Rachel first asked the oncologists whether they could accept the idea of their own deaths. Some said that they were completely at peace with their own deaths, and others indicated that they were terrified, but the majority said yes—sort of: “But I’ve not really had to face it, so I really don’t know how I’d feel.” They were being self-aware and honest with themselves.
Some reflected on how their sense of peace (or lack thereof) affected their interactions with patients—for example, whether they tended to talk about death directly with patients or whether they tended to use euphemisms or beat around the bush. Some would only discuss death and dying with the patient’s family members, sensing their own and the patient’s discomfort. Many said that when they were able to be more self-aware, they could bring more of themselves to the patients they were caring for.
Leeat Granek’s oncologists, similar to those interviewed by Rachel Rodenbach, saw a need for change in the culture of cancer care; currently, it glorifies the cure and conquest of cancer, treats death as failure, and regards expressions of emotion as a sign of weakness. Yet, oncologists said that they valued training, information, support, and validation to help them deal more effectively with their own grief; they could see that trying to push away painful feelings wasn’t an effective way of dealing with them.17 At Rochester, my colleagues Tim Quill and Michelle Shayne have developed a program to promote reflection and mindfulness for oncologists in training and clinical staff.18 Six times a year the trainees and clinical staff meet with a senior oncologist, a palliative care specialist, and a clergyman to enhance their awareness of and address the impact of grief and loss on their personal and professional lives. They share stories about patients for whom they cared. They laugh, they cry. Part of the time is set aside for self-care, including meditation. At the end of each session, they hold a moment of silence in remembrance of patients who have died. If so moved, they speak the name of one patient to remember and honor him. It sets a tone that would have been considered radical until recently; it hones clinicians’ ability to care for themselves in the service of being more present for patients. It brings awareness of shared humanity and intimacy as well as the relationship between clinicians’ vulnerabilities and those of their patients. They realize that feeling and sharing emotions is not self-indulgent, self-pitying, or a sign of weakness; rather, like Karan’s confessions project, it makes it more possible to attend to what’s really important.
SELF-COMPASSION
Self-compassion—active cultivation of kindness toward oneself19—is one antidote to the unforgiving, harsh, and isolating culture of medicine that becomes manifest in the face of bad outcomes. Practicing self-compassion means neither avoiding negative thoughts nor overidentifying with them. You don’t try to confront, overcome, or push through emotional pain, nor do you succumb to it. Rather, you inquire deeply and respond with kindness, clarity, and resolve rather than blame, shame, or despair.
As sensible as self-compassion sounds, doctors have a hard time with the idea. It sounds like self-pity or self-indulgence. But it’s none of these—self-compassion means not getting carried away with one’s own emotional drama; you don’t try to buoy a deflated ego or inflate your self-esteem. Rather, it is a movement toward a healthy balance. People who are able to be more self-compassionate—by either virtue of their prior life experiences or specific training in self-compassion—report feeling better able to own up to their failures and shortcomings without being consumed and paralyzed by negative emotions.20 They accept their own role in negative events; they experience a sense of loss and tragedy, yet they don’t ruminate obsessively. Self-compassion is ultimately altruistic; it frees you to attend to patients and set aside your own distress. While this is a good lesson for life in general, it’s especially important for physicians, who tend to be particularly demanding and unforgiving of themselves.
Marc Lesser is a Zen priest, business consultant, and developer of mindfulness training programs for Fortune 500 companies. Marc would say that self-compassion means knowing yourself and forgetting yourself.21 Knowing yourself seems self-evident; it helps you find your way in the world. But in a quintessentially paradoxical way, Zen also instructs you to forget yourself. By that, Marc means letting go of rigid assumptions about who you are and recognizing that the assemblage of ideas, habits, and perspectives that you call “me” is more evanescent than you think. Forgetting oneself means abandoning the kinds of self-torture that clinicians habitually engage in when things go wrong. For clinicians—and for anyone else—simultaneously knowing yourself and forgetting yourself helps you respond to error, grief, and loss in a healthier and kinder way.
THINKING BIGGER
Secondary trauma is not unique to anesthesiologists or oncologists or family physicians—all clinicians, regardless of specialty, can be “second victims.” The health care system has been slow to respond to this form of clinician distress; few clinicians can honestly say that they work within a culture of awareness, listening, compassion, and support.
But some institutions show signs of hope. The University of Missouri Medical Center has a Second Victim Rapid Response Team, which can be called by clinicians who are feeling distressed. The team offers brief peer and collegial support (Level 1), one-on-one counseling and mentoring by trained peer counselors (Level 2), and referral to mental health professionals for those who are more severely distressed (Level 3).22 Harvard’s Brigham and Women’s Hospital offers a peer coaching and support program for distressed physicians. The director, Jo Shapiro, is a surgeon who has trained peer coaches—fellow physicians—to attend to their colleagues in distress.23 Physicians either refer themselves or refer colleagues who they feel might benefit from one-on-one counseling and coaching. There are few data, making it hard to know how well these efforts work. Yet they represent small steps in the direction toward a culture of caring and support, recognizing that clinician well-being is a sign of health of the health care system overall.
San Francisco is mounting one of the largest efforts to address secondary trauma. San Francisco has enormous social and economic disparities. Their public health clinics care for the most challenging patients—those whose lives are an essay in tragedy, loss, and abandonment and who have repeatedly been failed by the social programs that were intended to help them. The emotional toll on health care workers is large, and attrition and burnout are real problems. Recognizing this, the San Francisco County Health Department instituted a mandatory program in trauma awareness to promote changes in the culture of the health care system as a whole. It’s a culture change toward mindful awareness, not just a Band-Aid. Eventually all of San Francisco’s nine thousand workers will be trained, and two-thirds of those who have participated so far are working toward concrete changes in their work settings.24 This kind of coordinated, multilevel intervention is rare in health care organizations and has great promise for sustained change. I’ll discuss more about individual and organizational efforts to address burnout and trauma in chapters 10 and 12.
10
Healing the Healer
These are the duties of a physician: First . . . to heal his mind and to give help to himself before giving it to anyone else.
—Epitaph of an Athenian doctor, AD 21
Diane, a midcareer primary care physician, came to our year-long program in mindful practice. She was passionate about clinical care and knew that clinical practice could be deeply fulfilling. However, she was burned out, as she said, “running on empty.” Something had to change.
By all accounts, Diane was an exemplary family physician and had excellent clinical judgment. She was a good listener, warm, and empathic, and she won the trust of her patients. Diane would go the extra mile, making home visits for patients who were terminally ill; she’d even drive an elderly patient home at the end of the day to avoid having the patient wait outside in the cold for a city bus. She took care of more than her share of challenging patients and wouldn’t turn anyone away. But her dedication took a toll. She
was always behind and couldn’t spend the time she wanted to with patients.
Meanwhile the landscape of clinical care was changing. More and more, she had to fight with insurance companies so that her patients could get the care that they needed. She had to keep up with eight different prescribing formularies—one for each insurance company—and the rules changed frequently, resulting in prescriptions being denied, and each denial prompted phone calls and paperwork, which cut into face-to-face time with patients. It was, as she put it, sucking her dry.
Then a large health care system bought her practice. Although the health system talked about “quality metrics,” in reality these nods to quality amounted to little more than completing meaningless check-boxes2 and were paled by the pressure to see more patients in less time. “Productivity,” not better care. The new electronic health record system provided easy access to patient information, yet because the system was designed primarily to maximize billing, entering clinically relevant data was clumsy and time-consuming. Diane spent more time looking at the computer screen, so much so that on one occasion she didn’t notice when a patient left to go to the bathroom and she started talking as if the patient were there. Electronic documentation added an hour to her day, and the promise of increased efficiency was never realized.
This only increased her resolve to work harder to maintain what quality she could. She achieved her productivity goals and quality metrics, but the effort came at a huge cost. At the end of the day, she was beyond tired. She was also increasingly isolated. Like most of her primary care colleagues, Diane had given up hospital privileges because the productivity demands of outpatient practice made it impossible to continue. She barely had time to exchange words with her practice partners during the workday and no longer knew the specialists to whom she referred patients.
The last straw was an encounter with her practice administrator. She saw a patient with worsening depression, and when the “billing specialist” reviewed her documentation of the visit, she suggested that Diane “correct” her diagnosis. Diane had documented the diagnosis as “depression.” The administrator suggested that she might write “fatigue” instead. The reason? Money. Reimbursement for mental health diagnoses was just half of that for physical symptoms. While fatigue is part of depression, it’s not as accurate a diagnosis. Diane complied. Then she felt nauseous. She realized that her decision was not morally neutral; her limited attention had migrated from the patient’s best interest to the financial bottom line.3
For the first time in her fifteen-year career as a physician, Diane began to think of her day in terms of quotas and numbers and realized that she was paying less attention to the details of her patients’ lives. The bloodless language of health economists had infected her communication patterns and eventually her medical decisions. She felt out of control—of the pace of clinical practice, over hiring employees, or even the design of the office, down to the art on the walls. She began to wonder if medicine was really for her.
Diane took a two-week vacation with her family and felt refreshed, back to her warm and vibrant self. On returning, her symptoms of burnout recurred within days. She couldn’t seem to get enough sleep. She had little energy for family and friends. Her staff noticed that she was more irritable, as did her family. Even her patients asked the nurses—or Diane herself—if something was wrong. They knew something had changed, and it wasn’t for the better. Diane considered moving to a different practice, but nearly all of the primary care practices in town had already been bought by large health care systems, and her children were in school so a move to a different city would be disruptive. She felt stuck. She thought about quitting practice altogether.
“AN EROSION OF THE SOUL”
Diane’s story is, unfortunately, common. It strikes close to home for many doctors. She was a casualty of a national epidemic of physician burnout. After twenty years of research documenting the epidemic, finally in 2016 Dr. Vivek Murthy, the United States surgeon general, announced that physician burnout would be one of two urgent health care problems that the nation needed to address. The reason was obvious—burned-out physicians cannot possibly provide the best care.
The statistics are daunting. Fifty-four percent of physicians nationally reported burnout in 2014, up from 45 percent in 2011.Those most affected were on the front lines of clinical care—primary care, emergency medicine, and general surgery.4 Nurses and other health professionals, medical assistants, and secretaries are feeling it too.5 Although anyone in a high-stress job can experience burnout, in medicine it is particularly nefarious, and patients have reason to worry. Burned-out physicians are more likely to take shortcuts, make diagnostic errors, and prescribe recklessly.6 They order too many tests and refer more, just because it takes too much effort to think through problems themselves.7 They don’t communicate well, with their patients8 or their colleagues, and are more likely to abuse alcohol and drugs and engage in unprofessional behaviors—shady billing practices, providing narcotics to addicts, inappropriate use of social media, and violating patient confidentiality. Some physicians are jumping ship. Of primary care internal-medicine physicians starting practice, a quarter of them will quit within five years,9 and others are taking early retirement. Replacing them is costly—over $300,000 per physician.10
Not everyone catches burnout in time. The majority of burned-out physicians will still be burned out a year later. A colleague, an excellent family physician whom I’d mentored when she was a resident, recently took an early retirement. The new medical records system—the four thousand clicks a day and completing charts at midnight—did her in.11 My own primary care doctor retired last year after I had been a patient of his for only two years. When he left, the practice sent a terse and impersonal letter that said that he was closing his practice after thirty years to “teach and mentor.” When I started with him after my previous primary care doctor left practice, he said that he would be good for another five to ten years. It’s not difficult to guess what was behind his decision. I called his office to get a personal recommendation for a new physician. I was directed to a list of three hundred local primary care doctors, only eight of whom were taking new patients, all of whom had just finished training. I felt abandoned. Clearly, something had changed.
Dr. Christina Maslach, a psychologist who has devoted her career to studying burnout, describes it as “an erosion of the soul.”12 Across all human services professions, Maslach found that burnout consisted of three factors: emotional exhaustion, depersonalization (treating people as objects), and a feeling of low personal accomplishment. This three-headed monster makes work an intolerable burden rather than a source of purpose and meaning, making physicians either work harder and harder or just give up.
Medical practice has always been intense. To give you a sense of the emotional burden of practice, let me take you through a typical four-hour session in my primary care office. I saw eleven patients. First was a thirty-eight-year-old amputee, blind and on dialysis due to diabetes, who was about to have his other leg amputated. The next patient, recently inherited from a now-retired physician, was addicted to prescription narcotics and fell asleep at the wheel, plowing into the car in front of him, shattering his knee and his shoulder. He had consumed an entire week’s worth of oxycodone in two days, and now he wanted more. Later in the morning were the struggling parents bringing their violent and hyperactive child, who was recently returned to them from foster care. Then, a fifty-five-year-old man with AIDS who forgot to get his blood tests and didn’t go for the X-ray to evaluate his pneumonia; I realized that he had the beginnings of AIDS dementia and had no family to care for him. The day ended with the repeated denials of a brilliant psychotherapist whose liver was being consumed by alcoholic cirrhosis. Without the inner scaffolding of presence and mental stability and the outer scaffolding of collegial and institutional support, no one can be expected to respond humanely to all this tragedy.
But now, in the age of the corporatization and widgetization
of medicine, there is a new kind of burnout, a slow, relentless “deterioration of values, dignity, spirit and will”13 that comes from the structure of health care itself. Patients become “covered lives,” and the intimacy of a clinical encounter is reduced to RVUs—relative value units—the productivity metrics that determine how much doctors are paid. The more that doctors’ work is tied to computer screens and the more “functionalities” that are added to the electronic health record, the worse burnout becomes. Casualties of efficiency, doctors turn off their emotions. They can’t wait until the end of the day, the weekend, retirement. They back their cars into their parking spaces so they can make a quick exit at the end of the day. Patients wonder if their doctors care at all.
Burned-out physicians are not only alienated from patients; they are also alienated from themselves. They feel as if they are on an assembly line, and the opportunity for the rich and rewarding human interactions they imagined when they chose to be doctors is reduced to a mere transaction of information. Recently I reviewed an emergency room chart for a six-month-old patient of mine who had had a fever. Apparently, the electronic health record required that the physician fill in templates about smoking, alcohol consumption, and sexual risk behaviors. The amazing thing is that the physician actually wasted his time by checking the boxes. With enough of these occurrences, feeling battered by systems they cannot change, some doctors capitulate and go numb and only later come to a crushing realization that they have abandoned their values. Others feel that their impact is nil, become depressed, and think only about escape. In one study, 17 percent of those reporting burnout considered suicide in the previous year.14 This is frightening, given that doctors kill themselves at a rate higher than those in any other profession. I’ve personally known several.
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