The idea that it is taboo to discuss physician mental health must cease
Burnout, it seems, is often written about, but the emotions underlying burnout are seldom described. I never appreciated what “burnout” really meant, assuming the term just referred to doctors who were chronically unhappy. Maybe they couldn’t handle stress. Maybe they just needed a vacation. Perhaps they needed to cut back on their work. If they were really *that* unhappy, maybe they just needed to find another line of work. Then burnout happened to me.
The amount of stress in my family was already in the red zone. We continue to deal with the aftermath of my brother’s death, trying to keep my brother’s widow from evicting my mother from her home. We’re working through significant medical issues with several family members. It sometimes seemed as if there was always an urgent issue needing attention before we could continue with our lives.
Once we addressed one issue, a random phone call or e-mail would present another urgent issue that had taken its place. It’s as if we were firefighters always scrambling to extinguish one fire after another before the whole forest was engulfed in flames. Oh, and the water pressure was getting low.
I was scheduled to work a holiday. My kids were coming home from college, and I would miss a planned gathering at our home, but holidays away from home are part of the job. Patients get sick during holidays, and someone must be there to shore up the safety net. I set aside some time in my schedule so that I could spend the remainder of the week with my family and could extinguish a few “smoldering” issues at home.
Then I got a call that a parent of one of our docs had passed away. He needed to leave on short notice. I didn’t think twice about helping to cover his shifts. We need to have each other’s backs. That still left me with one day to spend with my family and I could address other less pressing issues the following week. Then another group member came down with COVID and had three shifts that needed to be covered. I agreed to help because no one else was able to do so. The light holiday week was suddenly shaping up to be ugly. The smoldering issues at home were starting to rekindle themselves.
My first shift of the holiday week was horrendous. The rural emergency department where I work usually has several hours during the night with few patients, so physicians who work 24-hour shifts (not all of us do) can catch a nap and recharge their batteries when things slow down. That didn’t happen.
The emergency department was perpetually full of critically ill patients requiring high levels of medical care. We transferred six patients to other hospitals in the middle of the night. It wasn’t quite as easy as it sounds, though. Many referral hospitals had no available beds, so each patient required multiple phone calls to multiple facilities to get transferred.
Caring for patients that evening was like a cross between taking telephone orders at a busy carry-out restaurant and running a critical care unit without adequate staffing support. It seemed like every time I went to see a patient, I was pulled out of the room for another phone call. The entire shift was physically and emotionally taxing for all the staff. Running at full throttle for that long is hard to do.
I took a nap after my shift, went home the following morning, ate lunch, then slept until dinner. I got up, spent a couple of hours with my family and went back to sleep. When I arrived at work the following morning, the overnight doctor said that no patients registered between midnight and 7 a.m. He slept all night. I made some comments about my black cloud then hoped that his good fortune was a harbinger of a better day.
The department was full the entire day. I made time for bathroom breaks, but otherwise took bites of a sandwich between patients and had no down time. I was also receiving repeated phone calls from my mother about issues she was having at her home. Then I received a text message showing a picture of a large dent in the rear bumper on my daughter’s car. Thankfully, no one was hurt. I didn’t have time to calculate how many additional shifts I’d have to work to cover the increased insurance premiums. By early evening, my attitude had changed.
I could feel the change, but I couldn’t control the change. It may have been fatigue. I was still a little tired from the day before. Maybe it was irony. The day before, there were hardly any patients. Today, it was as if the patients waited for me to come back to work. I found myself getting easily frustrated. I was frustrated when I heard another ambulance call go out over the radio. I was even more frustrated when I heard that the ambulance was bypassing the closest hospital to come to our facility. I was frustrated when the lab took too long to return results. That kept patients in the emergency department longer. I even found myself becoming frustrated with patients.
One patient registered to be seen in our ER after being discharged earlier in the day from a university hospital more than 100 miles away. He drove to our rural hospital to get checked for bleeding from the site of a complex surgery – bleeding that was present before he was discharged. His wound had dehisced. We had none of his prior records. When we called to arrange for transfer back to the university hospital, no beds were available.
Another patient had a complaint that had been present for several months. I found myself feeling frustrated that she decided to come to the emergency department at 2 a.m. when she could have gone to see a primary care physician at any time in the prior 60 days. Then I learned that her appointment was still a month away, she got off work at 1 a.m., and she couldn’t take the pain any longer.
My guilt after learning her backstory made me feel worse. I found myself frustrated at patients who came to the emergency department for COVID testing because they did not want to wait in line at the usual COVID testing sites – and who then became upset about the wait times. More red marks on my Press Ganey surveys, I’m sure. The frustration built upon itself.
I walked away from the emergency department to take a breather and call my wife. No sooner were the words “it’s been a really bad day” out of my mouth then a tech came into the hall and tugged on my shirt. I had another phone call regarding a hospital transfer. Sigh. “I have to go.” A text message with a string of heart emojis made me smile, even if it was just for a moment.
As the evening progressed and ambulance gurneys formed a line in the hallway, it seemed that everything became an event to incite further frustrations. The doc who had no patients the night before my shift was a jinx. No. He was a backstabbing jinx bastard who probably yelled “quiet” in the hospital parking lot on his way out the door just to spite me. Fie on him! I got annoyed when orders weren’t completed in a timely fashion. What do you mean that I ordered Lopressor for the patient in rapid atrial fibrillation 45 minutes ago and you’re just giving it now?
My annoyance completely glossed over the fact that there were only two nurses, one tech and a secretary who were working harder than me. The whole “team” concept started to fall apart. I got frustrated when nurses had trouble starting IVs. I got annoyed when a nurse had difficulty putting a splint on a patient’s fractured humerus.
When I called the hospitalist to admit the next four patients, I felt myself getting physically angry when he expressed frustration about so many admissions. I didn’t bother mentioning how I had already worked up and stabilized all the patients for him. I also didn’t mention the multiple seriously ill patients I transferred and the many patients I discharged who he didn’t even know about. Instead, I nose-breathed into the phone receiver and bluntly stated “We’re *all* getting slammed right now.”
I like to think that I’m pretty good at putting on a smile and a poker face when things are bothering me. I’m sure that I’m not as good of an actor as my exasperated self thinks I am. My frustration showed during these shifts. I know it did.
Whether it’s me banging a fist on the desk when I think no one’s looking, whether it’s a head shake at hearing the next ambulance call over the radio or whether it’s just a change in my demeanor, the staff had to notice it. The patients had to notice it. When patients come to us for help with a medical problem, someone looking back at you appearing annoyed or preoccupied can’t instill confidence.
I tried to imagine how I’d feel if my family member was having a heart attack and the treating physician was exhibiting the frustration I’m sure I was showing. Frankly, I’d feel upset and probably a little scared. I began to feel like my frustration was overshadowing my compassion. In retrospect, I wondered whether my emotions had affected my medical care.
I can’t recall ever experiencing such feelings before. I still get frustrated, but not to that degree and I keep telling myself that my emotions at the time were just my reaction to having a really bad week. What if these emotions were instead the initial manifestations of my own burnout? Everyone has bad shifts or even bad weeks, but a day or two off to recharge your batteries and everything is supposedly better. How do we help physicians who are suffering from similar emotions without the means to recharge and without good social support?
Causes of Physician Burnout
A Google search for “causes of physician burnout” returns more than 1.8 million results. Articles attribute various causes to burnout including “the system,” cumbersome electronic medical records, performance metrics, regulations, medical culture, ineffective leadership, powerlessness, professional liability and perceived changes in the physician-patient relationship.
This is just a small sample of many factors that contribute to frustrations with medical practice. In retrospect, I can only attribute a few factors to my feelings of frustration during that holiday weekend: Stress, empathy and helplessness.
A buildup of stress was probably the largest contributor to my feelings of frustration. I was already experiencing stress at home. When I reached work, high patient acuity, high patient volumes, little available backup, overwhelmed staffing, bed shortages at other facilities and patient dissatisfaction with the circumstances all compounded the stress I was already experiencing. The more stress I felt, the more difficulty I had focusing on providing medical care. Stress caused me to focus on trying to offload some of my stress, but the inability to do so only made the stress worse. It was difficult to break that cycle.
It seems counterintuitive to claim that empathy could cause frustration. A blog post written by an executive at a national emergency medicine contract management group alleged that it is “hard to be burnt out when you realize what a difference you make and when you have compassion for patients.” That post has since been deleted – and with good reason.
Compassion doesn’t protect us from burnout. Compassion fosters burnout. I was feeling not only my own frustrations, but I was also affected by the frustrations of the staff who were having difficulty keeping up with multiple high-acuity patients and frustration of the patients and their families who waited patiently for medical care. We don’t have the same intensity of feelings toward people to whom we have no emotional attachment. In fact, one of the classic signs of physician burnout is ironically depersonalization – possibly a defense mechanism against the effects of empathy.
Understanding what may fix a situation but being relatively helpless to implement those changes creates tremendous frustration. This is where local and national leadership is most needed. Streamlining effective care and instilling a feeling of collaboration with medical providers is tremendously important. Instead, despite navigating a once-in-a-lifetime pandemic, physicians are told to do more work with less resources and less pay while maintaining meticulous documentation and keeping satisfaction scores in the top 10% of the nation – all by legislators or administrators who have often have little knowledge about proper medical practice.
Worse yet, physicians are subject to a plethora of governmental performance metrics and the pretty color-coded graphs that earn patient satisfaction companies billions of dollars (Press Ganey 2021 revenue: $318 million) when those data are often arbitrary, have little statistical value, have even less clinical application, and may increase patient morbidity and mortality.
If a restaurant employee’s job was threatened because too many yellow cars were going through the drive thru, the internet would be up in arms. When similarly irrelevant metrics are applied to medical practice, few bat an eyelash until they are unable to find medical care due to physician attrition.
A study of 20,000 respondents in Mayo Clinic Proceedings showed that 34% of physicians reported feelings of “high stress” and that 48% reported “burnout.” As a result, 31% of physicians planned to reduce hours in the next two years and 24% planned to leave practice altogether. The idea that it is taboo to discuss physician mental health must cease.
Physician wellness and the factors adversely affecting physician wellness must be treated not only as a crisis for medical providers, but as a public health crisis. Failing to address physician burnout will be at the peril of our profession and our patients. Our ranks are already thinning, and the medical safety net can’t take many more holes.
As I read this, I felt you were writing about my previous week during the Thanksgiving holidays. Everything you’ve written is completely true. I have no misgivings about being an emergency physician. It’s all I’ve ever wanted in my entire life. What I have misgivings about, is belonging to an organization that eats its young at every opportunity, there is absolutely no compassion or empathy for the physicians who are being put under the stress each article I’ve read there’s always a Monday morning quarterback, who thinks they know everything and puts us down which only compiles more stress on us. Thank you for such an incredible article, which was entirely truthful, and expressed everything that most of us feel at some time or another I recently covered the shift of a physician whose mother recently died. I,like you, felt we had to have each other‘s backs. When it came time for him to repay the favor he had other things to do that were more important than me. I do believe the era of having one back is gone. I don’t think they’re teaching that medical school, and now the docs are coming in value each other less, which is a total shame.
I agree with you. The ethos of emergency medicine is changing. When our specialty societies often don’t have our best interests in mind and our job is judged more on irrelevant and potentially harmful metrics than it is on how we can help patients and help each other, it doesn’t portend an encouraging future for our specialty.
Damn. I would have thought you to be bulletproof.
I’m retired 10 years and still can feel, emphathize and relive the thanksgiving weekends.
Bulletproof. Heh. If only …
Even body armor fails if it is hit enough times. 🙂