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Monday Mar 25, 2019

Not Tough Enough? What More Do You Want?

I was recently at a "wellness symposium" where a speaker told the crowd there was not an issue with burnout in physicians; instead, it is an issue of resilience.

[tough enough sign]

Wow, I thought, there has been all this talk about physician burnout for years, but it's really only a matter of resilience. Perhaps I was confused. Looking up the definition of resilience online I found that it is "the capacity to recover quickly from difficulties; toughness."

Essentially, the speaker was telling us we aren't tough enough.

I take offense at that. First, it takes a lot of long hours and hard work to become a family physician. It takes long hours in medical school. In residency, the work hours get longer, as does the call. We already have proven our resilience by meeting the requirements to become family physicians.

In private practice, I was on call for myself during the week, and shared call with others during the weekend. In the small town where I practiced in Georgia, being on call meant you rounded on at least 20 of the 35 beds in the hospital, then took ER call each Saturday and Sunday. The hours were long, but the work was rewarding.

When I taught at a residency program, I can remember a two-month stretch where I worked in the hospital or office every day, including weekends. When you are shorthanded, you do what you can to help the team.

I'm not looking for sympathy. We all have similar stories. It is part of what we do.

The average workweek in the United States is 34.5 hours.(www.thebalancecareers.com) On average, most physicians I know work at least an 80-hour week.

In the words of The Fabulous Thunderbirds, "Ain't that tough enough?"

Family physicians have to fill several roles during our day. We are detectives, taking all the clues of history, physical, lab tests and intuition to diagnose a patient's problem. We are negotiators, dealing with patients to find the underlying issues that may have led to a problem. We are social workers, looking at not only the patient in front of us, but also the family unit and the environment they live in. We are scientists, looking for the best evidence-based treatment options. Finally, we are great communicators so we can talk to and listen to patients and families in their time of need.

Family physicians often get to do it all, including taking care of prenatal issues, delivering babies, treating the young child with otitis media and the teenager with swimmer's ear. Family doctors take care of heart attacks and strokes, as well as helping patients prevent them. We advise people to stop smoking, and yet we are there to treat the emphysema that occurs when our warnings go unheeded. We cry when our patients cry, and we have the freedom to laugh when they laugh.

How can anyone look at a family physician and say we need to be more resilient, tougher? I invite that speaker to walk a mile in our shoes. If you want to see toughness, come and visit a family physician's office. You will see toughness in action.

I don't think it is a matter of resilience. Instead, a significant problem we face is loss of autonomy.

Physicians are a different lot. Most of us went to school because we wanted to make the world a better place. Family physicians, especially, want to make the life of their family and their patients better than how they found it. Medical students, residents and physicians are thinkers. You will find few followers in medical school. Everyone works and builds their own set of skills for the future of their work with patients. We called the aggressive ones "gunners" in medical school. And all of us wanted to know everything we could to become great doctors. Medical students take this seriously. They want to score as well as they can in medical school to get into a great residency. There is a drive there, a very personal, individual drive.

The drive in residency is to get as much knowledge and build as many skills as possible to get a good job in a good community to build your practice. Through the entire journey, the student or resident has been able to make many of their own decisions. In years past, when doctors would strike out on their own and work in a standalone business, they remained the individual in charge of their own destiny. Now, that is no longer the case.

With payer issues, tax forms, staffing responsibilities and all the regulations that go with running an office, many have opted to sign a contract for employment. And for many, this is where the burnout begins.

You see, this independent-thinking physician is no longer independent. Often they are no longer empowered to make decisions about what is best for their patients without first checking to see whether their insurance agrees, whether the medications are on the formulary, whether insurance will pay for the lab tests they want, or whether they will be reimbursed for the EKG they did in the office that they read without consulting a subspecialist.

It is the paperwork -- or should I say, cyber-paperwork, the thousands of computer clicks per day -- that continues to wear us down. It is the prior approvals, the copays, the continuing certification, the regulations for prescribing that vary from state to state that continually hammer away at our resilience. Stealing the meaningful time we can spend with patients has robbed us of our sense of purpose.

Are some family physicians burned out? You darn well better believe they are.

Is it because they are not tough enough? Hardly. Family physicians are the smartest, brightest, most positive-thinking group of people I have ever had the good fortune to work alongside. I would also say family doctors are the toughest bunch out there.

One major reason for the fatigue, the depression and burnout is the loss of autonomy. We need to regain some control in our lives -- a need that drives much of the AAFP's advocacy. We need to find that purpose that lead us through all those long hours of hitting the books and running codes at 3 a.m.

We need to remember how much fun it was to deliver a baby in the middle of the night and round on that baby and mother the next morning.

We have a purpose and a reason to do what we do. We just want some relief from the burdensome, time-wasting requirements and for our pay to reflect our value.

We are family physicians; we treat the entire family, from beginning to end. We are the answer to the nation's health care crisis because we can do it all.

Ain't that tough enough? You bet it is!

Leonard Reeves, M.D., is a member of the AAFP Board of Directors.

Posted at 08:43AM Mar 25, 2019 by Leonard Reeves, M.D.

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