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Monday Apr 23, 2018

In Face of Broken Health Care System, I Choose Happiness

I recently had the honor of speaking about physician burnout at Marshall Family Medicine's annual rural preceptor dinner. It felt rather bizarre to speak in front of my former mentors and teachers on this topic because I thought they would surely know more than me about surviving our profession.

[row of cars stuck in traffic]

I had spoken in front of this group before, but the topics then were clinical and the settings were academic. It was the topic that made me feel out of my league this time, which I think reveals one of our Achilles' heels in medicine: the hesitancy to be honest about our struggles outside of clinical or patient care realms. I will call or email just about any physician I've ever worked with to ask a question about a patient, but I felt uneasy talking about my own work-induced depression to a group of people who made me the doctor I am today.

During my preparation, I decided that if I was going to give this talk I may as well lay it all out and try to get at the actual cause of this growing problem in medicine. And I say medicine, broadly, because it isn't just primary care. Burnout is specialty-blind and spares no one. Although physician burnout is rapidly being recognized and intervention programs are being created, I have struggled to understand why this profession continues to find a way to defeat me despite my attempts at incorporating what I need to foster wellness and work-life balance.

I went to the AAFP's Physician Health First well-being portal to do my Maslach Burnout Inventory (MBI). I thought I could use my own results for what I hoped would be an ice-breaker, and I could encourage everyone else to take the MBI after the lecture. I've written about this subject before, so many may consider me a burnout survivor, but I think it is important to realize that although we may perceive that our physician colleagues have overcome burnout, the reality is that the effect of burnout sticks with us.

I may never be the same person or physician I was before I hit my wall, and I think my burnout inventory reveals data that makes the damage undeniable.

One theme I emphasized during my talk was the need to recognize that we hide our symptoms from one another. Those who have severe depression, even those who succumb to suicide, often seem well adjusted and even happy. Coworkers, family and friends sometimes may not have an inkling of how burned out someone really is until, unfortunately, it is too late.

The week prior to my talk, I had an annual review with my CEO and CMO, where it was conveyed that I seem to be one of the least burned out physicians in the organization. It really struck me that despite the fact that I have been rather vocal about my struggles with burnout, others seem to think I have won the battle. In reality, I have at least one point in every single day when I don't think I can do this anymore, and in those moments I regret becoming a doctor.

Two articles I read in the past month have helped me put all of this in perspective in a way I hadn't been able to previously. I saw a headline comparing the daily experience of a physician to that of military trauma.(www.statnews.com) I almost didn't read the article because even though I realize the effect this profession has had on me, I would never compare it to frontline combat or military deployment. But, because of the respect I have for the person who had posted the link, I decided to give it a read. It is spot on. In fact, it is the best description of what I think causes my burnout.

In the article, Elizabeth Métraux from Primary Care Progress(www.primarycareprogress.org) wrote that her friend, a physician who served in Iraq, told her he would rather be back in a life-threatening military situation than spend another day in his clinic. He also thought his post-traumatic stress disorder stemmed more from days in the office than from his combat experience.

Métraux called on the work of two other writers to help explain this phenomenon. Richard Gunderman, M.D., Ph.D., has written that burnout stems not from one traumatic experience but rather from repeated "tiny betrayals of purpose." Likewise, psychiatrist Jonathan Shay, M.D., Ph.D., in his book Achilles in Vietnam wrote that people suffer from an "undoing of character" when their actions contradict their core purpose.

We chose this profession to help people, to allow them to live better, longer lives, to diagnose and cure disease. But obstructing our way are hurdles that make us unable to do what our patients need and deserve. And after this process happens to us repeatedly, it causes that undoing of character.

This analysis makes sense to me on so many levels. When your goals are unattainable day after day, it eventually changes you -- especially when you are told by administrators and payers that you still aren't doing enough. Perhaps you haven't met the right quality goals or prevented enough ER visits. Or maybe you have struggled to hold back tears every day for months while your inbox filled with rejected orders from payers who doubt your ability and thwart your efforts.

It is like being forced to run on a hamster wheel that keeps shocking you. But at least you get a treat at the end, right? We get a paycheck. But as I pointed out in my talk, that paycheck does not prevent burnout. Anesthesiologists, who make far more than primary care physicians, report even higher rates of burnout.

Why does anesthesiology have a higher rate of burnout? I would speculate that it is due to a lack of direct patient interaction because that is what helps us primary care physicians get through the day, and then the week, and -- hopefully -- months and years. Relationships with patients are the replenishing source that helps offset the effects of burnout. But when we have less time for patients due to more administrative burdens, we lose the balance that makes us viable. That is the "betrayal of purpose."

The fact that patient relationships can replenish our emotional drive led me to a second article,(www.bustle.com) which also resonated with me, about simply choosing to be happy and refusing to let an awful situation ruin you. I was driving home from Florida during spring break. What should have been a 12-hour trip quickly turned into a gridlocked traffic situation, and I sat parked on the interstate for three extra hours. I thought of all the times that a similar situation would have put me in a terrible, angry mood, but I felt at peace. I wasn't even particularly annoyed. I was grateful to not be logged into an EHR or overwhelmed by my house that needs to be cleaned. I had no obligation other than to watch the brake lights in front of me. I created my own happiness in that moment.

This is the same concept that explains why running helps me and why meditation helps those who actually do it. We need breaks, real breaks, where we do not think and have no agenda or obligation. The big challenge is finding the time for those breaks and appreciating them when they happen.

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

Posted at 09:03AM Apr 23, 2018 by Kimberly Becher, M.D.

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