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Dr. Rushed snatches the chart for the third patient he will see in this half hour, hoping this visit won't be very complicated because he's got to see three more patients before 10 a.m. or he'll be running behind all day. Last night he didn't get home until the kids were ready for bed, and even then he was impatient with them and grouchy with his wife. Tonight he'll miss dinner again, as well as his daughter's basketball game, which will disappoint his whole family. Frustrated, he pushes open the exam room door. Lately, Dr. Rushed has felt like the cartoon character George Jetson, on an automatic treadmill spinning out of control. Unfortunately, it is a sensation all too familiar to many family physicians today.
More than you bargained for
You knew medicine
would be challenging and even grueling at times. The current restructuring of
the health care system, however, has led to unprecedented changes and increasing
demands. "People can do more for brief periods of time," says Donald E. Rosen,
MD, director of the Menninger Leadership Center and the Professional in Crisis
Unit at the Menninger Clinic in Topeka, Kan. "They can work harder, do more,
rise to the occasion," Rosen says. "But persevering and prevailing are different
than when the bar is raised and you've got to jump at the new height every time
into the foreseeable future."
If you find yourself experiencing continuous job-related stress, you could be headed for "burnout," the popular term used to characterize the loss of physical, emotional and mental energy. If ignored or denied, the consequences can be serious not only for you, but for your family, co-workers and patients.
Warning signals
"If it doesn't feel like fun
anymore, that should be a red flag," says Thomas J. Weida, MD, an associate
professor of family and community medicine at Penn State University's Milton
Hershey Medical School and medical director of Penn State Community Health
Center in Hershey, Pa. This rule applies in the office and at home. "If you're
so overwhelmed with commitments you made outside the home that you feel home is
a burden, that may be a sign you're doing too much somewhere else," says Weida,
a member of the Family Practice Management Board of Editors.
"Burnout is a cumulative process leading to emotional exhaustion and withdrawal," says John-Henry Pfifferling, PhD, director of the Center for Professional Well-Being in Durham, N.C. Other experts agree. When you feel a distinct loss of energy and motivation and a sense of paralysis about what to do about it, you may be spiraling into burnout, warns Dorothy Largay, PhD, co-director of the Center for Professional and Personal Renewal in Los Gatos, Calif.
The symptoms of burnout are as varied as the sufferers. Some people become angry, blowing up or growling at anyone who crosses their path, including other physicians. Some resort to blaming any annoyance, large or small, on external factors. Some become quiet, introverted and isolated, which can indicate the start of a serious depression. Others manifest burnout by under- or overeating or abusing alcohol or other mood-altering substances. Still others may experience a range of physical symptoms, including chronic illness, high blood pressure and frequent headaches.
Some people on the verge of burnout actually become obsessive workaholics, says Shay Bintliff, MD, a clinical professor of surgery and pediatrics at the University of Hawaii School of Medicine in Honolulu. "Some doctors work more because it's the only thing they know how to do," she says. "It helps the patients when they do more, so they think it will help them, too."
Others become chronically late or psychologically absent. They shuffle papers at their desks or bustle from appointment to appointment, without actually getting anything done. Some physicians may even resort to self-prescribed pick-me-ups, whether in the form of caffeine or prescription stimulants.
Family and friends are often the first to notice the warning signals. "Spouses are great at picking up on nonverbal cues," Rosen says. "Sometimes we'll call and ask them what they see when their spouse is under stress, and they'll generally point out things that the doctor didn't see."
Figuring out if you're overstressed isn't difficult -- if you can find the time for a little self-evaluation. There are various tests you can take to determine your level of stress and where you are on the burnout spectrum. See "Assess your risk for burnout" on page 35 and "Are You Stressed Out?" Family Practice Management, March 1997, page 85, for two examples.
Stressors
"People know if they're stressed,"
says Gigi Hirsch, MD, executive director of Gigi Hirsch, MD & Associates,
Cambridge, Mass., a consulting group focusing on physician career development.
The more difficult issue, according to Hirsch, is teasing apart the various
causes of stress and trying to identify any that are controllable.
The system. Among the most obvious stressors, or causes of stress, are the demands associated with practicing medicine today. "It's a time of unparalleled change, and there's a tremendous loss of autonomy in medical practice," says Rosen. "There's a loss of autonomy in being able to decide what's best for your patient, and in being able to set up the type of practice you want rather than having your style dictated by the economic powers that be."
Under managed care, doctors are dealing with more contracts, more insurance forms and more bureaucratic headaches. Plus, they're often being paid less per patient, which means they have to either lower their financial needs and expectations or take on more patients. Either way, it's a stressor.
As gatekeepers, family physicians are expected, in some instances, to wear more hats while seeing more patients. In the worst case, their scope of practice may be limited to the point where they merely become the guardians of the gate through which patients must pass to reach a "real" doctor. Family physicians must also spend more time explaining the changes in the system to angry patients who do not understand why previously granted requests are now being denied. And there is always the constant pressure to know more. Just keeping up with the changes in the health care system and staying apprised of the growing body of information and technological advances can be a full-time job.
Family. Fulfilling family and personal responsibilities can create another set of stressors. Kimberly Manganaro, MD, a family physician in Lewistown, Pa., has gradually stepped back from committee and association work to give more time to her family and community. Yet she admits that there are days when the stress is still overwhelming. "It gets to a point where something has got to give," Manganaro explains. "You've got three kids saying, 'Why are your patients more important than us?' You're trying to keep your family and your marriage together, and you realize you can't do everything."
| Assess your
risk for burnout There are two types of stress: eustress and distress. Eustress, or positive stress, occurs when you control your stress. Distress, or negative stress, occurs when stress controls you. Here is a simple test, developed by the Center for Professional Well-Being, to help you determine your predisposition to distress in your life. The more questions with a "yes" response, the greater your risk for burnout. | ||
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Self. An often overlooked source of stressors lies within. While external demands continue to increase, self-imposed demands can create even more pressure. "There's always a very subtle, yet strong, call to do more," Weida says. There's also, Weida admits, an insidious ego-stroking involved in working harder. "It makes you feel good when you've made someone's life better," he says. "And, over time, you begin to believe that if you see more patients, if you help more people, those individuals will be grateful and think you're wonderful -- or so the thinking goes."
Expectations don't always match reality, says Pfifferling. Many doctors go into family practice expecting respect from their patients and peers, only to find that instead of being treated like the venerable family doctor, they're treated like an employee. Or they may have expected a true partnership -- one in which the partners take time to discuss patients and treatment plans and what they can do to relieve their collective stress -- only to find that that type of interaction didn't materialize, Pfifferling says.
Although anyone can experience excessive stress, physicians tend to possess certain traits, which are reinforced in medical training, that make them more susceptible to burnout. Doctors are conscientious and committed and tend to be high achievers. Their personal identity is often tightly wrapped up in their professional identity. "So when the inevitable negative things happen, they fall apart, because they haven't put any effort into any other part of their life," Pfifferling says. "All of their eggs are in one basket."
Too many doctors don't see their identity going beyond specific roles, Largay adds. "It's 'I'm good or bad relative to how well I do as a doctor.'" The same attitude, according to Largay, carries over into their family lives, where they see themselves primarily as a provider and spouse, rather than as a parent and partner. "Because they're so role-bound, when they're with their spouse or their children, they don't get the emotional satisfaction that would give them more fuel to enjoy their job," she says.
Many physicians also suffer from an incongruent lack of self-esteem, says Bintliff. Even though they are bright and talented, they don't firmly believe in their own value. "They think getting that MD behind their name will give them self-esteem, but self-esteem comes from within," she says.
Medical training also contributes to burnout long after the textbooks have gotten dusty. Many doctors adopt "mental models" during their medical training that keep them from reaching for help when they're overwhelmed, Largay says. "There's still the idea out there that real doctors do it on their own -- it's a pattern that becomes your modus operandi over time."
If any or all of this discussion strikes a particular cord with you, it's time to take stock of your own well-being. See "Measure your wellness with the Adult APGAR," page 38, for a simple self-test.
The best defense
If you want to better manage
the stressors in your life, improve the quality of your life and avoid burnout,
you need to have a personal plan of action.
Take care of yourself. "Doctors are good at taking care of everybody but themselves," says Peter S. Moskowitz, MD, a pediatric radiologist at Columbia Good Samaritan Hospital in San Jose, Calif., and co-director of the Center for Professional and Personal Renewal. Doing something good for oneself is a difficult concept for doctors to accept, according to Moskowitz. "There is an intrinsic bias that somehow they're failing as doctors if they want to take time out and be good to themselves," he says. Bintliff agrees. "The medical profession is up on a pedestal," she says. "You sacrifice your life and your whole family's life for it, and it's not OK."
So what should you do? For starters, practice what you preach -- eat right, get sufficient rest and exercise routinely. Pay more attention to your body's signals of stress. Learn to pinpoint the sources of stress and practice stress-reducing strategies, such as progressive relaxation techniques, breathing exercises and meditation. (Also see "Rediscovering the Joy of Family Practice," Family Practice Management, November/December 1996, page 32.)
Make life balance a priority. One of the best ways to arm yourself against burnout is to have a rich, fulfilling life outside the office. "You have to look for real life satisfaction away from work," Rosen says. "Just as a good financial adviser doesn't have you put all of your assets into one stock, you shouldn't put all of your emotional assets into work." Of course, knowing there's life outside the office and making the changes necessary to tap into that life are two very different things.
If it's important to you to be a leader in the politics of medicine, for example, you must decide what you're willing to give up to make that time available. If your family is what's most important, perhaps you have to ease back on your workload, something most physicians are loath to do.
Measure your wellness with the Adult APGAR
The following self-test, if answered honestly, measures wellness and can be used to predict impairment, according to Shay Bintliff, MD, who designed the tool. Drawing from her experiences working with Virginia Apgar, MD, creator of the well-known test for newborns, Bintliff devised a similar tool for physicians. Bintliff, a clinical professor of surgery and pediatrics at the University of Hawaii School of Medicine in Honolulu, has been concerned for many years about physicians' inability to recognize the signs of burnout in themselves. Too often, she says, physical and mental exhaustion is simply blamed on overwork and, as a result, many physicians don't realize they are in trouble.
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Scoring: A score of 9 or 10 indicates a high level of wellness. A score of 6 to 8 indicates imbalances and stresses that need attention. A score of 5 or less indicates significant trouble or pain, requiring crucial changes to achieve wellness. Professional counseling, a therapeutic support group or individual work is strongly recommended.
Copyright 1991, Shay Bintliff, MD, reprinted with permission of the author.
Rebecca Lueckenhoff, MD, a family physician and member of a multispecialty group in Jefferson City, Mo., decided to limit her practice to outpatient care. "It wasn't easy," says Lueckenhoff. "I felt like I was abandoning my patients, but I saw how other doctors who limited their practice to outpatient medicine were enjoying themselves." When Lueckenhoff approached her partners with the idea, she admitted that burnout was a factor. "I said, 'Call it burnout. I'm willing to accept that label, if it will get me what I need and want,'" recalls Lueckenhoff.
Achieving balance in your life can be a process that takes considerable time and effort. "It's similar to physical fitness," says Moskowitz. "You can't just go on a diet and frantically exercise for a month; you have to make life-long decisions about how you will spend your time, what things you'll say 'yes' to, and what things deserve a 'no' and then feel good about your answers," he says. Since it is difficult to strike such a balance alone, many physicians, according to Moskowitz, benefit from having a mentor or coach to provide insight and inspiration.
Develop a strong support system. "Doctors have a particularly hard time reaching out for help," Largay says. "But if you're not willing to reach out, you're going to stay in your own mental model and not make the fundamental shift that will allow you to approach your problems differently."
One of the most therapeutic things you can do for yourself and others is to form a support group. It cannot, however, be a bunch of people sitting around complaining, Largay says. "When you talk about a problem, you need to add what you want to do about it and how you see yourself contributing to the problem," she says. "That gets you out of the whining and blaming and moves you toward finding a solution." (Also see "Physician Support Groups: A Place to Turn," Family Practice Management, October 1995, page 26.) There are also a wide range of programs available to help physicians with stress management, including seminars and consultation services. (See "Physician stress management programs" on page 46.)
It is extremely important to practice in a supportive work environment, and you can take certain steps to foster a healthy workplace. Encourage open communication in your office. Take time as a group to develop a mission statement and goals for the practice. Make sure that there are clearly defined policies and procedures for office operations. Be sensitive to overwork patterns of other physicians and staff in the practice.
A final thought
The people who
are most protected from burnout have a strong sense of self-esteem, Pfifferling
says. They also have a good social support system, a confidant and a network of
friends, and they accept their own talents without being egotistical. It's also
important to be able to laugh. "If you're in an environment where you can't
sometimes be light, the gloom and solemnity will drag on your spirit," he
says.
Above all, you must acknowledge your priorities and build your life around them. The stresses on family physicians are not likely to ease up soon, so it's essential that you find the things that bring joy and meaning to your life and then create time for them.
| Physician stress management programs
There are several organizations across the country studying physician stress and offering seminars and consultations for individual doctors and practices. The following are a few examples.
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Copyright © 1997 by the American Academy of Family Physicians.
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