Lifestyles: Say Goodbye to Burnout

Can you imagine practicing as part of a coequal “team” that includes orderlies and nurses? Where your treatment orders are relegated to suggestions? Where if you object to a lack of follow-through you’re asked why you even care?

And yet, despite all this, you’re still responsible for patient outcomes?

This is exactly where psychiatrist Jay Bauer (not his real name) found himself at a North Carolina hospital from 2000 to 2003. “The doctor has to take all the medical and legal responsibility, and he’s responsible for how everyone else performs their jobs, with no authority,” he says. “I felt like I couldn’t tell them what to do without getting into trouble. It was an awful trap.”

So awful, in fact, that he quit - but not before developing non-Hodgkin’s lymphoma and other serious health problems that have kept him from practicing to this day.

Extreme? Maybe. But hardly unheard of. John-Henry Pfifferling, who has counseled hundreds of burned-out physicians as the founder and director of the Center for Professional Well-Being, estimates that “80 percent of doctors will go through the burnout process at some point in their careers.”

But it doesn’t have to be this way. You can protect yourself. Know the facts and learn the skills before you begin to wonder if you still love being a physician.

At risk, right from the start

As a physician, you’re more likely than most to have personality traits that put you at greater risk for burning out, even as they may make you a better doctor. Among these:

Idealism - For most, the decision to become a physician is more of a calling, based on a strong desire to help people, than a career choice. “Idealism brings you to caring, and then you want to achieve all the academic accomplishments,” says Pfifferling. Unfortunately, many new doctors are unprepared for the realities of practicing medicine in the United States.

Perfectionism - As a doctor, you are inclined to be a perfectionist - for obvious reasons. Yet this tends to make you extremely self-critical. In short, good enough is just not good enough. “We keep trying to emulate an impossible role,” says Pfifferling. Gynecologist James Haley of Acworth, Ga., concurs. Having suffered through his own burnout last year, Haley says his quest for perfection is the norm among his peers. “There are few physicians I know that don’t shoot for perfection in what they do,” he says. “They expect it of themselves and so does the general public.”

Independence - Physicians tend to reject offers of support, often feeling they must project an image of strength and infallibility, says Pfifferling. “If we show any need for help, then we’re not good doctors.”

People-pleasing - An inability to say no is prevalent in physicians, particularly those in primary care. The result? You quickly become overburdened and overworked.

Work/life imbalance - The sustained pressure of practicing medicine often monopolizes a physician’s attention, leading to a skewed view of success by confusing professional and personal achievements. This results in a psychological phenomenon known as enantiadromia - a sudden, extreme transformation into an opposite state; in this case, passion becomes burnout. Swiss psychiatrist Carl Jung refers to this as “life’s contradictions” - love vs. hate or thinking vs. feeling. Failing to honor opposite aspects to being human puts a person at serious risk of imbalance.

Emotional detachment - Dealing with suffering and death is a reality of practicing medicine. Many physicians mistakenly feel they must distance themselves from their emotions and always be strong for others. This is unhealthy. “You’re not supposed to get out of medical school with your feelings intact,” says family physician Pamela Wible of Salem, Ore.

“Pedestal-itis” - Pfifferling concocted this term to describe a common physician mindset. “They get told, ‘You’re special’ from pre-med on,” he explains. This ego-stroking is necessary, as the student can draw strength from the knowledge that he’s got the chutzpah to make it through his education, but also debilitating, because requesting help becomes beyond embarrassing.

Encroaching flames

Other factors that can contribute to burnout include:

Work stressors - Most physicians in private practice are working in volume-based environments, running a daily hamster wheel of patient encounters to meet revenue demands. Wible, who set up an atypical solo practice after suffering serious burnout in 2005, knows how dehumanizing this scenario can be. She recalls a colleague’s sadly amusing response to a patient who was miffed at having to remind the doctor why she was there for a follow-up visit: “Honey, I’ve seen 2,000 patients since I saw you last. I can’t remember your name.”

Physical exhaustion - “When they give all day long, they get drained,” Pfifferling says. “I was just talking to a cardiovascular surgeon who’d just done four surgeries that day - two emergency and two scheduled. He’s very concerned about the life on that table. When he gets home, he’s bone-tired, and he may be on call that night.”

Attending hospital physicians are particularly at risk for this. Since 2003, residents are legally prohibited from working more than 80 hours per week. Yet a survey released by Academic Medicine in December 2006 shows the unintended consequence of this restriction: half of attending physicians are now logging more hours because residents must clock out when they hit the 80-hour limit. “The attending doctor is stretched like a rubber band, ready to break,” says Pfifferling.

Asymmetrical work relationships - Because medicine is fraught with risk, most physicians give their patients their full effort. But like a car slowly leaking oil, your intellectual, emotional, and physical engine will eventually seize, and you will have no more to give, unless you are occasionally replenished.

Information and cognitive overload - An unrelenting flood of new clinical and practice management information inundates you every single day. Overwhelming, to be sure. Physicians are “supposed to synthesize all this, and keep up with whatever’s considered cutting edge at that time,” says Pfifferling. “In the smallest specialties there are 20 journals. How do you keep up?”

Litigation stress - The average malpractice suit takes three to nine years to resolve. And although the chances of a plaintiff winning the suit is about half that of all other tort cases, the awards are 16 times higher, averaging about half a million. Notably, 25 percent of all U.S. doctors get sued annually; 65 percent will face some sort of malpractice lawsuit during their careers. Fear of malpractice partially determined Haley’s decision to bail out of obstetrics altogether; he now focuses only on gynecology.

Financial pressure - Physicians “are the only organization that cannot by law collectively meet, bargain, and represent ourselves to protect our rapidly declining reimbursements,” Haley laments in a recent letter to Physicians Practice editors. “Insurance companies have known this for years, and have continually used it against us with little means of any recourse on our part. … [Physicians] never thought there would be such a concern about our financial futures as it has become.”

The feminine unique

Do women and men experience burnout differently? Wible thinks so. And studies suggest she may be right. Wible maintains that the path for a woman physician differs from that of a man because, generally speaking, women react to the world in fundamentally different ways. “Men are really good at turning [practicing] into a game,” she says. “How many patients did you see today?”

But women “like to hang out with their patients more. Call it touchy-feely or whatever you want, but it’s looked down on in the medical culture,” she says.

“Minimizing Error, Maximizing Outcomes,” a three-year study sponsored by the National Institute of Child Health and Human Development, shows that female doctors tend to have patient panels that contain more complex cases, and many more publicly insured or uninsured patients than male physicians. Also, female doctors want to spend more time with their patients. They often find themselves at odds with the values of the practice in which they work.

“Working in a high-volume atmosphere takes its toll on women more than men,” says Wible. “It makes it hard to balance their home and work. Women reach the empathy burnout stage. They have one foot on either side of the door. They’re trying to live with their instincts, and it doesn’t work.”

Burnout fallout

How do you know when you’re burning out? You might “act out” by becoming abrasive with staff and patients or by demonstrating aggressive anger and rudeness. Or maybe you “act in” with depression, pessimism, and brooding.

Tragically, some physicians respond in the most self-destructive manner possible. As early as 1858, British researchers noted a higher suicide rate among physicians, compared to the rest of the population. This holds alarmingly true today. Male physicians are 70 percent more likely than other men to kill themselves. For women doctors, the risk is even greater: the suicide rate is 250 percent to 400 percent higher than that of other women. (One possible reason for this, among others, is that physicians’ medical expertise makes them more likely to succeed.)

More commonly, desperately stressed-out docs quit medicine or fantasize about quitting. “I was contemplating going down and getting a job as a waitress,” recalls Wible. Haley says that had there been some other field he could’ve switched to that would allow him to maintain his standard of living when he was burned out, he may have left.

A physician in need

But most, it seems, simply live their lives in quiet desperation. In December, the American College of Physician Executives (ACPE) released the results of its survey of 1,200 physicians on their perceptions of physician morale. Respondents readily admitted to experiencing fatigue (77.4 percent) and emotional burnout (66.7 percent). Indeed, six in 10 said they had considered leaving medicine.

But only about a third acknowledged experiencing family discord or depression, and fewer than 5 percent of docs confessed to having had suicidal thoughts or to abusing drugs or alcohol.

Our hunch is that these latter figures are higher in reality than in the ACPE’s survey. But who could blame physicians for their reluctance to admit they’re deeply troubled? What doctor, held to a nearly unattainable standard, would admit she’d turned to four double scotches (or worse) every night to ease the stressball in her gut? Not many, especially since license renewal can come into question for a physician who has sought treatment for substance abuse or a mental illness, to say nothing of the professional stigma (and potential legal consequences) if such treatment, or even the admission of a past problem, should become public.

The ACPE survey reflects another reason to believe physician morale is even lower than most doctors will admit: Respondents were much more likely to suspect serious problems in their colleagues than to acknowledge the same problem in themselves. More than 35 percent suspected peers of substance abuse, for example, but only 2.9 percent would come clean about their own problems. In actuality, physicians may not see the reality in either themselves or others. The real figures likely fall somewhere in between.

Re-lighting the fire

Pfifferling insists that there is hope and help. Much of it comes from within. Here’s what to do if you’re feeling burned out:

Talk about it. Only one-third of you share your feelings with other doctors, reports the ACPE survey; that’s not enough. Do it for your own good, and that of your patients.

Take care of your health. Paradoxically, doctors tend to skip routine healthcare for themselves. About one-third of physicians have no regular source of care, states the AMA. Also, most believe that good or bad health is largely up to chance - fatalism that flies in the face of preventive health measures. This laissez-faire perspective causes many physicians to skip screenings for breast, colon, and prostate cancer, and many don’t bother to get flu vaccines. Take time to take care of yourself, but not by yourself. Doctor, see your doctor.

Get a hobby. Way back before you became a doctor, what did you like to do? Sports? Art? Globe-trotting? Are these still of interest? Whatever “it” is, do it, and do it regularly.

Educate yourself about yourself. Yes, you are certainly well-educated medically, but that’s a pretty narrow focus. Take some time to learn what’s available to help you learn about yourself. A seminar. A good self-help book. Tivo Dr. Phil if that’s what you’d like. But get inside your own head a little bit.

Gigi Hirsch, CEO of MD Intellinet, a career-counseling firm for physicians, says doctors fall into four types:

1. Narrow and deep - Follows a specific interest (typical of professors);

2. Linear - Wants to rise through management hierarchy (medical directors);

3. Spiral - Tends to broaden a sphere of influence (policymakers, advocates); and

4. Transitory - Needs to change environments regularly (consultants, entrepreneurs).

Which are you? Maybe you’re a composite. That’s fine, too - it just means you’re an individual, so celebrate that. In any event, understanding your type can help clarify your own desires. Hopefully, that can help you develop a model for your career that’s based on your true needs, even if it means following an unconventional path.

Determine a practice style that works for you. Only you will truly know what you can handle. Determine what that is, and stick to it. And there’s no need to be Superman or Wonder Woman. Say “no” when demands compromise your plan. Wible tried five or six different practices before striking out on her own. “They all had their own dysfunctions. It became clear to me I had to create my own solution,” she says.

Haley’s burnout flashpoint last year made him realize he needed to jettison the stress of doing obstetrics. “I really wanted to get back to giving women the care they want and I know they were missing,” he says. “I’ve been open about nine months. The joy of running a practice has returned.”

Through his transition, Haley learned that, for him, nurturing his spiritual self provided a great deal of comfort. “I just trust God and put it in his hands,” he says. “That’s how I practice.”

Renew yourself daily. If you’re running on fumes halfway through the day, how can you give your patients what they need? Take a few minutes to recenter yourself, as often as you need it, in a way that works for you. Meditate. Eat something. Breathe deeply. Whatever. Just do it. Yes, there’s paperwork to complete and phone calls to return, and patients to see, but if you don’t screw your brain back on straight, you’ll just waste time trying to work while hobbled.

Support others. One of the best ways to ensure you’re not alone in the world is to reach out to others. Get involved with a physician support group, or start your own, even if it’s with just one friend or associate. Ask for and give clear, honest feedback. Remember, within every criticism lies a greater truth. Consider what is being said to you before reacting emotionally. What can you learn from it? “We don’t always have to put on the façade that we’re perfect,” says Pfifferling.

Can you recover?

Absolutely. Wible’s story bears testament. In 2005 her world spiraled into what could’ve been inspiration for a country music ballad: “I went into this huge depression. I was in bed for about two months after I left my last job. Then my dog died. I was in a very negative place.”

Wible felt better after dragging herself to a self-help seminar, where “just one weekend of being in a supportive atmosphere was able to turn the tide of being in 12 years of an abusive one.”

A few weeks later she decided to open a different kind of clinic, one she says gathers the community together and that better reflects her values and work style. Everything fell into place. “It was all so effortless,” she says. Haley’s practice model remained the same, but pared down the scope to what he really wanted. Bauer says he will be investigating alternative therapies, overhauling his philosophies on food, supplements, and such.

“Some can grin and bear it and turn [practicing medicine] into a scheme, but it really erodes our humanity. And I don’t think that’s in alignment with anyone’s value system. When someone thinks and lives within their values, it all works. When you’re out of alignment, that’s when the burnout happens,” says Wible. Do what works for you, she says, because “really, this is a sacred honor to be able to practice.”

Shirley Grace, senior writer for Physicians Practice, holds an MA in nonfiction writing from The Johns Hopkins University. Her articles have appeared in numerous publications, including The Washington Post and Notre Dame Business magazine. She can be reached at sgrace@physicianspractice.com.

This article originally appeared in the May 2007 issue of Physicians Practice.