The article is not an article that puts forth solutions. Although it is a great Box 1 (reason for action) in what should be an industry wide A3. It is an understated call to action. It seems also to have been written as a “call out” of a problem that should concern patients. It points out that the problem for young physicians is getting inadequate responses from the profession and that the efforts from the rare individual institutions that are trying to make a difference are inadequate. Efforts to address physician and house staff depression and burnout and to question the culture that feeds the problem remain controversial even at prestigious academic medical centers like Stanford where one of their best and brightest, a well respected Chief Resident in Surgery, committed suicide. Oaklander implies that although training programs have been brutal since the late nineteenth century the impact on the lives of residents now is greater than ever before because of the increase in personal debt associated with education and the decline in the respect for the profession, even as the work is rapidly becoming more taxing and more complex.

The article launched me on a trip down memory lane that I want to share with you for what it might be worth. I come from a culture where we pay attention to the power of “personal testimony”. In medical school I felt extremely stressed moving from a state university where all I needed to succeed was to give back to the professor on the exam what I had been told in the lecture. At Harvard that was the bare minimum to answering the exam question. What they wanted was a synthesis of that factual knowledge with the the demonstration that you could apply what you had learned to answer a new question. They were looking for evidence of “synthetic thinking”. There were other differences between Harvard and my previous academic experience. First, they did not give us our grades so I just assumed that I had barely passed since those who failed did get a note to visit the Dean’s office. Secondly, I was awed by those who seemed to know more than me because of their Ivy League education. My assumption was based on the confident way they tossed around facts that suggested to me that they clearly learned more in a rigorous college experience than I had at the “state u”. Thirdly, the culture of the Northeast was an anathema to me. I was the hick from the ignorant and backward South with all of its “racism and misdirected culture”. Finally, unlike most of my classmates, I had a wife and young child who were also struggling with me in this new and different environment.

I was occasionally frightened under the stress of all that was happening and all that seemed to be on the horizon. I had never failed before and just the prospect or possibility became a recurring concern and burden. I had additional concerns and the guilt of a coward because I would at times have a sudden impulsive desire to hit a bridge abutment while driving home. I lived in the married student housing of Harvard University that is on Memorial Drive. I. M. Pei was the architect and had designed an open deck on the 22nd floor of our building from which there were great views of the Charles and the city beyond. I became terrified of the deck because of concerns of what I might do. Ironically, Harvard did not consider me an isolated or struggling student. Despite all my pain and self doubt I was under the radar.

I graduated with honors from what some consider the most prestigious medical school in the world and then received an internship at the Brigham, an equally rigorous and impressive training program considered then and now to be one of the best in the country, yet at times I was depressed and struggling with my fears of failure, living with a substantial degree of stress and a work life imbalance that was a problem for myself and others. It only got worse when my house staff years began. Outlander was reading my mail from 1971 when she said:

Stories like the one I published earlier this year about my patient who may have committed suicide after I failed to recognize her depression troubled me and accumulated with each passing day in a hospital where many of the patients had come because they were up against unsolvable medical problems that we continued to deny as unsolvable. I was often part of a clinical team in research units or in programs with clinical trials that treated many patients in those days long ago who I am sure died in part in relationship to what we were trying to do to “save them”. We threw a lot of “Hail Mary” passes. Each time the pass was not caught the concerns and worries became a little worse. There was the occasional relief from a remarkable success but each day was filled with the knowledge that it would be long, complicated, and full of surprise problems that would need sudden attention no matter how prepared or unprepared, how able or how disabled, you were.

I was lucky to be where I was. For some reason I asked for help. Perhaps Dr. Henry Fox who was a staff psychiatrist showed me something in his demeanor that encouraged me to ask him if I could talk with him. Looking back on that time I can see now that his willingness to sit down and talk with me was a turning point in my life. I do not know if he spoke to the people responsible for the training program. I doubt he would have “outed me” to the powers that controlled my life and were shaping me to their concept of what a graduate of their program should be. Nothing changed in the way I was treated. I continued to be treated like a star when I felt like a phony. He did reassure me that what I was experiencing was understandable.

The most important thing that he did was to refer me to a psychiatrist on the staff at Tufts Medical Center, Dr. Charles Magraw who was also an analyst. He was a perfect match for me in every way. In the end I worked with Dr. Magraw for over eight years. Long after the acute concerns were resolved I made the decision to go into analysis in the late seventies. My guess is that if I had invested the same amount of money with Microsoft, Apple, or Southwest Airlines I would be able to buy my own island but I am convinced that I would have never survived 40 years of practice. I did take enough medical deductions on my income tax to get audited twice.

I tell my story for several reasons. Data now tells me something that I did not know then. I was not alone. I presume that in medical school there might have been other students who felt just as inadequate in my presence as I did in theirs. We were all struggling to become something that is not easy to become. I was probably no more tired and no more burned out than many of my colleagues in my internship and residency groups. We would have never talked with each other about what we were feeling, so how could I have known what it felt like for them? It sounds like from Outlander’s article that there are a few out there now like Dr Fox and Dr. Magraw but I doubt that there are many young physicians who were cared for then or now by better physicians than I had to help me. I was very fortunate.

Another reason I tell the story is that Dr. Magraw not only helped me get through a difficult period but he also gave me tools with which I could manage myself as I moved into the even greater stresses of a lifetime of practice. There were times for sure when despite my “tools” I was depressed and felt that old fear of failing a patient, but here I am on the other shore of that wide and turbulent river of a life in healthcare. I can say from where I now stand on the far shore and look back across the water at the people just beginning the swim that we can do more to help them. We must do more.

I am drawn to Lean and the culture that it espouses because it creates a learning environment that is collaborative and supportive. Errors become assets in the construction of better processes of care. We are encouraged to collaborate for a greater good more than compete for survival. Human development and work life balance are stated goals and not something that we must individually fight for or discover. Like the tools for individual management that my work with Dr. Magraw developed for me, the tools we learn to use together in Lean prepare us as individuals and institutions to approach whatever the next challenge might be.

As luck would have it, my good friend, Dr. Paul DeChant and Lean guru Mark Graban put out a forty minute podcast this week on the ability of Lean to address the issues of burnout. I have already listened to it twice. I encourage you to listen to it. It is just a beginning but no one is taking the challenge of burnout or the more positive concept of “returning joy to the practice of medicine” more seriously than Dr. DeChant. Perhaps you might load it into your music device and enjoy it on a walk this weekend.

Burnout has been a part of medical training and medical practice for a very long time. With the current stresses in healthcare it is an increasing and less well managed problem than ever before. It is now so widespread and such a part of our organizational existence and industry that I fear that we may consider it to be more like the weather that we can not control than like global warming which we could manage, if not control, if we just had a collective will to take it on and treat it as the threat to everyone that it represents. I am no longer a practitioner. I am now now a patient. My personal concern now becomes the last concern on the list that I constructed from Outlander’s article.

Patients have no idea of the significance of the problem. [Perhaps this fact is the major motivation for the article.] : “As a patient, you’d never guess that half of all American doctors are burned out, because the culture of medicine dictates that doctors show no weakness.”

I think that doctors as well as nurses, PAs, MAs, office secretaries and organizational executives, everyone up and down the hierarchy of healthcare, is struggling and our patients are feeling it. Addressing burnout may be one of the most effective ways of improving quality, patient service and cost. I know that without addressing burnout more effectively than we are now with changes in systems and culture, it will only get worse. There may be many ways to do it but I believe that since we can’t send everyone to eight years of extensive psychiatric counseling and psychoanalysis, trying to institute Lean based culture and systems improvement is a logical strategy and has great potential for everyone including our patients.