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Monday Jul 24, 2017

I Bounced Back From Burnout by Setting Boundaries, Priorities

Near the end of 2016, I reached a point in medicine where I never wanted to be. Less than three years out of residency, I realized I was burnt out.

[Kim Becher, M.D., with husband Mike and son Ewan in Costa Rica]

Here I am with my husband, Mike, and our son Ewan. Our recent trip to Costa Rica was my first real vacation in more than two years.

It was at that point that someone asked me whether I would still choose medicine as a career if I had it all to do over again, and I said no.

I hated hearing that answer as a medical student and resident, but not because I was afraid for my own future. I honestly thought physicians who regretted their career decisions were failing themselves because they weren't trying to change the things that made them miserable. So when I reached that point myself, it forced me to begin some serious introspection.

The first thing I did when the realization hit me was stop taking medical students because my focus was not on teaching. I knew I needed to make serious changes in my life and my practice, and that process could make family medicine in general seem like a less desirable career choice if it were a student's only exposure to our specialty.

Things are getting better now, and I have a student scheduled for September. So how did I get back on track?

I knew part of my problem was depression. I wasn't taking time for myself, and I hadn't taken a true vacation that didn't involve checking my electronic health records (EHRs) daily in more than two years.

I wasn't exercising because I felt I didn't have time because of the number of notes and tasks I had looming over me every evening. My house was a disaster. I wasn't cooking or eating as healthily as I used to. I spent little time with my family. The only thing I continued to do well was care for my patients.

The first step I had to take was the hardest. I had to start saying no. No to new patients, no to being double-booked, no to addressing four patients who happen to be in the same room when only one of them is on my schedule. No to taking care of employees off the schedule. I had to create a daily routine that not only kept my head above water but also gave me time to catch my breath.

Fortunately, I had a couple of conferences in the spring that forced me out of the office and gave me time to analyze my workflow more clearly. I also did some critical thinking about my own weaknesses.

I dug through old leadership books because I knew that to really change things in my office, I had to have an engaged workforce. Any physicians who think they can run an office effectively without building staff morale and a solid approach to patient-centered care are fooling themselves. Who hasn't heard the saying "You are only as good as your staff'?"

After a few months of changes in the office, I started to see the light, literally, because I wasn't working until after dark anymore. My patient navigator was accessible because I freed her up from some front-office duty so fewer things fell through the cracks (or accumulated on my mental to-do list for later that night). My schedule still was full every day, but I wasn't double- and triple-booked.

I found that I could handle a completely full schedule just fine. Overbooking had been the Achilles heel in my day. If I let myself get an hour behind, I lost all discipline with notes, orders and referrals, pushing it all until after the last patient had left the office.

I had been miserable because I didn't have time to exercise, spend time with my family or go on vacation, but could I make needed changes in my life and give up some of the obsessing about my EHR task list? I had to start with small changes or I felt my work-related anxiety would sabotage me.

I was invited to speak at the National Rural Health Association meeting in early May in San Diego, so while I was there, I got up and exercised every morning before logging into my computer. I already knew that exercise was the most effective antidepressant for me, but I hadn't realized until that week how much more efficient I was when I exercised every day. And as embarrassing as it is to admit, I went to a yoga class for the first time in at least a decade. (Teaching yoga was one of the interests that motivated me to be a doctor in the first place.)

I came home with much clearer goals. I was going to incorporate exercise into my day at any cost: hungry family waiting at home, phone calls unanswered, changing my work schedule if necessary. And so far, I've met that goal. I have a schedule change in the works that will enable me to exercise in the morning, which will mean I work through lunch with no break, but it will also allow me to take my son to school.

Then came the daunting challenge of vacation. I knew I needed a break, one where I would have no phone or internet because if I had online access, I would still work.

I hate asking people to cover for me. It isn't a trust or medical decision-making issue. I feel guilty for putting so much work on someone else. But I went to Costa Rica and didn't take a computer or buy an international data plan for my phone. What I found reassuring was that when I told my high-risk patients that I would be inaccessible for a week, they encouraged me to do it more often!

We have all had patients make snide comments about us being out of the office on occasion, and I have felt as though I failed them when they needed me. But patients have to be realistic -- and so do we. Physicians are humans, too, and we also experience things like flat tires or illness.

Six months later, I have lost 10 pounds, and I am in better shape than I've been since I started medical school. I've left my office every day for five consecutive weeks with all notes and tasks completed. I've gone on at least a biking or hiking day trip with my family every weekend since the end of the school year.

I am seeing more patients per hour now than I was six months ago, but they are scheduled more appropriately. Every appointment time is filled during the course of the day rather than, for example, being overbooked multiple times in a three-hour period. I'm sure some patients can tell a difference. I do find myself a couple of times per week telling patients that we just have to stop for the day and that we need to see each other more often instead of for so long at once. If family members start asking me questions about themselves during someone else's appointment, I sign them in to be seen so I get credit for my time and they understand that to get medical care, you really do need an appointment. I tell staff point-blank when they ask me medical questions about themselves that they need to get on my schedule.

It was a long, hard road, but I eventually realized that my sanity is more important than being nice. And sometimes it is just about letting go of things (my house is still a disaster) and remembering who we were when we started our journey into medicine.

Finally, it's worth noting that the AAFP plans to launch its Physician Health First initiative during the Family Medicine Experience (FMX) Sept. 12-16 in San Antonio, which will entail expanding related CME tracks and workshops at FMX.

The initiative also will offer several other resources, including

  • the AAFP's first physician health and well-being conference in 2018;
  • a chapter workshop series;
  • creation of an enhanced well-being portal on the Academy's website;
  • access to the Maslach Burnout Inventory; and
  • development of a web-based planning tool members can use to address their wellness needs.

Kimberly Becher, M.D., practices at a rural federally qualified health center in Clay County, W.Va.

Posted at 03:05PM Jul 24, 2017 by Kimberly Becher, M.D.

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