After my residency and fellowship training were over, I continued the ER work for several more years until I replaced that work with extra contract work at HCHP and eventually the governance activities that began in the mid eighties. The silver lining to all that work was that I became quite comfortable with my clinical skills and probably learned more functioning as the only doctor in the hospital when moonlighting. At the Brigham I was always supported by an army of other house staff and available senior physicians at any hour of the day or night.
By the time I read Coles’ book I had been doing the eighty plus hour a week schedule for over twenty years. I was running on empty. Ironically, I probably had gotten as far as I did with the killer schedule because I was also running, although my marathon times were in free fall. I had gotten to the place where my game was to see if I could finish a marathon with thirty five miles or less of training per week. I was not a “crack of dawn runner”. By 1993 10 PM was the usual time for one of those runs.
My first response to the inevitability that everyone was vulnerable to burnout was personal concern but then I announced to myself, “Not me!”. Perhaps I had viewed my running as magical “protection”. As I look back now on those busy years of professional hyperactivity, I realize that my sense of smugness, satisfaction and pride in my ability to “multitask” was in fact a lie to myself. A more realistic view of the previous twenty years was that during this time I had experienced a failed marriage and that my children were struggling in ways that might have been mitigated by my presence. My contact with my extended family had fallen past occasional to rare. I hope that no patient ever suffered but I do know I left a few colleagues in the lurch.
Reading Coles’ book did not really offer me specific solutions that I remember putting into play, but just reading about the issues of burnout and the frequency with which committed and involved people encountered burnout was helpful and I did realize that I was vulnerable. My response to this insight was subtle. I did not resign any of my responsibilities to lighten my load but I did begin to realize that other people were supporting me. I was making it through with the support of my second wife, the acceptance of my family, and the support of colleagues. Now, more than twenty years later, I also recognize that I was the beneficiary of the culture of team based care in our practice.
I came to depend more and more on the skills of my practice partner, Maxine Stanesa, a physician assistant, who was famous in our practice for her energy, her clinical skills and her empathy. I had total trust in Maxine’s skills and knew that if she called saying that she needed my help, she really needed me to drop what I was doing and focus on her problem. She rarely called because we did regularly spend some time discussing our patients. We felt jointly responsible for their welfare. Those discussions were a good investment of my time because I was reassured that things were well managed and our discussions enabled Maxine to do more to support me. In retrospect my experience confirmed that teamwork produced better care and a more efficient use of resources and was a hedge against my burnout.
I have mentioned Robert Coles’ book before. In one of my previous letters I have also mentioned the book, What Doctors Feel: How Emotions Affect The Practice of Medicine (2013) by Danielle Ofri MD. Her book is built on observations and stories from her own experience but her positions and assertions are also well documented from the literature. She spends a lot of time talking about the self reliant culture that was introduced by Osler as a mixed benefit. That culture has been largely positive but it has also contributed to the professional isolation and individual responsibility that is impossible to continue and is probably a large contributor to the sense of burnout that compromises so many of our colleagues. It occurred to me that both Coles’ book and Ofri’s book “describe” the problem but do not really “prescribe” a “treatment” or a solution to what has become such a growing concern. This week I spent some time reviewing Coles’ and Ofri’s work because the online blog, KevinMD.com, seems to be running a series of stories and essays about burnout. Like the Coles and Ofri books the articles seemed heavy on description and light on suggestions to resolve this threat that seems to be growing.
Take for example last Friday’s posting on “Kevin”: “Physician burnout is physician abuse” by Pamela Wible, MD. She uses some abbreviations common in social media these days to add emphasis to her points. The piece contains some interviews to bolster her point which she carries to the place where she says that burnout is not a “condition” but is the result of “abuse”. She does not offer a therapeutic solution for abuse. Abuse requires what sounds like a call to war with the “system”. I present this to you because it may contain some truth but it does not solve problems. I believe it represents an approach to a serious problem that has about as much efficacy as Donald Trumps’ “wall with a golden door” for the complex problems of illegal immigration from Mexico. Both are an appeal to emotion, not to reason. Read her words and draw your own conclusion. After you read the excerpts that I have copied below, check out the videos on the link above to KevinMD. There is another link at the end of her piece to a TED talk that she has given.
Physician burnout is the latest trend among doctors. There are books, workshops, even special breathing exercises for physician burnout. Suddenly every other doctor I meet has burnout. And half of all med students have burnout before they graduate. WTF...
...Physicians are overworked and overwhelmed with bureaucratic B.S. during most of their careers. They are trapped in assembly-line big-box clinics where they are treated like factory workers and berated for not seeing enough patients per day. Some experience human rights abuses in our nation’s hospitals...Folks, this is not health care.
Our health care cycle of abuse starts on day one of medical school. Abused medical students are trained to be abused doctors who may one day end up abusing patients. Wait! We wanted to help people, not harm them...
You are the victim of abuse.
So what should you do? Sign up for a resiliency class? Meditate? Take deep breaths? Your goal should not be to cope with abuse. Your goal should be to stop it.
Physician burnout is a diagnosis that blames the victim, not the perpetrator. In fact, the term physician burnout IS physician abuse. It implies that you are to blame, not the system and perpetrators of the mistreatment….Warning: You can not meditate your way out of abuse. You can not take enough deep breaths to end your abuse.
What you must do: If you are being abused, you must leave your abuser...You were born to be a healer, not a victim.
...It seemed like just yesterday; I sat in a posh auditorium in Chicago as an enthusiastic young adult during my first day of medical school orientation at Northwestern in 1995. Eighteen years later I was a forty-three-year-old burned out physician, practicing in Boise, Idaho, doing Google searches on the most effective way to end my life. ...I observed that I was becoming the type of physician that I never wanted to be. I was impatient and sarcastic...
....I came to recognize I was not alone. ...I realized burnout is not some psychological abnormality to be embarrassed to speak about in public — quite the contrary. For example, survey results in the past five years show 87 percent of American physicians experience symptoms of burnout. On the extreme spectrum, female physicians have a successful suicide rate of 250 to 400 percent higher than their counterparts in the general population…..At some point in almost every physician’s career, we had a powerful desire to help others. When suffering burnout, many of us become so disillusioned by our failure to achieve these aspirations that our passion is replaced by a strong contempt, bordering on hatred, for the profession we chose and once loved. My goal is to reignite that flame as I have been able to do for myself and give physicians a chance to rediscover a sense of joy, pleasure, and fulfillment from this noble profession.
Burnout impacts not only the physician experiencing the problem, but also their families. It also has dramatic implications for the patients the burned out physician treats. Increasing time constraints, burgeoning bureaucracy, increased patient expectations, and technological advances have made the challenging, stressful profession of medicine even more so... I have realized burnout is an almost inevitable response. Something needs to be done about it.
Another point of view also appeared this week on KevinMD. It is a “faux speech” created by Janice Mancuso who started The Osler Symposia: Weekend Retreats for Doctors & Nurses. She has assembled the “faux speech” from quotes from Sir William Osler, considered by some to be the father of modern medicine. Osler never actually made the speech. Remember that in Orfi’s book she posited some of the difficulties of this time in our medical culture, training and professional attitudes to attitudes introduced by Osler. Never the less, Mancuso’s piece is an interesting and enlightening contrast to the other two pieces and perhaps speaks to our super ego in the way the other pieces speak to our id and ego.
Below I have excerpted a little of the speech to give you a flavor of its content. Since this speech never happened, I have added emphasis to some of the points in the “speech” by bolding sections that I imagine cut both ways. There is no doubt that Osler was a man of high ideals and high intellect who set an example of empathetic brilliance that few have come close to matching. At the best the bolded words define our objectives and at the worst they demonstrate how we failed when we cannot reach them.
We doctors do not “take stock” often enough... Acquire the art of detachment, the virtue of method, and the quality of thoroughness … but above all, the grace of humility....the more carefully you scan your own frailties, the more tender you are for those of your fellow creatures.
You are in this profession as a calling, not a business; as a calling which exacts from you at every turn self-sacrifice, devotion, love and tenderness to your fellow men. Once you get down to a purely business level, your influence is gone, and the true light of your life is dimmed....
...the ideals which inspired our earlier physicians are ours today — ideals which are ever old, yet always fresh and new.
...I have had three personal ideals. One is to do the day’s work well and not to bother about tomorrow … The second ideal has been to act the Golden Rule … towards my professional brethren and towards the patients committed to my care. And the third has been to cultivate such a measure of equanimity as would enable me to bear success with humility…
In the “faux speech”, Osler suggests worshiping the heroes of medicine, reading inspirational medical texts at bedtime, and getting a hobby, and avoid taking yourself seriously. Although this is sound advice, does this imaginary Osler believe that a person suffering from burnout working in a dysfunctional system could have avoided it by reading at bedtime and having a hobby? Most of the lists about causes of burnout make reference to not enough time in the day.
... There is no such relaxation for a weary mind as that which is to be had from a good story, a good play or a good essay. It is to the mind what sea breezes and the sunshine of the country are to the body — a change of scene, a refreshment, and a solace.
Finally there is the expectation that the distressed clinician will be self observing.
But whatever you do, take neither yourself nor your fellow creatures too seriously...
Things cannot always go your way. Learn to accept in silence the minor aggravations, cultivate the gift of taciturnity. Dr. Wirble would definitely disagree with this advice. She wants to loudly fight the abuse.
The speech finishes boldly.
To prevent disease, to relieve suffering and to heal the sick — this is our work.
The speech still has a nineteenth century sense of duty and nobility that is charming. Echos of the attitudes expressed and the actions that are suggested perhaps establish a bar that many of us can not clear in our day. Some of Osler’s values are similar to the concepts of professional life that my parents instilled in me. Perhaps in a future letter I will come back to Osler and the burden that we have shifting for a valid set of values that were appropriate at one moment in time but are a source of confusion as they are applied at this time. That would be too much to do within this letter.
I would expect this “faux speech” to be a source of inspiration for someone like Dr. Murphy and a source of anger or cynicism for others like Dr. Wible. Osler stressed personal accountability and I would expect that we could create a second “faux speech” from his writings about clinical autonomy. His words are directed at the individual. Healthcare is now so complex there are few if any viable individual solutions. Help comes from good systems and teammates just as the chief source of burnout is from poorly functioning systems and professional isolation. I will accept Dr. Wible’s point that bad systems are an origin of burnout.
The greatest advances in quality and safety over the last twenty years are attributable to the recognition that those are systems issues. Over the last two years I have been a member of an advisory group at Simpler. Our goal has been to explore how to make Lean an asset to practices, hospitals, and health systems that are searching for solutions to the complexities of the delivery of care in our time. We have come to believe that just as waste is eliminated and quality and safety are advanced when you improve the system, it is also true that system solutions can reduce burnout.
Within our group Dr. Paul DeChant has been the most passionate voice for the concept that the high rates of “burnout”, like high cost and low quality and safety, are in most cases connected “systems issues”. Paul views burnout as our most significant forms of waste, plus it is a personal tragedy and represents a huge liability for us now that will only become worse in the future.
Most of the literature of burnout falls into the buckets of “reason for action” or a description of the current state. That description covers the books by Coles and Ofri. Some articles like the ones above by Dr. Wible and Dr. Murphy explore a partial “box 4” analysis of root causes, but the resultant solutions are unlikely to make much of a dent in the universal nature of the problem, even when they consider a system's origin as Dr. Wible did. Her solution was to fight the system. Dr. DeChant’s solution is to transform the system. There is a big difference.
Dr. DeChant is an “A3 thinker” and his credentials as a PCP, medical leader and medical executive are impressive. Through his leadership Sutter Gould Medical Foundation in California was transformed and many physicians experienced a joy from practice that had been missing from their lives for decades. He has all of the personal and professional characteristics that Osler advocated. He has described his personal mission as “returning joy to the practice of medicine”. He considers burnout a preventable and treatable disease. Patty Gabow and John Toussaint have described Lean as potential “treatment” for an ailing health care industry. The “treatment” will be effective if Lean thinking, culture and leadership can spread through the health systems, hospitals and ambulatory practices of the nation. Paul imagines Lean as a balm for the burnout of individuals and all healthcare professions. Burnout is not a disease specific to physicians but is easily measurable in nurses, PAs, other clinicians, medical assistants, managers and executives.
Click on this link to sign up for Paul’s blog, Returning Joy to Patient Care Through Lean Transformation. Below is an excerpted early posting that succinctly lays out his case. Again, the bolding is my added emphasis.
A New Site, A Renewed Theme – Burnout is a Preventable Disease
14 May
...I’m focused on the “Plus One” of the Triple Aim Plus One – a positive working environment for those who care for patients. Doctors, nurses, and other technicians come to work ready to do their best. Our processes and workflows create barriers to them providing the great patient care that they are striving to deliver.
Burnout is rampant in health care. It’s no surprise, with a growing number of external pressures bearing down on an already overly stressed process. The current state of health care delivery is the result of a long tradition of a physician-centric system that honored physician autonomy over consistent demonstrable quality care for the patient.
As the long-standing traditions in health care are being uprooted by new regulations, new payment systems, and new technology, the old top down management approach is not working. Caregivers are burning out.
In fact, there is so much caregiver burnout that a new sector of professional services is growing rapidly – physician burnout coaches and physician wellness programs. These are vitally important as they help struggling physicians cope with their frustrations and find purpose in their work and the strength to go on.
Yet there is a basic problem. Burnout is a preventable disease. When present, it should be treated aggressively. And, we should just as aggressively work to prevent it from developing in the first place.
Key drivers of caregiver burnout include excessive workloads, inefficient work environments, inadequate support, loss of autonomy and flexibility, difficulty achieving work-life balance, and overbearing management.
A lean management system and culture address every one of these drivers, providing caregivers a collaborative and supportive work environment that can prevent burnout. And like most preventive measures, it takes work and time.
...Are you ready to be a part of the solution by:
- creating a workplace culture that respects the people who do the work,
- by going to the place where the work is done in order to truly understand the problems, and
- by supporting the plans that those who do the work have for fixing the problems in the workplace?
If so, please share your ideas, your successes, and even your failures. We can learn from them all...
It is important to reiterate that Paul is describing a journey and an approach that conceptualizes poor systems performance and not individual frailty as the core issue to be improved. He is realistic. Solutions like the militancy recommended by Dr. Wible or the creation of inner strength and awareness recommended by Dr. Murphy have little chance of success at a level that will make a measurable difference in the total population of vulnerable caregivers and healthcare professionals. My own salvation through collaboration and support was a weak preview of the power of Dr. DeChant’s proposal and the primary reason that I shared it with you. Osler’s vision of the ideal physician is well worth our attempts to adopt, but the impact, if successful, will be limited and probably unsustainable if that noble physician is working in a dysfunctional environment.
Paul, John and Patty know that the potential of Lean is not easy to access in a world defined by volatility, uncertainty, complexity, and ambiguity. Those are the generalized descriptors of the issues that make our current system of care unworkable and breed burnout. Whenever I think about the problems of our systems of care the term “systemic evil” pops into my head. That happens so often that I have a personal definition for the ominous term for the clarity of my own thinking. “Evil” is a word that is not used as often in our contemporary world as it was in the past when it was a very personalized term most often referring to the outcomes of personal failure or the work of the personification of evil, the devil. [Have you ever notice that devil is evil plus a “d”.]
By my definition, systemic evil is when you and everyone else is doing what they think is the right thing to do in a dysfunctional system and the outcome is a tragedy like the burnout of an earnest clinician or the injury of a trusting patient. It is interesting that others have worked with the idea of systemic evil and the responsibility of individuals. In an article entitled “The Banality of Systemic Evil” in the “opinionator blogs” of the NYT, Hannah Arendt is quoted on the subject in a way that is pertinent to the responsibilities of those who work in, as well as those who manage our systems of care, and in so doing have a responsibility to consider “burnout” on the long list of things that need amending or attention. Arendt’s work suggests to me that we all have an obligation to assume an overview of the system and ask two tough questions, “What part of the problems am I and what can I do to make things better?”. The passage in “The Banality of Systemic Evil” that explores this idea is:
...Hannah Arendt made an observation about what she called “the banality of evil.” ...what happens when people play their “proper” roles within a system, following prescribed conduct with respect to that system, while remaining blind to the moral consequences of what the system was doing — or at least compartmentalizing and ignoring those consequences.
People who think about the volatility, uncertainty, complexity and ambiguity of systems have generated responses to the instability and harm of the status quo that match nicely with the responsibility of leadership in Lean culture. Leaders in these times are expected to oversee the evolution of a vision (notice “oversee” and not “develop”). The system needs a vision and the development of vision and the deployment of that vision as a strategy is a process that requires a vigorous conversation with all parts of the system up and down the standard hierarchy. That vision should be communicated in such a way as to lead to universal understanding within the organization of its direction and strategy. As the process evolves there should be a growing clarity about all aspects of the plan and direction and especially the role of each individual. The “standard work” of each team member from the board through senior management right down through those who interface with the patients and those who support the work of the entire line should be clarified and understood. Such an organization will take action and not tolerate ambiguity. It will be an organization that supports the personal growth of individuals and is constantly learning by measuring the success of its experiments and efforts to improve.
Every action, no matter whether a success or failure, will yield an understandable result that will advance everyone toward the Triple Aim Plus One. Paul believes, and I agree, that Lean is the operating system that most rationally improves the system and has the greatest likelihood of diminishing burnout. We have seen it work. We can show you what good looks like. Decreasing burnout and restoring joy to practice are two of the most important reasons for any organization to consider adopting Lean as the core of their culture and as their operating system for the future. Seeking the benefits of Lean is a choice. Realizing the benefits of Lean to improve burnout is a dividend of the journey.
Making the Most of Late August
Deep into winter I usually discover that I am in the minority. Most people are sick of the cold, ice and snow but I am still looking forward to the excitement of the next snowstorm. At the end of spring, whenever that is, the fishing is pretty good and summer is on its way, so I hardly note its passing. Fall is sort of sandwiched in between summer and winter and when the leaves are brown and down my head is into the anticipation of gathering with family and friends for the holidays. Summer is my favorite season and I have a lot of trouble letting go of it. Late August must be like knowing that you have a terminal illness but you are still feeling good and having the strength to do everything that you enjoy doing. There is a slight feeling of melancholy that begins when the Patriots start their preparation for the season. My sadness is intensified as my interest in baseball becomes centered on the players of the future that might make next season better than this catastrophic year. It is the faithful who fill the stands and still turn on the game in late August when there is little hope.
In late August on Little Lake Sunapee you can sense that the Loons are getting in shape to fly to the Maritimes for the winter. We still have mosquitos at dusk but the fish get lazy in the warm water and do not seem as interested in my artificial enticements. Yes, there is only one more Monday and two more weekends before Labor Day, the finish line of summer. I ponder the passing of the season as I walk up Burpee Hill Road. The new red barn at the top frames a view of Mount Sunapee and the big lake that matches my mood. They are images fading into the mist and obscured in part by the gloomy low hanging clouds after the late afternoon thunder storm that has just passed. (This is the picture in the header. Mt. Sunapee is lost in the clouds.)
I am consoled by knowing that after Labor day and through all five seasons (I forgot to mention mud season), I will still get just as much pleasure climbing this hill as I do on the most glorious day of summer. I hope that you too will be out and about enjoying an invigorating walk during this, the last weekend of August. I will be walking with friends on the Cape, where summer does linger into fall.
