The character of medical practice has changed over the past fifty years. The changes go far beyond our technological and scientific advances. Many reflect on the change in the experience of providing care. Others focus on how the experience of receiving care has changed. I enjoy reflecting on what is the same and what is new in my own experience.
My great grandfather, Cato Baxter Wiseman, M.D, was the only doctor in Rutherford County, North Carolina back in the early 1900s. In 1920, while still in his early fifties, he died after a massive stroke. Perhaps that was the 1920s version of “burnout.” He died the year after my mother was born in his home. The common family wisdom shared with me by my grandmother was that her father had “worked himself to death.”
It has occured to me that there was much less change in the practice of medicine in the half century between my great grandfather’s death in May 1920 and my graduation from medical school in 1971 than the changes we have processed in the nearly fifty years since I started my internship. Indeed practice in the time of my great grandfather Wiseman in 1920 and the practice of my great great great grandfather Dr. Ebenezer Childs,III in Shelburne Falls, Massachusetts back before 1850 had more similarities to the character of practice in 1971 than to practice now. Even in the interval between 1920 and 1971, there was much less change than has occurred during my practice lifetime.
My physician ancestors delivered babies, sutured lacerations, set broken bones, used various tinctures of opium for diarrhea, and were present to provide some comfort to their patients while they died. They may have used digitalis leaf for the treatment of the “dropsy” or nitroglycerin for angina. For most cancers and severe infectious diseases there wasn’t much more than their presence and empathy that they could offer. My great grandfather lost three of his children to diphtheria, and another daughter died in her mid thirties of rheumatic heart disease after acquiring rheumatic fever while she was in nursing school. As an accomplishment that we have forgotten, rheumatic heart disease has virtually disappeared from this country during the first third of my practice, although it is still present in the third world.
Perhaps my great grandfather could be called an innovator. He owned the first car in Rutherford County which made him more efficient on house calls than he was in a horse and buggy, and I assume that by 1920 he could take phone calls from a few of his patients. Perhaps that saved even more time and a few lives. He also practiced “team based care.” My great grandmother managed his practice, and according to family stories she practiced a little unlicensed medicine after he died using the skills that she had learned from observing him. She held the practice together for a few years after his death until her oldest son, my mother’s uncle Perry Wiseman, graduated from the University of North Carolina Medical School, and returned to take over his father’s practice. It was a very different world. I knew “Mama Wiseman” because she did not die until 1961, at the age of 91. I wish I had known enough as a teenager to ask her about how much medicine she had “practiced.”
As I think of medicine in the 1840s and medicine in the early twentieth century, I realize physicians in either era did not do much chronic disease management, although I imagine “spiritus frumenti” was frequently prescribed for chronic anxiety and other persistent miseries. People called the doctor for life events like giving birth and to have the doctor administer some relief as they lay dying. Country doctors tried to manage trauma, and could offer some symptomatic relief for acute diseases like diarrhea. If a cancer could not be surgically removed, there was not much to offer. An old surgeon that I once knew described the situation to me as, “A chance to cut is a chance to cure.”
We began to offer relief for some chronic diseases in the 1920s when insulin became available for diabetics. Not long after insulin, pernicious anemia responded to “liver extract,” and then to B12 injections a few years later. Iodine and thyroid hormone extracted from animals offered relief for goiter and hypothyroidism. By the thirties we understood, and could manage pellagra as a dietary deficiency that ravaged the rural South. The “king of poisons,” arsenic, was used to treat syphilis, and other toxic compounds like mercury offered some diuretic relief if used with care and experience. Mercury was still being used sparingly when I was a resident. Despite these discoveries the practice of medicine was mostly about OB, surgery, and orthopedic trauma. Chronic medical conditions were largely endured. Diagnostic radiology probably had not reached the mountains of North Carolina by 1920, but by the fifties after the Hill Burton Act had built thousands of hospitals across the country, we were using fluoroscopy to diagnose ulcers and some forms of heart disease. In the fifties you could even get your feet radiated at the Thom McAn Shoe Stores, just to be sure you got a good fit.
Diabetic management, the treatment of thyroid diseases, relief from anemias, and immunizations were important elements of office based practice before antibiotics were widely available in the forties, but again oral antibiotics and episodic infectious disease were just a small addition to office practice. In my memory the big breakthrough that created chronic disease management as an economically viable foundation for office practice was the proof presented by Fries and others in 1970 in the VA collaborative study that demonstrated that there was benefit for tens of millions of Americans in the long term management of hypertension, the chronic medical problem that caused many premature deaths by stroke and myocardial infarction. Using small fixed doses of reserpine and a thiazide diuretic, the study showed substantial benefit in lowering the risk of strokes and heart attacks by lowering blood pressure and closely monitoring them to make sure that they reached a treatment goal. 140/90 became the nation wide goal, and chronic disease management became an economically important activity in primary care offices across the country.
About the time we started treating hypertension seriously, and with a goal, we were using more than 900 hospital days per thousand insured patients. It was obvious to thoughtful physicians like Dr. Robert Ebert, the Dean of the Harvard Medical School, that there were huge economic and therapeutic advantages to moving care to the ambulatory environment. When I was a resident at the old Peter Bent Brigham, a patient was hospitalized for five days for a diagnostic cardiac cath and three weeks for a myocardial infarction! Now you may be home in time for lunch if you have a diagnostic cath, and you can have an uncomplicated MI managed with an angioplasty and stent and be home the next day or so, and back to running for president in less than a week! Just ask Bernie. Yes, things have changed, and I have not even mentioned ultrasound, CTs, MRIs, fiber optic enabled procedures, cholesterol management, dialysis, transplants, gene therapies, immunotherapies, and the list goes on and on. Our challenges have also increased. Covid-19 is only one of dozens of diseases that have evolved since 1971.
My great grandfather probably died prematurely of a combination of hard work and hypertension. I sometimes wonder if I should include “burnout” among the new diseases that challenge healthcare since the time of my great grandfather. Was it always present, but just ignored? I never thought about “burnout” as a potential problem for healthcare providers until I read Robert Coles’ 1993 book, The Call of Service: A Witness to Idealism. It’s now a free download from Google. In that book, Coles examines the personal satisfaction and perils of the “service” professions. Coles addresses burnout in chapter four which he named “Hazards.” The appropriate sections in the “Hazards” chapter are “Weariness and Resignation,” “Cynicism,” “Arrogance, Anger, and Bitterness,” “Despair,” and “Depression (burnout).” I felt like someone had been reading my mail when I read Coles’ book in 1994.
In the 1990s we were in the midst of the demise of managed care. Healthcare finance and the financial underpinnings of our practice were being complicated by heavy handed attempts at managing the cost of care through sole source contracting, and shifts to self insurance by employers with “administrative services only” provided by insurance management. Simultaneously, RVUs and EMRs were changing the flow in the office, and we were beginning to wonder if the quality and safety in our offices and in the hospital would survive the pressures we were feeling from payers and managers. We were on a new and unfamiliar treadmill.
Let me digress for a moment. More important to my personal growth and development than the accidental reality that there are a couple of doctors on distant branches of my mother’s family tree is that the tree is full of storytellers and readers. A favorite childhood pastime during the visits to my grandmother in North Carolina was to sit with her on the comfortable glider on her front porch and go through a big box that contained old family pictures. I would pull a picture out of the box, and then after I had looked at the old cars and funny clothes, she would tell me stories about the people in the picture. Her bookshelves were full of Dickens, the works of Shakespeare, and other books by writers like Robert Louis Stevenson and Mark Twain. It was clear that she had read many of these books to my mother. Back at home, my mother read many books to me. I remember the Arabian Nights, King Arthur and His Knights of The Roundtable, and Black Beauty, Tom Sawyer, Huckleberry Finn, Brighty of the Grand Canyon were also great, but my absolute favorite was the memoir “Papa Was A Preacher.” I related to that one.
It should not be a surprise that I enjoyed reading to my sons. Of all the books that I read to my two younger sons, my favorites were the books of E. B. White. You know them because they are classics: Charlotte’s Web, Stuart Little, and The Trumpet of The Swan. Through reading to my children, I discovered the adult prose of White and enjoyed reading his books like One Man’s Meat, The Second Tree From the Corner, and his essays. It’s been a while since I have read any of his works, but his books are still on my shelf. You might imagine my surprise when I recently came across a quote from E.B. White in a book by Barbara Brown Taylor, Leaving Church: A Memoir of Faith. As I have mentioned before, in that book Taylor beautifully describes the evolution of her own form of burnout which she calls “compassion fatigue,” and hints at a solution with a quote from White:
“If the world were merely seductive, that would be easy. If it were merely challenging, that would be no problem. But I arise in the morning torn between a desire to improve (or save) the world and a desire to enjoy (or savor) the world. This makes it hard to plan the day.”
If you are really burned out, you are no longer thinking about “improving the world,” and you are likely to have no remaining capacity to “savor” the world. The quote was thought provoking, and just by chance I happened to note an article in Medical Economics written by Todd Shyrock, “Physicians Fight Burnout.” The article begins by repeating facts that we all know so well.
Burnout has become as much a part of medicine as the stethoscope, with too many doctors feeling overworked, over-regulated, and underappreciated. The result is physicians retiring early, changing careers, or losing their love of medicine at a time when there is already a shortage of primary care physicians.
In the Medical Economics 2019 Physician Burnout Survey, 92 percent of respondents indicated they have felt burned out from practicing medicine at some point in their career, 68 percent said they are burned out right now, and 73 percent said they have thought about quitting medicine. Despite the prevalence and scope of the problem, only 13 percent plan to seek or have sought professional counseling.
Solutions are elusive, because the causes can vary by specialty, location, or practice, and doctors rarely have any control over contributing factors like regulations or EHR design. But that doesn’t mean all doctors have given up or are willing to tolerate the status quo. In fact, as burnout has become increasingly common among physicians, so, too, has the fight against it.
Here are the stories of seven health professionals and what they are doing to battle burnout in the profession.
The description matches the results of the surveys done at the institutions for which I have personal experience. I would venture a guess that the description also matches the experience where you work, and may also match your personal experience. The seven stories are worth your time to read. I have lifted a quote from each one.
Story #1: (It’s really two for one to make seven to be consistent,) This is about two family physicians who are married. Both were exhausted and feeling like their marriage and family were in trouble. Their solution was to merge their practices, and for each to give up half of their practice time so that one of them was always at home. It was an expensive solution as their income was reduced by 50%. The husband comments:
One proven solution for reducing burnout is to have physicians meet in a social setting outside of work to share experiences, where they can see they are not alone in their feelings and can share coping advice…
Story #2: This story is from a pediatrician who solved his problem by giving up practice for teaching and administrative duties. I know many who have pursued this solution, but it’s not available to everyone. Like the first example it ends up reducing the number of active professionals at a time when we need more. Is it really a solution? Is leaving practice a solution for the community or a personal choice to avoid an impending disaster that does not change the root cause problem?
Winters says doctors don’t always recognize signs of burnout in themselves, such as apathy, or coping through alcohol or food. “They write it off as just having a bad day or just needing some sleep,” he says.
Physicians need to focus on what brings joy in their lives and find a way to escape from the rigors of their day. He recommends finding a couple of hours to do something that isn’t work-related, whether it’s exercising, binge-watching Netflix, or in his case, dancing.
Story #3: From an ACP VP in charge of efforts to reduce burnout. Her comments are helpful in recognizing the problem, but short on actionable solutions.
Physicians should look for sudden changes in behavior in their colleagues as a warning sign that all is not well. “If someone who was outgoing and is now withdrawn, that can be an indicator,” says Smith. Missing meetings or conferences, or even not answering pages can also be a sign of potential burnout. Physical pain, difficulty sleeping, changing appetite or a crisis of confidence are other warning signs.
“They may have a lack of confidence in their work that comes from a sense of powerlessness because they can’t change things or make things better,” she says. “They may become more cynical, be quick to anger or have relationship problems or trouble getting along with family or friends.”
Story #4: From an internist and AMA practice efficiency expert. She does address the problem of the EMR with a surprising suggestion. She suggests ignoring alerts that come with incomplete results. Would it not make more sense to improve programs so that the physician is alerted only to complete results that deserve attention? I do agree with her conclusion that the ability to do a quality job is a foundational principle in the struggle against burnout.
“The greatest driver in preventing burnout is being able to deliver quality care, but there are so many obstacles that stop us from delivering it,”
Story #5 From a program director in urogynecology. I do agree with most of what he has put on his list of what doctors want, but how do we get from what we want to what our patients need without putting our own health in jeopardy?
Listening is a great way to reduce burnout. “There’s not a lot that providers want,” says Holzberg. “They want to take care of patients, have a say in the plan for the organization, and have some recognition for what they do. They want to have the supplies and tools they need to do their jobs and do it without a lot of obstacles. If you pay attention to a lot of that, you will be surprised at how much difference it can make.”
Story #6: From a pulmonary medicine/ critical care fellow. I think he nails it. I bolded his statement that made me say, “Amen, brother.”
While he appreciates employers providing yoga or massages for physicians, those do not address the root causes of the problem. “I personally find a lot of wellness in running and doing yoga, but that doesn’t address the root cause of sitting in front of a computer going mad trying to click all the boxes.
“Burnout is a symptom of an incredibly broken healthcare system. It needs addressing, but the root causes are deep and pervasive.”
The sad outcome to Barbara Brown Taylor’s “compassion fatigue” was that she left her role as a parish priest, and like the pediatrician in story #2, she became a teacher. I think there is merit to finding the balance between improving the world and enjoying it. The place to start, as with all problems, is to understand its origin. I think part of the origin can be understood by looking at the increasing complexity of what we have evolved over the last fifty years. Ironically, the solution to burnout may have some similarity to what is evolving as the most effective way to manage chronic disease, self management in the context of a supportive system. To that I would add that the fellow in pulmonary and critical care medicine is right about systems issues. All the supportive therapy in the world won’t work until we improve the infrastructure and finance of our current system.
Atul Gawande’s assertion that “we are no longer ignorant” is manifestly true when I compare what I had available to me in terms of information and technology when I retired to the tools and understanding of my great grandfather when he died prematurely. On the personal side, he would have probably been able to practice into his sixties or seventies if he could have taken lisinopril and hydrochlorothiazide like I have for the last thirty years. What is a surprise is Gawande’s observation that the scientific and technological “ignorance” of my great grandfather’s generation has been replaced by the “ineptitude” and inefficiencies in our generation. We have benefits and opportunities that we have not figured out how to deliver without harming ourselves. I do believe that if we faced the problem squarely and addressed the brokenness of our systems, as the young doctor in training in story #6 suggests, we would see many good things happen, not the least of which would be a reduction in the tragic reality of burnout. Perhaps a focus on reengineering the complexity of how we finance and deliver healthcare might be the best route to having the luxury of deciding whether to spend the day “improving things” or “savoring” the beauty of the world and the joy of practice. I am amazed that Dr. Ebert saw the problem, and offered us direction to the solutions for what drags us down when he said fifty five years ago:
The existing deficiencies in health care cannot be corrected simply by supplying more personnel, more facilities and more money. These problems can only be solved by organizing the personnel, facilities and financing into a conceptual framework and operating system that will provide optimally for the health needs of the population.”
I believe “existing deficiencies” includes our epidemic of burnout. We must pursue both of E. B. White’s objectives. We need to both “improve” practice and “savor” much more than generating a positive operating margin. I know we can do it.
