Friday, October 04, 2013

How to Solve the Doctor Burn-out Problem

A piece recently appeared in the New York Times entitled "Who Will Heal the Doctors?" The piece is written by Donald Borstein and I encourage all to read it. Mr. Bornstein offers a solution to the doctor burnout problem in health care, a course called The Healers Art, now being promoted in US medical schools that uses "mindfulness" as his means of creating compassionate, caring doctors as a way forward.

I should say at the outset, that I do not disagree with the concept that doctors should not be more attuned to the circumstances for which they are being trained. But the overall argument that such "mindfulness" practices can repair his so called "McDonaldization of Medicine" is somewhat disingenuous concept. It skirts the very real challenges doctors have today when caring for patients and the many layers of bureaucracy and paperwork, both electronic and manual, along with the hidden costs that their patients are subject to as a result of doctor orders entered on a computer as they try to follow certain care "standards."   Blind-siding one's patients doesn't make for the best of relations.  Still, as bad as these realities are, they are probably not the reason most doctors are turning away from medicine.  I think there's another issue that is even bigger.

I believe the overriding reason doctors leave medicine is because there is a  growing hostile dependency patients have toward their doctors. 

I have mentioned this concept of hostile dependency before.  The theme is like an adolescent who realizes his parents have feet of clay.  In adolescence, he comes out of his childhood bubble and realizes his parents have failures and limitations because they are human beings.  This results in the adolescent feeling unsafe, unprotected and vulnerable.  Since this is not a pleasant feeling, narcissistic rage is triggered toward the people he needs and depends on the most.  Yet (and this is important) none of this occurs at a conscious level.  Most of us understand this behavior simply as "adolescent rebellion," not understanding the powerful issues at play.  So when we spotlight doctor burnout, or, say, the lack of patient safety in hospitals without acknowledging the realities health care workers face like looming staffing shortages and pay cuts, we risk fanning the flames of narcissistic rage against the very caregivers whom we depend on the most - the very caregivers who are striving to do more with less, check boxes while still looking in the patient's eyes, meet productivity ratios, all while working in a highly litigious environment. 

A comment from "Victor Edwards" posted after Mr. Bornstein's article demonstrates this growing hostile dependency toward doctors perfectly:
Doctors? I no longer afford that kind of respect: I call them "medical services providers." They and their families and the medical cabal created this mess when they got control of med schools so that the wealth of a nation would remain in the hands of a few medical elites and their families. The very notion that doctors are smarter, more productive, more anything than others is ludicrous. They are among the worst sluff-offs of our society, yet the richest at the same time. It is an unreal world they have created themselves and they are now watching the natural outcome of such a false system.
How do we fix this attitude toward doctors?  Who would want to work in an environment where patients perceive their doctors so?

Yet this is what we're creating with our increasingly consolidated "McDonaldization" of medicine.  Given where things are heading, I'm not sure this will be an easy fix as doctors are shoved farther away from the patients.  But let me be perfectly clear: if you want to keep doctors from getting burned out quickly  in medicine, it is this growing hostile dependency that patients have toward their doctors that must be addressed head-on.



Darrell White, M.D. said...

Brilliant! I am always searching for a better, more accurate vocabulary to describe the world around me. "Hostile dependency", so starkly demonstrated in your quoted comment, is so much more descriptive than my oft-stated "decreased respect and recognition" to describe the dramatic decrease in our non-cash compensation as physicians. Couple this with the "guilty until proven innocent" stance re: HIPPA and it's sometimes a wonder any of us show up to work at all.

What should I take home from my day today? Shall I ride the magic carpet of the smiling faces on each of my post-ops, all of whom can drive this morning w/out wearing glasses, or should I slide out on the oil slick of the note from a patient's wife who excoriated me for failing to diagnose the not-yet existent retinal hole that my out-going education allowed my patient to recognize and bring to another doc to fix when it arose 7 days later? The sad fact is that the mis-placed vitriol will choke out the joy of the successes, even though clinically I did a superlative job for all, including the patient I apparently so adequately educated.

Vanessa M said...

In my experience, it's the vast majority of patients who show this kind of hostile dependency towards their providers. I admit that my perspective is bounded, because my work is within a cancer center in an academic medical center, so perhaps this is not true in other settings. I often see patients forced to sit in the waiting room for hours because providers are running behind due to overbooking, and patients who can't get all the pertinent results during thier visit, because their past providers and us couldn't coordinate the transfer of MRIs or lab results. But what I don't often see is patients who take it out on the doctor because of this. They are still grateful for the time and care taken by the doctors when they do finally get into the visit and here their results, because they also know the system is broken in a way that harms both patients and providers.

I completely agree on all the challenges you pointed out that make today's doctors' jobs less rewarding, and more importantly, less effective. Bureaucracy, paperwork, understaffing, poor communication systems and organizational processes all place a burden on healthcare workers, and take away from the time they could spend with patients. It is these factors that need to be addressed if we'll ever have a chance at reducing the everyday frustrations providers face, preventing burnout, and bringing physicians back to what brought most of them into the profession - patient care.

Anonymous said...

I would disagree with your post, Dr. Wes. While there are some patients out there who display hostile dependency towards docs, the vast majority of patients are respectful, courteous, patient, and considerate of our time. We tend to have a recall bias of the difficult patients, who can derail our day and mood, but if the other 20+ patients we see in a day are nice, why should we sour towards all patients? It's similar to a patient writing off all doctors as greedy, after going to a doctor who recommended an unnecessary procedure.
Even in this day and age of medicine, doctors are still among the highest respected profession in US - right behind military and teachers!
On average, most patients do not have hostile dependency, or have anything short of the utmost respect for us.

Anonymous said...

Change the patient experience from start to finish and I bet you'll see the hostility disappear overnight. For regular patients, ones who don't work in or have family in healthcare, the overall experience is terrible. Think airlines, and then worse.

Rescheduled appointments, delays with no communication, billing problems, sterile facilities, miles of forms with redundant information, the list goes on...

It's hard to muster goodwill towards and confidence in a Doc when the whole experience up to that point has been so bad.

I think many docs underestimate how much the experience before they see the patient, by far the majority of the experience, wears on people.

I'm not looking for a Ritz Carleton experience. Something like Chik-fil-a would be a blessing.

Anonymous said...

Anonymous at 10:08 is either an amazing doctor, or is early in practice and has not been sued yet. Walk into the courtroom and see how eager the judge is to cede any status to the medical profession.

If we want to give doctors a little clout, we need to make hospital practice independent from office practice (as it is in Germany) to free us from the yoke of administrators, OR we need to get rid of malpractice cases. Maybe a worker's comp type of thing. Alternatively, we could eliminate the hired gun "whore of the court" expert witnesses who produce whatever their employing attornies desire and ask local M.D.'s to testify for free.

Anonymous said...

You know Wes, I've always said it's tied to demographics of your practice. Yours and mine are one in the same... Other parts of the country have things a little better, as there is still an amount of general respect given to everyone a person might encounter.