Monthly Archives: July 2016

Doctors and Gun Control: Get Politics OUT of my Exam Room

 

Let me preface this blog by stating that I write this to stimulate discussion and debate, NOT to sway opinions…..

Today, doctors are required to spend more and more time doing administrative work—including checking off electronic boxes in the Electronic Medical Record (EMR)—the result is less quality time with patients. Now, those that are in Washington, DC think that requiring physicians to ask about guns in the home may somehow reduce gun violence and gun related deaths in the US today. For me, the answer is simply NO. Physicians should focus on the prevention, diagnosis and treatment of disease—we should advocate for our patients BUT we should not be government agents (unless we all collectively become employed by the state. In an article published this week in the Atlantic, author Olga Khazan argues that doctors have a responsibility in preventing gun related deaths. When I read the article, I was simply struck by how much controversy surrounds this issue—How do we protect patient’s privacy rights? How do we preserve our relationships with patients? Certainly, as physicians we may ask many uncomfortable questions of our patients—Sexual history, drug and alcohol use, and other sensitive subjects—BUT should we really be asking about guns? The legal implications alone of these discussions are enough to make even the most steadfast physician a little weak in the knees….

For far too long, the government has attempted to insert itself into the sacred (and privileged “Doctor-Patient” relationship. The bond between doctor and patient is like no other-honesty, confidentiality and trust are paramount to all other concerns. There is already a debate on the role physicians should play in gun control/gun safety. Our own US Surgeon General has proclaimed in the past (prior to his appointment by a Democratic President) that gun control was a top priority for his office. In Florida, there is a law that does not allow Physicians to ask about guns except is certain circumstances. Others want to require physicians to ask and document the patients answers in the EMR. I fear that allowing discussions on guns to enter an exam room may completely undermine a physicians’ relationship with his or her patient. Patients may feel uneasy about answering the questions and may also be suspicious of why they are being asked in the first place. Patients may be less likely to TRUST their physician (for fear of some repercussion) and my also be less likely to discuss other medical issues with honesty. Lack of honest dialogue between doctor and patient can result in a lack of patient engagement and, ultimately, negative clinical outcomes.

Don’t get me wrong, we MUST educate the public about the proper use and storage of firearms. Guns should never be accessible to children and any person who owns a firearm must be trained in its safety and proper use. However, the role of the physician should remain, first and foremost, as healer—We should not be required to become firearm educators, nor should we be required to document firearm possession to the government. While I do concede that there is likely a role for the discussion of guns in a Pediatrician’s office (with the parents) in order to ensure that guns are stored properly in the home, I do not think that there should be any type of discussion in Adult medicine. There has been much research in this area and much controversy remains. This past week in the Annals of Internal Medicine, researchers from Colorado found that there is a vast array of opinions among patients when it comes to physicians asking them about guns. Only 25% of patients surveyed thought that it was ALWAYS appropriate for a physician to have a discussion about guns. 34% of those studied in stated that it was NEVER appropriate for a physician to ask about gun possession or gun use. While study authors spin the data to say that nearly 2/3rds of respondents think that it is SOMETIMES ok to ask about guns, the reality is that many Americans feel that this type of interaction is not appropriate.

Sadly, there are far too many gun related deaths in the US today. We must do more to prevent criminals, those with mental illness, and others who would do us harm to possess guns. This should be the work of the community and the local, state and Federal government—NOT the work of the physician. I fear that if we begin to mandate data collection of this sort by physicians and other healthcare providers we will undermine the trust that our patients place in us every single day.

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Avoiding Burnout in Medicine: Tips For Success

Medicine has become increasingly stressful for all levels of healthcare providers. Every year, nearly 400 physicians commit suicide and in a study published in the Journal of Academic Medicine, it was found that nearly 10% of final year medical students and first year residents (called Interns) reported having suicidal thoughts. Previous studies from the National Institutes of Health found that physicians were twice as likely to kill themselves as non-physicians. The statistics are staggering—suicide accounts for 26% of deaths in physicians ages 25-39 as compared to 11% of deaths in individuals of the same age in the general population. More must be done to both recognize and prevent physician depression—this all starts with working to avoid burnout.

Burnout in medicine has been defined as Physician burnout is quite common—A study in the Mayo Clinic Proceedings found that burnout rates continue to rise and most physicians are very unsatisfied with their own work-life balance.

Warning Signs of Burnout

As burnout becomes more prevalent we have been able to identify some early warning signs. Awareness of these signs may lead to early intervention and prevention of more serious burnout resulting in physicians leaving medicine entirely.

Warning signs include:

–Emotional Exhaustion

–Depersonalization and trouble connecting with patients

–Reduced accomplishment/Confidence in skills

Causes of Burnout

In order to make a difference in the lives of physicians and their families-and prevent burnout– a great deal of effort has gone into trying to determine the causes of burnout in hopes of making more of an impact early on and preventing burnout before it occurs. In order to make this happen, we will need the support of lawmakers, regulators and medical societies.

–Too many clerical tasks—Doctors now have to perform more administrative duties and metrics are now putting increasingly daunting non-clinical tasks before physicians. Most doctors go to medical school to care for patients. Patient care provides fufillment where paperwork does not. Physicians are now scribes, coders and schedulers—in addition to healers. Many doctors are left to wonder why they went to medical school—it certainly was not for a data entry job.

–Too little time to effectively work with patients—As physicians most of us went to medical school because we loved science and we cared for patients. Patients provide challenges, opportunities for relationships and a way in which we can improve the world.

–Declining salaries—Medicine takes commitment, time and money for education. Many physicians have taken on a great deal of debt and have made numerous personal sacrifices in order to train for years to provide top-notch care to the patients that they treat. As healthcare reform moves forward, physicians are caught in the middle. Salaries decline, workload and non clinical demands increase and without meaningful tort reform, frivolous malpractice claims continue to propagate. All of these factors work to diminish physician satisfaction and contribute to burnout.

–Longer work hours—With declining reimbursement, physicians are being asked to do more with less time. Documentation requirements and Electronic Medical Records have resulted in more time spent at home completing paperwork. All of this takes away from private time with family and significantly impacts happiness and life-work balance.

Consequences of burnout

–Poor patient care—When Physicians are emotionally and physically depleted as commonly seen in burnout, patient care may suffer. Distraction, lack of attention to detail and poor decision-making can be more common. In order to provide the best care, physicians must engage with their patients and develop a personal connection. If physicians have burnout, often there is no time or energy left for cultivating these important relationships.

–Depression/suicide—A staggeringly high number of physicians, when polled, have clinical signs of depression and many have contemplated suicide. Sadly, every year in the United States, over 400 physicians commit suicide. Depression can adversely affect family life and can impact a doctor’s ability to perform in the clinical setting. Sleep disturbances and fatigue are common.

–Early retirement/MD shortages—For many, the prospect of practicing medicine is no longer tenable. Many physicians are looking for other business opportunities and are leaving medicine entirely. As the pool of insured patients grows, a physician shortage looms—If we continue to lose practicing, experienced physicians due to burnout and early retirement from medicine this shortage will only become more significant. Patient access to skilled physicians is a critical part of patient engagement and improving outcomes. If more physicians leave medicine, the work load will only grow for those who remain.

What we can do about Burnout

Burnout is a real issue in medicine today. We must make efforts to address this problem before more doctors are lost. Here are a few things that I believe will help ward off Burnout:

  1. Schedule Regular time off—extended vacations (2 weeks) While it is not the typical American way to take vacation, I think that extended time away from clinical responsibilities may be important to avoiding burnout. By “unplugging” from the office and clinical demands for more than a week at a time, healthcare professionals are able to recharge and return to clinical practice more refreshed and ready for the challenges of patient care.
  2. Schedule Regular exercise—It is a fact that regular exercise is associated with lower rates of depression and other chronic disease. In general, when we exercise, we are able to turn our thoughts away from work and outside stressors and focus on the moment. Exercise also promotes a more ideal body weight and overall improved health status.
  3. Healthy diet—Along with exercise, healthy eating can help physicians avoid burnout. When we eat good healthy well balanced meals we are able to maintain a more ideal body weight. Avoiding sugars and alcohol can certainly help avoid the depression and other burnout related complications.
  4. Supportive spouse—Having a life partner or spouse who is able to listen and support the stressed physician is very important. A supportive partner can serve as a sounding board and can offer suggestions and facilitate interventions when necessary. In addition, the supportive spouse can also help identify early warning signs for burnout and suggest early intervention..

What does the future hold?

Burnout is more common that many physicians think. No healthcare provider is immune. It is essential for physicians as well as their coworkers and families to understand the signs and symptoms associated with burnout and intervene early. Burnout can have severe consequences including depression, and in severe cases—physician suicide—are completely avoidable if we begin to better understand what the root causes of burnout are. By understanding the etiology of burnout, we may be able to design a better working environment for today’s physicians. If we do not make these changes, I fear that many physicians will leave the practice of medicine within the next 5 years.