Curbside Consult with Dr. Jayne 4/10/17

Physician burnout is always a hot topic within informatics circles, especially since clinicians frequently cite the rise of EHRs as a key reason for stress and burnout. In reality, though, it’s difficult to prove causality, especially since increasing requirements for EHR use have generally been timed with governmental regulations, demanding payer programs, and the overall shift from fee-for-service to value-based care. I’m always looking for ideas to help physicians at the breaking point, and a friend recently shared this article about using military training concepts to help physicians build resiliency.

According to the American Psychological Association, resilience is “the process of adapting well in the face of adversity, trauma, tragedy, threats or significant sources of stress – such as family and relationship problems, serious health problems, or workplace and financial stressors.” As physicians, we’re assaulted by these kinds of stressors all the time, and they often cross work/home boundaries as working hours become longer or as physicians bring work home with them, now that they can access charts from anywhere. During residency training, many physicians develop the skills to adapt to the intermittent stress that being a trainee brings – long call nights, resuscitations, emergency surgeries, high-risk procedures, and more. For the most part, residency training doesn’t prepare young physicians for the daily grind of being in an office setting or dealing with the stressors of owning a practice or being an employed physician.

The article discusses statistics for physicians – that depression hits nearly a third of residents, and that physicians have higher suicide rates compared to the rest of the population. It goes on to look at how some Canadian hospitals and medical schools are using training based on US Navy SEAL programs to help build psychological skills. Both populations are under ongoing stress with overlaying episodic stress, sometimes involving life and death situations. I think the latter element is important – the life and death situations. Although many think of those as being in-hospital, emergent-type situations, I see more and more of my primary care colleagues experiencing that “life and death” level of stress even within the boundaries of office-based medicine. When patients can’t afford their medicines and physicians have to cobble together plans to try to ensure compliance, we are in effect fighting for that person’s life.

The diabetic patient who came into my urgent care last night with a blood sugar of 434 wasn’t sick enough to be admitted to the hospital, since his sugars had been high for months and his body had been trying to compensate for it. Yet, he needs intensive therapeutic interventions to get his disease under control. I can send him back to his primary care physician, but then she has to battle to get him to see the diabetic educator, get him a new blood glucose meter to replace his broken one, and try to help him figure out how to get to appointments and take care of his disease when he’s working long shifts as a municipal bus driver. Those situations, which sometimes border on hopeless depending on the patient’s insurance coverage (or lack thereof), job situation, and social supports add to the ongoing level of stress faced by physicians. This is worse now that the primary care physician is going to be penalized for this patient’s lack of blood sugar control.

This problem isn’t unique to our US system. According to the article, studies show that as many as 75 percent of Canadian resident physicians experience burnout. One can anticipate that those burned-out residents are going to carry that baggage into practice. The resiliency training created for the Canadian trainees is delivered as a four-hour course. It encourages trainees to identify how they’re faring on a mental health or stress scale. They grade themselves as green, yellow, orange, or red depending on their current level of stress and dysfunction. Similar to the kind of asthma action plan we provide patients, it also details recommended steps the trainee can take to reduce stress. Another component of the training includes skills to help the body process physical responses to stressors, such as the fight-or-flight response. It seeks to move decision making away from the emotional response and to instead harness the rational thought process.

The article also mentions that “discussions around physician mental health still remain very taboo.” Unfortunately, this is also true in the US. I know of quite a few physicians who have untreated mental health conditions who are afraid to seek help and have it on their records. Our state still asks a question during the license renewal process about treatment for mental health conditions, and people don’t want to risk whatever process might arise from checking “yes” on the affidavit. A friend of mine who is a psychologist specializes in physician care, and doesn’t bill insurance for those patients so that there isn’t a record of treatment.

Although the article doesn’t specifically mention it, we also need to work on skills for physicians to understand that doing their best really is good enough. We can’t really give it more than our best, can we? Although the quality metrics might not support this approach, the idea that we can save everyone or ensure all our patients are compliant is ludicrous. As quality increases, it’s more and more difficult to be “better” when everyone is already earning an A. I’ve lost two colleagues to suicide in my career, and both were brilliant, caring individuals who unfortunately felt their best wasn’t good enough, that they should have been doing more. No one in their lives, including spouse or fiancée, realized how bad things were or that they were at high risk for suicide.

Additionally, this discussion doesn’t just apply to physicians. It applies to all of us working in the patient care arena regardless of your title. Most of my support staff at my patient care sites are paramedics, and many have migrated to urgent care as a solution to the stressors in the field. For those readers not in the patient care space, ask your organizations what they’re doing to address caregiver burnout. Ask your friends and colleagues how they’re doing and offer support when you can. Their lives might just depend on it.

How does your organization address burnout? Email me.

Email Dr. Jayne.