Attending

by Ronald Epstein

  29 For further information, see H. G. Engen and T. Singer, “Compassion-Based Emotion Regulation Up-Regulates Experienced Positive Affect and Associated Neural Networks,” Social Cognitive and Affective Neuroscience 10(9) (2015): 1291–301.

  30 H. Y. Weng et al., “Compassion Training Alters Altruism and Neural Responses to Suffering,” Psychological Science 24(7) (2013): 1171–80.

  9. WHEN BAD THINGS HAPPEN

  1 L. T. Kohn, J. M. Corrigan, and M. S. Donaldson, To Err Is Human: Building a Safer Health System (Washington, DC: National Academy Press, 2000).

  2 T. H. Gallagher et al., “Patients’ and Physicians’ Attitudes regarding the Disclosure of Medical Errors,” JAMA 289(8) (2003): 1001–7.

  3 Kohn, Corrigan, and Donaldson, To Err Is Human.

  4 In this chapter most of the examples about errors that I have chosen are ambiguous. This was intentional. Dramatic errors due to gross incompetence or neglect—such as amputating the wrong leg or giving a lethal dose of a medication—are uncommon, and the brute force of the litigation system can override mindful attempts to restore balance and connection. In fact, though, much of the total burden to patients and clinicians from bad outcomes results from a combination of small lapses in attention, unfortunate coincidences, miscommunicated intentions, and team and systems failures.

  5 H. B. Beckman et al., “The Doctor-Patient Relationship and Malpractice: Lessons from Plaintiff Depositions,” Archives of Internal Medicine 154(12) (1994): 1365–70.

  6 B. Ho and E. Liu, “Does Sorry Work? The Impact of Apology Laws on Medical Malpractice,” Journal of Risk and Uncertainty 43(2) (2011): 141–67.

  7 N. M. Saitta and S. D. Hodge, “Is It Unrealistic to Expect a Doctor to Apologize for an Unforeseen Medical Complication?—a Primer on Apologies Laws,” Pennsylvania Bar Association Quarterly (2011): 93–110.

  8 N. M. Saitta and S. Hodge, “Physician Apologies,” Practical Lawyer, December 2011, 35–43; and N. Saitta and S. D. Hodge, “Efficacy of a Physician’s Words of Empathy: An Overview of State Apology Laws,” Journal of the American Osteopathic Association 112(5) (2012): 302–6.

  9 A. D. Waterman et al., “The Emotional Impact of Medical Errors on Practicing Physicians in the United States and Canada,” Joint Commission Journal on Quality and Patient Safety 33(8) (2007): 467–76.

  10 A. W. Wu, “Medical Error: The Second Victim. The Doctor Who Makes the Mistake Needs Help Too,” Western Journal of Medicine 172(6) (2000): 358.

  11 M. P. Stiegler, “A Piece of My Mind. What I Learned about Adverse Events from Captain Sully: It’s Not What You Think,” JAMA 313(4) (2015): 361–62.

  12 S. K. Howard et al., “Anesthesia Crisis Resource Management Training: Teaching Anesthesiologists to Handle Critical Incidents,” Aviation, Space, and Environmental Medicine 63(9) (1992): 763–70.

  13 C. P. West et al., “Association of Perceived Medical Errors with Resident Distress and Empathy: A Prospective Longitudinal Study,” JAMA 296(9) (2006): 1071–78.

  14 In her thoughtful article about the program, Karan reported that a resident drew up medications into two syringes then forgot to mark which drug was in which syringe; another resident administered an entire syringe of a powerful stimulant thinking it was saline solution; another noted that blood-pressure cuffs in the operating room had “questionable” stains on them, likely another patient’s blood; and so forth. See S. B. Karan, J. S. Berger, and M. Wajda, “Confessions of Physicians: What Systemic Reporting Does Not Uncover,” Journal of Graduate Medical Education 7(4) (2015): 528–30.

  15 L. Granek, “When Doctors Grieve,” New York Times, May 27, 2012; and L. Granek et al., “Nature and Impact of Grief over Patient Loss on Oncologists’ Personal and Professional Lives,” Archives of Internal Medicine 172(12) (2012): 964–66.

  16 R. A. Rodenbach et al., “Relationships between Personal Attitudes about Death and Communication with Terminally Ill Patients: How Oncology Clinicians Grapple with Mortality,” Patient Education & Counseling 99(3) (2015): 356–63.

  17 L. Granek et al., “What Do Oncologists Want?,” Supportive Care in Cancer 20(10) (2012): 2627–32.

  18 M. Shayne and T. E. Quill, “Oncologists Responding to Grief,” Archives of Internal Medicine 172(12) (2012): 966–67.

  19 C. K. Germer, The Mindful Path to Self-Compassion: Freeing Yourself from Destructive Thoughts and Emotions (New York: Guilford Press, 2009); and K. D. Neff and C. K. Germer, “A Pilot Study and Randomized Controlled Trial of the Mindful Self-Compassion Program,” Journal of Clinical Pscyhology 69(1) (2013): 28–44.

  20 K. D. Neff, Y.-P. Hsieh, and K. Dejitterat, “Self-Compassion, Achievement Goals, and Coping with Academic Failure,” Self and Identity 4(3) (2005): 263–87; Neff and Germer, “Pilot Study and Randomized Controlled Trial”; and M. R. Leary et al., “Self-Compassion and Reactions to Unpleasant Self-Relevant Events: The Implications of Treating Oneself Kindly,” Journal of Personality and Social Psychology 92(5) (2007): 887.

  21 M. Lesser, Know Yourself, Forget Yourself: Five Truths to Transform Your Work, Relationships, and Everyday Life (Novato, CA: New World Library, 2013).

  22 S. D. Scott et al., “The Natural History of Recovery for the Healthcare Provider ‘Second Victim’ after Adverse Patient Events,” Quality and Safety in Health Care 18(5) (2009): 325–30.

  23 See http://www.brighamandwomens.org/medical_professionals/career/cpps/default.aspx.

  24 The San Francisco Department of Public Health has developed a Trauma Informed Systems (TIS) framework, intended to help improve organizational functioning, increase resilience, and improve workforce experience. This includes mandatory foundational training to all nine thousand public health employees to create a shared language and understanding of trauma, a Champions Learning Community (CLC), a train-the-trainer program, intentional efforts to align TIS with all workforce and policy initiatives, and leadership engagement and outreach to support integration of TIS principles into day-to-day operations as well as promote system change at the program and policy level.

  10. HEALING THE HEALER

  1 This was quoted in JAMA 189 (1964): 97.

  2 To give just one of many examples, care for patients with diabetes in primary care is typically measured according to the frequency of testing for hemoglobin A1c, a marker for long-term control of diabetes. Some clinics actually use the test results (normal vs. high vs. very high) as the quality metric. However, frequency of testing does not reliably predict control of diabetes, and long-term outcomes for many people over age sixty-five with type 2 diabetes is minimally affected by whether the A1c level is below 7 (considered optimal) or if it’s closer to 8 (considered poor care), and in some cases higher levels are desirable if there is risk of low blood sugar. The factors that go into control of blood sugar go well beyond the prescription pad and are usually unreimbursed (e.g., exercise programs, nutritional counseling, social support). Conversely, the quality of physician empathy is a powerful factor in blood sugar control in patients with diabetes, yet goes unmeasured and unreimbursed. See M. Hojat et al., “Physicians’ Empathy and Clinical Outcomes for Diabetic Patients,” Academic Medicine 86(3) (2011): 359–64.

  3 Moral distress—when people are put in situations in which they’re kept from doing what they know is right or are forced to do things that conflict with their values—can be blatant, such as being told to deny a patient needed pain medication, or more insidious. See A. Catlin et al., “Conscientious Objection: A Potential Neonatal Nursing Response to Care Orders That Cause Suffering at the End of Life? Study of a Concept,” Neonatal Network—Journal of Neonatal Nursing 27(2) (2008): 101–8; L. H. Pololi et al., “Why Are a Quarter of Faculty Considering Leaving Academic Medicine? A Study of Their Perceptions of Institutional Culture and Intentions to Leave at 26 Representative US Medical Schools,” Academic Medicine 87(7) (2012): 859–69; C. H. Rushton, A. W. Kaszniak, and J. S. Halifax, “Addressing Moral Distress: Application of a Framework to Palliative Care Practice,” Journal of Palliative Medicine 16(9)
(2013): 1080–88; C. H. Rushton, A. W. Kaszniak, and J. S. Halifax, “A Framework for Understanding Moral Distress among Palliative Care Clinicians,” Journal of Palliative Medicine 16(9) (2013): 1074–79; and C. Varcoe et al., “Nurses’ Perceptions of and Responses to Morally Distressing Situations,” Nursing Ethics 19(4) (2012): 488–500.

  4 Burnout gets worse toward midcareer, as clinical and administrative responsibilities increase while other aspects of life become more complex. Some surveys suggest that women are more burned out than men, which is understandable given their more complex social roles and responsibilities—and other surveys suggest that they are also more resilient. See T. D. Shanafelt et al., “Changes in Burnout and Satisfaction with Work-Life Balance in Physicians and the General US Working Population between 2011 and 2014,” Mayo Clinic Proceedings 90(12) (2015): 1600–1613; and http://www.medscape.com/features/slideshow/lifestyle/2016/public/overview#page=1 for 2016 statistics on physician burnout, overall and by physician specialty. Also see M. W. C. Friedberg, PG, K. R. VanBusum, F. M. Aunon, C. Pham, J. P. Caloyeras, S. Mattke, E. Pitchforth, D. D. Quigley, and R. H. Brook, “Factors Affecting Physician Professional Satisfaction and Their Implications for Patient Care, Health Systems, and Health Policy,” 2013, http://www.rand.org/content/dam/rand/pubs/research_reports/RR400/RR439/RAND_RR439.pdf; “Physician Wellness Services and Cejka Search: 2011 Physician Stress and Burnout Survey,” 2011, http://www.cejkasearch.com/wp-content/uploads/physician-stress-burnout-survey.pdf; and Physicians Foundation, “A Survey of America’s Physicians: Practice Patterns and Perspectives, an Examination of the Professional Morale, Practice Patterns, Career Plans, and Healthcare Perspectives of Today’s Physicians, Aggregated by Age, Gender, Primary Care /Specialists, and Practice Owners/Employees,” 2012, http://www.physiciansfoundation.org/uploads/default/Physicians_Foundation_2012_Biennial_Survey.pdf. An article in the November 2014 Atlantic cites five current books in the popular press documenting the devastating consequences of physician burnout. See M. O’Rourke, “Doctors Tell All—and It’s Bad,” Atlantic, November 2014, http://www.theatlantic.com/magazine/archive/2014/11/doctors-tell-all-and-its-bad/380785/; and D. Ofri, “The Epidemic of Disillusioned Doctors,” Time, published electronically July 2, 2013, http://ideas.time.com/2013/07/02/the-epidemic-of-disillusioned-doctors.

  5 M. D. McHugh et al., “Nurses’ Widespread Job Dissatisfaction, Burnout, and Frustration with Health Benefits Signal Problems for Patient Care,” Health Affairs 30(2) (2011): 202–10; and C. A. J. Dixon et al., “Abusive Behaviour Experienced by Primary Care Receptionists: A Cross-Sectional Survey,” Family Practice 21(2) (2004): 137–39.

  6 Most of the work on physician burnout has been done by a research group at the Mayo Clinic in Minnesota and the Physicians Worklife Study, with some important studies done by other groups. See L. N. Dyrbye et al., “Relationship between Burnout and Professional Conduct and Attitudes among US Medical Students,” JAMA 304(11) (2010): 1173–80; L. N. Dyrbye et al., “Burnout and Suicidal Ideation among US Medical Students,” Annals of Internal Medicine 149(5) (2008): 334–41; L. N. Dyrbye et al., “Physician Satisfaction and Burnout at Different Career Stages,” Mayo Clinic Proceedings 88(12) (2013): 1358–67; A. M. Fahrenkopf et al., “Rates of Medication Errors among Depressed and Burnt Out Residents: Prospective Cohort Study,” BMJ 1(7642) (2008): 488–91; S. Gabel, “Demoralization: A Precursor to Physician Burnout?,” American Family Physician 86(9) (2012): 861–62; L. N. Dyrbye et al., “Burnout among US Medical Students, Residents, and Early Career Physicians Relative to the General US Population,” Academic Medicine 89(3) (2014): 443–51; T. D. Shanafelt et al., “Career Fit and Burnout among Academic Faculty,” Archives of Internal Medicine 169(10) (2009): 990–95; C. P. West et al., “Association of Resident Fatigue and Distress with Perceived Medical Errors,” JAMA 302(12) (2009): 1294–300; M. Linzer et al., “Predicting and Preventing Physician Burnout: Results from the United States and the Netherlands,” American Journal of Medicine 111(2) (2001): 170–75; J. E. McMurray et al., “The Work Lives of Women Physicians: Results from the Physician Work Life Study. The SGIM Career Satisfaction Study Group,” Journal of General Internal Medicine 15(6) (2000): 372–80; E. Williams et al., “The Relationship of Organizational Culture, Stress, Satisfaction, and Burnout with Physician-Reported Error and Suboptimal Patient Care: Results from the Memo Study,” Health Care Management Review 32(3) (2007): 203–12; and E. S. Williams et al., “Understanding Physicians’ Intentions to Withdraw from Practice: The Role of Job Satisfaction, Job Stress, Mental and Physical Health,” Health Care Management Review 26(1) (2001): 7–19.

  7 T. Kushnir et al., “Is Burnout Associated with Referral Rates among Primary Care Physicians in Community Clinics?,” Family Practice 31(1) (2014): 44–50; K. H. Bachman and D. K. Freeborn, “HMO Physicians’ Use of Referrals,” Social Science & Medicine 48(4) (1999): 547–57; and B. E. Sirovich, S. Woloshin, and L. M. Schwartz, “Too Little? Too Much? Primary Care Physicians’ Views on US Health Care: A Brief Report,” Archives of Internal Medicine 171(17) (2011): 1582–85.

  8 See J. S. Haas et al., “Is the Professional Satisfaction of General Internists Associated with Patient Satisfaction?,” Journal of General Internal Medicine 15(2) (2000): 122–28.

  9 Most of these will continue to practice medicine but not primary care. Many choose urgent care and hospital medicine. Some take on administrative roles.

  10 R. L. Lichtenstein, “Review Article: The Job Satisfaction and Retention of Physicians in Organized Settings: A Literature Review,” Medical Care Research and Review 41(3) (1984): 139–79; J. E. Berger and R. L. Boyle Jr., “How to Avoid the High Costs of Physician Turnover,” Medical Group Management Journal 39(6) (1991): 80–82; S. B. Buchbinder et al., “Estimates of Costs of Primary Care Physician Turnover,” American Journal of Managed Care 5(11) (1999): 1431–38; and J. D. Waldman et al., “The Shocking Cost of Turnover in Health Care,” Health Care Management Review 29(1) (2004): 2–7.

  11 R. G. Hill Jr., L. M. Sears, and S. W. Melanson, “4,000 Clicks: A Productivity Analysis of Electronic Medical Records in a Community Hospital ED,” American Journal of Emergency Medicine 31(11) (2013): 1591–94; and S. Babbott et al., “Electronic Medical Records and Physician Stress in Primary Care: Results from the Memo Study,” Journal of the American Medical Informatics Association 21(e1) (2014): e100–e106.

  12 C. Maslach, “Job Burnout,” Current Directions in Psychological Science 12(5) (2003): 189–92.

  13 A. Spickard Jr., S. G. Gabbe, and J. F. Christensen, “Mid-Career Burnout in Generalist and Specialist Physicians,” JAMA 288(12) (2002): 1447–50.

  14 Dyrbye et al., “Burnout and Suicidal Ideation.”

  15 L. Y. Abramson, M. E. Seligman, and J. D. Teasdale, “Learned Helplessness in Humans: Critique and Reformulation,” Journal of Abnormal Psychology 87(1) (1978): 49–74.

  16 For a discussion of physicians’ psychological vulnerabilities, see A. Nedrow, N. A. Steckler, and J. Hardman, “Physician Resilience and Burnout: Can You Make the Switch?,” Family Practice Management 20(1) (2013): 25–30; and G. E. Vaillant, N. C. Sobowale, and C. McArthur, “Some Psychologic Vulnerabilities of Physicians,” New England Journal of Medicine 287 (1972): 372–75.

  17 Physicians’ overtesting is not entirely driven by fear of malpractice lawsuits. This behavior is also common among doctors in countries with low rates of malpractice litigation. See G. O. Gabbard, “The Role of Compulsiveness in the Normal Physician,” JAMA 254(20) (1985): 2926–29.

  18 See J. Legassie, E. M. Zibrowski, and M. A. Goldszmidt, “Measuring Resident Well-Being: Impostorism and Burnout Syndrome in Residency,” Journal of General Internal Medicine 23(7) (2008): 1090–94; and P. R. Clance, The Impostor Phenomenon: When Success Makes You Feel Like a Fake (New York: Bantam Books, 1986).

  19 For further discussion, see A. D. Mancini and G. A. Bonanno, “Predictors and Parameters of Resilience to Loss: Toward an Individual Differences Model,” Journal of Personality 77(6) (2009): 1805–32. />
  20 J. Halifax, “A Heuristic Model of Enactive Compassion,” Current Opinion in Supportive and Palliative Care 6(2) (2012): 228–35.

  21 See the “A Piece of My Mind” sections of JAMA and “On Being a Doctor” sections of the Annals of Internal Medicine.

  22 N. N. Taleb, Antifragile: Things That Gain from Disorder (New York: Random House, 2014).

  23 S. M. Southwick and D. S. Charney, Resilience: The Science of Mastering Life’s Greatest Challenges (Cambridge: Cambridge University Press, 2012).

  24 S. J. Russo et al., “Neurobiology of Resilience,” Nature Neuroscience 15(11) (2012): 1475–84.

  25 Self-determination theory, a psychological model developed at the University of Rochester, suggests that a sense of autonomy (rather than a sense of feeling controlled), a sense that you’re competent and have the skills to reach your goals, and strong caring relationships with others would be associated with greater resilience. See E. L. Deci and R. M. Ryan, Intrinsic Motivation and Self-Determination in Human Behavior (New York: Plenum Press, 1985).

  26 D. Cicchetti and F. A. Rogosch, “Gene × Environment Interaction and Resilience: Effects of Child Maltreatment and Serotonin, Corticotropin Releasing Hormone, Dopamine, and Oxytocin Genes,” Development and Psychopathology 24(02) (2012): 411–27; A. Feder, E. J. Nestler, and D. S. Charney, “Psychobiology and Molecular Genetics of Resilience,” Nature Reviews Neuroscience 10(6) (2009): 446–57; and Russo et al., “Neurobiology of Resilience.”