It was a brutal 3-hour drill-down on what's ruining our profession and killing our colleagues. The ACC.19 Clinical Wellness Intensive I and II sessions chaired by Dipti Itchhaporia, MD, and James Januzzi Jr, MD, included expert advice on self-care. Panelists and discussants comprised corporate employers, politically couched individuals, and physicians who gratefully shared their stories about navigating burn-out and recovery. Tait Shanafelt, MD, the chief wellness officer at Stanford University, provided the Louis F. Bishop Keynote Address. There were some surprising bullet points from his talk:
There is an astoundingly high prevalence of suicidal ideation in female physicians. A study has shown that our attempted suicide rate is double or triple that of women in nonmedical careers.
The male physician suicide rate is 50% higher than that of the average white-collar worker.
A doctor's thoughts of suicide double when we realize we've made a mistake.
Burn-out peaks at 10-19 years into our practice.
Shanafelt then listed several factors that impact burn-out:
Half of our work day is now spent doing "desk top" medicine, such as refills, prior authorizations, and insurance appeals. A third of our time in the exam room is spent staring at a screen, and 44% of us work more than 60 hours per week. He pointed out that spending less than 20% of our time in our "passion area" increases burn-out by 50% to 60%, and it doesn't help that we spend 28 hours each month working while off duty. "That's nearly an extra week of work per month," Shanafelt remarked.
"And it's not about the money," he was careful to point out. Similar high earners in other professions don't burn out or kill themselves at anywhere near the rate of doctors.
He didn't let us physicians take the blame for our current demise, either.
"Pre-med students are some of the happiest college students," he said, even though we bring a set of personality traits into medicine known as the triad of compulsiveness: doubt, guilt, and an exaggerated sense of responsibility. By the second year of medical school, though, "that has reversed," he said. Stress and depression then further escalate during residency. "It's what happens when we get our hands on them," he quipped.
Burnout Costs … a Lot
But wait for it….
Though it's hardly news that burnout leads to turnover, the sticker price associated with this is finally getting some attention. The Stanford University School of Medicine projects that burnout-related turnover costs about $84 million in recruitment alone. The BIG news is that the impact of that price tag is finally bubbling to the top of corporate ladders. That was evident in the make-up of today's panelists.
Moving Away From RVUs
Joseph Cacchione, MD, senior vice president of Ascension and chief executive officer of Ascension Medical Group, said, "It's not just one thing. It's organizational. We have made a commitment to making this important and making provider wellness a priority." -[By way of disclosure, I previously worked in the Ascension group]. He believes it needs to be a global commitment by an organization, and it has to be supported by the American College of Cardiology and the American Heart Association. He then described his change of heart over time. "I was that guy that judged the cardiologist who wasn't doing as many RVUs", he admitted, but "for 10K docs, we are changing our compensation system, going away from RVUs. There has been a lot of teeth mashing … but the culture of a practice will win out," he said.
And by all accounts, some of his other approaches have already helped. Cacchione spoke of a senior physician who told him, "'I'm done, I'm spent. I'm running on the treadmill and it keeps speeding up.'" They retooled his practice to a team-based approach by encouraging all team members to work at the top of their license. The physician is happy again and tells his story everywhere.
We need more outcomes like those.
Cacchione also mentioned a planned 2-year roll-out at Ascension that will include offers of job-sharing or even part-time options for those who find themselves under duress. I wish those had been available when my parents' illness prevented me from continuing a regular full-time job. Regardless of great patient satisfaction surveys and a wonderful comradery with a tremendous team of colleagues, personal obligations won out. Only a hard-driving PRN locums position has saved me from falling into the depression that jumping from the hamster wheel of medicine to cleaning out closets can invite.
Further cause-and-effect analyses of the intricacies of physician burn-out yielded a tangled web of etiologies. The hook on the back of many office doors hangs empty for a variety of reasons. Some former white-coat wearers have committed suicide. Others have taken a leave of absence or quit the profession altogether.
Some who remain working have changed to a more supportive or less stressful practice, but many are ill or depressed; have ongoing family needs or marital difficulties; or are simply worn out with too much call, not enough food, too little exercise, and the isolation of cursing at a screen instead of talking to our colleagues. These are the built-in hazards of running on the hamster wheel.
Shanafelt flashed a slide of two men engaged in a boxing match. One of them was being pummeled by his opponent. His point was that like the loser in that match, "We do not need to be taught wellness. We need a better work environment." That's in large part true, but meanwhile the session provided helpful suggestions for dealing with stress until someone throws us a life preserver.
Anand Chockalingam, MD, from the University of Missouri spoke on best practices for survival. "Life is not lived fully unless we motivate ourselves," he said. We recommended finding activities where you lose track of time. He emphasized the acronym HEART, for "humility, empathy, aspiration, reciprocation, and trust." He advocated for prevention through heartful living, which he described as the need to move naturally, to celebrate food, and to practice resilience. "The Idea is not to live 100 years. It's to live today," he said.
There's a Few Apps for That
Kapil Parakh, MD, a cardiologist who now works for Google, had several technical support recommendations to get us on the right track. "There are 300K health apps and the majority are not evidence based. Some are viewed as digital snake oil," he said. He then referenced the Medscape Happiness and Lifestyle Survey, which showed that one third of physicians surveyed get little to no exercise and that nearly half are trying to lose weight. He gave a "personal" recommendation for the Google Fit app, of course, but he also likes Johnson & Johnson's original 7-minute workout because it addresses the issue of "no gym and no time" with workouts that are 7 to 24 minutes long. He also recommended Sworkit ("Simply Work It") for in-home workouts that include cardio, yoga, and stretching.
When it comes to nutrition, he conceded that the science is less clear. He believes that the NOOM app has the best evidence for weight loss — it provides advice from coaches and automation. He described MyFitnessPal as very labor intensive: "It has a high attrition rate. It's good to figure out patterns, though." Honorable mentions included Weight Watchers, Lifesum, Healthy Out, and Fooducate for grocery shopping. "This is an ecological approach," he said. "It's important to surround yourself with healthier options."
Hope on the Horizon
We can take heart at today's presentation. It's the first time I've attended a session on burn-out and felt hopeful by the conclusion.
Thad Waites, MD, the Chair of the Health Affairs Committee for ACC, showed a letter to Senator Lamar Alexander from ACC President Michael Valentine. Senator Alexander had reached out to the ACC as chairman of the HELP committee to optimize physician work flow. Valentine's letter said, "We are pleased to offer several concepts for discussion" that included electronic health record usability, medical liability reforms, and bundled payments. This was the most heartening point today because it hinted at less talking and more action. Just knowing that Senator Lamar Alexander cared enough to ask for guidance from our ACC president is heartening.
Perhaps the most disheartening thing was Waites' last slide, labeled "A Child Playing Doctor." She was staring at a laptop with no stethoscope in sight.
What have we become?
Most of us didn't willingly agree to type, click, and reconcile our days away on a computer screen. I do believe, though, that the red tide may be turning. Data suggest that the burn-out rate has finally dropped slightly, dipping below 50% for the first time since 2011. I hope that's real evidence that something may be finally be working.
The loss of 300 to 400 physicians and med students per year to suicide, combined with the projected cost of turnover, cannot continue. The majority of us don't seem to know how to worry appropriately for ourselves. It is my hope that today's presentation is an accurate indication that others are finally picking up the mantle.
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Any views expressed above are the author's own and do not necessarily reflect the views of WebMD or Medscape.
Cite this: Melissa Walton-Shirley. Burnout: Is the Red Tide Finally Beginning to Turn? - Medscape - Mar 19, 2019.