Focus On: Physician Burnout
Focus On: Physician Burnout
Issue: March 2020
Source/Disclosures
Disclosures: The physicians report no relevant financial disclosures.
March 20, 2020
10 min read
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Facing Burnout: How One Cohort Moves the Topic from Taboo to Safe Zone

Issue: March 2020
Source/Disclosures
Disclosures: The physicians report no relevant financial disclosures.
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Imagine a guest lecture where fellows are given the opportunity to ask an invited speaker about burnout and work-life balance. Now, imagine the surprise when none of those fellows asks the lecturer a single question about that topic. Afterward, you approach the group to inquire why no one asked any questions. One of the fellows responds that they were uncomfortable asking burnout or work-life balance related questions in front of their peers and attendings.

While this scenario may seem fictional, this happened to one of the physicians who approached Healio Gastroenterology and Liver Disease about the taboo of discussing physician burnout and work-life balance and how representations like our feature “My wedding during DDW shows positive work-life balance is possible” can be problematic.

Despite the perceived taboo in conversation, physician burnout is rather common.

According to a survey of more than 700 gastroenterologists presented at the World Congress of Gastroenterology at American College of Gastroenterology 2017, 49% of gastroenterologists reported having experienced burnout with work-life imbalance as the primary cause.

Steven Krawitz, MD, and his cohort of former cofellows from Thomas Jefferson in Philadelphia may have moved on to new roles and locations but they continue to rely on one another for advice and support to help combat burnout.
Steven Krawitz, MD, and his cohort of former cofellows from Thomas Jefferson in Philadelphia may have moved on to new roles and locations but they continue to rely on one another for advice and support to help combat burnout.
Source: Steven Krawitz, MD.

When Healio Gastroenterology and Liver Disease published the guest commentary from Ruchit N. Shah, DO, of Geisinger Medical Center, about his wedding during Digestive Disease Week and how he had planned to fly to the conference the night of his wedding to present research until bad weather forced the cancellation of his flight, we received many comments about work-life balance.

We spoke with multiple physicians who were fellows together at Thomas Jefferson University in Philadelphia. They have since moved away to various parts of the country to practice but stay in touch and help each other combat burnout and any tough questions they might have.

How do you sense if you’re burnt out?

Natalie Cosgrove, MD
Natalie Cosgrove

Natalie Cosgrove, MD, Assistant professor of medicine at Washington University School of Medicine in St. Louis: “I don’t always notice when burnout is first starting. Occasionally, I recognize it too late, once I’m completely burned out. I’ve been working on trying to catch it earlier and to help prevent it. Sometimes, in trying to be a better physician for my patients, I take on too much and don’t look out for my personal well-being. I get to a place where I’m completely emotionally exhausted and less equipped to take optimal care of either my patients or myself. I’m learning that sometimes the best thing I can do for my patients is to step back and ensure I’m keeping myself in a healthier place where I can continue to provide my patients with the same level of care.”

Christina Tofani, MD
Christina Tofani

Christina Tofani, MD, Assistant professor of medicine at Thomas Jefferson University in Philadelphia: “I can be outspoken and I have a slightly fiery edge, especially when advocating for my patients, whether that’s with other providers, insurance companies, etc. I pride myself on having a strong sense of empathy for my patients. When I’m burned out, I kind of lose that edge. I become more complacent. I rely on this kind of self-awareness, so as subtle as that may be for some people, that’s my cue.”

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Steven Krawitz, MD
Steven Krawitz

Steven Krawitz, MD, Clinical instructor of gastroenterology, Department of Veterans Affairs: “For me, there is no defining moment, but it does affect my mood. My wife picks up on it before even I do. She notices if I’m not interacting the way I usually do or if I’m not being present at home. It’s a pervasive feeling that gradually takes root. Once it’s pointed out to me, I see it better for myself. I sometimes think, ‘But I’ve only been in practice 4 years, how can I be burned out?’ As physicians, we’re used to overcoming challenges by ourselves and, as a result, we often blame ourselves if things aren’t turning out as they should. I think we tend to look for any reason other than to call it what it is.”

Christopher H. Henry, MD
Christopher H. Henry

Christopher H. Henry, MD, Assistant professor of medicine at Thomas Jefferson University in Philadelphia: “I have guilt about acknowledging it. The first person I blame when I’m feeling really frustrated or exhausted is myself. I think, ‘Maybe it’s my fault that I’m unhappy’. I am generally someone who is very outgoing and always willing to help, but when I fail to set limits, it comes at a cost of losing some of the joy in what I do. My family were the ones who pointed out to me that I was less upbeat than usual and more withdrawn. I am very thankful for the solidarity of this group of friends. Our shared experience makes me feel more comfortable. They helped me to realize that maybe it wasn’t my fault.”

Colin Smith, MD
Colin Smith

Colin Smith, MD, Assistant professor of medicine at Thomas Jefferson University in Philadelphia: “About a year ago, I noticed that I was dreading opening the EMR to review my task list. I felt like I was becoming more distant from my patients due to the administrative obligations. I felt like I was losing empathy. Those were my burnout symptoms.”

How is it viewed when physicians discuss burnout?

Cosgrove: “It seems overall more institutions are discussing burnout and trying to help prevent it. While it’s becoming more acceptable to talk about burnout as an issue, I think the reality to self-identify this and discuss it as an individual can feel taboo.”

“The best thing I can do for my patients is to step back and ensure I’m keeping myself in a healthier place.” – Natalie Cosgrove, MD
“The best thing I can do for my patients is to step back and ensure I’m keeping myself in a healthier place.” – Natalie Cosgrove, MD

Krawitz: “It is definitely taboo. We are all hard-working individuals who have spent most of our adult lives training in a culture where the mentality is not to complain and to just ‘get it done’. We feel like admitting burnout can be perceived as a weakness. There’s a perception that there will be pushback from other people within the field, because they ‘had it worse’ or are harder working, so complaining of burnout may not be received well.”

Tofani: “There may also be a slight generational gap. As tech-savvy practitioners, there’s an increasing expectation of 24/7 access to your doctor. Good or bad, that’s what it is. We care on a personal level what our patients say and what our patients think, but we also now have to worry about our online or public persona via Press Ganey scores and online patient satisfaction ratings. The stress of this obligation can lead to burnout.”

Cosgrove, Tofani, Henry and other fellows from Thomas Jefferson became a close-knit group, traveling together with their spouses for celebrations outside of work.
Cosgrove, Tofani, Henry and other fellows from Thomas Jefferson became a close-knit group, traveling together with their spouses for celebrations outside of work.
Source: Christopher H. Henry, MD.
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Is it difficult to keep up with this instant gratification culture where patients expect immediate responses?

“I never realized that pressure was coming largely from myself. The realization of allowing myself some flexibility has been really helpful for me.” – Colin Smith, MD
“I never realized that pressure was coming largely from myself. The realization of allowing myself some flexibility has been really helpful for me.” – Colin Smith, MD

Smith: “Phone calls and online messages pour in every day. Sometimes, there is just not enough time to reply to everybody. Newer modalities, like online portals where patients can email you have been helpful. You can wait to write a thoughtful reply when you have time. You and the patient can have a meaningful exchange incrementally at times convenient for both, as opposed to trying to reach multiple patients individually via phone and spending 15 minutes talking to each patient.”

Henry: “In the era of Amazon, where people have an expectation of wanting and then getting something almost instantaneously, the dynamic of the patient-physician relationship is becoming distorted.

For example, in the field of GI, where many of our patients present with symptoms rather than diagnoses, we often require time to identify the root cause of the symptom before we can successfully treat the underlying diagnosis and provide meaningful relief. Patients sometimes expect this process to happen much faster than in the past and this can lead to frustration. In turn, their frustration with the process translates into a frustration with the physician, which can lead to a stressful environment where patients are dissatisfied and physicians feel undervalued or ineffective.

“I have guilt about acknowledging it. The first person I blame when I’m feeling really frustrated or exhausted is myself. I think, ‘maybe it’s my fault that I’m unhappy’.” – Christopher H. Henry, MD
“I have guilt about acknowledging it. The first person I blame when I’m feeling really frustrated or exhausted is myself. I think, ‘maybe it’s my fault that I’m unhappy’.” – Christopher H. Henry, MD

This issue is complicated further by increasing patient volume and pressures on physicians to see more patients. Understandably, when patients are ready to make an appointment to be seen, they assume they will be accommodated immediately. In a perfect world, that would be ideal; but in reality, medical practices have limited resources, time, space and staffing. There is a disconnect between the logistics of how medicine operates and the needs and expectations of patients, which I think leads to dissatisfaction (and sometimes burnout) of both parties.”

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What are some ways you attempt to combat feeling burnt out?

Tofani: “I have been on the elliptical during this call. A common answer you’ll find from a lot of people is some kind of hobby or an outlet for stress. For me, it certainly used to be running and exercise; that’s always helped me. I now have a 1-year-old daughter and she’s changed my perspective on things quite a bit. I’m learning to roll with it more and accept that life and priorities change. The short answer is hobbies, something that has nothing to do with medicine. Whether it’s cooking, running, working out, art or whatever, you need something to allow a break from medicine.”

Tofani recalls, “During fellowship, the eight of us just piled into this little teeny, tiny office. There weren’t even enough chairs, but it was ours. That’s just symbolic of what our chats are now.” Source: Natalie Cosgrove, MD.
Tofani recalls, “During fellowship, the eight of us just piled into this little teeny, tiny office. There weren’t even enough chairs, but it was ours. That’s just symbolic of what our chats are now.”
Source: Natalie Cosgrove, MD.

Henry: “I talk a lot with the residents about having a work-work balance in addition to a work-life balance. I counsel residents on finding another passion in medicine, aside from clinical care, that can become part of a multi-faceted career. They can be clinicians, but also allocate time for research, or education (which is what I love), or quality improvement, or health IT, or whatever endeavor excites them. There are other hats we can wear in our roles as physicians, which I think helps to temper the busy day-to-day of clinical responsibilities. For me personally, an educational role gives me time to teach medicine and share in the enthusiasm of young learners and residents. It helps to reignite my passion for patients. When I return to clinical duty, it is with a renewed assurance of what I loved about medicine in the first place.”

Cosgrove: “Everyone’s optimal work-life balance differs, and may also fluctuate over time as situations change. What we’re all learning, including myself, is what we each need outside of work that allows us to continue feeling fulfilled and energized at work. I keep asking myself and reassessing, what is my personal balance where I still feel fulfilled and not burnt out? Am I getting what I need right now?”

Smith: “We all sometimes worry about what our colleagues will think. What if I tell them I need to leave at 4 pm today because of a family event? Truthfully, I’ve found that nobody cares. You can sometimes forget that you have flexibility. As trainees, we had less flexibility. We fit life in around our schedules, not the other way around. Now as attendings, we actually have a little more control over our schedules. I work at two different clinical sites, sometimes in the same day. I would get really stressed about being on time when traveling between the two locations, so I finally asked if I could block some time for commuting. The response was ‘Of course. We all do the same.’ I never realized that pressure was coming largely from myself. The realization of allowing myself some flexibility has been really helpful.”

“Sometimes you need to step back to figure out the right balance for yourself and what you really want to do.” – Steven Krawitz, MD
“Sometimes you need to step back to figure out the right balance for yourself and what you really want to do.” – Steven Krawitz, MD

Krawitz: “I took stock of where my career was headed, but also how those goals would impact my work-life balance. I needed to identify my priorities. Deciding what was important to me in life and at work allowed me to make a career change, even so early in my career. That realization helped improve my quality of life as a whole. Sometimes you need to step back to figure out the right balance for yourself and what you really want to do.”

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You all became friends during fellowship and still keep in touch. How important is that connection?

Henry: “It’s been invaluable. It’s funny, because despite training in the same fellowship, we have since gone off to do such different things. So, while we rely on the familiarity of our friendship, it actually provides a lens through which we can help each other with very different aspects of our individual practices. It has gotten me through a lot of really challenging times. It can sometimes be lonely working as an attending, since you’re left to tend to your own schedule. Instead, our group chat has made it feel more like a shared experience lending support and confidence to those of us that need it.”

Cosgrove: “To know you’re not alone, to hear others going through similar things, and to be able to confide in someone else is invaluable. I was feeling really burned out a couple of months ago and I confided about it to these guys. Just acknowledging it, saying it out loud, and hearing everyone’s support helped alleviate so much of it. That alone made me feel better. I felt like I wasn’t alone, that what I was feeling wasn’t my fault.”

Krawitz: “I think it’s really important. For me, these people helped get me through my fellowship. Of course, there’s other people in your life that you can get advice from. We’ve all had major milestones in our lives such as relationships, marriages, jobs and what have you, but we’ve all gone through hard things together. We are never judgmental. So, I often go to these people for advice.”

“It feels so much better when you have someone who you can talk to and no one judges you. What we have is really invaluable.” – Christina Tofani, MD
“It feels so much better when you have someone who you can talk to and no one judges you. What we have is really invaluable.” – Christina Tofani, MD

Tofani: “It’s a great idea to develop some type of safe space. During fellowship, the eight of us just piled into this little teeny, tiny office. There weren’t even enough chairs, but it was ours. That’s just symbolic of what our chats are now, more than 4 years later. We’re not in this little teeny, tiny office anymore, but it’s still a safe place. When we’re talking about issues that may be taboo or not easy, I think back to those days. It feels so much better when you have someone who you can talk to and no one judges you. What we have is really invaluable.”

Smith: “It’s nice to have this safe zone. It can help clinically too. For instance, there will be a time where I might think, ‘Can you guys remind me about what this is or how to help with this patient I have?’ and it’s great to know that you aren’t going to be judged.” – by Ryan McDonald

Disclosures: The physicians report no relevant financial disclosures.