We don’t really understand the multiple origins of depression. And yet, as Hari emphasizes, we have subjected many patients to drugs that may have little more than a placebo’s chance of making them better. Despite ingesting Prozac, Paxil, and a whole host of other meds, many patients get only temporary relief and remain depressed and in pain. I do not propose that anyone act on my partial theory of the origin of the current increase in burnout. Like any hypothesis it must be subjected to study. “Natural experiments” between finance and practice have been going on for decades. We had the era of capitation. We are considering value based reimbursement as an alternative to fee for service. Perhaps we need to more directly observe how finance mechanisms impact the relationship between the clinician and the patient, and measure in more thoughtful ways how finance may impact all of the concerns that the Interested Reader is discovering in her queries about burnout.
Some of Hari’s proposed solutions that might repair the lost connections that create depression and anxiety seem far fetched, like a universal floor for income for example, but deserve further exploration. He sites a Canadian experiment that seems to suggest a universal floor to income may substantially reduce depression. Would an experiment like more generous public funding that tests reducing the stress of failing finance on clinicians and patients show a reduction in burnout? We are still a long way from universal healthcare and have an administration that is trying to reduce, not expand social supports, so that experiment is unlikely to occur in the near future. Some of the solutions that I hear proposed for clinician burnout, like a focus on work-life balance, seem inadequate to solve all aspects of the problem, but cause me to hope for more.
I do believe that recognizing the need for clinicians to have the time to connect with one another, connect with their patients, and pursue ideas that might improve the productivity of their work is a laudable objective that would be a start, one that has been advocated now since the publication of Crossing the Quality Chasm in 2001. Perhaps we will discover if we look closely that how we are paid impacts how we work together to eliminate the overuse, underuse, and misuse of care while improving safety and quality. Talking about the problem of burnout, and accepting that it exists, and is the source of pain for more healthcare professionals and patients than we have ever admitted, is a necessary first step that I think we are finally taking. There is much more to learn.
A Place With Crepe Myrtle, Kudzu, Red Clay and the Beautiful Blue Ridge
Today’s header is a screenshot lifted from an amazing six minute video, “Four Seasons On Little Lake Sunapee.” The drone videographer, Peter Bloch, is an artist/craftsman who is famous for his gorgeous and translucent lampshades that he “frees” from poplar logs. He is my neighbor and has lived most of his life on, or near, the lake we both love. There is also a short video that shows how he makes the lampshades.
In confusing times it is important to feel connected to a place, or maybe a few places. After spending a lot of time over the last quarter century in the Kearsarge/ Upper Connecticut Valley/ Lakes Region of New Hampshire, and the last ten years on Little Lake Sunapee, I do feel connected to the place and the people who also love the area. I am an expatriate of both the South and of the urban hustle of Eastern Massachusetts. I enjoy my trips to both places and return often, but there is nothing that is as soul soothing as looking out at the lake and watching it rotate through the four seasons as I go through the calendar building fires in winter, taking out the gardening implements my wife uses in the spring, fishing, boating, and swimming in the summer and early fall, and walking, reading, fooling around with musical instruments, and playing Mexican Train dominoes with friends the year round.
This week I left the lake to make a trip back to North Carolina where my father has been struggling to regain his health for most of the last year. I have made many trips to see him over the past few years. Recently the trips have been more frequent as his changes in status have become more alarming.
Because of his lower gastrointestinal bleed last October, followed by aspiration pneumonia, and the need for a g-tube less than a month later, followed by many ER visits and short inpatient stays, the last year has been tough for my Dad and his wife, despite the fact that they live in a beautiful life care center that does a lot more than just “assist” living. I have said many times before that if we were trying to imagine an ideal world of care for the elderly, a good starting point would be to give everyone access to someplace like the amazingly well appointed, gorgeously landscaped 130 acres of Abernethy Laurels in Newton, North Carolina.
I am so pleased that such a wonderful place, and such a caring group of healthcare professionals are available to us. I wonder what sort of change in national priorities would be necessary to make such an asset available to every family as an expectation. The fact that only a few have such benefits is evidence of our failure to embrace the the needs of the elderly and focus on the Triple Aim. How we fail our seniors is yet more evidence of how difficult we find it to be to solve the many other complex questions of our times. It is also evidence of the poor choices we make about how to use our collective resources.
Since the very successful and enjoyable family reunion on the Father’s Day weekend, it has become clear that my Dad needs a higher level of care. When his wife suffered a shoulder injury trying to care for him in their home he moved across campus to the nursing facility from which he had been recently discharged. His admission was justified to him as “respite” for her, and as a way of perhaps avoiding the feared move to “the big house” which every intellectually intact resident of such facilities recognizes as their last move. The prospect of returning from the “big house” to even “semi” assisted independent living in your own home becomes a rapidly fading hope.
In my frequent phone conversations with both dad and his wife it became clear to me that I needed to make another trip to North Carolina, even though the last one had been hardly a month earlier. As we discussed my coming, I was surprised to learn that he hoped that during the visit I would take him to see Mars Hill University which is about a half hour north of Asheville. He had started college at Mars Hill three months before his seventeenth birthday back in the fall of 1937, when Mars Hill was a junior college. His uncle, who owned a 1929 Ford ragtop, drove him up to the mountains and Mars Hill from their home in Greenville, South Carolina where his father and most of his relatives worked in the textile mills. He was the first member of his family to go to college. After graduation in 1939, he transferred to Furman where he finished college in 1941. I always had the feeling that going to Mars Hill had been the “leap of his life.”
I agreed to the trip. It required a lot of preparation and accommodation by the staff at the nursing unit where he was getting rehab for his wife’s respite. He requires four tube feedings each day, some with meds. It would be a six hour trip, two hours out, two hours there, and two hours back. His diet has moved up to thickened liquids and some easy to swallow foods from a short list and we decided that he could omit at least one of the tube feedings. After a lot of hesitation and probably against better judgement, we set out. We took Interstate 40 west to Asheville and then I 26 north to Mars Hill. You do not see much other than 18 wheelers when traveling the Interstate. The day was perfect except for the typical mid nineties temp, and the high humidity. Lunch in a pub that predated even his undergrad years, plus a wheelchair spin around the old quad, and a trip to the student union where he bought a baseball cap with a big block MH on the front, did consume the planned two hours. Then we faced the sixty four dollar question. Do we take the Interstate or chance the slower, more scenic, winding country roads down through the mountains and back to the Piedmont? He chose the slow road. It was beautiful.
Kudzu is an invasive plant that covers much of the South in a blanket of green that smothers tall trees and blankets acres of roadside and untilled land, but it is a beautiful green in summer, and the contrast of its huge green leaves with red clay can take your breath away. It also seemed that the yards of the rusted house trailers and little homes along the byways were all adorned with crepe myrtles of sizes ranging from little shrubs to near oak tree magnificence. They were all still covered with their reddish, pinkish, purplish blossoms deep into July. The streets of every little town were lined with the same crepe myrtles. All of this green, red, and near pink/red/purple lay at the feet of the Blue Ridge that we approached on the Interstate and then dove into on our return.
It was a great day. It was such a great day that he asked whether we could go back the next day to Chimney Rock and drive around Lake Lure. He had his honeymoon with my mother at Chimney Rock in July 1944, and his new wife had spent her honeymoon and many happy vacations and weekends at Lake Lure. I said, “Sure, why not.” It was a second great day topped off by a piece of salted caramel creme pie. Is it true that you can have too much of a good thing? I think not. As my dad intuitively knew, there is nothing more therapeutic than renewing a deep connection to place and taking a chance with your diet.
Be well, take good care of yourself, let me hear from you often, and don’t let anything keep you from doing the good that you can do every day,
Gene
