Showing posts with label burnout. Show all posts
Showing posts with label burnout. Show all posts

09 December 2018

Part Two: Physician Burn Out and Suicide - The Road She Forged.


by Mary Fernando

Dr. Mamta Gautam developed complications in her pregnancy and, after delivering twins in 1991, she was in a coma for days. She was soon forced to return to work with an open abdominal wound. She realized then and there that, “Medicine doesn't care about the health of their healthcare workers.”

What Dr. Gautam did with this knowledge was to carve out a new way to do medicine. A psychiatrist by training, she became the “Doctor’s Doctor” and, in the 1990’s, began work with individuals and organizations to address burnout and suicide before it was on anyones radar.
A pioneer in the field of Physician Health, Dr. Gautam founded the University Of Ottawa Faculty Of Medicine Wellness Program, the first in the world to deal with physician health issues. She is now an international expert in physician health and leadership. 

So, when I was searching for answers on how to help reduce burnout and suicides in physicians, I reached out to her to find solutions.

Dr. Gautam said, “Before I answer, I want to talk about complexity theory.”

At this point, I had my pen poised. When interviewing people, I always wait for what Virginia Wolfe eloquently asked of them: “…to hand you after an hour’s discourse a nugget of pure truth to wrap up between the pages of your notebooks and keep on the mantelpiece forever.” I was a little disappointed to be sidelined by a theory I hadn't heard of, rather than an actual solution to the serious problem we were discussing.

Luckily, my disappointment was short-lived because that theory, and how it applies not just to medicine but all professions, actually was a nugget of pure truth. So, here it is for you to wrap and put on your mantelpiece. Forever. Whatever your profession.
  • Dr. Gautam explained that some problems are Simple and can be solved by following simple instructions, like baking a cake. There are instructions, and if they are followed, we have a cake.
  • Some problems are Complicated but can be solved by following more detailed instructions and require expertise, like sending a man to the moon. With the right expertise, we can again have a solution that we can replicate.
  • Some problems are so Complex that their solution cannot be boiled down to a list of steps and and expertise doesn't always help, like parenting. If you add people in, we have different outcomes depending on the person (in this case both the child and the parent). So, we are better off with guiding principles, rather than strict recommendations and rules. 

With physician burnout and suicides, prevention is best thought of in terms of guiding principles, at the level of the individual physician, the culture of medicine, and the healthcare system.
One key principle is the need for community. For some this may be implemented by re-creating the doctors’ lounge. This where we can gather and talk about the day; the hard parts, the best parts and the funny parts. It is the ability to break out of the isolation and connect. For all of us, no matter what profession we are in, the trauma of our day can haunt us. For physicians, this might be the patients who died despite our best effort, the metallic smell of the blood that covered the patient, the room and us in surgery as we struggled to save a trauma patient, the young baby who fought valiantly and the breathless sobs of her parents after she died. Those traumas we need to talk about. 

The next part - and the crux of the matter: doctors are human. They should not be so tough that their hearts aren't wrenched when patients suffer. We can and should viscerally feel the often soundless sobs of the families that mourn. That is who we are, and that is the best of us. So, there must be an end to the ‘tough doctor’ and a new opening for the human doctor.

This is a principle for all healthcare workers and for all professions. We have many ideals that we strive towards, never being able to truly fulfil them but always keeping them in mind as we move through life. Many are worthy ideals. However, the ideal of the very strong, very together, never broken and beaten down person is an ideal that many of us hold dear. That person, that ideal, is actually a Trojan horse: if we let it into our lives, it will become stuffed full of all that will defeat us. It will be filled to the brim with the guilt of not living up to this ideal and the feelings of vulnerability that we stuff in it because we are terrified that the feelings are not worthy of the person we should be. It will be filled with the trauma we face, the small and large wounds we suffer but do not speak about. So, it is time to find another ideal and recognize the Trojan horse for what it is. We need to be human, striving to be strong when we need to be and allowing ourselves to be vulnerable, weepy and sad, infuriated and needy too. Because our empathy, our compassion, that makes us vulnerable, is actually the true iron in our spine. Wholly and wonderfully complexly human.

So, how to recreate community where we are allowed to be fully human?

Dr. Gautam said, “There is not one answer. If people accept the need for community and allow each person to be human, how they create that community depends on where they are and what they need.” 

So, Dr. Gautam asks for solutions to this, from each of us. The principle matters, the execution of the solution, like all good answers to difficult problems, is written on water and open to life. 

She sees this article, and others like it, as an opportunity to ask each person what they need and how to carve out this solution. It is a beginning of a conversation we all need to have.

11 November 2018

Part 1: Physician Burn Out and Suicide
– The Road they Travel.


by Mary Fernando

When the fall meets winter, before the snow is thick enough to obscure the road, the black tarmac can beguile you into driving on it. For those of us who have watched as winter makes it’s entrance, we know that the most dangerous driving is on those clear roads, topped with black ice, that can send your car careening off course.

Research shows us that one out of every two doctors are burnt-out and that doctors have the highest rate of suicide of any profession. Beware of suggestions that the problem will go away when doctors develop more resilience, take personal time or do yoga: these are just putting a coating of black ice on the problem- it looks safe but can send us careening dangerously off course.

To show you the road on which one doctor travels, let me introduce you to Dr. Johns, a Canadian family physician. Before we look at the road he is now traveling, let’s take a peek at the road he took to get to where he is. In his late teens and twenties, he worked hard, often around a hundred hours per week, with his nose in a book and caring for patients. Car accidents, severed arms, the agony of multiple illnesses coupled with old age, cancer in children – all the most devastating human conditions, sent him to study more, work harder, learn what he needed to to care for these patients. Many say medicine is a calling but it is built on a foundation of tenacity to help patients, coupled with the grit and determination to do so. Dr. Johns accumulated debt while others were earning, spent his nights by bedsides of the ailing while others were out having a drink with friends and eventually became a doctor. Resilience? He had that in spades.

Let’s zoom forward to the road Dr. Johns walks on today. Fifteen years after his training, he now has well over a thousand patients in his care.

“I carry these patients with me. The ones that are suffering, worry me. We are the ultimate patient advocate. We are responsible for their care, their well-being and ultimately their lives. Their care is my responsibility.”

Is he burnt out?

“I see it as a cumulative moral injury that I carry.”

Moral injury? Let’s break that down by looking at some of his patients, like the ones with knee or back injuries. The first problem is getting the tests needed for diagnosis - sometimes with wait times of one to two years. When the tests are finished and surgery is needed, add another year or two of waiting, at least. During that time, Dr. Johns explains, his patients are less mobile, maybe unable to work or adequately care for their children or aging parents. They are plagued with chronic pain, with each step eventually bringing agony. Dr. Johns works longer hours seeing these patients and calling hospitals and surgeons to try to get them better care.

“I work harder than ever before but I have so much more guilt about the patients I can’t help. It is enforced mediocracy.”

So what can Dr. Johns do? He worries about treating the pain with painkillers and risking drug dependence. He worries about their financial precariousness and their loss of independence and dignity. He worries about the patients who have multiple illnesses and are increasingly isolated form their community by their lack of mobility. He worries about the development, often inevitable, of depression secondary to chronic pain and the loss of the ability to work and care for those who need them, because mental healthcare is simply another wait of years.

Many of these factors Dr. Johns cannot change, because “the decisions about the availability of diagnostic tests, access to surgery or mental health services are decided by administrators who manage the system but are not accountable: they never sit with the patient and hear their stories. They never feel responsible for their care.”

In Canada, these administrators decide what services are available and in the United States, they decide access in different ways. But all administrators forge the care patients receive, without having any responsibility for each patient impacted.

So, moral injury? Dr. Johns argues that the care that he trained so diligently to provide is not the care his patients get and he is powerless to change that. It is, for him, a deep moral injury. This is the evisceration of doctors.

Dr. Phillips, who works as a hospitalist, points out another serious gutting of doctors: doctors in hospitals are discouraged from bringing to the attention of the media the lack of beds, equipment and access to operating room times. Many are threatened with loss of privileges or loss of their jobs if they speak to reporters directly. So, how do you fix a problem that is out of your control when you cannot speak about it?

Recently, the NRA told doctors to stay out of the gun control debate, by asking them to stay in their lane. Responses from doctors on twitter told stories of gun violence with the sassy hashtag #ThisIsOurLane. However, despite speaking out, patients with gunshot wounds are still flooding into hospitals because doctors have no control over policy, but are responsible for saving the lives impacted by policy.

This is just a small glimpse into the road that doctors travel. If we let administrators and policy makers have control over patients’ lives but never have even one patient under their care, if we muzzle doctors from speaking out or ignore them when they do speak for patients, then we have the conditions for burnout. If you coat that road with thin ice of words like ‘resilience’ and suggestions like ‘lunchtime yoga’, there is a good chance that you are creating black ice that will drive any change dangerously off course. Worse, much worse, it is patients who drive that road with their doctors and often careen off into the ditch of increased disability, pain and suffering.

Doctors suffer in a system they cannot change for the better — they burnout and they die — because when they are crushed by the moral injury caused by the weight of the thousands of patients who they cannot help.

11 May 2013

Losing the Edge




by John M. Floyd


Lately I've been reading a lot of mysteries by James W. Hall. His series protagonist lives in the Florida Keys and enjoys, among other things, tying fishing lures. In Hall's fifth novel, Buzz Cut, the hobby has become sort of a business venture, and the lures don't seem to work anymore. They won't catch fish. Here's an excerpt:

His flies had lost their allure.

He had always tied them for himself. Sold his extras. The compulsion behind each one was the simple desire to snag his own bonefish. To concoct his own bait so appetizing it would guarantee the thudding strikes and wrenching excitement he had relied on for more than thirty years. But he'd lost something, tying them exclusively for others. His fingers committing the same act, tweezers and scissors, Mylar and feathers, hackle and ribbing. Everything exactly the same. Identical to the eye. But now they were duds. Failures on some level so subtle, so subatomic that only the fish could see it.

That got me to thinking. Can that kind of unconscious burnout happen in other creative endeavors as well? Can it happen in writing?

Sure it can.

The Over the Hill Gang

How often do you find that certain authors whose work you've been reading for years suddenly don't seem to write as well or as compellingly as they used to? I won't call any names here, but I can think of at least half a dozen bigtime novelists whose latest work doesn't seem to be able to deliver the same punch that their earlier (and sometimes earliest) books did. The style and voice are the same, but the stories themselves just aren't as entertaining. They don't pull you in and hold you the way they once did.

If that's true--and I believe it is--then it's certainly a contradiction. One would expect a craftsman of any kind to get better the longer he or she practices that craft. So the question is, what could cause a writer to lose some of his or her appeal, and effectiveness?

Part of it could be the fact that doing something--anything--day after day, year after year, can grow boring for the person doing it. The old saying "familiarity breeds contempt" was probably meant to apply to relationships, but it could also apply to fields of endeavor. The quality of the product can be directly proportional to the level of enthusiasm of its creator. I recall reading someplace that the cars that go through the assembly line on Monday usually don't turn out as well as those assembled later in the week.

Or maybe, as in the case of the fly-tying fisherman, the artisan starts doing things more for the end user than for himself or herself. I realize we should all try to "write with the reader in mind," but we must also write in a way that pleases ourselves. I've said that even if I knew I would never publish another word of fiction, I would continue to write it anyway because spinning these tales is so much fun to do. For me it's therapy as well as recreation. The process itself is enjoyable and satisfying and relaxing.

But what if you're writing under a tough deadline? I once heard a well-known novelist tell a group of beginning writers that "your first novel will probably be the only one that's really fun to write--and might be the only one that you're ever completely satisfied with." The reasoning is that if that first novel is successful, your agent and publisher will probably want another book from you every year. Maybe more. And when that happens, what started out as play can quickly become work. All of a sudden you have responsibilities, your audience and your publisher have expectations, your hobby has become gainful employment, and your merry romp in the fictional clover is now a real job.

(By the way, when I say "first novel," I'm referring to published work. All of us have stories and novels that never saw the light of day, and for good reason. I suspect that many famous authors have a few unpublished books--truly first novels--stuffed underneath their beds or in the back of their closets.)

The Top of the Hill Gang

I can think of several ways that writers might prevent or recover from "losing their edge." Intentionally or not, some authors seem to have extended their popularity--and probably their careers--by writing in different genres (Larry McMurtry, Nora Roberts, Evan Hunter), writing both series and standalone novels (Harlan Coben, Elmore Leonard, Robert Crais), creating more than one series (James Lee Burke, Robert B. Parker, John Sandford), writing both novels and shorts stories (Lawrence Block, Stephen King, Jeffery Deaver), and collaborating with other writers (James Patterson, Tom Clancy, Janet Evanovich). It might also be said that authors like Thomas Harris and John Irving stay at the top of their game by going more than a year--sometimes several years--between novels. However effective these kinds of things are, I suspect that they are done more for personal reasons than commercial reasons. Maybe they ward off the boredom we talked about earlier.

In closing, let me mention that some authors seem to have kept their ability to thrill and entertain throughout their careers. Lee Child, Carl Hiaasen, Greg Iles, and Dennis Lehane come to mind, and I think some of Michael Crichton's later books were as strong as some of his early ones.

As for Stephen King, his novel The Stand remains one of my favorites, but his 11/22/63, published 33 years and thirty novels later, was just as good, and possibly better. That's comforting news to me, in more ways than one: King and I are the same age--well, he's two months older--so maybe if he can still think clearly, so can I.

Hey, I'll take inspiration wherever I can get it.