Pandemics of disease have altered the course of human history. The bubonic plague in medieval times wiped out almost half of the population of Europe and forever changed the political and economic landscape. The Spanish flu and related disorders decimated millions of lives in the early part of the twentieth century. And now another pandemic has dramatically changed the face of society: The pandemic of healthcare provider burnout.
National healthcare policy wonks have defined this national crisis and the impact on us as healthcare providers and for our patients. So what are the practical, actionable tasks for the healthcare community to go the distance so we can honor our values and the needs of our patients and their families?
The Faustian Bargain
We in medicine are the epitome of the Faustian bargain. In mythology, Faust wanted fame, wealth, and notoriety. He made a bargain with the devil for his soul if the devil would give him what he wanted.
We make the same “bargain.” We commit the most productive, youthful, and engaging years of our lives in pursuit of the medical academic degree: MD, DO, RN, DC, NP, PA, PhD, or related designation. We are the epitome of delayed gratification.
For our efforts, we anticipate acknowledgment of prestige by society and a comfortable reimbursement. But now, somebody changed the rules. We have become employees—drones producing a product, worker bees creating a commodity rather than being engaged in that sacred relationship with a vulnerable, ill human being.
No wonder doctors and nurses and associated healthcare providers are switching occupations, or burning out in their current positions and toughing it out until retirement, or, sadly, ending our lives.
Burnout Erodes the Soul of Medicine
Let’s talk about burnout. It’s the erosion of the soul caused by deterioration of values, dignity, spirit, and will, according to one source. And what has fueled this catastrophe? Every healthcare provider can outline a litany of events, but here are some major drivers:
Loss of autonomy. At one point we doctors and other providers had some control over our schedule, over the kinds of patients’ conditions to be cared for. But now, most of us are anonymous employees in a vague healthcare delivery system producing a product, a commodity, a service.
Who are we working for? An armada of stakeholders are influencing that doctor/patient relationship. Consider who else is in that exam room: insurance companies, Big Pharma, management, managed care organizations, employers. Are we working for the institution, for the insurance company, for Big Pharma? If we put a patient on a clinical trial and that trial receives funding from a drug company, is that a conflict of interest, and, if so, does the patient understand that relationship? If we prescribe a certain medication and the HMO doesn’t have that drug on their formulary, where does that leave the patient? What if we want an MRI to rule out or rule in a condition, and a nameless nonmedical person in a big office building hundreds of miles away says no? Not covered. What if the patient has no insurance? Should that make a difference in care?
Who speaks for the patient? The doctor/patient relationship, which had been the cornerstone of care, has been eroded and distorted. In some studies, the electronic health record, which is actually a billing tool, consumes one to two additional hours per day and an additional thirty hours per month as medical care teams try to document the patient’s record on a cumbersome digital platform. In some emergency rooms, a clinician will launch 4,000 clicks per shift. That’s time taken away from patient care, live-saving patient care. And in a study of internal medicine residents, 75 percent of their professional time is spent feeding the digital monster rather than face-to-face with desperately ill patients.
What’s the end result of these drivers? Burnout, apathy, and disinterest. Not on the part of the patients (yes, they are frustrated, confused, and disappointed in a system that doesn’t serve them well). No, burnout strikes the healthcare providers who just want to do the work they signed up for when they decided to enter the medical professions.
Healthcare providers have one of the highest rates of suicide in all professions with at least one clinician death a day. Depending upon the source, up to half of all medical staff fit the criteria for burnout. And about half of clinicians today will leave medicine within the next three to five years.
Are these the docs you want greeting you in the exam room? The nurse who tends to your children? The PA who assesses your aches and pains? The cancer specialist who is forced to fit too many patients into an already long day? The orthopedic surgeon who is pushed to add yet one more hip replacement on a surgical schedule? The pharmacist who has worked too many shifts that week?
So what can we care providers, the boots on the ground, do about this situation for ourselves? Mindfulness, yoga classes, and eating yogurt and granola are not enough. In fact, the healthcare system is killing us all, but we can throw ourselves a life preserver before the ship sinks.
ABCs of Empowerment for Healthcare Providers When Mindfulness Is Not Enough
We have to mind our ABCs. I have found, in practicing medicine for over forty Minnesota winters at the Mayo Clinic, some tips to go the distance.
A stands for athleticism. If we are not “dead fit,” to use a race track term, we will certainly not practice medicine for forty-five years as had been the case in the past. Marcus Welby, MD, will be transported to the ER with a myocardial infarction at a young age. At an absolute minimum this means seven hours of restorative sleep per night. If we are up for seventeen grueling hours, we are functioning at the legal level of intoxication, and we do not know it.
We spend more time purchasing a car than investing in ourselves. A personal trainer, a strength and conditioning coach is part of the team of most athletes, and we should not ignore the impact of these professionals. It’s obviously a no-brainer to follow a plant-based diet and have 150 hours of aerobic activity each week. This is hardly new news, so let’s move on.
B stands for boundaries. Once upon a time we worked for the firm, the foundation, corporation. We came home, the drawbridge went up over the moat, and we were safe inside our castles. Today, with the current carnivorous digital dragon, there is no place to hide. Directly or indirectly we are on the grid 24/7. We ruminate about clinical decisions, and this absolutely erodes the soul.
We conscientious clinicians, at some point, need to turn off the gimmicks and the gadgets or we will have nothing left.
Let me share an example. Few months ago I was planning to leave for a family reunion on a Saturday. Tickets, reservations, pet sitters were all arranged. On Thursday before the departure I consulted on a patient who had progressed on a standard lung cancer treatment. We had a frank discussion with the patient and family and everyone was on board to go ahead with another biopsy to analyze for particular mutations, which, if present, would have required another lung operation with the usual risks.
I agonized over this decision, and it weighed on my mind. While away I continuously accessed the health record to see how everything went. Fortunately, the patient did fine. But the laboratory detected some obscure mutations, and I spent about another ninety minutes analyzing the literature about the next treatment decisions. And I contacted several other colleagues for their guidance.
Looking back, I should have explained to the patient and the family that I would not be available, that one of my colleagues would be available during my absence, but we may not have all the information to make a decision. Upon my return, we could revisit when we had all the information. My “time away” was clearly not “time away.”
Dr. Tait Shanafelt had been the Chief Wellness Officer at the Mayo Clinic and now holds that esteemed position at Stanford. He has been a close friend and had been our neighbor. He offers some sage advice on this issue: What are the nonnegotiable events that we will not compromise for a corporate medical environment? How many birthday parties, soccer matches, piano recitals, and family picnics will we compromise for a work-related situation? Each of us has a certain threshold. Set yours.
For me, a nonnegotiable is a daily workout routine, typically in the morning and lasting ninety minutes. I have deliberately declined early morning meetings, and perhaps this closed some professional opportunities but it’s a decision I made. Most meetings are informational and of little substance. Therefore, I am highly selective about attending some of these mind-numbing events. Likewise, a family illness or illness with my family needs attention and likewise should not be dismissed.
C stands for concentration. We live in the land of distractions. The land of intermittent partial inattention. In one publication, knowledge workers access their emails about 150 times a day. It may require approximately 60 seconds to reboot, to refocus which means 150 minutes are consumed each day. And most emails are a demand, complaint, or an expectation.
Some top executives have learned to access email only two or three times a day but never first thing in the morning because then we become consumed with someone else’s drama. Now, let’s be realistic. This may not always be feasible, but it is reasonable to open a tablet or screen and quickly scroll to identify a mission-critical email and address it. The rest of the stuff can wait. On a weekend we typically batch our chores. If we do not batch our emails, we will drown in a sea of electrons.
Edward T. Creagan, MD, FAAHPM, a cancer specialist, is the first Mayo Clinic doctor board certified in hospice and palliative medicine. His new book, Farewell: Vital End-of-Life Questions and Candid Answers, is about navigating those precious last days, at the bedside, and saying farewell with hope, love, and compassion.