10 Ways to Mitigate Physician Burnout
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The following is a guest post by Steve Sanders.

Mitigating Physician Burnout

Mitigating Physician Burnout

Those who work in service professions in the medical disciplines are susceptible to a psychological condition known as burnout. It’s of particular concern in healthcare because of the potential effect on the health or even the life of patients. By some estimates, burnout effects as many as half of US physicians. A recent study published in The Lancet shows that solving this problem requires changes on both the individual and the organizational front, not to mention health care policy changes.

1. Personal: Prevention

Mark Linzer, MD, is the Director of the Division of General Internal Medicine at Hennepin County Medical Center in Minneapolis and has studied burnout for at least 20 years. Linzer says certain characteristics, qualities or situations increase the risk of burnout: a high tolerance to stress, a chaotic practice, disagreement with the boss’ values or leadership and being an emotional buffer for patients. Others factors include practices interfering with family life, lack of control over a schedule or free time and insufficient self-care. According to Linzer, the first step in prevention is recognizing that these conditions exist.

2. Self-Care

Burnout is the result of excessive or poorly managed stress. It’s an old truism–how can physicians care for patients when they don’t care for themselves? Self-care strategies include all the basics of adequate sleep, a healthy diet, regular exercise and supportive relationships. Stress is a normal part of life, but self-care strategies make a positive difference. Managing your reactions to stress is also key.

3. An Outside Life

It’s important not to let your profession consume you. Hobbies can provide you with a sense of identity and competence not associated with your medical career. Make it a point to develop relationships with people outside of health care. Get involved in the community in ways that aren’t related to medicine, for example; be a mentor to a teenager, tutor a child, volunteer at the library or perform community clean-up tasks.

4. Build Relationships

Many physicians who have experienced burnout say it was their close relationships that sustained them and helped them heal. Those who have not experienced burnout often credit supportive relationships as the reason. A mentor may be helpful as can peers who know what you’re going through.

5. Start Early

Many experienced physicians note that the intern year is often the place where burnout begins. The intern year, if you go back to Linzer’s findings, contains most or all of the seven high potential burnout situations. Awareness of these conditions can help organizations and individuals develop strategies to recognize symptoms and implement solutions.

6. Provide Support

Counseling, support groups and formal mentoring programs are always to provide support. Technology and staffing practices (especially adequate support staff) can also make a difference.

7. Limit Demands

One idea behind limiting resident work hours is to decrease stress on the physician, it may also help protect patients by limiting mistakes made by physicians caused by sleep deprivation. Organizations should explore all possible options to do so through flexible work schedules and processes or systems to make life easier.

8. Resiliency Training

If burnout begins in the intern year (as seems likely), an organization that begins resiliency training at that point can make a big dent in the problem of burnout. Ideally, starting this training in medical school equip physicians to control their reactions to stress, so they can glide instead of crashing.

9. A Wellness Culture

An organization that implements wellness programs, stress management education and support systems should be the norm. Burnout prevention should be a topic of discussion, said Dr. Lotte Dyrbye at the 2015 AMA Annual Meeting, and physicians should talk about medical errors rather than blame themselves or others.

10. Health Care Policy – Environmental Change

For many physicians, the demands to see more patients in less time create several of the conditions Mark Linzer notes above. There are ways to make it better, but health care system reform is required to make them most effective. Physicians can help by getting involved in health care reform.

Steve Sanders is a self-described recovering alcoholic, writer, and blogger at Haven House Addiction Treatment. He lives in Los Angeles, California and enjoys spending time with his family and on his motorcycle when not writing. He can be reached at oneroadtorecovery@gmail.com

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Fickle Finger of the Year Award for 2016 – the American Electorate
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The Fickle Finger of the Year Award for 2016The Fickle Finger of the Year Award for 2016 goes to the American electorate. Now you may think this post is a rant about the election of Donald Trump as President-elect. Not so. I accept that Mr. Trump will soon be sworn in as our new President, and it will take at least a year or two to know if the American electorate made a good decision, or a bad one.   My reasons for awarding this recognition for dubious achievement relate to some actions that became even more apparent this year, but in truth have been going on for some time. The most prominent dubious achievement of the American electorate is their frequent failure to vote, even in presidential election years.

In the last 10 presidential elections, the percent of the voting age population that actually votes has hovered around 50-55% (see the spreadsheet below). Participation in midterm elections has historically been even worse. The chart below that from Business Insider shows the percent of eligible voters who vote in all of our presidential elections.

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According to Pew Research, Compared to other developed countries, the U.S. also ranks pretty low for voter turnout.countries

Perhaps, like Belgium, Turkey, and four other countries on this list, voting ought to be mandatory in our country. I thought that education might be the issue, until I learned that physicians have lower adjusted voting rates than the general population (and, incidentally, lower than lawyers, too).

Voting rates are just part of the problem with our electorate. It appears that despite all the election coverage in the press, according to Ilya Somin’s book Democracy and Political Ignorance: Why Smaller Government is Smarter, our electorate is woefully uninformed. Somin reported that one-third of Americans think that foreign aid is the government’s largest expense, and nearly half of Americans think cap-and-trade has to do with healthcare or financial regulation instead of the environment.   Only about 34% of Americans can even name the three branches of the federal government: executive, legislative, and judicial.   The ignorance (notice I did not say stupidity) of the voter is somewhat understandable.  With the infinitesimal chance that one vote will make a difference, people “intuitively realize that there is little payoff to devoting lots of time to studying government policy. The problem is further exacerbated by the enormous size, scope and complexity of modern government, which makes it hard for even relatively well-informed voters to know about more than a small fraction of what our government is doing.” The result of uninformed voting is that voters “often support counterproductive or contradictory policies.” This was widely apparent in the most recent election.

Adding to this is the fact that money has hugely distorted the political process in our country. Benjamin Page has identified several disturbing consequences of the quest and need for money as it tends to: filter out centrist candidates, filter out candidates on the economic left; tilts candidates’ priorities and policy stands; gives affluent citizens extra influence; can tip the outcome of close elections; buys access to officials; and affects officials’ priorities and policy stands. Together with the consequences of “the upsurge in alternative media, individual contributors, and bloggers with often times slanted agenda, and outrageously biased reporting, resulting in a fake news free-for-all”, as reported in The Hill, coupled with the uncertain but probable impact of intentional interference by countries like Russia and China and others in our elections; it is a wonder the electorate can make any kind of informed decisions in our electoral process.

Nonetheless, the fact that the electorate in the U.S. has an uphill battle in order to participate effectively in our democracy is no excuse. This is why they earned the Fickle Finger for 2016.

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Some Variation in Clinical Practice is OK
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Reducing Variation in Clinical Practice

Reducing Variation in Clinical Practice

I would argue that some variation in the way physicians practice, in the emergency department or in any group practice, is ok, and even inevitable. I a recent excellent article by Richard Bukata, MD in Emergency Physician’s Monthly, Rick points out that the goal of reducing variation in practice is to “create a narrow bell-shaped curve focusing on the uniform practice of evidence-based medicine”. The question is, how narrow? Not only do best practices change from time to time, but I believe there is some risk associated with trying to create too narrow a band width for practice patterns among a group of physicians with considerable differences in education, training, experience, and particularly, personality.

It is fairly intuitive that differences in medical school education, social background, residency training with different mentors and different training hospital missions, length of experience in practice outside training, exposure to continuing education courses, and other deviations and disparities in the development of a practicing physician lead inevitably in variations in practice. I believe that these differences can be mitigated to a degree by the various methods available to medical directors and mentors to narrow the spectrum of practice along the lines suggested by Dr. Bukata. The motivation to try to do the ‘right thing’ for patients is a strong one, and the existence of sound best-practice guidelines for many of the conditions physicians see in their practices most commonly certainly helps those who are comfortable following these guidelines. When variations in practice patterns are exposed for all to see, the motivation to conform, to meet expectations, and to avoid being labeled an outlier, is often difficult to ignore. In my experience as a medical director of a busy ED, I have come to recognize one particular difference among physicians that deserves particular attention, and that is differences in personality.

There are lots of ways to categorize differences in personality and how these differences are expressed. My wife likes to refer to the Enneagram, a typology of nine interconnected personality types principally derived from the teachings of Oscar Ichazo and Claudio Naranjo. These nine ‘types’ in order from type 1 to type 9 include the: Reformer, Helper, Achiever, Individualist, Investigator, Loyalist, Enthusiast, Challenger, and Peacemaker. Each type has different expressions of their: ego fixation, holy idea, basic fear, basic desire, temptation, passion, and virtue, and their tendency to move toward different ‘types’ under stress or when relaxed. The Enneagram can be quite a complex tool to use or understand, but frankly I wish I had been familiar with this topology much earlier in my career. In retrospect, it explained a lot about myself, and my partners, and how we practiced and interacted in our group.   You can imagine that an Achiever whose basic desire is to feel valuable and is tempted to push themselves to always be the best, will respond differently to a call to adhere more closely to a best practice for evaluation and management of ‘possible pulmonary embolism’ than a Challenger who fears being harmed or controlled, and believes they are completely self-sufficient.

Each personality type, and I am certain that physicians can be found amongst all nine archetypes, adopts a practice style and practice patterns that to a degree conform to and ‘fit’ them best, even if these patterns are ultimately problematic or even harmful for them and their patients. Each physician goes about their daily medical practice in ways that they believe work for them, and sometimes this is predicated on an appreciation of their own strengths and weaknesses, and sometimes this is predicated on their fears, their desires, and their virtues, which they may or may not really appreciate. (If you would like to know what your Enneagram type is, take the RHETI test here.) Most of the time, a physician will approach a clinical challenge in a particular way that they have become familiar with, and that seems to work for them and their patients, because it usually does. There is risk in pressuring the physician to change this approach abruptly, even if the change is likely to work better, and is more consistent with evidence-based medicine. In most cases, especially when a physician has adopted strategies that really do make them an outlier in the group practice, it is worth the effort, provided their underlying personality is taken into consideration. Trying to coerce a Helper, whose basic fear is being unloved, to conform to a best practice using humiliation (exposure as an outlier), will simply generate the resistance of the Challenger (see the diagram and spreadsheet in the Wikipedia article). A Helper would respond better by encouraging them to help chose among the best practices for this condition, and appreciating their cooperation and contribution to the goal.

You can see that a ‘one strategy fits all’ approach to narrowing practice variation may not work so well, especially in a very diverse group. There are many different ways that practice variation is approached. One typical article on the subject by Martin Sipkoff in Managed Care lists 9 ways to reduce unwanted variation, including: identify high risk patients, give physicians incentives, intervene with outliers, improve continuously, implement disease management programs, invest in provider level information technology, encourage evidence based medicine, get patients involved, and control capacity. Since you can’t do even half of these in any one year, I would start by looking at a standard set of practice measures and data sets that you have access to on a regular basis, and at services your group uses or performs that are costly and have a clinical impact (like CT use in headache). Chose your targets with input from your group, your hospital staff, your administrator, and perhaps even health plans with whom you work closely. Refer to this post on The Fickle Finger.  Adopt a best practice to address the variation, using evidence-based medicine when it applies, using consensus if you can achieve this in your group. The goal should be to reduce variation in practice over time, not to achieve total conformity or even a specific rate target. At that point, I would then identify one or two outliers, evaluating as large a number of cases as you can, and making sure there are no obvious reasons that explain this variation (for example, if someone works only night shifts, their rate of admissions might stand out for good reason). Then, pull some sample cases and review the medical records. Before having any one-on-one discussions with the outlier, or hosting group case reviews or M&M conferences, go to the Enneagram or at least consider the personality of the outlier(s), and decide which approach would work best for each individual. Sledgehammers do not work well in group practice, and kid gloves may not either; but carefully selected interventions can have a significant impact on practice variation.

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Role of Emergency Physicians in a Violent World
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The Role of the Emergency Physician in a Violent World

The Role of the Emergency Physician in a Violent World

The recent news about Aleppo, the assassination of Russia’s Ambassador to Turkey, the truck attack on Christmas shoppers in Germany, and the daily barrage of shooting victims in the United States, is weighing on my frame of mind, and probably yours as well. Emergency Physicians are often on the receiving end of this violence, from resuscitating individual victims to responding to multiple casualty incidents. The medical / trauma care response to this violence is clearly the most important role for emergency physicians, but it is not the only role.   If the only thing that emergency physicians do is put a finger in the dike, without making some serious efforts to impact the incidence of this violence; they will have passed up the opportunity to use the medical soapbox and other public health tools to interdict this cascade of violence. It is not enough to stand in front of the cameras and talk about how frequent disaster training exercises and careful planning made it possible to save x number of lives, or limit the toll on the individuals victimized by the terrorist attack or the drive by shooting or the victim of domestic assault. I would like to see emergency physicians stand in front of the public and implore us all to recognize how senseless this violence is, how harmful it is to the victims, the perpetrator, and the community; and to challenge us to do something about it besides gawk or sit passively watching the bodies pile up on TV.  And, I would like to see these physicians walk the talk.

Doctors were once a moral force in their communities, looked upon as leaders, protectors, advocates for the public health and for their individual patients. Now many physicians struggle to find meaning in their professional lives, and are under fire just for trying to make a comfortable living. How physicians react to violence and terror outside of the actual practice of medicine is not just important for our communities, it is important for physicians themselves. Important for self-respect, for pride in the virtues of the profession, for personal growth and a sense of commitment. In this day of internet trolls and tweeters, there is some risk for physicians who take a public stand on gun violence or inadequate psychiatric care resources, or argue for more aggressive efforts to thwart or undermine the recruitment of home-grown terrorists, or stand up for victims of internet bullying and abuse, or oppose threats of violence against minorities. Every thoughtful assertion by a physician advocating for solutions to the threats to our public health has, it would seem, a bevy of thoughtless, antagonistic, vilifying, threatening respondents who try to suppress or oppose or even legislate against this advocacy. Even so, physicians need to stand up against the violence that pervades our world, and not be afraid to take a stand.

Almost all physicians have something they can teach the world that would make our lives better, and safer. I have plenty of experience treating the victims of gun violence, and a long history of gun ownership and use (I was once a ‘Distinguished Expert’ marksman); so I feel reasonably comfortable addressing this issue publically. As important as Second Amendment rights may be, it is beyond me why any responsible gun owner or legislator finds it necessary to oppose any restrictions on the purchase of 30 or 100 round magazines for AR-15s.   There is even less sense in restricting studies of gun violence, as Congress did repeatedly. As a gun owner, I want to know the actual benefits and risks of gun ownership, so that I can make informed decisions about the practice. Statistics can certainly be damn lies, but suppressing this information is far more dangerous to our democracy.

When I say that physicians should walk the talk when addressing violence, it’s not hard to find examples. Thumbing her nose at Congressional efforts to suppress firearm research, University of California President Janet Napolitano recently established the University of California Violence Research Center at UC Davis’ Sacramento campus under the direction of Dr. Garen Wintemute, an emergency department physician and recognized authority on the epidemiology of firearm violence who has conducted leading-edge research for more than 30 years. A number of emergency physicians and trauma specialists have developed programs throughout the country to interdict gang violence and retaliation, and most of the efforts within the National Network of Hospital-based Violence Intervention Program focus on victims of violent crime between 15 and 25 years old.

The American College of Emergency Physicians has a long-standing policy which states that “ACEP believes emergency physicians have a unique opportunity and responsibility to reduce the prevalence and impact of violence through advocacy, education and research initiatives.” Many emergency physicians participate in ACEP’s Trauma and Injury Prevention Section. Past ACEP President Jay Kaplan, MD took some heat for a statement decrying violence against people of color by law enforcement. You can argue that the statement was inappropriate or (as one commenter said) “was honest and brave in specifically recognizing and condemning the pervasive racism in our society”. Standing up against violence in our society doesn’t necessarily require inordinate courage or a significant commitment of time and energy, however, and it is often personally and professionally rewarding. Several years ago, I joined the Board of Directors of the Stanislaus Women’s Refuge Center, and assisted in expanding the facility’s capacity and outreach. What participating in these activities does require from emergency physicians is the willingness to step beyond their role as trauma care providers and assume the mantle of advocates for the public health and welfare.   I believe this role is represented as the Rod of Asciepius stitched into the white coat that every physician owns.

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The ER is Not a Good Substitute for Coverage
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Accessing the Trumpcare safety net

Accessing the TrumpCare safety net: the ER

As Liam Yore (Movin’ Meat) noted in a tweet recently, now that repeal of Obamacare is likely, and replacement with an alternative will probably leave many millions more without health insurance coverage; we are beginning to hear once again the refrain that ‘the uninsured can always go to the ER’.   There was the recent comment by Eric Bolling, co-host of Fox News, who, in response to a concern that those who may lose insurance coverage after repeal would end up on the street (i.e. with no health care coverage), said: “They’re not on the street. You still have Medicare and Medicaid. So that’s always going to be there. And you have emergency rooms, which we had before. Until another plan is floated, that’s acceptable.” Rush Limbaugh, who said in 2010 critiquing the ACA, that we have already have health care for the poor: it’s called the Emergency Room, was not the first to offer this cynical thought. President Bush in 2007 said famously: “The immediate goal is to make sure there are more people on private insurance plans. I mean, people have access to health care in America. After all, you just go to an emergency room.”  In 2012 on CBS’s 60 Minutes, Mitt Romney suggested that emergency room care suffices as a substitute for the uninsured. Mr. Trump has recently declared that once Obamacare is repealed, he will not leave people to die in the street for lack of insurance, presumably relying on the ER to cover the millions that Trumpcare leaves uncovered.

In my 34 year career practicing emergency medicine, probably half of the near 100,000 patients I treated were under-insured (Medicaid) or uninsured. Many of these people were the working poor, some were recently laid off, some uncovered because of pre-existing conditions or changes in employment. In other words, a lot of them probably were, or would have been, Trump supporters. A lot of these patients came to the ER because they had no where else to go to get health care, and because EMTALA regulations meant that if they had a medical emergency, or just a medical ‘urgency’; they would likely get evaluated and treated for their medical problem(s), regardless of their lack or insurance or ability to pay. Honestly, if I had been resentful of these people for relying on this mandate, or on government subsidized health insurance coverage (note: Medicare is a subsidized program, too); I don’t think I could possibly have endured practicing this specialty. Yet resentment appears to be the common link to various expressions of the disdain that leads so many political leaders and opinion-makers to look to the ER as the default safety-net provider for the under- and uninsured.

There is so much about this default role for the ER that is antithetical to conservative ‘family values’ and prudent fiscal policy that it boggles the mind. ER care is not a cost-effective way to provide insurance coverage to these patients; and ultimately these additional costs are shifted to the taxpayer, the premium payer, and employers. Back in 2009, “the average U.S. family and their employers paid an extra $1,017 in health care premiums …. to compensate for the uninsured.” Families USA. found that “about 37% of health care costs for people without insurance — or a total of $42.7 billion — went unpaid last year.” That cost eventually was shifted to the insured through higher premiums, according to the group. You can bet the cost shift will be much higher if the repeal of Obamacare leaves millions more uncovered. We know that being uninsured or underinsured leads people to put off necessary care until their conditions become much more expensive to diagnose and treat; and how can it possibly be good for corporate America to have an employee base that is chronically ill? Emergency care providers and ERs can only do so much for patients with chronically untreated or smoldering illness, with unmet preventative care needs, with ignored mental health conditions, or lack of a long-term relationship with a primary care provider.

Dumping these patients on the ER to keep them from ‘dying in the streets’ is the height of hypocrisy, especially for politicians who claim to be practicing Christians. If Christ had turned a blind or unsympathetic eye to the poor and infirm, he wouldn’t have been revered, he would have been ignored. How can you reconcile complaints about ‘abuse of the ER for non-emergency care’ with policies that force patients to rely on the ER to get this care? Rush also said: “Pre-existing condition coverage is not insurance; it’s welfare”. You would think someone who suffered from a prescription drug addiction would understand that allowing health plans to reinstitute coverage exclusions for those with pre-existing conditions would make it difficult for him to get insurance, even with his millions.   Of course, he can afford to go bare, but few of us are so fortunate. Somehow we need to get our leaders to understand that ER care is not a good substitute for health insurance coverage, even in the short-term; and that ‘repeal and replace’, if it relies on the ER to backstop a huge pool of newly uninsured, will undermine the ability of emergency care providers to take care of anyone that might have a medical emergency, regardless of their social or political standing.

 

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