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Wednesday, October 4, 2017

Physician Burnout and Suicide

Physician burnout and physician suicide has been getting more attention in the last several years. Suicide among physicians is horribly tragic, and maybe moreso because of several factors. Suicide is the quintessentially most preventable fatal event. In order to prevent suicide, the person killing him or herself needs only not do it. To anyone who knows the victim/perpetrator it seems that if only the right words had been spoken, the right sentiment expressed, comfort offered, their death would not have happened. Among the family and friends of a suicide, this is one of the agonies that is added to the pain of loss. Physicians have a huge number of close contacts, patients and coworkers, who have a pretty intimate connection with them, all of whom mourn their loss and many of whom question whether they might have had something to do with it. Beside the emotional impact of the loss is the very real fact that physicians are responsible for some part of the care of potentially thousands of people who are left stranded by their abrupt departure. There is the very sad fact that someone whose job it was to help people was unable to get the help they needed.

It is not clear that physicians commit suicide at a higher rate than people in other professions, according to a report by the CDC last summer, and although it is the number one cause of death among male medical residents per a study that was released this year, their suicide rate was lower than average for their age group. Although burnout is clearly increasing among physicians, I have not seen any data that shows that suicide is increasing.

I have been a witness to the kinds of stresses that lead to suicide in physician colleagues. So far, knock on wood, none of the doctors who work closely with me have committed suicide. I have, however, been around some pretty spectacular cases of burnout. According to a Medscape poll, 40-60% of physicians show signs of burnout. Surprisingly, the major problem they complained about was the excessive bureaucratic tasks that they had to do. It was not the stress of making life or death decisions but the grinding demands of the computer, the paperwork, satisfying insurance companies, convincing organizations that monitor quality that they were delivering it. Other frequently mentioned complaints included extended work hours and feeling like they were just a "cog in a wheel." My experience is that it takes more than a bad job to push a person over the edge, though. But life is pretty good at offering that little bit more. The breakdown of a marriage, a child with troubles, an illness can take a person who is competently holding on with her fingernails and plunge her into failure. Alcohol and drugs provide respite and destroy that last pretense of being able to do the work. The colleagues I've seen go through this usually step away from practice and may or may not return.

My worst times were early on in my career. During my first year in medical school, I comforted myself with the thought that if things got too bad I could just jump out of the tenth story window of my dorm. After awhile I replaced that with deciding that I would  just go live with my sister and cook for her. The first year was bad because there was just too much stuff to learn and if I stuffed my head full of it, as I needed to if I was going to pass my tests, I couldn't sleep. If I couldn't sleep I couldn't stuff more information into my head so I walked around gripped by fear of failing. Occasionally I was distracted from my misery by some of my really excellent teachers and was eventually saved by a prescription for sleeping pills. These I hoarded and doled out by the fragment so I wouldn't have to ask for more. A boyfriend and increasingly close friendships helped make the second year almost imperceptibly better. By the third year the opportunity to interact with real patients and be of use cured me. Training continued to be stressful, but there was always something rewarding that came back to me from grateful patients or collegial professors which gave me the joy I needed to make the process sustainable.

After completing my residency, I took some time off to find the right job. I got a house with the man who would eventually be my husband and a big yellow dog. The position I finally found was good, though demanding, and I enjoyed learning from other physicians at my work who had different skill sets than I did. I was able to keep up and felt I did a good job. Burnout threatened when my workload increased and I felt like I couldn't keep up. There was always more that I needed to do at work but home needed me too. Having a baby actually helped because the woman who we hired to help take care of her was wonderful and made me feel like home was well taken care of.

Six years ago I transitioned from a pretty sustainable to a very sustainable lifestyle, doing shift work as a hospitalist. My children have fledged and I no longer need to help them with their homework after work or worry about childcare if they get sick. I still do some outpatient medicine, but have not been sucked up into the complexity of documenting for merit based payment or pay for performance systems. I did go through the growing pains of adopting several computerized health records, both inpatient and outpatient, and have experienced first hand how that can make everything seem impossible.

I can see that in a clinic system where an employer was pushing the physician to see more patients in an hour and patients were pushing back to get what they need, administrative tasks could be a big part of burnout. The recipe, I think, for burning out is one cup of impossible and maybe conflicting demands and several tablespoons of feeling like something terrible will happen if you don't meet those demands. When the demands are from both home and work, things get pretty grim pretty fast. If the work is not rewarding, as it would tend not to be when you can't do it properly, then there is no joy to counteract the stress.

Medical offices and hospitals right now are in a time of transition, which makes things particularly bad. We are moving toward making computers do the work that humans find tedious, but the interaction of computers and people is still awkward. We end up doing lots of the work that the computers eventually will be able to do themselves, keeping track of nearly endless and very complex data, remembering schedules invented and tweaked by organizations charged with optimal care for chronic diseases. We are wrestling with computers instead of doing the human job of reading people and helping them solve their problems.

It is not entirely our jobs which lead us to the brink of suicide and beyond. We are humans with sadness and stories and connections which can be difficult or even crushing. But we can make the job part of this much easier. We need to allow computers to do what they do best and have doctors do doctoring. We need to figure out how to unhook a doctors monetary compensation from how many patients we see, so we can keep those patients healthy and out of our offices and hospitals where they belong. We need to not take on more than we can do well, even if that means saying "no" to the person who writes our paychecks.

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