Physician burnout demands change today for healthy medicine tomorrow

Mechele R. Dillard's picture

In an earlier article, Huliq addressed the problem of lack of sleep for physicians in the operating room; today, we address the growing problem of physician burnout, and take a deeper look into the issue with Dr. Carol Wiley Cassella.

The January issue of Anesthesiology addresses the issue of burnout among two groups of physicians. One study, from researchers at the University of Vanderbilt School of Medicine, found that “physicians, especially younger ones, had higher levels of cynicism and emotional exhaustion and are at a high risk of burnout,” said Steve A. Hyman, M.D., M.M., and an associate professor of clinical anesthesiology. “This is a particularly troubling finding as we look to the future of America’s health care system. We need a strong young physician base.”

A second study, from Northwestern University Feinberg School of Medicine, indicated that burnout was not only an issue with young physicians, but senior physicians, as well. “Our data suggests that burnout is evident in approximately one half of the chairs of academic anesthesiology departments,” said Robert J. McCarthy, PharmD, the study’s senior author. “This has substantial implications not only on the individual physician and his or her patients, but also the functioning of the department and the training of future anesthesiologists.”

Carol Wiley Cassella, M.D., is a staff anesthesiologist at Virginia Mason Medical Center in Seattle, WA. Dr. Cassella shared her own experience in an interview for Huliq.com:

Mechele R. Dillard: While in medical school, did you anticipate the strain the hours required would have, not only on your career but on your life in general? Do medical schools typically approach this topic with students as they progress? Should they?

Dr. Carol Wiley Cassella: I did anticipate the strain, but in an almost romantic way--images of running to the emergency room in the middle of the night and staying late to figure out some obscure diagnosis. And there were (and are still) moments like that. But it is almost impossible to anticipate the effect fatigue can have on your outlook after years and years of long hours and the less fulfilling time spent chasing down data or test results or filling out computer forms and chart records. It has a frightening capacity to chip away at your compassion and patience.

Residents now have stricter limitations on the hours they can work, but we are seeing rates of burnout continue to rise, so the problem is far more complex than just fatigue. Unfortunately, as medicine strives to become safer and more efficient--assuredly necessary goals--it is becoming more standardized and regimented. The typical successful pre-med student is ambitious, independent, curious and motivated by a desire to help people. But the new reality of medical practice leaves less time with patients, more conscripted protocols, more production pressure and far less autonomy. We may be setting the stage for such high rates of burnout by selecting the very personalities that will be frustrated within the medical system.

Unfortunately every doctor must now also be a business person, and there is no preparation for this in medical training. Until recently, academic medicine has been more sheltered from the financial stress of private practice, and so few students have seen a glimpse of what awaits them. I think it is imperative that we do a better job in medical schools and residency programs teaching young doctors how to realistically assess their choices and their practice options.

MRD: At what point did you realize your life was being overwhelmed by your career?

CWC: It would be easy for me to say it was purely a conflict between time with my family and time with my patients, but if I examine the emotional factors that really led to my own burnout they began when I found myself spending as many hours on paperwork as I spent with patients. I was in a primary care practice when the first waves of medical reform were rolling though, and suddenly many decisions I made felt like a battle--for more time with each patient, for the specific drugs or tests I felt were necessary, for the appropriate referrals. For every positive stroke I got from a satisfying patient interaction, I got two or three negative strokes filling out myriad insurance forms or telling a patient their health plan would not allow mental health counseling. The gap between the doctor I had intended to become and what I did day-to-day was crushing my spirit.

MRD: Did you ever actually regret going into medicine?

CWC: Well, I have now cut back on my hours practicing medicine and started a second career writing novels. Now that my novels are selling, I'm often asked if I'll give up medicine, but it still has hooks in me. While I hope my novels give people some pleasure, I still believe my unique interaction with patients in the peri-operative arena can make a lasting difference in their surgical experience. I also do some volunteer work in medicine, and I would miss that terribly. But I can no longer look to my medical career to fulfill the creative challenges and appetite for intellectual growth that I hoped for when I applied to medical school.

Certainly there are many paths to take in medicine, and I can only speak to my own experience. I am the person I've become in part because I've been a doctor, so I can never say that I regret my choice.

MRD: How did you rejuvenate your desire to practice medicine?

CWC: I quit fighting the battle. When internal medicine became too frustrating I changed to anesthesia--a specialty I enjoy and find satisfying and that also allows me to work part time. I joined a practice where I am paid purely on a salary, where my sole focus is patient care and I don't even know what insurance my patients carry or lack. I have no desire to tie my clinical care choices to the money I earn.

MRD: Today, you have moved beyond the “burn-out” you experienced as a physician; do you have any suggestions for other physicians, not only those who are coming into practicing today, but those who may currently be feeling the signs of career burn-out, as well?

CWC: Before you choose a specialty, spend time talking to doctors out in the community who work in that field--don't shy away from the facts of what the work involves beyond caring for patients, Be honest with yourself about the hours you want your career to consume, the work environment you'll be living in every day, the costs of malpractice and tail insurance and the business models employed by different types of medical groups. The drive and determination that got you into medical school and through residency are usually not sustainable for a lifetime--nor should they be. Life needs to be a journey of joy as much as purpose. But most of all, I strongly encourage younger medical student and all doctors to keep a close ear to their hearts and reach for other activities and dreams as they call to you.

Ultimately, Dr. Cassella indicated that change, on many levels, is crucial for the future of medicine and for the well-being of physicians, as well as patients:

I would like to emphasize one phrase I wrote in my article that may get a bit lost, but I believe it goes to the heart of burnout. Medical science and technology have advanced to the point that we have invented our way beyond what we can afford, both financially and ethically. We are capable of delivering care well past when nature would urge us to stop, and we have ever more spectacular tools and drugs that are leading us toward bankruptcy. No medical practice can escape this dilemma and so asking the system to revert to good old fashioned medicine is impossible. We have to change--in what we hope for, what we expect, and what we ask of one another, particularly those just beginning their careers.

Dr. Cassella graduated from Baylor College of Medicine in 1986, completing a residency in internal medicine. After practicing for three years, she returned to study anesthesiology. She has four children and, as she mentioned, is a published novelist: Oxygen (Simon & Schuster, 2008) and Healer (Simon & Schuster, 2010).

The referenced Anesthesiology articles can be accessed at Anesthesiology online.

Read "Sleep-deprived surgeons may not recognize their own impairments" on Huliq.com.

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