physician burnout

Ten Reasons Why Physician Burnout is so Prevalent.

‘If you study even the smallest bit of science, you will realize that, for all practical purposes, we are nothing. We’re basically monkeys on a small rock, orbiting a small, backwards star in a huge galaxy, which is an absolutely staggeringly gigantic universe, which itself may be part of a gigantic multiverse. This universe has been around for probably 10 billion years or more, and will be around for tens of billions of years afterwards. So your existence, my existence, is just infinitesimal…this is such a short and precious life, it is really important that you don’t spend it being unhappy. There is no excuse for spending most of your life in misery. You’ve only got 70 years out of the 50 billion or however long the universe is going to be around.’

Naval Ravikant in Tools of Titans, by Tim Ferris

On Thursday, I was given the last-minute, unexpected opportunity to give a two-minute pitch about my concept to help reduce rates of stress, burnout, and suicide amongst doctors (and later other professions), and how to increase their wellbeing. As a doctor talking about this issue, I do have a sense of not wanting to make a storm in a teacup. I don’t want to dramatise the situation, as serious as it is. I feel it deserves to be approached with gravitas and pragmatism, without any hint of emotion.

But then, I think, ‘what the f**k? Why are doctors killing themselves?’ It’s a privileged position to be a doctor in the west, no matter which way you look at it. It means that the person has had access to excellent education, has personal attributes to undertake this arduous education, and are, in most cases, guaranteed a job for life, with salaries that are dependable and will provide a secure income. If the doctors are committing suicide, who is going to look after the suffering?

Working in psychiatry, I am faced with suicidality on a daily basis. Suicidality as a symptom of mental illness. Suicidality as an expression of emotional overwhelm and distress. Suicidality with explicable causative factors, and suicidality in the most unlikely of places. The fact is, suicide is one of the saddest plights of the human experience. That one act, or thoughts of, tells a thousand stories of helplessness, hopelessness, guilt, fear, anger, rejection, isolation. It is so contrary to what we consider to be the essence of our human-ness: being hope-finding, meaning-creating, resilience-expressing animals. The act separates us from non-homo sapiens (as far as I know). Something about our exquisitely developed prefrontal cortices which have endowed us with the ability for abstract thought, executive decision-making, and meta-cognition, has also made us vulnerable to states of nihilistic hopelessness.

So why do doctors get to this stage? What are the causes for the preceeding burnout and chronic stress? A recent systematic literature review, reported in Medscape, states that physicians experience the highest suicide rate of any profession, more than twice that of the general population, and over 400 doctors a year suicide in the US. The Australia beyondblue study of medical student and doctor mental wellbeing in 2013 identified that 24.8% of physicians had thoughts of suicide prior to the past 12 months, and 10.4% had thoughts within the last 12 months.

So, here are a summary of what I think are the main factors contributing to chronic stress and burnout, in no particular order:

  1. Doctors have an inherently stressful job. Buddhist philosophy suggests that our main motivation in our natural state is escaping suffering – which, ironically, it argues, creates more suffering. This helps us to understand and empathise with others if we accept that everyone is just doing their best to escape suffering. We can all probably see this in our lives: we work to have money to avoid going hungry or being homeless; we maintain strong social bonds to avoid loneliness. A doctor’s (and many other professions’, some of whom have similar issues with burnout) job is intrinsically tied to engaging in the depths of human suffering. Day in, day out, the job requires engaging with people’s pain, unhappiness, loneliness, fear, worry, depression, and disappointment.
  2. Lack of autonomy. Doctors exist in a constant tension between a) the resources available to them from the health provider; b) what a patient wants; c) what a patient needs; d) what a patient can afford, or what a provider will pay for for a patient; e) legislative and social expectations of what health should/should not do.
  3. Complexity of healthcare delivery. Long gone are the days when a patient attends for a straightforward prescription, or for a surgery – or neither if they cannot afford them. A doctor must dance a complex rhumba which involves a multitude of invested stakeholders. These are informed by international, national, and local recommendations and protocols; by the payers for the health service; by the local service’s resources; by the patient’s wishes. And this often requires a decision to be made in a short period of time looking at an individual patient with their unique requirements and biopsychosocial factors affecting their illness experience. The paradox of choice in treatment is increasing at break-neck speed, and humans struggle to keep up.
  4. Sandwiching. Related to the above. A term I use to describe doctors being caught between patients and the service or provider or political power behind them, and having to mediate that complex relationship.
  5. Evolving nature of healthcare delivery. Doctors are having to become adept practitioners of a new digital world. Again, instead of dealing with the individual patient in front of her, the doctor now has to refer to, record, and involve a litany of digital material via electronic health records. Whilst the glitches are many as they are embedded, many doctors would agree that it may benefit patient care in the long run. But another layer of administration has been added to doctors’ jobs.
  6. Leadership. Leadership within healthcare often comes from a) clinicians who have been in the game a long time, but may not have had formal management training; or, b) non-medical managers who transfer management skills from other sectors. I would argue that management does need to be taught, it is not an intrinsic character trait, and I would argue that healthcare is different from most other sectors in that the commodification of health has multiple ethical and moral considerations. This is not to say that these divides are not successfully crossed; but a lack on either front can exacerbate the stressful expectations of doctors.
  7. Personality types that self-select for medicine. This is perhaps the biggest generalisation here but most good doctors (and we are still working out how to screen that ‘good’ and define what it means), have traits that are associated with high rates of conscientiousness, diligence, integrity, and empathy. These are also traits which are associated with neurosis in its original form: excessive anxiety or obsessiveness. Laissez-faire, non-obsessive doctors tend to come up against issues very early on in their careers which can have negative effects on patient care. These traits emphasise the, ‘I better not get this wrong’, ‘what if XYZ happens? How do I prevent this?’, or, ‘the negative sequelae of this action – or lack of action – could – or could not be – XYZ.’ Essentially, medicine requires working with vast swathes of uncertainty and uknowns, and reassuring a patient in the midst of that, and finding out what can be known, actioning it, and avoiding complications in that course of action.
  8. Shiftwork. There is no need to reiterate the multiple studies and bodies of evidence which outline how bad shiftwork is for physical and mental health in the long run. Now imagine handling an apnoeic (not breathing) neonate at 3am, or repairing a bleeding aneurysm, or talking down a psychotic patient. The effects are inevitable.
  9. Work intensity and competing demands. After five to eight years of undergraduate study, doctors embark on a baptism of fire into life as a junior doctor. This can be anywhere from one to four years, which is then followed by training under a specialist pathway (general practice, psychiatry, general surgery, ophthalmology, etc), which can range anywhere from three to 8 years. Many specialties require onerous exams – which must be studied for for months whilst working full-time, and costs thousands of dollars at a time, paid from a trainee doctor’s salary. Resits are incredibly demoralising as doctors have put their lives on hold to study for them. Many will also have research requirements, which may need to be done on top of the ‘day’ job, or may need time away from the training scheme with a reduced salary. Many doctors will be starting a family during this time, which puts a particular pressure on female trainees (in general), who have to decide how much (if any) time to take away from time-limited training schemes. People are also doing other life ‘stuff’ expected in their respective societies: getting on the property ladder, for example. And many have other commitments: carer role for children or a spouse or a parent with a serious illness. All the while working in a job with shiftwork and all the issues listed above.
  10. The normalisation of chronic stress and vicarious trauma. Finally, doctors are exposed to trauma on a daily basis. This may involve the death of children, or losing a patient unexpectedly, or watching people decline through chronic illness. It can involve seeing people self-harm, and listening to endless stories of every type of abuse under the sun. It can involve hearing about and observing some of the darkest parts of humanity. Unfortunately, the evolution of the culture within medicine has been centuries in the making. There is a hardening and desensitisation expected. The fragile, flimsy line between self-preservation and displaying compassion and empathy is often trodden upon and unrecognisable. People glorify the hours and disasters and trauma and awfulness at times, as a way of coping. Burnt out colleagues, often those who have been in the game a long time, have become so depersonalised and emotionally exhausted themselves that they lack insight into their own dearth of emotional connection. They then externalise anyone else’s difficulty processing something, or a throw away comment about the amount of hours worked, as being a sign of ‘not coping’ and advise them to suck it up because, ‘when I was a junior doctor I worked 110 hours a week.’ I often feel like holding up a mirror and saying, ‘Yes. Yes you did.’ The evidence suggests that even with improvement in absolute working hours for some doctors, that stress and burnout has massively improved. In light of the above issues, I understand why.

It may sound rather bleak, but my own burnout has receded far enough that I have hope. I believe that human connection amongst colleagues can provide relief and strength. I believe that radical transparency, as described by Ray Dalio, can save us from repeating the closed-up, ever-more-cautious, more overwhelmed by the paradox of choice that the modern medical paradigm presents. I believe that medical culture can change. I believe that its leaders can adapt. I believe that empowered patients can better share the risk and unknownness of their own health and healthcare. I believe that AI and VR can get to a stage that some of the mechanised parts of modern medicine – digital health records, diagnostic algorithms contained in doctors heads – can become part of the doctor-patient interaction. Doctors are humans, and their humanness needs to be prized and protected. Patients deserve nothing less when they see their healthcare provider. As Naval Ravikant said, we have so little time in which to live. Let’s make it count, and make it enjoyable.

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Five (+2) favourite quotes thus far from Tim Ferriss’ ‘Tribe of Mentors’

If you’re reading this on your phone, on social media, whilst I share life hacks from a book subtitled ‘Short Life Advice From the Best In The World’ – then shame on you.  Sit down. Turn off your phone. Pour a cup of coffee. Then read the book yourself.

But failing that, here are some of my favourite curiosity-inducing, potentially  life-changing quotes to disrupt your 2018:

1. Kyle Maynard – first quadruple amputee to reach summits of Mount Kilimanjaro and Mount Aconcuagua without prosthetics, champion wrestler and CrossFit instructor. Phew.

If happiness is just above the status quo, bliss is what makes you feel most alive. Expect it will take courage to follow your bliss, and expect it will suck at times. Expect you’re going to have to take risks for it. Expect others won’t necessarily understand.

2. Debbie Millman – the ‘Queen of Branding’, founder and host of Design  Matters podcast (excellent – a must-listen), editorial and creative director of Print magazine, and co-founder of world’s first masters in branding at NYC School of Visual Arts. She also has an incredible life story – check it out here.

Busy is a decision…If we use busy as an excuse for not doing something what we are really, really saying is that it’s not a priority…

One piece of advice I think [a smart, driven college student] should ignore is the value of being a “people person.” No one cares if you are a people person. Have a point of view, and share it meaningfully, thoughtfully, and with conviction.

3. Naval Ravikant – angel investor, CEO of [lots of sexy-sounding Silicon Valley-esque companies I’ve never heard of]. Smart enough to have cashed in on Twitter and Uber. And smart enough to say,

Suffering is a moment of clarity, when you can no longer deny the truth of a situation and are forced into uncomfortable change. Inside suffering is the seed of change…

Ignore: The news. Complainers, angry people, high-conflict people. Anyone trying to scare you about a danger that isn’t clear and present…

Self-esteem is just the reputation you have with yourself. You’ll always know.

4. Lewis Cantley – professor of cell biology and chief of Harvard’s Division of Signal Transduction. He discovered the cell signalling pathway phosphoinositide 3-kinase (PI3K), a significant advance in cancer research. He has also been involved in significant treatments for diabetes and autoimmune diseases.

Choose a profession that is really easy for you to do and that also allows you to be creative…One should not pursue a profession just because it is viewed, at the time you begin college, as the one that will have the most jobs of where you will make the most money. If you are uncertain of your talent, get a broad education that does not narrow your options. The best skill is to be able to communicate efficiently both in writing and speaking…

The worst recommendation [in my area of expertise] is to keep your ideas and data a secret until you have a paper describing these results accepted into a journal. Anytime I have a crazy idea or see an unexpected result, I talk about it with my colleagues to see if they have seen anything similar and whether they think my idea is crazy. This is the fun of science. Multiple scientists with different experiences and expertise can collaborate and get to the right answer much faster than a single scientist.

5. Jerzy Gregorek – born in Poland, emigrated to the US in 1986, and subsequently won four World Weightlifting Championships. In 1998 he earned a Masters in Fine Arts in writing from the Vermont College of Fine Arts. His poems and translations have appeared in multiple places, including The American Poetry Review.

I bought a bracelet for $19.95 with the first letters of each word of a sentence: IARFCDP…They are the key to my personal proverb, a line that brings awareness and helps me see through my own emotional storms. It means: I Am Responsible For Calming Down People. Sometimes it helps me to teach what I need to learn myself…

“Hard choices, easy life. Easy choices, hard life.” Nothing truly meaningful or lasting has ever been created in a short period of time.

5+1 (bonus quotes, because I’m greedy): Anna Holmes – writer and editor who has worked with The Washington Post, The New Yorker, and The New York Times. Creator of website Jezebel which discusses the intersection of gender, race, and culture.

“Follow your curiosity, wherever you can find it.” Embracing a curious mind and always trying to learn more – about others, about yourself, about the world and our place within it – is an important way to express yourself.

5+2: Annie Duke – one of the top poker players in the world. In 2004 she won her first World Series of Poker bracelet. She won the $2 million invitation-only World Series of Poker Tournament of Champions in 2004. Prior to becoming a professional poker player she had a National Science Foundation Fellowship at the University of Pennsylvania to study cognitive psychology. She blogs at Annie’s Analysis on the science of smart decision-making.

Seek out dissenting opinions. Always try to find people who disagree with you, who can honestly and productively play devil’s advocate. Challenge yourself to truly listen to people who have differing ideas and opinions than you do…The fact is, when two extreme opinions meet, the truth lies generally somewhere in the middle. Without exposure to the other side, you will naturally drift toward the extremes and away from the truth of the matter. Don’t be afraid of being wrong. Because being wrong is just an opportunity to find more truth…

Stay flexible and open to opportunities as they come your way…Be open to what the world brings your way. Don’t be afraid to change jobs or careers, no matter how much time you have already put into something. There is no urgency to have it all figured out…

If you define failure as merely losing, then you will think failure is just an outcome. And you might try to adjust your play to avoid losing even though your decisions were great (or repeat poor strategies just because you won executing them once). This would be the equivalent of deciding it is wise to run red lights just because you made it through safely a few times…What matters is the decisions I made along the way, and every decision failure is an opportunity to learn and adjust my strategy going forward. By doing this, losing becomes a less emotional experience and more an opportunity to explore and learn.

Okay, signing out. Heading off to the bush for a few days without phone and internet. It will be all nature, books, wine, and quiet.

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What would happen if we lived compassion in 2018?

On January 1st 2017, I wrote:

This morning, Eva was discussing about aiming to ‘make friends with discomfort’ in 2017. For her, the discomforts are many and multifaceted and are not limited to the discrete physical symptoms associated with treatment for breast cancer. The complex psychological effects of living with this illness and its treatment continue to surprise us, as well as the inevitable emotional instability associated with tiredness and stress and anxiety…[we] discussed further this making friends with discomfort and amended it to making friends with vulnerability and discomfort. The last weeks’ journey has been one of vulnerability in different ways. The sensation of being vulnerable to a life-threatening disease process; the vulnerability towards treatment; the vulnerability of our family to this massive emotional and practical upheaval; the emotional and psychological vulnerability we have all felt as individuals…

The last couple of years we have discussed personal intentions for the year ahead. For example, a couple of years ago my wife suggested ‘making friends with uncertainty’. Of course, by the end of each calendar year we had not risen to such fabulous heights of enlightenment that we had perfected dealing with these complex feelings and experiences. However, like goal-setting, identifying an area for personal growth is the minimal start needed in the process of change. Rather than choosing an arbitrary or completely abstract concept (perhaps making friends with vulnerability is a completely unrelateable issue for you…I would argue it’s not, but that’s another story…) choose something which you see would make demonstrable, tangible difference in your life right now if you learned that lesson. For us, these were concrete, workable concepts that we felt we could pursue in the year ahead.

Last night (New Year’s Eve, in bed by 9.15pm, thank you very much), after writing my first blog post yesterday, I was assailed by the predictable onslaught of doubts and negative self-talk: ‘what the hell are you on about? What is ‘curiosity, disrupted’? What is the deal with that shitting comma? Yes, I know it’s a fabulous grammatical tool which will bamboozle your readers with its utterly disruptive ambiguity, but really? And how pretentious is blogging anyway? Like there aren’t enough blogs in the world. And just because you had a few compliments on last year’s blog (where you obviously hijacked your wife’s experience of cancer to express your own existential angst, you bastard) you now feel like 2018 is begging for another edition of your own naval-gazing self-absorption? What about the Rohingya? Do you think they give a shit about your blog? Go to Mosul if you think you are such a gift to the world.’

Although my own internal, unfiltered, uninvited monologue sounds perhaps rather extreme when written down verbatim, I imagine it’s not too different from that which runs through the minds of us all when we choose to present our wares to the world. For many this can be sharing your creativity, whether that be in artistic form or a presentation to the board suggesting an innovative solution to a complex problem. We are called in our base human-ness to share ourselves. Some choose to do it for artistic expression’s sake; others do it to put food on the table.

Once I’d retired to bed positively bursting with optimism about my latest blog, sans phone (intention number two), I turned to the pile of books on my bedside table: The Compassionate Mind by Paul Gilbert, Tribe of Mentors by Tim Ferriss, Finding My Virginity by Richard Branson, Rising Strong by Brene Brown, The Art of Happiness by the Dalai Lama and Howard C Cutler, The Mindful Path to Self-Compassion by Christopher Germer, and Bringing Yoga to Life by Donna Farhi. (No, you’re not mistaken; it’s like the self-help section of a major bookshop vomited up Bali in the middle of Silicon Valley.) All are in various states of readedness.

I picked up the first one, Paul Gilbert’s brilliant analysis of the old mind/brain v the new mind/brain, and how the biological and social evolution of the human prefrontal cortex has caused all sorts of irritating habits along with its ability to meta-analyse our internal states. He describes three types of affect (emotion) regulation systems in the human brain which he describes as:

  1. The driven, excited, vitality system: this is incentive/resource-focused, and is characterised by wanting, pursuing, achieving, and consuming. It has an activating effect on us.
  2. The content, safe, connected system: this is non-wanting/affiliative-focused, and is characterised by safeness and kindness. It has a soothing effect on us.
  3. The anger, anxiety, disgust system: this is threat-focused, and is characterised by protection and safety-seeking. It can have both activating and inhibitory effects on us.

These systems can also be conceptualised as relatively discrete but closely interlinked neurobiological and hormonal systems.  It’s not difficult to look at ourselves in our day-to-day lives and see how and when these affective systems are driving us. (Affect is a fancy word for emotions in this context.) Emotional intelligence is the concept that by being aware of what is happening at an affect level, we can better gauge what is transpiring both in our own internal state as well as that of others. Again, it is not difficult to figure out why this is important in business, organisational reform, the doctor-patient relationship, politics, romantic and parent-child relationships, etc etc. But how often do we do it?

He later writes,

…We require both a sophisticated and an agreed form of welfare-focused social organization to contain our potential tribalism and abusive power hierarchies, and we must also recognize that, if we don’t understand and train our minds very carefully and learn to be wary of  allowing ‘new brain/mind’ competencies to be directed by ‘old brain/mind’ passions, we’re going to be in trouble…We are a species that has evolved to thrive on kindness and compassion.

That last sentence struck me. We have evolved to thrive on kindness and compassion.

It makes sense on first pass; we know that we ‘feel’ better when others are kind and compassionate towards us…but we rationalise it along the lines of, ‘I don’t live in a world where I can expect to feel pleasurable feelings all time.’ Which is true.

So what does compassion actually mean? Is it a weak sense of gushing over pictures of malnourished orphans on the other side of the world? Is it something only nurses feel? Is it intrinsically related to the maternal and the feminine – that whole stereotyped characteristic which is not championed and modeled by the (generally) male leaders we follow? (A whole other issue and problem which I would love to write about at some point.)

Compassion is derived from the Latin com- ‘togther’, and pati– ‘to suffer’.

To suffer with. To suffer together.

As a doctor, I am galled by the focus on ‘personal resilience’ which is extolled as the answer to the ‘tribalism and abusive power hierarchies’ that haunt my archaic and ponderous profession. A medical school colleague of mine was found dead late at night in the operating theatre changing rooms back in Scotland in August. In Australia, stories abound over the past few years of doctors who have suicided in the pursuit of what was traditionally considered an altruistic and compassionate vocation.

So what would happen if we lived compassion? I have clues and ideals and visions of what could happen, and I will strive in my relationships and professions and society to be a ‘compassion disruptor’. To be explicit: it is not about simply being nice to people or ourselves. Compassion is about stepping out of our comfort zone and proactively engaging with our own, and others’, suffering.

Here are some examples of questions about how compassion could disrupt:

  • In a meeting, a manager publicly humilates a colleague for a genuine mistake they have made. How would you engaging in their suffering affect them? Do you fall on the side of, ‘they made a mistake so they deserve this’, or ‘we all make mistakes and it is not helping the situation by humiliating the perpetrator of it.’ Mike Maples Jr., a partner at Floodgate, a venture capital firm that specialises in startups, says, ‘I find it is better to be focused on honoring the discovery of the truth rather than determining who is to blame.’ Would being compassionate, focusing on the ‘discovery of the truth’ (e.g. a root-cause analysis to identify the chain of events leading to the mistake) rather than lambasting an individual be more helpful?
  • When facing a client, and presenting a solution to the problem they have presented you with, you end up receiving all the credit and praise. You know, however, that a junior associate was the one who came up with the paradigm. The client knows your CEO personally and is likely to mention you favourably. How would compassion towards your junior colleague affect this situation? You know that they stayed late finishing the proposal; how would you empathising with them ‘in their suffering’ change your response? The moral or ethical answer is not difficult to deduce; but would you choose to believe that being seen as charitable and humble is something you would rather be valued for rather than being perceived as cut-throat and win-at-all-costs?
  • As a doctor in a busy emergency department, you are faced with an emotionally dysregulated young person who has self-harmed. They have presented to your ED multiple times, and have a history of cannabis and alcohol misuse. You have treated other family members of this person, who have a selection of forensic charges and substance abuse issues between them. How could the situation be defused by you responding with compassion? How have people usually responded to this young person – both professionals and other family members throughout his/her life? Is acting compassionately likely to smooth the transition of this patient through the ED to the appropriate inpatient setting, or as appropriate to be discharged with follow-up? How does your previous experience with this patient, and other similar clinical scenarios, affect your decision to ‘suffer with’ or to reduce your emotional engagement with this patient?

In 2018, I wonder how we can change our relationships if we acted compassionately? How could we treat ourselves differently (more effectively) if we responded with an awareness of our old mind/brain – that reactive, defensive, safety-seeking part that avoids danger, and which is hijacked by the new mind/brain which chastises us for being in the situation of experiencing those feelings?

If we can change in our intimate relationships?

If we can change in our family relationships?

If we can change in our professional relationships?

If we can change in our societal relationships?

If we can change in our relationship with and to the Other, seeing our selves reflected there?

It could be great.

(But honestly, that f***ing comma.)

 

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