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Monday Jan 23, 2017

After Hitting the Wall, How Do I Bounce Back?

I've been out of residency less than three years. Throughout my training, I heard patients talk about other physicians and say things like, "She was different when I first saw her," or, "He used to take more time with me. He just doesn't seem the same as he did a few years ago."  

Most of the time, I didn't know the physicians my patients were talking about. But regardless of my personal knowledge of the physician in question, my answer was always the same: "They are probably really busy and just feel overwhelmed." And each time I worried a little more that one day, I would be the doctor who seemed different to her patients. 

Two weeks ago, my fear became reality, but I've since found some ways to address it.

I used to run a lot. There is a concept that runners call "hitting the wall." Everybody understands what it means -- you have done so much, and you can do no more -- but the moment you actually hit the wall is unforgettable. You truly have nothing left to give, and no adrenaline or discipline can overcome the fatigue.  

Two weeks, ago I hit the wall. But I wasn't in my running shoes. I was at work. The term one of my colleagues used was "compassion fatigue."  

Our work as physicians isn't primarily physical, anyone wearing a Fitbit can tell you that. It is the mental overload, the endless work we have to do that is unrelated to the actual patients in our offices(www.kevinmd.com).

The priority should be the patient in the exam room, and for some time each day, it is. But the bulk of our work takes place outside the exam room, doing things we enjoy far less than being in that room with the patient. We went to medical school to be in that room, and we chose family medicine because we absolutely love being in exam rooms listening to patients tell their stories.  

Increasingly, physicians are choosing to work in employed settings. The AAFP conducts surveys to track these data on employment settings and even what types of procedures are performed or diseases are managed to ensure the Academy is serving its membership and providing appropriate resources and CME. I've heard criticism from older doctors that younger doctors, like me, don't want to run our own businesses; we just want to go to work and get a paycheck. That stance has repeatedly annoyed me. I chose my federally qualified health center setting primarily because I wanted to see uninsured patients and have access to a 340B contract pharmacy for their medications.

There is also the reality that it takes staff to navigate meaningful use, quality metrics and incentive-based payments from all the insurance companies, which has made it increasingly challenging to own one's practice.

But not until I had a couple of years under my belt did I also have the insight to speak to the downfalls of being an employed physician.

I spent two years pouring my heart into my patients. I agreed to be overbooked to see any patient of mine who walked in requesting a same-day or sick visit, regardless of how busy I already was. I accumulated 31 homebound patients. Not a day passes that I don't hear from a family member, caretaker or home health nurse regarding one of my homebound patients, and sometimes I get calls from quite a few. I was working long hours, working though lunch to see more patients, going on home visits during lunch or after office hours.  

My last scheduled appointment is early in the afternoon, but I often was seeing patients up to two hours later because of overbooking and home visits.

But I was happy, and I wasn't complaining. And my nurse was happy, but what I didn't once think about was the fact that all my work meant she was getting paid overtime.

As an employed physician, I don't do payroll or review time sheets. I don't even know what people in the office make per hour. So here I am thinking that I'm just killing it, building a large patient panel, running quality metric reports, coming up with strategies to improve measures and outcomes.

Then just like that, I hit the wall.  

Hard.

Why? Administration came down hard and said no overtime for my nurse. None. Disciplinary action would result from any more overtime.

At the same time, everyone else in the office decided they couldn't talk to any of my patients -- that all calls had to be dealt with directly by me or my nurse because they couldn't complete their work within their scheduled work hours, either. Some things had to change.  

After I got past being so angry I couldn't even start to formulate a survival plan, I started to rationally think through how I could do all this work while allowing my nurse to have a hard stop every day. And I realized I couldn't.

Maybe my frustration had nothing to do with the actual administration vs. nurse situation. It may have been rooted in my epiphany that what I want to do every day is not possible. I had built a patient population with what are apparently unrealistic expectations. I can't agree to see all of my patients who walk in acutely ill. Someone else will have to, or my nurse won't get to clock out for lunch. I will cut down my homebound patient panel and refuse to accept new ones.

This is not how I envisioned medicine, and it's not how I imagined working as an employed physician would be. I am in one of the most supportive employed physician settings I've heard of. I have longer visit times than most physicians, I can change my schedule on short notice to accommodate my family's needs, and I take zero call.

Yet I wasn't spared from the wall.

Being a doctor now feels like an impossible feat. Not once does a patient walk out the door that I don't think of some quality measure, lab order or discussion I was supposed to have to satisfy an insurance or agency metric that I just didn't have time to do.

I'm depressed, and I'm burned out. And I'm less than three years out of residency.

This is not good for our patients or for the future of medicine. Granted, I'm not representative of everyone, but too many will relate to my story.

I'm sure people will have suggestions for how things could be done differently in my particular office. Clearly, additional staff would alleviate some issues, but in the end, none of the above details matter because too many physicians are becoming less happy and more miserable.

Suicide statistics are alarming, and many of us have lost a colleague. Too many of us are one step away from hitting that wall, and the only people who truly understand are those who have been there. I hope that as more of us talk about it, just like with any unspoken trauma, doctors will be more comfortable reaching out for help.  

Although the buzzword is burnout, the real problem is depression. Two years ago at the National Conference of Constituency Leaders (NCCL), a new physician delegate broke into tears talking about the time she hit the wall. She didn't use those exact words, but in retrospect, that is exactly what she was trying to convey to those of us drafting resolutions. A year later at the same event, she spoke about how support from other new physician delegates at her first NCCL had not only helped her in her practice back home but had motivated her to get involved at a higher policy-making level to work on issues that are beating us down as physicians.

Particularly as new physicians, NCCL is our home, our place of refuge. We all have a connection, and regardless of the long hours or the stress of residency, we have camaraderie with our fellow residency classmates because we all endured it together.

To the overwhelmed, depressed, already-tired-of-medicine new physicians out there, NCCL is your throwback to the call room. Come and find someone who knows exactly how you feel, and more importantly, hear from those who have found concrete solutions in their practices, because there will plenty of those, as well. This year's event is scheduled for April 27-29 in Kansas City, Mo.

In the meantime, there are other ways to communicate with your family medicine colleagues, including the AAFP's online communities, which include the Academy's member interest groups.  

The Academy has made improving member well-being a high priority. Last fall, a track on well-being was offered at the AAFP's Family Medicine Experience. The AAFP also plans to roll out expanded resources with the goal of improving family physician well-being and decreasing the burden of physician burnout later this year.

In addition, the Academy recognizes there are far too many barriers to providing high quality care and it continues to work to alleviate the system issues involved.

For me, my personal plan also includes saying no, often, to things that get in the way of me sitting in the exam room -- or a patient's living room -- listening to patients tell me their stories.

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

Posted at 04:30PM Jan 23, 2017 by Kimberly Becher, M.D.

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