Burned Out?

When things began to go awry for Kernan Manion, the Massachusetts physician wasn't sure exactly what was happening to him. All he knew was that his hospital job as the primary counselor for people with new spinal-cord injuries was getting to be too much.

Sure, he liked what he was doing and felt he was providing a valuable service. But at the same time, Manion was feeling worn down emotionally, wiped out physically, and progressively more irritable and distant from his colleagues.

Then his father had a stroke, along with a sudden diagnosis of bipolar disorder; Manion was called upon to assist in his care. And on top of that, the hospital where Manion worked was being sold to a for-profit chain. Layoffs were inevitable.

Manion's breaking point came soon after that, in the middle of a team meeting with a patient. When the other doctors and the patient turned to Manion for his input, he was completely choked up.
"The intensity of the work had gotten to me," says Manion. "I was baked, fried, crisp -- and the personal matters were just making things worse."

Manion stepped out of the room to try and regain his composure. In the hall, he wondered if he should quit hospital life in favor of spending more hours with patients in his small private practice. Another part of him toyed with leaving his practice altogether to become a chef, one of his long-held dreams.

Instead, after some soul searching and time with a career coach, Manion decided to stay in the field but shift his focus to helping other doctors who were going through what he had: an acute case of physician burnout.

And since then he has been busy. While Manion's situation may have been particularly severe, studies show that increasing numbers of doctors -- up to 40 percent of physicians and 70 percent of residents -- are feeling burned out and dissatisfied with their professional life these days. Corresponding with that are much higher rates of alcoholism, drug addiction, and suicide among physicians.

A growing risk

"No question about it -- physicians are at greater risk for burnout now than they've ever been in history," says Wayne Sotile, clinical psychologist and co-author of The Resilient Physician: Effective Emotional Management for Doctors and Their Medical Organizations.

Sotile says the primary culprit is the "high demand and low control" environment doctors face in many practice settings these days. Doctors struggle to squeeze more patients into their day to make up for reduced reimbursement, in between calls to payers to justify the services they've provided. There's more and more paperwork, including stacks of literature to keep up with as technology marches forth at break-neck speed. There's also an increasingly demanding patient population, who attempt to direct their care according to what they've seen on TV or read on the Internet. Frustration with the process is epidemic.

"Physicians generally will say one of the reasons they went into medicine was to help people, and part of that is having a relationship with the patients," says Manion, who now runs Work/Life Design Associates, a Wilmington, N.C.-based coaching firm for people in healthcare. "When you diminish the patient encounter and have to speed through, both the patient and the physician feel robbed."

The result? "Burnout robs [physicians] of positive resources such as humor, enthusiasm, empathy, appreciation and being present," says John-Henry Pfifferling, director of the Center for Professional Well-Being in Durham, N.C., and author of Techniques for Coping with Stress and Change. "Burned-out doctors catch themselves, in increasingly common moments, being curt, uncaring - or even hating their patients."

Anatomy of the problem

One of the keys to avoiding burnout is knowing the warning signs. The first phase, explains Manion, is "wear down," which is marked by emotional exhaustion and a feeling of being drained and beaten down by the system. At this point, doctors become irritable and impatient with their colleagues and patients. They tend to isolate themselves and feel a diminished sense of accomplishment. Work is no longer fulfilling.

If nothing's done to remedy the situation, full burnout will soon follow. This is when a physician is so stressed, he or she walks around angry, feeling inept, chaotic, panicked, and depressed.
For instance, says Manion, "As a burned-out doctor, if Blue Cross only pays me two-thirds of what I bill, I will have an internal dialogue going on, either consciously or unconsciously. I might think: 'Those inconsiderate SOBs -- what right do they have?' Or, 'Not another patient with this insurance.' Next, you learn your malpractice rates are getting raised and another internal dialogue starts: 'Where will I get the money? Every patient is a potential litigator.' Soon the internal dialogues turn into screams."

That doctor is heading toward the final phase: meltdown. This is when the physician has hit a wall and can't go on, feeling traumatized and emotionally ill from all the stress.

There is usually some sort of breaking point, a confrontation with a colleague, for example, or a run-in with a patient, which forces the doctor to face their burnout.

"Wear down is like the fatigue that comes with a heart that's got coronary insufficiency," explains Manion. "Burnout is the work-life equivalent of a heart attack. And meltdown is a full-blown code blue. It demands immediate intervention."

Next step? You can change the factors that are bothering you, change your practice altogether, improve your coping techniques, or leave medicine entirely. A therapist or a career coach can provide useful support at this point.

Control what you can

It may seem obvious, but the best defense against burnout is taking appropriate care of your mind, body, and spirit. Physicians, he says, are notorious for not taking care of themselves. In fact, studies show that about 60 percent of doctors don't even have a physician, but instead self-administer care or get occasional medical consultations from colleagues in the hallway. "You have to change your lifestyle to take care of yourself," says Sotile. "Don't forget the basics."

A big part of that is taking periods of recess from work and engaging in healthy pleasures, whether that means golfing, traveling, or just sitting in a sunny room reading, says Sotile. He adds that doctors should make sure to get regular exercise, a proven stress reducer.

If burnout has already set in, though, experts suggest first making an effort to identify all of the issues that are affecting you.

"Give [yourself] time to explore these issues and events and their meaning to you," says Manion. "Determine which ones you can work on, which ones you can't, and which ones you could use someone else's help with." Then, focus on what you can control in your practice and prioritize.

For example, can you hire someone to handle all the payer calls you can't get to? Can you find a way to delegate more tasks that will allow you to spend more time with each patient? Would it help to reconsider your scheduling process to allow you to complete paperwork and dictation between visits, rather than leaving it to pile up at the end of the day?

In addition to your work environment, it's important to take a closer look at your significant relationships. Are they healthy? Could they be more mutually supportive? Your relationships at work count, too. Though doctors may not realize it, there may be troublesome communication issues between them and their staff. Sotile suggests working hard to forge better connections at work, which can go a long way toward easing stress and increasing motivation. 

Instead of just rushing by, ask your receptionist about her weekend or how her family is. "This will make you feel more connected to her, and her to you -- and then she may feel compelled to stay late making more calls for you," says Sotile.

And although it sounds counterintuitive, Sotile recommends holding frequent staff meetings -- even a five-minute "huddle" each morning just before the office opens can help you to stay connected and on the same page.

"Take a lesson from corporate America," says Sotile. "Meetings create relationships and help foster teamwork. You achieve more when you're a member of a cohesive team."

Building more supportive, collaborative relationships with other physicians can help, too. Most doctors are trained to have the lone wolf approach to their work, says Sotile, doing more competing with colleagues than collaborating. Instead of continuing in that vein, Sotile recommends that physicians forge and maintain caring connections with other doctors, asking for help when it's needed. 

But take care not to engage in too much demoralizing talk about how unbearable it is to be a doctor in this day and age; that will only serve to highlight the negative and make you feel worse. "Try very hard to embrace what is good about today," Sotile says.

Making changes

If these measures don't relieve some of the stress, Pfifferling suggests looking more closely at the practice you're in. Is it reflective of your values? Is it allowing you to use all of your talents? Does your input matter there? If not, a move to a new practice might be what's needed. Or, says Manion, a closer look at the situation may show it's time for a career change, as he made. There are plenty of options that will allow you to use your medical training and skills.

Sometimes, though, it's not outside factors that are the biggest culprits in burnout. David S. Brody, a professor at Hahnemann Medical College in Philadelphia, contends that personality traits can play a huge role in preventing future burnout issues for residents he's taught.

"Some people look like they're having fun in residency; others always look frustrated and upset and are clearly not having a good time -- though they're in the same environment," says Brody, one of the few medical educators to teach residents how to tend to their own emotions while treating patients.

The glass-half-empty types -- whom Brody calls "the mopers" -- seem to have an innate need to control their environment, with a corresponding feeling that they can't. This brings them much stress. The copers, on the other hand, are more confident, have a greater sense of control in general and don't feel like the medical environment forces them give up that control, says Brody.

The take-away message? Physicians already in practice who are copers likely won't face burnout, says Brody. Rather, they adapt easily, juggle tasks well, and take charge of the factors that trouble them. The mopers, however, may be at greater risk.

Even so, Sotile says burnout doesn't have to ruin a career. Most physicians will view it as wake-up call, a signal that something has to change. And then they will act on that.

"Physicians are smarter than 99 percent of people and more hard-headed and hardworking. When they decide to do something, they will work at it until they get it done," Sotile says. The key is to recognize that you're not infallible and you're not the exception to all the rules. You're vulnerable to pressures like everyone else.
"Our culture tells physicians, 'You don't have permission to be human," he adds. You have to give that to yourself.

Suz Redfearn writes can be reached at
editor@physicianspractice.com.

This article originally appeared in the January 2004 issue of Physicians Practice.