Saturday, January 24, 2015

On burnout...

This post actually started as a very long Facebook post, and as I was starting the third paragraph I thought "wait! I have a blog!" A long neglected blog, but still there nonetheless and waiting patiently for me to post. You'll notice that everything went quiet a few months into my intern year. I'll get around to writing up some sort of brief summary of how the rest of intern year went, as well as how the transition to being a "senior resident" is going. But for now:

I'd like to write a little about this article.

Image from the actual NYT article, which I think is 
evocative of the chaos in a hospital or clinic setting, too. 

This article is focused more on business than medicine, but it's an interesting read from the perspective that so many are concerned about physician burnout and yet the medical system is so so far away from being able to do anything substantive about it. The article proposes four areas that can prevent burnout in the workplace: renewal, focus, value, and purpose.

We could probably bolster the "value" and "purpose" areas in medicine, as physicians frequently feel undervalued and despite a purposeful mission we are often pulled away from the bedside to do much less satisfying tasks. Medicine is not the exalted profession it was fifty years ago, and that is fine. But sometimes it feels like we are little pill-prescribing drones in a giant money-making machine. A lot of times it feels that way. I do agree with the article that feeling valued and protected by your supervisors matters. I am very lucky in that regard, and my staff and program directors are lovely people who care about us and are trying their best to look out for us.

The part of medicine that most physicians love is actual patient contact, which gives us purpose and touches back to why many of us started down the insane road toward medicine. Sitting with a patient and learning about his problems and then teaching him about his disease is how I get away from feeling like a robot. The "patient load" ie the number of patients we are expected to see, and the ever-expanding amount we are expected to document pulls us away from the bedside. In clinic I get a generous 20 minutes per patient encounter (40 minutes for a new patient), which is theoretically supposed to include time to document what happened in addition to taking a history, doing an exam, checking out with staff, and teaching the patient. Yesterday my clinic was 90 minutes behind at times because I felt like spending more than a few seconds teaching my patients and it just snowballed out of control.

A patient of mine expressed concern and confusion that she had been gaining weight on insulin. So I explained (as plainly as I could, as this is complex but I was trying to be at her level) "the insulin doesn't make the sugar in your blood disappear. It makes your muscles and fat pull it out of the blood where it can cause damage and turn it into more muscles and fat. So we can keep giving you more insulin for the higher sugar in your blood but you could keep gaining weight that way. It would be better if you ate a little less sugar." And she got it, and she asked a few more questions that I answered, and she thanked me. And she said "I knew I liked you," which meant a lot to me. And that helped carry me into the next room where I had to apologize to the next patient for the delay. I spent another three hours at home documenting last night because I chose to spend the budget of my clinic time talking with my patients instead.

"Renewal" and "focus" are certainly fantastical concepts, and I can't imagine anyone being able to take a brief break in their day to renew unless we're counting bathroom breaks. Nor can I imagine anyone being able to focus on any one thing for more than a few minutes (thanks, pager).

From the article: "Employees who take a break every 90 minutes report a 30 percent higher level of focus than those who take no breaks or just one during the day. They also report a nearly 50 percent greater capacity to think creatively and a 46 percent higher level of health and well-being. The more hours people work beyond 40 — and the more continuously they work — the worse they feel, and the less engaged they become."

About a year ago there was a survey sent out to students and employees about how we might be able to incorporate physical activity into our day. The idea came from, I'm sure, something like this article and a naive attempt to make our workplace healthier. There just doesn't seem to be any possible way that doctors or nurses for that matter could carve out a completely selfish block of time during the day to, say, walk for 15 minutes over lunch. As residents we actually have a mandated-by-law limit of 80 hours in a week and when you are working in a system with that kind of constraint you have to make every minute of work matter. Every day there is a mountain of work that has to be done by midnight and you can't reasonably say, at 6:00pm, "I'll finish this tomorrow." Most of the time when I take a pee break my pager goes off in the bathroom, so even those few minutes of "selfish me time" as I attend to my biological necessities seem indulgent.

On more than one occasion I've wanted to take my team outside for five minutes on a nice day to see the sun (particularly because that would be our only chance to see the sun for that day). Or take my med students down for coffee. This has never actually happened because always, always something comes up or we run out of time. Even just learning about the people I work with is a struggle, crammed in to those few brief seconds of pause when I glance at baby pictures on a phone as we wait for someone to return a page. Or when we are walking down the hallway between wards and I remember I'm not a robot and I ask "so do you have any family here?" Should we have been running down the differential  diagnosis instead? Maybe. I don't know.

A few weeks ago I covered a night admissions shift ("night float MOD") on a Sunday. As soon as I arrived I was getting paged by the ER with admissions every few minutes to the point where I literally could not GET UP OUT OF THE CHAIR and actually focus on admitting someone because the pager would go off and I'd have to call back. That lasted an hour. Sometimes when I'm documenting and my pager goes off I'll actually take a few seconds to finish the sentence that I'm typing before calling back - a practice that causes me a lot of personal angst because who knows what disaster waits on the other end of that page. Outpatient medicine seems no better, as you barely get one patient out the door before moving on to the next. And you sit down at the end of clinic to "focus" on documenting and realize you have 12 minutes to obtain food, eat food, and go on to the next thing.

So how to fix it? My radical suggestions are not tenable, and primarily are rooted in pulling everything way back. We admit way too much. We document way too much. We doctor way too much, we do too many things, and yet somehow we spend very little time actually talking to our patients because there are too many patients and too many things. We and our patients are swept up in this tidal wave of medicine and the water keeps rising. Not everything can or should be fixed and yet we do a lot of doctoring to try. The system values volume and so cutting back won't happen.

Maybe just being mindful of these four areas and trying to find little ways to cultivate renewal, focus, value, and purpose in the medical system can help. Hopefully. I'll try to make more of an effort to carve out five minutes of respite for my team in a day - to take a detour that pulls us outdoors in the sunshine on the way to conference maybe. Or to hold their pagers so they can focus on documentation for an hour. To send the med students to the bedside to spend time with patients while we sit at the computer and answer the phone. And to echo my staff and directors who always tell the residents "thank you" and show that they, at least, value our efforts.

Why am I ranting about this? Because I'm burned out. It's better now, but it was really bad from winter last year until about two weeks ago. I had no energy or desire to read about medicine or study for boards after getting home every night. I went from the person who studied all the time, every day, to the person who maybe studied for ten minutes and then read Harry Potter and Facebooked for two hours. My husband pointed out to me that I was becoming callous toward my patients, which hurt but was important to hear. I tried a lot of things to snap myself out of it, and none of it took. Ultimately the thing that had the biggest impact was deciding to pick a different and much shorter tunnel so that the light at the end is just in my reach. I've found something to be passionate about - teaching medicine - and I've found that I can start doing that now without waiting to finish training. Seeing myself as a teacher even now, and realizing that I'm really just a year and a half away from being a fully fledged internist has brought everything back into focus. I'm back to hitting the books nearly every night and it feels awesome.