Physician Burnout: Other Viewpoints

By Michael Baron, MD, MPH, FASAM
October, 2018

Editor's Note: This is part four in our four-part series on physician burnout. Part I was published in the January 2018 edition of The SVMIC Sentinel; part II was published in the April 2018 edition; and part three was published in our July 2018 edition.

Physician burnout syndrome is a pervasive problem that can impair clinical competence, shorten careers, distress families, and is an independent predictor of reporting a major medical error and being involved in a medical malpractice suit. This will be the fourth and final article in this series about Physician Burnout Syndrome (PBS). The first article discussed the signs and symptoms of PBS using a tragic clinical case for illustration. The second article in this series looked at the causes of PBS and described the three aspects that make up PBS as first described by Christina Maslach in the 1970s: Emotional Exhaustion, Depersonalization, and Low Personal Achievement. The third and most recent article in this series discussed prevention and treatment of PBS.

In this fourth and last article, we will look at burnout from a different viewpoint. Dr. Dike Drummond has written extensively on this subject. I mentioned Dr. Drummond in Part 3 when discussing prevention of PBS by improving physician resilience. His thoughts are that “physicians are the canary in the coal mine of medicine.” PBS is a reflection on the condition of the practice and business of medicine. Improving the conditions of medicine is much more appropriate than improving the resilience of the physician. It’s not the canary that needs help, it’s the canary’s environment. Likewise, the problem is not the resilience of the physician, but the environment in which the physician is practicing.

Like many syndromes, PBS has many consequences. As we’ve seen, these consequences include quality of care issues, decreased patient satisfaction, decreased patient compliance, increased medical errors leading to increased malpractice risk, increased use of alcohol and illicit drug use, and increased number of suicide attempts and suicide completions. PBS can be especially lethal if not acknowledged or treated. Physicians are masters at denying their own problems, something that we encounter every day at the Tennessee Medical Foundation Physician’s Health Program (TMF-PHP). Their focus is never on their own health, which is why physicians seldom ask for help. They are generally forced to get help by a peer, spouse, or superior in the workplace. However, the leaders of organized medicine, including the National Academy of Medicine, American Medical Association, Federation of State Medical Boards, and other national groups, are taking aim at PBS to find effective prevention and treatment that doesn’t focus on fixing the canary.

PBS is a low-energy state analogous to functioning with a depleted energy store – not the type of energy manufactured from glucose and carried around in ATPs; this energy source is better described as transcendent or spiritual. Dr. Drummond makes the analogy of an energy that is more like “The Force” in the Star Wars movies than anything measurable with units of energy.1 Drummond describes an energy account, much like a bank account where deposits and withdrawals are made. Rest, relaxation, and rewarding relationships are positive deposits in the energy account. Withdrawals of energy are made by life activities that are not rewarding or pleasant such as illness, unpleasant or difficult relationships, or unrewarding types of work. For example, being named in a malpractice lawsuit or making a medical error are quick ways to drain one’s energy account. Having little to no autonomy or control over your work environment also depletes this type of energy but at a slower rate. Burnout is likely to occur when an energy account remains depleted or in the negative over a period of weeks to months.

Using the energy analogy described above, Dr. Drummond describes the five main causes of burnout he sees most:

  1. The practice of clinical medicine is a difficult task that utilizes a lot of energy. However, this can be very rewarding to physicians and can be a net gain of positive energy. After all, we attended medical school to join the healing arts, but at some level dealing with sickness and death can erode that positive energy.
  2. On a more basic level, the personal aspects of a practice situation such as specialty, call rotation, compensation, office personalities, location, and the type of practice can all influence the type of energy – positive or negative – that is produced.
  3. The lack of work-life balance. This balance is necessary to recharge your energy. Work-life balance was not taught in medical school or residency. Actually, the opposite was reinforced, that is, to disregard your home life, your emotions, your spiritual connections, or anything that keeps you out of the hospital and gets in the way of your education. The old joke, “The problem with every-other-night call is that you miss half the good cases,” isn’t funny because it is or was the mindset of our medical education system. A home life that is healthy and nurturing is important to have and to use to help replete this type of energy. Unfortunately, some types of home life can cause energy depletions, such as illness, conflicts with spouse or children, and financial problems. When looking for causes of PBS, it is important to include the home as a potential etiology.
  4. Dr. Drummond describes four character traits that create good physicians but leave them vulnerable to burnout and other mental health disorders: the workaholic, the superhero, the perfectionist, and the lone ranger. The workaholic uses work and more work to overcome any difficulty. The superhero faces every challenge alone, not needing or asking for help. The perfectionist can’t make a mistake and demands the same from everyone else. The lone ranger is unable to delegate responsibility and is a micromanager. In 1985, Dr. G. Gabbard described three characteristics that physicians have – doubt, guilt feelings, and an exaggerated sense of responsibility – that he called the “triad of compulsiveness.”2 This triad can easily lead to PBS or negative energy. These characteristics are present in most physicians but they do come with a cost.
  5. One of the most direct causes of PBS is the leadership skill set of the physician’s immediate supervisor. Unfortunately, most physicians either do not receive or innately have good or effective leadership qualities. In the medical education world, the immediate supervisor is the person with one more year of experience. Thus, the medical student answers to the intern, who answers to the resident, who answers to the chief resident, to the junior attending, to the department chair, up the chain of command to the Dean. Research and attracting grant money are the usual prerequisite for promotion, so the top dog may produce Nobel-winning research but have terrible leadership skills, making everyone in the department miserable, which results in mass resignations. 

Physician Burnout Syndrome is a real and potentially lethal problem that is increasing in prevalence. When a physician becomes burned out, it is noticeable as they proceed from happy to indifferent, from engaged to apathetic, from a high-energy state to a depleted state. The repercussion of burnout can be devastating to the physician and to their patients. Quality of care suffers, as does patient satisfaction. Everyone suffers.

As mentioned, there are changes being discussed by the leadership of our national organizations to reverse this trend. However, those changes are not occurring overnight. If you are struggling or know someone who is struggling with burnout, please give the TMF-PHP a call, or encourage them to call. 615-467-6411) All calls are strictly confidential; getting help does not mean getting reported. We have the expertise to identify causative problems and initiate changes to help remedy the situation. Please think of the TMF as a resource, not a punishment. Asking for help is a sign of strength.

The Tennessee Medical Foundation can be contacted at 615-467-6411. 

The Federation of State Physician Health Programs provides a comprehensive listing of state programs here.

 

1. Drummond D. Physician Burnout: Its Origin, Symptoms, and Five Main Causes, Fam Pract Manag. 2015 Sep-Oct;22(5):42-47.

2. Gabbard GO. The Role of Compulsiveness in the Normal Physician. JAMA1985 Nov 22-29;254(20):2926-9.


Michael Baron, MD, MPH, FASAM

About the Author

Dr. Michael Baron attained his Medical Degree, Masters in Public Health, and completed an internal medicine internship at Tulane University, School of Medicine. He completed his first residency in anesthesiology at Washington University School of Medicine, and his Psychiatry training at Vanderbilt University School of Medicine.  He has maintained Board Certification in Anesthesiology, Psychiatry and Addiction Medicine. He has practiced in the Nashville area since 1998 in a variety of settings including private practice, teaching hospitals and residential treatment centers.  Dr. Baron was appointed to the Tennessee Board of Medical Examiners (BME) in 2010 and served as Chair of the Controlled Substance Monitoring Database committee.  He resigned from these positions in January 2017 to become the Medical Director of the Tennessee Medical Foundation – Physician Health Program. As well, he is the psychiatrist of record at the Davidson County Drug Court- DC4.


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