Physician suicide rates are two-to-four times that of the national average; what are the experts trying to tell us about it?
Burnout: The Symptoms*
Emotional Exhaustion
More than merely physical fatigue, this is the feeling of
an emotional tank that has been emptied.
Depersonalization
When those around you do not register as human beings,
when patients become merely a medical record or a room
number with a condition to be treated.
Low Sense of Accomplishment
Experiencing feelings of not making a difference, or fear
that others will discover you’re just a fraud.
* Christina Maslach, Wilmar B. Schaufeli, and Michael P. Leiter, “Job Burnout,” Annual
Review of Psychology, February 2001, Vol. 52: 397– 422
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In the last few years, studies have shown what is widely understood: burnout is a major problem that plays a silent role in preventing safe and error-free medicine. Most providers are slow to acknowledge—to themselves or anyone—that they may be suffering the effects of burnout. And most organizations are not doing enough to support their staff. As a result, staff members suffer alone, they burn out, and sometimes they leave the practice of medicine altogether, despite years of hard work to get there.
FACTS & FIGURES
According to Dr. Mick Oreskovich, a Seattle psychiatrist and leading national researcher on burnout, over 45 percent of physicians meet the clinical definition of burnout. Oreskovich’s involvement in conducting the 2012 study, “Burnout and Satisfaction with Work-Life Balance among US Physicians Relative to the General US Population,” published in the Archives of Internal Medicine, has served to highlight the extent of the problem (see Figures 1 and 2)1.
For this body of work, researchers conducted a national study with a large sample of US physicians from all specialty disciplines using the American Medical Association Physician Masterfile, the largest database of practicing physicians. The results concluded that burnout is more common among physicians than among other US workers; those at greatest risk are physicians in specialties at the front line of care access.
WHO’S SATISFIED? WHO’S NOT?
While we may not know all the specific factors that may cause a given individual to experience burnout, according to Oreskovich, “it is very much related to specialty. Specialty is an independent, predictive factor.”
In the 2012 study, physicians were asked if they were satisfied in their jobs, and if they were left with enough time for their personal lives. Not surprisingly, the physicians in specialties that allow more free time or flexibility of time reported higher levels of satisfaction. Among those most satisfied—occupational medicine, dermatologists, pediatricians—the hours are fairly regular, they conduct their work in their own office, and they might have the flexibility to modify their work week.
However, says Oreskovich, “Even among the most satisfied specialties, no one had a job satisfaction rating of higher than 60 percent. That’s pretty low.”
WHO IS USING SUBSTANCES?
WHO ARE HURTING THEMSELVES?
In wanting to understand the impact of burnout and the relationship between substance dependency and major medical errors, Oreskovich and his peers queried physicians about their habits concerning alcohol and drug use. Among those who did not register as having alcohol dependency, 8 percent acknowledged a major error in the preceding three months versus 11 percent among the group who did register alcohol dependency.
In another exercise to understand the effect of substance use, researchers trained laparoscopic surgeons on the Minimally Invasive Surgical Trainer Virtual Reality lab, then selected a random group to drink to intoxication the night before being assessed. Both consumers and non-consumers performed similarly at baseline, but the group instructed to consume excessively showed deteriorated performance throughout the following day.2
Finally, 15 percent of the physicians studied met the diagnostic criteria for being alcohol or drug dependent, compared to a 8.6 percent national average.3 However, it’s the split between men and women that is perhaps most alarming: 13 percent of males met the diagnostic criteria for alcohol or drug dependence, while 22 percent of the female physicians—nearly twice as many—met the criteria.
The study also that showed suicide rates among physicians are more than double than the national average for men and four times more likely for women. This, too, goes against the national statistics, where males represent 77.9 percent of all US suicides.4
(UN)LIKELINESS TO GET HELP
Oreskovich observes that physicians put their own health and well-being behind that of others, which makes them all the more likely to get sick and suffer from depression or other challenges. Physicians tend to feel outside of their comfort zone when they need to ask for help. They also aren’t comfortable when they, themselves, are in need of care.
“Those suffering from burnout and or depression often have pretty delusional thinking. They are going to work and thinking that they’re still doing a good job,” says Oreskovich. “They are often the last person in the room to know how depressed they are.” The study showed that only 25 percent of those depressed had a prescription for an antidepressant, and half of those were prescriptions given by a surgical colleague rather than a psychiatrist providing treatment.
Routinely, when Oreskovich speaks at events, he’ll query the audience and ask for a show of hands. “The same response patterns replicate each time,” he reports. “When I ask who has had their annual exam, maybe 25 percent raise a hand.When I ask if they have someone they can confide in—a spouse or coworker—no male hands go up, but about 40 percent of the females put up a hand.”
Regarding these dramatic gender differences, Dr. Oreskovich says, “Worklife balance continues to be difficult for women, more so than for men. We have much, much more to learn about the unique issues around work/life balance for women.”
GETTING HELP WHEN & WHERE IT IS NEEDED
If you’re in senior leadership, you undoubtedly feel some responsibilities for ensuring that your providers are at their best in order to care for others. And if you’re responsible for patient safety and reducing risk of liability, you have a stake in this, too. The cost to an organization for replacing a physician who quits or burns out can be $200,000 or more. But the cost of a suffering physician’s quality of life is immeasurable. That’s not even taking into account the emotional cost to family and friends, or patients and the patients’ families. The ripple effect—both emotional and financial—is huge.
“One of my biggest concerns is the prevalence,” says Chad Krilich, a family practitioner who is also CMO at Multicare’s Auburn facility. “When you see the literature on burnout, you’ll realize that physicians are leaving medicine at a high rate.” Krilich feels that, because of what is required of physicians, combined with staffing shortages, our culture is doing a great job at burning out providers. “At the top of every CMO’s agenda is how to successfully manage the workforce in such a challenging setting,” he says.
Krilich finds it important to make rounds in order to understand who has a rough road at the moment and to learn what kind of support might be needed, whether tangible support, such as additional resources or assignment shifts, or mental and emotional support, such as acknowledgement, a pat on the back, a peer to talk to, or more.
Krilich also cites having a code of conduct in place as important for documenting issues when they first surface. Establishing procedural guardrails helps bring others into the fold sooner rather than later so those professionals are better able help before an issue spirals into a serious hazard for the provider or his/her patients.
“With policies to guide us, I will have conversations early on that I might not otherwise be invited to have,” Krilich says. “I can start with ‘so I heard you threw an instrument the other day,’ and start a dialog to begin understanding how I can help a situation.”
It is in the early conversations that leaders can do some of critical probing. “‘Are you feeling depressed? Are you having thoughts of hurting yourself?’ are questions that are or should be routinely asked,” says Krilich. “In Washington, we are fortunate to have the Washington Physicians Health Program (WPHP) as a resource. We use it often to connect physicians with resources around counseling, assessments, or treatment.” (Learn more about WPHP and similar organizations on page 23.)
Krilich points out, “We’re accountable for acting accordingly when we see our physicians struggle, we need to have a plan for them. I like to see my surgeons coming through the halls saying, ‘I had a great day!’ I want them to have the emotional reserve for whatever kind of day they might face in the OR.”
EARLY INDICATORS AND POSITIVE PERSPECTIVE
Residency Program Director Dr. Kerry Watrin has developed his perspective on burnout from working with residents at Tacoma Family Medicine for the past 20 years. During that time, he’s thoughtfully observed who is struggling and who is doing better than others.
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“Medical providers are known as overachievers in getting successfully
through medical school and beyond — they’re geared for excellence.
Perfection is their enemy.”
- Dr. Kerry Watrin
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“Despite duty-hours restrictions, residents report burnout in the 50 percent range and are only getting an average of 22 more minutes of sleep per day,” says Watrin. “Each situation is individual. Each young physician comes with their own genetic predispositions, imprinting from upbringing, thinking style, and current life situation—and it all impacts their resilience.”
At the end of each year, he has asked residents to list the top three to five things that have supported them or made their work more stressful. Consistently, the residents reported the following as providing the most support to them when times were tough:
- People: loved ones or supportive colleagues
- Activities that hold meaning for them: sports, art, music, reading, spiritual practices, etc.
- The outdoors: spending time in nature, enjoying The Great Northwest
On the flip side, the contributors to stress were consistently reported as:
- People: struggling personal relationships, ill or dying family members, missed family events
- Being witness to dying and suffering: most had yet to experience the death of a loved one, yet in their first month will watch a patient die
- Managing time effectiveness: mastery of the task-oriented portion of the job (i.e., only typing 40 words a minute means spending an additional two hours per day completing administrative work.)
Concrete ways through which their program promotes resiliency in its training are by offering lectures, retreats, humanism gatherings, by building teams of classmates to rely on each other, and by assigning advisors who accompany and coach individuals in both positive and painful growth times.
Dr. Alan Shelton, who presents talks on burnout to residents at Tacoma Family Medicine, describes the remedy as exercise. Watrin elaborates: “If we exercise in each of the four realms of physical, intellectual, emotional and spiritual-meaning, we are balanced. If we are only exercising one realm, we are out of balance.”
Residents are also involved in interviewing the incoming class, which offers a chance to look at the bright side of the work. “The focus of burnout is often on the negative side of the story, but there is a beginning body of knowledge on well-being as it relates to burnout,” says Watrin. While burnout symptoms are measured by three key indicators—emotional exhaustion, depersonalization, and sense of accomplishment—“wellbeing has its own five measurable characteristics: pleasure, engagement, positive relationships, meaning, and achievement,” he says.
The body of work around positive psychology includes studies of people who consider themselves to be happy. The purpose is to learn what such people do differently or how they are different in makeup than those who do not consider themselves happy. For instance, something as simple as stating the three things that one is grateful for each day is reported to lead to increased happiness. Conventional thinking is that working hard leads to success and, in turn, to happiness. Rather, Watrin notes, current research promotes the reverse: that positivity and happiness are what breed success. (See the additional resources in Learn More on page 7.)
“Medical providers are known as overachievers in getting successfully through undergraduate school, medical school, and so on. They’re geared for excellence. Perfection is their enemy,” says Watrin.
Amidst unprecedented change and a continual push for improvement, the entire medical field is working hard on perfecting itself. While “perfection” may not be a realistic goal, the increased importance of satisfaction scores, the growing number of insurance codes and patient visits, and ever-evolving technology (and more) are sure to keep pressure high. All professionals owe it to themselves to learn, use, or create tools that will assist them in maintaining the joy in their careers.
LEARN MORE
VIDEO
The Happy Secret to Better Work
Dr. Shawn Achor, Psychologist
Harvard University
The New Era of Positive Psychology
Dr. Martin Seligman, Psychologist
University of Pennsylvania
ARTICLES
Gene Is Linked to Susceptibility to Depression
New York Times
BOOKS
- The Happiness Advantage: The Seven Principles of Positive Psychology That Fuel Success and Performance at Work, by Shawn Achor
- Flourish: A Visionary New Understanding of Happiness and Wellbeing, by Martin Seligman
- Peace Is Every Step: The Path of Mindfulness in Everyday Life, by Thich Nhat Hanh
- Flow: The Psychology of Optimal Experience, by Mihaly Csikszentmihalyi
- The Upside of Stress: Why Stress Is Good for You and How to Get Good at It, by Kelly McGonigal
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References
1. Tait D. Shanafelt, Sonja Boone, Litjen Tan, Lotte N. Dyrbye, Wayne Sotile, Daniel Satele, Colin P. West, Jeff Sloan, and Michael R. Oreskovich, “Burnout and Satisfaction with Work-Life Balance among U.S. Physicians Relative to the General US Population,” Archives of Internal Medicine, October 8, 2012, Vol. 172, No. 18: 1377–1385.
2. Anthony G. Gallagher, Emily Boyle, Paul Toner, Paul C. Neary, Dana K. Andersen, Richard M. Satava, Neal E. Seymour, “Persistent Next-Day Effects of Excessive Alcohol Consumption on Laparoscopic Surgical Performance,” Archives of Surgery, April 2011, Volume 146, No. 4.
3. “DrugFact: Nationwide Trends,” National Institute on Drug Abuse; National Institutes of Health; U.S. Department of Health and Human Services, last modified June 2015, http://www.drugabuse. gov/publications/drugfacts/nationwide-trends
4. “Suicide: Facts at a Glance”, Injury Prevention & Control: Division of Violence Prevention, Centers for Disease Control and Prevention (CDC), accessed October 26, 2015, http://www.cdc.gov/violenceprevention/pdf/suicide-datasheet-a.pdf