The Real Solution To Burnout

One of my favorite things these days is the concept (or is it diagnosis?) of burnout.  It seems to be a popular topic in medical and psychiatric news these days.  In the Psychiatric Times January 2016 edition, Editor in Chief Allan Tasman, MD published a column on burnout entitled My New Years Prescription for You.  He goes on to detail the syndrome and what can be done about it.  He points out the high prevalence of burnout in physicians including house staff, physicians in general and psychiatrists.  These studies generally depend on checklist surveys of symptoms suggestive of "burnout."  Dr. Tasman points out that they are relatively nonspecific and people may not see psychiatrists about burnout until there are more recognizable syndromes of anxiety or depression.

My problem with the concept of burnout is that it doesn't accurately describe the problem.  As I think back on some of my most engaging clinical rotations in training - the teams frequently worked to the point of exhaustion.  The attending came in the next day.  There was an air of collegiality and a lot of learning occurred.  There was a lot of dark humor on the part of house staff.  There was an understanding that all of this exhausting work would end some day when you made the transition to a staff or attending physicians and could work more normal hours.  That was the late 1980s and early 1990s.  As politicians and business people wrested control away from physicians, suddenly most physicians continue to work like they are house staff.  Senior physicians in their 60s are suddenly taking all night call and working 60-70 hours per week.  Hospitalist services were invented requiring physicians to work 7 days on and 7 days off - another exhausting schedule.  I have observed to many of these physicians that they are working like they did when they were house staff - interns and residents.  They numbly shake their heads in the affirmative when I ask them that question.  They also acknowledge the fact that by day 6, their cognitive capacity is markedly diminished.  Suddenly it takes them twice as long to do tasks especially all of the documentation.

The reference to Studer in the Tasman article is interesting.  I don't know if any other physicians have had to suffer through a business consultant-based inservice on how to improve "customer satisfaction scores".  There are discussions on how to introduce yourself to the "customer".  There are the usual business based mnemonics.  Physicians may actually have to demonstrate that they know how to introduce themselves to "customers"!  Think about that for a second, especially if you are a psychiatrist who was trained for years in how to interact with patients rather than customers.  If you are a psychiatrist who passed the oral boards,  you know that failing to make the appropriate introduction led to an immediate failure on that exam.  Now flash forward to the bizarre world where patients are "customers" and now there is a formula designed by business people who know relatively nothing about interacting with patients in a therapeutic manner.   You are expected to demonstrate competency in this shallow business paradigm that is setup to optimize results on customer satisfaction surveys.  This is a great example of how physicians are stressed on a regular basis in health care organizations and their time is wasted.  It is also a great example of how public relations, rather than the latest medical knowledge is the dominant performance metric for healthcare organizations.  If there is a recipe for burnout - this is it.

The dynamics of burnout are the dynamics of many clinical situations that psychiatrists try to address.  The referrals are people with chronic depression or depression that seems to have occurred as a result of a sudden change in their life circumstances.  A common scenario is an unreasonable employer or work supervisor.  I will understand it if the employers jump in here and say that they are entitled to tell people how they want them to work for their salary or that their employees are free to find another job.  Those are political arguments that I don't really care about.  Those arguments are also improbable ways of addressing burnout.

When I am faced with person who is chronically anxious and depressed, chronically sleep deprived due to forced swing shifts or double shifts, is dealing with an obnoxious demanding boss, and is not able to change jobs for economic or insurance reasons - I know the patient and I are up against a wall.  I speculate that there are millions of people in this situation who are diagnosed with one anxiety or depressive disorder or another or chronic insomnia and who are trying to get some kind of treatment to alleviate this stress.  There is no evidence that I am aware of that treatment that targets what is basically a chronic stress response is effective.  There may be some small incremental changes if people feel supported and are getting active feedback in therapy about how to deal with the stress in realistic ways, how the dynamics may have personal meaning, and how to reframe the stressful relationships but many people are likely to stay in treatment for the diagnosis for months or years and have little to show for it.  Many people have the expectation that there is a medication that will restore their ability to function in this situation and not require any significant changes on their part.  That is completely false.

That brings me to the issue of physician burnout.  Burnout is more than the clinical diagnoses that are used to describe people who are experiencing chronic workplace stress.  The current work environment for physicians is designed to produce burnout, anxiety, depression, and all of the associated comorbidity.  One of the central dynamics is administrators with no medical knowledge creating an environment that moves physicians away from patients and creates an onerous clerical and administrative burden.  The large increase in managers has created an environment that is both hostile and full of busy work.  The idea that this is something that can be overcome with medications, meditation, exercise, lifestyle management or psychotherapy leaves a lot to be desired.  It is time that psychiatrists focus on an optimized environment for mental and physical well being rather than than trying to treat the fallout from some of those horrific scenarios.

Addressing burnout in physicians is more than a health and wellness consult.  It is more than a weekend retreat to a local resort.  It is more than "lifestyle changes" when you don't have enough time to have a life.  It is a lot more than going on vacation and realizing that on the day you come back - it is like you never left.  Optimizing the work environment for physicians rather than treating burnout is a good place to start.  Recognizing this when it happens in our patients is also more useful than treating it like depression.



George Dawson, MD, DFAPA





  

No - I Don't Have Generalized Anxiety Disorder

I was reading a copy of JAMA the other day and a story written by a transplant surgeon Jeremy M. Blumberg, MD.  It was an excellent description of surgical training to the point of autonomy and then the nagging uncertainty of whether the surgery you have trained for years to do will go well.  Will you avoid mistakes?  He describes his first transplant as an attending:

"This operating room was new to me; the nurses were friendly but foreign.  The instruments were familiar, but somehow felt different - was there just a barely palpable increase in tension in the muscles of my hand causing this effect?  The patient's blood vessels were hard, thickened from years of dialysis and diabetes.  She bled more than usual when we reperfused the kidney.  It felt as if every last molecule of epinephrine had rushed out of my glands and nerves, squeezing my blood vessels and taunting my intestines to detonate...."  (p. 1676)

I hear you brother.  I thought that level of anxiety over the balance between doing the impossible and not doing harm might fade away over the years but it has not.  In psychiatry a lot of it depends on the level of complexity that your patients have.  It can be an acute situation but more often than not - it is a problem throughout the day that you take home with you.  Additional medical conditions, non psychiatric medications, polypharmacy, and difficult to treat disorders all compound the problem.  I have designed a hierarchy to illustrate what I mean.  It turns out that when I think about it, the acute problems seen by psychiatrists are not at the top.  The problems at the top are typically problems where there is no good guidance, where you are on your own, left with biologically determined probabilities and you need to come up with your best estimate of what will happen given current circumstances.  The problems encompass both psychiatry and the medicine associated with psychiatry.

Let me provide an example of both.  In the case of the psychiatric problem the usual scenario is a case of impaired judgment.  Is the person at risk for death or self injury?  Are they able to cooperate with the assessment and treatment plan.  Do they seem changed to the point that you can no longer accept their responses as being accurate?  Are you treating them for acute and chronic suicidal ideation and behavior?  Any acute care psychiatrist ends up assessing thousands of the situations across the course of their career.  It is often much more complex than an acute assessment.  Many of these scenarios unfold in the context of ongoing psychotherapy and in order for the patient to be able to improve some risk is taken.  In other cases there are calls to warn people and in extreme cases - calls to the police to check on a person who might be in trouble.  I have not seen it studied but the stress of these situations for the psychiatrist involved is well known.   Overthinking the situation in order to avoid the unexpected call that one of your patients has suicided or killed someone is common.  In my conversations with medical students over the years, one of the main deterrents to psychiatric residency is the worry about suicide prediction.

The medical situations are as complex and they frequently have no clear solution.  A common scenario is that the person has a severe mental illness and they develop a problem that leads to to rethinking the medication they are taking.  A common scenario is a person on maintenance therapy who suddenly develops a renal or hepatic problem necessitating a change in therapy.  The best example is bipolar disorder and lithium therapy.  Lithium remains the drug of choice for many people with bipolar disorder and it can be highly effective.  When I first started to practice it was common to see people who had repeated institutionalizations for bipolar disorder suddenly stabilized on lithium.  Their functional capacity was restored and they were able to return to work and establish families.  In those early days, the issue of lithium nephrotoxicity was not clearly observed.  There was a major study of people on lithium maintenance for decades that showed no difference in renal function.  In the last 15-20 years most nephrologists agree that lithium can lead to renal insufficiency and failure in a minority of patients on lithium therapy.  In the case of a person that lithium has been working well for 30 years, there is no guarantee that anything else will work as good.  That translates to no hospitalizations in a long time to frequent hospitalizations every year.  Monitoring that therapy and in some cases following the patient while they are in dialysis or after transplantation is on example of a situation that you can't leave at the office.

In many ways, the stress and anxiety in psychiatric practice is a measure of attempting to predict the unpredictable.  Psychiatry has accurately said that psychiatrists can't predict future behavior or rare events to explain why all suicides and homicides cannot be prevented.  But some sort of probability statement is inherent in all medical practice.  I would estimate it still happens to me about every three weeks.  Something isn't right and I don't have an exact answer.  It becomes an obsession to an extent.  Laying awake in bed.  Getting up to do some additional research but realizing ahead of time that the yield is low.  Realizing that no matter what decision you make - all of the outcomes are probably going to be suboptimal.  You always get to the point where you  can feel the adrenaline molecules rushing and your heart pounding.  You know you are tense and starting to break into a light sweat.  You readjust yourself in bed and realize your back and shoulders are as tight as a frozen hydraulic jack.  You might actually check your pulse and blood pressure and find that  they are elevated.  It goes on like this until something happens and the intellectual crisis abates.  Sometimes that takes a while - at one point months and a beta blocker to break up the stress induced tachycardia and hypertension.

No I don't have generalized anxiety disorder - I am a doctor trying to deal with the uncertainties of being human.

George Dawson, MD, DFAPA