Monthly Archives: February 2012

Life-Work Balance: Downtime can be good for BOTH doctor and patient!

In these days of decreased reimbursement, increased workload, and non user-friendly EMRs, physician burn-out rates can be quite high. Stress, depression, and overwhelming fatigue associated with burn-out can interfere with our ability to care for our patients. If we, as providers, are not emotionally healthy, we are not able to provide the very best of ourselves to our patients. When we allow ourselves to become over extended and over committed without adequate recharge time, we may not be able to respond to a sick patients and their families with much-needed empathy and compassion. Moreover, our congitive skills and our diagnostic abilites may not be as sharp. This can lead to less than our best care. Physician burnout may be the cause of medical errors. These errors can then in turn result in worsening of the burnout…a vicious cycle. Family life may suffer as well. Stresses at work are often transported home in the briefcase and can result in negative interactions with spouse and children–further compounding the pressures that lead to burn out. Several studies on physician burnout have been published and two of the most notable articles are found in Annals of Internal Medicine and in JAMA both in 2002.

How can we identify burnout?

Burnout is defined as emotional, physical and mental exhaustion due to overwhelming prolonged periods of stress. It has been said by Dr Glen Gabbard that physician burnout is the “erosion of the soul”. It is a condition most common in middle age physicians but research has shown that younger MDs are at the greatest risk. Physicians and other health care providers are frequently overloaded with caring for the sickest patients with fewer resources and mounting economic challenges.

As physicians, we are trained to put our own needs aside in the care of our patients, our colleagues and our institutions. From the time we begin our training in Medical School and continue through Internship, Residency, and Fellowship, we are embedded in a culture of selflessness. This makes for great patient care and great partnerships with colleagues but is not a recipe for good care of one’s self. In the medical education culture, overwork and tireless labor is seen as a sign of success or “being a good doctor”. The skewed Life-work balance begins early, at the inception of our medical careers. We tend to push aside our own physical and emotional needs in favor of a compulsive need to work and over-work. These maladaptive behaviors (while excellent for making exceptional grades in medical school and receiving superior reviews in training) can have a detrimental effect on ones professional, personal and family lives.

The first step in dealing with unhealthy life-work balance is to perform an honest self assessment. As physicians, we are taught in training to routinely assess our own clinical perfomances but rarely are we asked to determine how we balance our personal life with our practice of medicine. Ask a few simple questions: Are you happy and fufilled? Have your patient satisfaction ratings remained the same? Do you have a shorter fuse than normal? Are there conflicts arising at home? Has the way in which your partners perceive you changed? Do you take time to laugh? Are you overly obsessed with work and work related issues?

Physicians must come to understand the risks for burn out and talk frankly with their spouse and colleagues and practice administrators about achieving balance. Frank discussions with trusted advisors and family can lead to identification of the early signs of burnout. Just as in medical practice, when we identify an issue or risk factor early we can take actions focused at prevention of the burnout and improve outcome.

How can we prevent burnout?

Just as with preventative medicine we can take action to avoid burnout in our own careers. Work to identify things that promote well being on a physical, emotional, psychological and spiritual level. As I reflecton my own career thus far, I have employed several of these strategies over the years (sometimes without even realizing it). Strategies below are adapted from JAMA 2002: 288; 12, 1447-1450.

Personal Strategies:

1. Identify personal and professional values. Do some soul searching. What brings joy to your life both inside and outside of work? Focus on how to find more of these things and weave them into your daily routines.

2.Engage in religious or other spiritual activities

3. Pay attention to your personal life. Find things that give meaning to life outside of work. Strive for a calmness and sense of wellbeing. Schedule TIME OFF.

4. Spend time with family, friends and engage a supportive partner or spouse. See above Schedule TIME OFF.

5. Exercise regularly. MAKE time to care for your own physical health.

Professional Strategies

1. Analyse your practice situation and attempt to restructure things in a way that makes you feel empowered and ready for success.

2. Find meaning in your work and set limits.

3. Identify and routinely spend time with a mentor

4. Develop adequate administrative support systems.

In addition to working to identify and prevent burnout in our own lives, we have a responsibility to ensure that our trainees and future MDs do not suffer burnout. Early mentorship programs in medical school and residency are essential. I believe that the concept of burnout should be discussed regularly with trainees so that all can be proactive in prevention.

Always at Risk!

As Physicians, our workloads remain daunting. We will always be at risk for burnout. The key is to strive for the holy grail of the proper Life-Work balance. This balance is individualized for each person and can change over time. We must constantly re-evaluate and routinely self-assess. Prevention is critical. If I am honest, I have certainly flirted with burnout many times during my career. Luckily, I have a supportive spouse who routinely keeps me in check. February tends to be a tough month for many of us. Its cold, dark and often the weather is quite bad. For me, my strategy is to go somewhere warm, rejuvenate, relax and come back to my practice once again inspired and excited to be at work.

On that note, I’ll not be blogging next week. In fact, no tweets, no Facebook , no email. I’ll be sitting under a palm tree, reading a book, getting a tan (wearing SPF 50 of course). BUT, the week after that a new, fresh and more inspired blog entry will likely appear.

Physician to Patient Communication: Speak the Truth, Say what you mean!

This week I came across two articles in the press concerning doctor-patient relationships and communication. I began to reflect on what makes communication between doctor and patient most successful and many questions surfaced. In the New York Times, a new study published in Annals of Internal Medicine was referenced. In this study, the way in which doctors communicate non-verbally was examined. Non-verbal communication was often discordant to the message being relayed, particularly when African American physicians were delivering bad news to white patients. Previous studies showed similar differences in communication and found that female physicians were delivering discordant verbal and non-verbal messages to male patients. Certainly cultural and gender differences must play a large role in how we do our jobs–but what can we do to improve? In a second article published in the Wall Street Journal, referenced a survey of 1891 physicians from the Journal of Health Affairs. The investigators found that a significant number of respondents were not honest with patients. Nearly half admitted that they had described a patient’s prognosis as more positive than it really was and 20% stated that they had kept medical errors hidden from patients. Interestingly, the study found that cardiologists and surgeons were more likely to achieve open and honest communication. Patients need clear messages and accurate information in order to make good healthcare decisions. When delivering bad news, it is important to provide some glimmer of hope–how much is enough?

How Can this be?

In Medical Schools today, communication is emphasized. When I was in training in 1996 at Bowan Gray School of Medicine at Wake Forest University, we had regularly observed (through a two way mirror) and graded doctor-patient interactions during the first year. Not only were the history and physical exam skills evaluated, but the “patient” (typically an actor from the NC School of the Arts) would provide a grade for compassion, communication, etc. Today’s medical schools continue to emphasize communication. Entire classes and lecture packages have been developed in an effort to arm our emerging physicians with superior communication skills. But, given the recently published studies, maybe we are not focusing on the total communication package. Few lessons in non-verbal communication skills have been delivered. Discordant verbal and non-verbal messages serve only to confuse and frighten patients. Moreover, more discussions on medical ethics, end of life issues and honest communication are clearly warranted. The basic tenet of a doctor-patient relationship is TRUST. Without it, no cooperation in the delivery of healthcare is possible. Today, more than ever, preventative health care is a two way street–a contract between provider and patient. Trust and honest communication is paramount for success.

How can we Improve?

We must start by better educating ourselves and our physicians in training in the art of communication. According to Stuart Foxman, communication consists of three distinct components: 1. What we say, 2. How we say it (tone, pitch and volume), 3. non verbal body language. Each component is an integral part of the doctor patient relationship and any one part can destroy the communication process. Those of us in practice must self evaluate and identify communication inadequacies and areas that must be improved. Annual Scientific sessions (such as ACC in March) should begin to include workshops on communication and more sessions on medical ethics. As physicians in practice, we must set an example for the physicians in training in medical school, residency and fellowship. Although most of us are unaware, we mentor trainees as much non- verbally as we do with didactic teaching.

It is obvious to all that hiding errors from patients is unethical and discordant with the Hippocratic Oath–honesty is the basis of all communication. Multiple studies have demonstrated that patients are much less likely to litigate when a physician communicates regularly and effectively and has been truthful about any medical errors. We must treat patients and families as we would want to be treated. Doctors are not immune from mistakes but how a physician handles a mistake is what separates average caregiver from exceptional healer.

So remember, as you meet with patients and families this week, be cognizant of how and what you say–Speak the Truth and Say what you mean!

Super Bowl and Super Stress: The Heart-Brain Connection

I am sure that almost everyone has plans for Super Bowl Sunday, even if you are not a football fan.  The Super Bowl has become a mega-social event surrounded by lots of food, spirits and fun.  Families and friends gather for the game and many folks are emotionally invested in the game.  For some, the stress of the Big Game can be life threatening.

As we prepare for Super Sunday, I am reminded of a New England Journal of Medicine article from 2008 that addressed the cardiovascular effects of watching major sporting events. (N Engl J Med 2008; 358:475-483 Jan 2008).  Soccer’s FIFA World Cup was held in Germany in 2006.  Utilizing several sites in Bravaria, researchers studied patients treated in area emergency rooms for acute CV diagnoses during the World Cup event.  Investigators examined the relationship between viewing a stressful world cup soccer match and myocardial infarction, cardiac arrest and other signficant major cardiac events.  Event rates spiked on days when the German team played and seemed to be at their greatest on the day in which Germany narrowly defeated Poland in a very close match.  After the data was analyzed, it was concluded that viewing a stressful soccer match was associated with a doubling of risk for an acute cardiovascular event.

There has been much work done linking stress and the heart.  Typically, when stressed, heart rate and blood pressure increase and the body may release large amounts of catecholamines or other stress hormones.  Stress mobilizes our resources in a way that allows us to respond to emergencies with increased  cognitive and sensory skills for a short period of time.  However, in a heart  previously damaged by coronary artery disease or other insults, stress can be devastating.  Studies suggest that the acute stress reaction can result in myocardial infarction or heart attacks in susceptible individuals.  These victims may not even know that they are at risk and that they are harboring undiagnosed cardiovascular disease.

So, what can American Football fans learn from this?  First of all, remember to breathe.  There are lots of techniques to reduce stress and many involve biofeedback and invoke breathing techniques for relaxation.  Meditation, yoga and other modalities are useful for stress management.  An abstract published in Circulation in 2009 showed a 43% reduction in risk for myocardial infarction and all cause mortality when a transcendental meditation program was utilized by an at risk population.  Practicing relaxation techniques may produce positive effects on the cardiovascular system such as lowering blood pressure and heart rate and increasing blood flow to large muscle groups.   In addition, these techniques may reduce anger and frustration and improve your ability to concentrate and accomplish your goals.  All taken together, these events make us happier, more confident and allow us to better enjoy both work and play.

So, go ahead, cheer for your team.  Jump up and down, clap your hands, eat a few snacks (healthy ones, of course).  Enjoy the company of friends and family.  But, when you become angry about a bad call  or feel the overwhelming stress of a last second field goal attempt to send the big game into overtime…Breathe!  

Physician: Heal Thyself! (and Set the Example)

In the last week an interesting study was published in Obesity online journal.  It examined the relationship between a provider’s body mass index (BMI) and his or her’s obesity counseling  behaviors and practices.  The study involved a questioniare given to more than 140,000 physicians.  Researchers found that physicians with normal BMIs were more likely to engage in activities that were focused on weight reduction and diet modification with their patients.  Physicians with normal BMIs were perceived as more confident when faced with opportunities to discuss weight loss.  Conversely, obese physicians typically avoided any weight loss related conversations with their patients.   Interestingly, the study showed that  overweight  physicians were more likely to have  weight loss counseling conversations with patients that they percevied to be more obese than themselves. 

As physicians, we are role models for our patients.  We must set the example for a  healthy lifestyle and risk modification.  Our patients look to us for guidance and an overweight caregiver has limited credibility when giving weight loss advice.  As providers, we must make sure that our risks for cardiovascular disease and other illnesses are modified in the same way in which we would like to counsel our patients.  This study highlights the fact that sometimes a physician’s own health status may be a barrier to the treatment of his/her  patient.  Additionally our patients rely on us to remain healthy and in good physical shape so that we are able to care for them optimally.   In short, we must practice what we preach.   It has been demonstrated many times over that health care costs are ultimately reduced through  preventative care.  In this day of escalating costs, it seems to me that prevention must  start with the health of the provider. 

As we enter February and recognize Heart Health month, I would challenge all physcians and other healthcare providers to take a hard look at your own risk for CV disease and begin to make lifestyle changes that can modify risk.  Use your efforts as an example for your patients and openly discuss the challenges that you face as you modify your own risk.  By relating to patients on a very personal level, we may have an even greater impact on their ability to change and reduce their individual risk.  Not to mention the fact that each of us will be healthier, happier, and ready for the next patient who walks thru our door.