Why Are MDs Burning Out in Record Numbers? ~ NURSING DIAGNOSES

(Medscape and Dr. Paul Griner)

   Physicians who feel a sense of burnout, take heart — you're not alone. A recent study of 7288 doctors published in the Archives of Internal Medicine showed that nearly one half — 46% — reported at least 1 symptom of burnout, as measured by the Maslach Burnout Inventory.
   According to physician Paul Griner, MD, author of The Power of Patient Stories: Learning Moments in Medicine, the figure is especially alarming considering that burnout can lead to inadequate assessment of patients and misdiagnoses.
   Further, a recent study published in General Hospital Psychiatry suggested that job stress, coupled with inadequate treatment for mental illness, may account for the higher than average suicide rate among US physicians.
   In an interview with Medscape Medical News, Dr. Griner discussed the importance of identifying the clues of burnout, stepping back to regain a focus on the patient, and seeking the empathetic advice of a mentor who just may have been there once him- or herself.
   Dr. Griner, a professor emeritus of medicine at the University of Rochester School of Medicine and Dentistry, in New York, implemented mentorship programs at the Massachusetts General Hospital and more recently at Danbury Health Systems, in Connecticut. He has been a senior lecturer at Harvard Medical School and has served as president of a number of national medical organizations, including the American College of Physicians.

Medscape: What are some key signs that the everyday stress of clinical practice has crossed the line into a more risky realm of burnout?
   Dr. Griner: Some key signs of burnout for clinicians can include a lack of interest, chronic fatigue, and unprofessional behaviors with patients, such as lack of empathy, anger, impatience, and irritation. Some physicians with burnout may be in denial, while others may recognize they are under stress but attempt to hide it from family and colleagues.

Medscape: What are some of the most notable risks and consequences of physician burnout?
   Dr. Griner: Any or all of the characteristics of good patient care may be compromised when the physician experiences burnout. The most serious risk is that the physician may make an incorrect diagnosis or prescribe an inappropriate treatment, and there are potential consequences of burnout to the physician as well. He or she is at risk for serious depression, abuse of alcohol, use of habituating drugs, and family problems. Some physicians experiencing burnout may even make the decision to leave the field of medicine. This outcome is particularly disturbing given the investment in time and energy that the physician has made in the profession of medicine and the experience that is lost to future patients.

Medscape: The Archives of Internal Medicine study on burnout indicated that the specialties most at risk were family medicine, general internal medicine, and emergency medicine — what are the unique implications of burnout in these specialties?
   Dr. Griner: These are the physicians who are on the firing line of first contact with patients, and as such, they must be readily available. The brunt of paperwork, regulation, and hassle from health insurance companies falls upon these physicians and their staffs, and primary care physicians are less well paid than their subspecialty colleagues, yet they work longer hours. The combination of these factors helps explain why burnout is more common among these specialties.

Medscape: How is the risk for burnout unique to this generation of practitioners compared with others?
   Dr. Griner: Burnout is more frequent with this generation of physicians than their counterparts in eras gone by, for a number of reasons. For one thing, new medical knowledge and technology are advancing more quickly than most physicians can keep up with and utilize wisely.
   Further, physicians must process much more information about each patient than was the case among their peers in years past. In addition, many physicians are asked to see more patients in the same amount of time than their predecessors did.
   In many cases, the physician is not able to spend the time with any one patient that he or she feels is necessary. Realizing this can be extremely frustrating and demoralizing.

Medscape: Can you summarize some of the most important strategies for avoiding burnout?
   Dr. Griner: To begin with, in order to remain physically and mentally healthy, physicians should follow the advice they give their patients — eat a healthy diet, exercise, rest, take time with and enjoy their families. At the end of each day, reflect on what went well, who you helped, and what challenging diagnoses you made.
   Physicians need to nurture relationships and should avoid colleagues who are always negative. Associate as much as possible with those who remain upbeat.
   Retain the passion that brought you into medicine in the first place. For instance, steal some time from administrative meetings to share a fascinating patient story with your colleagues.
   Many physicians, particularly male physicians, are reluctant to share feelings. They find it easier to "stuff" their feelings even while recognizing that this tendency may not be healthy.
   Engaging in a 1-on-1 session with a trusted advisor or mentor can help physicians begin to understand how therapeutic it may be to share feelings, including feelings about patients and feelings about their lives in general.
   A recent article in the Journal of Physician Executives reported the results of a survey showing that as many as 25% of physicians would suggest a mentor to help reduce burnout. The ideal mentor is a good listener, is nonjudgmental, and is practical. He or she can give good advice on how to achieve a better balance among one's personal and professional life.
   Paying attention to what's going on in patients' lives can be very helpful in reducing burnout. The patient will be more empathetic. Knowledge of the psychological, social, and economic aspect of a patient's life helps the physician better understand the patient and leads to greater professional satisfaction.
   Physicians would do well to remember this comment by Sir William Osler, generally acknowledged as the greatest physician of his time: "The good physician knows the disease the patient has. The great physician knows the patient who has the disease."
   Physicians should participate actively in health reforms that return a greater level of control to their patients and themselves. Embracing the concept of team care is important. Moving from a philosophy of "I am responsible" or "I am in charge" to "We are responsible" or "We are in charge" is an important step.
   Supporting the concept of payment for quality instead of "the more you do, the more you get paid" is an equally important step. Reimbursement to physicians and hospitals is moving toward various forms of global payment, such as payment for an episode of illness or payment for the care of a patient for an entire year.
   Such payment arrangements will favor primary care physicians — those at greatest risk for burnout — by giving them greater control and by reducing paperwork and hassle.

Medscape: Can you share any personal experiences you have had with burnout — and how you responded to the situation?
   Dr. Griner: It's interesting that you should ask. I have experienced burnout, but it was very early in my career in hematology, in an era when most of the patients we saw had fatal disease.
   had Hodgkin's disease, for example, and the average life expectancy back then was only about 5 years. Today, at least 90% of patients with Hodgkin's are cured. Also, most patients with leukemia passed on within a few months, so there was a lot of mortality, and I had a constant concern of losing patients.
   suppose the most important lesson I learned from the experience was the importance of being able to share these feelings and frustrations with someone else, but I don't know if I ever had anyone that I felt comfortable opening up to about it. In many cases, I think I suffered needlessly because those were the days when you kept your feelings to yourself.

Medscape: What has been the response to the most recent mentoring program you implemented at Danbury Health Systems?
   Dr. Griner: The program was initially focused on primary care physicians as the target group, and we've now branched out into the subspecialties. Many physicians have come forward, and many of those have come back for additional sessions.
Very few physicians have an opportunity to spend an hour with a trusted advisor in a quiet setting, and the insights that can be gained through such an approach are amazing. In addition, being with a mentor doesn't engender a feeling of having failed — much of this is just talking to a wise senior person who has had a great deal of life experience, who is a good listener, who is nonjudgmental, is supportive, and has practical advice to give.

Medscape: How can physicians find out about mentorship programs available to them?
Dr. Griner: There is not a lot in the literature on the subject, but an interested physician should inquire with the administration of his or her hospital and ask if such a program is available. Such mentorship programs are often offered to residents at teaching hospitals but not as much for practicing physicians. But the more inquiries a hospital receives on the issue, the more likely they may be to realize this is something they can offer to their doctors.