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Burnout and Post-Traumatic Stress Has Reached Epidemic Proportions

Posted on Thu, Jun 22, 2017
Burnout and Post-Traumatic Stress Has Reached Epidemic Proportions

By Jane Sullivan, Ph.D.

Epidemic is the term currently used to describe the increased incidence of both burnout and post-traumatic stress disorder (PTSD) in emergency physicians. It’s difficult to know if calls to action to address this epidemic have been responded to with any successful intervention. So perhaps the statistics will continue to be astounding:
 

  • 300 to 400 physicians commit suicide a year
  • 52 percent of emergency physicians report being burnt out
  • 60 percent of midcareer doctors have been involved in lawsuits
  • 10 to 15 percent of all doctors have issues with substance abuse during their careers
  • 80 percent of physicians state that they believe that the medical profession is on the decline

PTSD

Post-Traumatic Stress Disorder (PTSD) is a trauma and stress related disorder that may develop after exposure to an event or ordeal in which death, severe physical harm or violence occurred or was threatened, according to Psychology Today. Witnessing the pain and suffering of patients who are impacted by traumatic events such as mass shootings, car accidents, suicides, opiate overdoses and terminal illnesses can erode the barriers that help protect physicians from incapacitating, overwhelming emotions. It is, however, the inability to access emotions and the lack of support to express genuine and understandable grief that may set the foundation for the symptoms of PTSD.

The Symptoms of PTSD

The symptoms of PTSD are usually quite demonstrable — flashbacks, nightmares, startle responses that can last for months and can become debilitating. Treatment options exist for those medical providers suffering from PTSD, and most organizations are sympathetic to and supportive of providing help.

Burnout

Recognizing burnout may be more elusive. The term “burnout” suggests that one was on fire at some point, but now the fire is gone. Christine Maslach, who has done significant work on burnout, defines it as, “an erosion of the soul caused by a deterioration of ones values, dignity, spirit and will.”

The Symptoms of Burnout

The symptoms of burnout are varied and refer to a change in a person’s behavior and personality. They include:
 
  • Loss of a sense of personal satisfaction, accomplishment and meaning
  • Isolation from friends and family
  • Increase in cynicism and sarcasm (patients become stereotyped)
  • Appetite changes – weight gain, weight loss
  • Loss of interest in favorite activities
  • Depersonalization
  • Robotic actions
  • Fatigued before the day begins
  • Increased alcohol and/or drug use
  • Change in demeanor
  • Overreaction to minor incidents
  • Angry outbursts
  • Increased rate of divorce
  • Loss of empathy
  • Disengagement from patients, profession and other providers

The factors contributing to burnout are numerous and somewhat predictable. They include:
 
  • Societal and patient expectations for medical “perfection” (no mistakes)
  • Personal physician expectation of “perfection” (personal cost of mistake)
  • Too much output, not enough input
  • Pressure to see more patients
  • Medical malpractice creates defensive medicine
  • Focus on the negative
  • Repeat narcotic-seeking patients, drunk patients in the ED
  • Emergency physicians becoming “social workers”
  • Loss of autonomy
  • Increased scrutiny, e.g., physicians judged by quality measures, documentation, chart reviews, peer reviews
  • Standardized medicine
  • Repetition of patients who may appear to be willfully self-destructive or neglectful, with expectations that doctors will “fix them” (“Same stuff, different day”)
  • Decreasing public respect for the medical profession
  • Increasing reliance on technology by patients
  • The impact of night shifts on sleep patterns
  • Disillusionment in medicine, whereby idealism becomes disappointment and dissatisfaction
  • “Destination sickness”; You’ve “arrived,” but now what?
  • Decreasing trust between doctor and patient and increased distance
  • Adversarial relationship with administration
  • Years of ongoing litigation, which generates guilt and, worse, profound shame
  • Shame for failing to live up to one’s image
  • Repetitive grief with no space to grieve
  • Constant stress, fear of making a mistake

Given the impact of burnout on physician behavior, higher medical errors, suicide and lower quality of care, it would seem imperative to understand the causes of burnout and generate concrete actions to address the “epidemic.” However, there are barriers and challenges that exist in addressing both PTSD and burnout which impacts mobilizing treatment interventions.

First, medical organizations and administrators whose focus is on the financial bottom line may believe that it’s more cost effective to replace a “hurting” physician than invest in supporting that physician. Individual physicians, who view themselves as heroic and strong, may have difficulty admitting to their own pain and need for help. Peers who witness other doctors with the symptoms of PTSD or burnout are reluctant to talk with their fellow providers about what they are witnessing, perhaps because of a concern about what the reaction may be. In addition, there may be fear of acknowledging a potentially debilitating distress because of the medical licensing board’s question: “Have you ever had a medical condition or been treated for a problem that could hinder or impair your ability to provide patient care?”

Identifying and Treating Burnout and PTSD

Although some organizations do attempt to assess how their physicians are doing by surveying clinicians, such surveys typically have only about a 40 percent response rate. It will, therefore, take vigilance on the part of peers, fellow practitioners and medical directors (who may themselves be burning out) to be observant of physician behavior and attitudes. Engaged physicians maybe the ideal, but identifying and supporting those physicians struggling with PTSD and burnout needs to be a more immediate goal.

Treatment of both burnout and PTSD is the responsibility of all involved. There are many support systems available to help individual physicians in their struggles, such as the American Medical Association and The HappyMD.com.

As Nietzsche said, “Physician, heal thyself: then wilt thou also heal thy patient.”

Peer groups provide safe, non-judgmental environments to address issues of mistakes, guilt, shame, disengagement, anger and all of those emotions that impact physicians’ attitudes and behaviors. Knowing one is not alone can be very helpful. Staff meetings could include some of these topics for general discussion. Hospital administrations can advertise their commitment to not only helping identify those physicians struggling with the cost of their profession, but also their investment in support activities. In fact, several large hospital systems have hired professionals trained in physician health and well-being to provide care, both proactively and reactively.

If burnout and PTSD in healthcare is indeed at epidemic levels, it will take mobilizing all of the resources necessary to respond adequately. The cost is too high to continue to ignore this issue.

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Jane M. Sullivan, Ph.D., is an adjunct professor at Albert Einstein College of Medicine, Bronx, N.Y.; Yeshiva University, New York City; and Fairleigh Dickinson University, Teaneck, N.J., teaching courses on conflict resolution and family dynamics. Much of Dr. Sullivan’s recent professional work has been on leadership development, generational transitions and supporting effective and productive interpersonal communication in organizations. Dr. Sullivan has been a guest speaker on topics such as emotional intelligence, burnout, dynamics within family business, conflict resolution, effective communication and gender differences. She has written several articles on topics related to interpersonal dynamics in business.

References:
Danielle Ofri, M.D. What Doctors Feel: How Emotions Affect the Practice of Medicine, Beacon Press, Boston, 2013.
Tom Murphy, M.D. Physician Burnout: A Guide to Recognition and Recovery, Aloha Publishing, 2015.
Joseph S. Bujak, M.D. Inside the Physician Mind: Finding Common Ground with Doctors, ACHE Management Series, Health Administration Press, 2008.
Burnout: Emergency Medicine Hit Hardest, J. Duncan Moore, Jr., Health Leaders Media
Physician Burnout: Why It’s not a Fair Fight (blog article), Dike Drummond, The Happy MD.com
Physician Burnout: It Just Keeps Getting Worse, Medscape, Carol Peckham

Resources:
Whole Health Medicine Institute
Lissa Rankin, M.D. – Self Healing Kit
 

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Podcast Provides Tips for Banishing Burnout

Posted on Wed, Mar 15, 2017
Podcast Provides Tips for Banishing Burnout

More and more clinicians are reporting feelings of burnout and a need to find a better work/life balance. In fact, the Medscape Lifestyle Report 2016: Bias and Burnout concluded that burnout among U.S. physicians has reached “a critical level.”

While each physician’s personal and professional pressures vary, most research on the topic suggests that to amp up their resiliency and stave off compassion fatigue, clinicians should reconnect to the people and activities that are a source of joy, and make the most of their “downtime” to provide a sense of control amid the chaos.

Gretchen Rubin has written several books on happiness and forming positive habits, including Better than Before, The Happiness Project and Happier at Home. Rubin shared the following tips during her weekly podcast, Happier with Gretchen Rubin.

Finding Everyday Joy

  • Take photos of everyday life – the foam on your coffee, rain patterns on the window pane, the assortment of pens and sticky pads in your lab coat – for a new perspective.
  • Pick a one word theme or phrase for the rest of the year. For example, “novel” to remind you to try new things or finally get your thoughts in print, or “vision” to frame where you see yourself personally, professionally, spiritually, health wise and/or financially in the near future.
  • Set a timer for writing, painting, baking or any other creative endeavor that you’ve had trouble fitting into your schedule.
  • Be a minor expert, meaning if you have an interest in a topic, commit to learning as much about it as you can.
  • Buy – and read – three magazines that you'd usually never read.
  • Start a passion project. Much like being a minor expert, follow your gut and pursue that project that keeps you awake at night.

Maximizing Your Time

  • If it only take a minute to do it, do it now and cross it off your to-do list.
  • Plan a “power hour” each week to knock out lingering tasks.
  • Turn off your TV to avoid falling into a Netflix binge.
  • Use reminders on your phone for tasks you keep forgetting to complete.

Forming Healthy Habits

  • Use scheduling to build positive habits. Block out time for the gym, meditation, meal prep, etc., on your calendar and don't make excuses when those “appointments” come up.
  • Set an alarm for your bedtime as well as your wake time to reinforce your routine and ensure healthy sleep patterns.
  • Give yourself “gold stars” and “demerits” each week. By reviewing your successes and misses, you’ll be better prepared next time.

For more information about the topics of burnout and resiliency, visit EmCare’s website or the wellness resources on ACEP’s website.

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How I Get My Mind Ready for the Night Shift

Posted on Wed, Nov 30, 2016
How I Get My Mind Ready for the Night Shift

By Shilpa Amin, MD
 
I have been out of residency for seven years. For the duration of my career I have worked the late shift, either 4 p.m. to 2 a.m. or 5 p.m. to 3 a.m. In the past four years, I transitioned solely to nights. Why, you ask. How? I usually get looks of bafflement when I tell people that I work overnight in a very busy urban emergency department with single coverage, while juggling a family with three young children.
 
I transitioned to nights because it was easier for my family life. My children are in school. I typically leave when they are sleeping and can get home just before they wake. I sleep when they are at school and wake up to pick them up after school. They hardly notice that I’ve gone to work. This works well until they have a day off from school and don’t understand why I’m sleeping all day! Luckily because I work nights, I have a fairly set schedule and can work around their school calendar.
 
People ask me how I stay up all night. After all, it’s not natural. The key is having a routine that I go through each time I leave for work. My shift starts at 9 p.m. I start my routine at 7 p.m. My ritual is to read books to my children, put my scrubs on, brew and drink Mauritius tea at the kitchen table and decompress. l leave at 8:30 p.m. and pick up treats for the night staff from the same café. I call my husband or my sister on the drive, and park my car in the same spot.
 
I take a look at the waiting room on my way in. It’s been busier than normal the past few weeks. When I walk inside, I greet everyone and mentally get my plan together with my advanced practice provider about which patients to see. Throughout the night I drink a few cups of green tea for a boost of energy. The 4 a.m. hour is especially tough for me.
 
On my 20-minute drive home, I listen to my favorite station on Pandora and that’s usually enough time for me to decompress from the events of the night. When I get home, I send the kids off to school and fall back to sleep!
 
I look forward to my evening and morning routines because it gives me a sense of control, and that is rare during an ED shift.

Shilpa Amin, MD, FACEP, is a full-time attending emergency physician. She received a bachelor’s degree from Rosemont College in Rosemont, Pa., and her medical degree from SUNY Downstate, Brooklyn, N.Y. She completed the Jacobi/Montefiore Emergency Medicine Residency Program at Albert Einstein College of Medicine and served as chief resident. She enjoys spending her free time cooking, traveling and trying new cuisines with her husband and three young children.
 

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Physician Burnout Is Prevalent, But Preventable - Part 2

Posted on Wed, Nov 02, 2016
Physician Burnout Is Prevalent, But Preventable - Part 2

This is Part 2 of a 2-part series.

By Ronald Tompkins, MD

When I attended EmCare’s Annual Leadership Conference, I heard several speakers discuss physician burnout, and while the conference covered a variety of topics, the sessions that addressed this topic stuck with me the most. I wanted to share what I learned, and some of my thoughts about burnout and resiliency.

It’s said that the ER doctor only controls about 10 percent of his day and is at the mercy of his surroundings the other 90 percent of the time. But we do control 10 percent, and we have to own that 10 percent. Control the ground under your feet and inch forward, adapting and being flexible and willing to learn. We have to learn resilience to prevent and treat burnout. As we get burned out, we get mean and stupid both at work and at home. This is very costly. Happiness generates a better work life – and a better home life.

We have what is often called a toxic work environment that negatively impacts our health to the degree of smoking a pack of cigarettes a day. The resilient docs are those who embrace change and move forward. They surround themselves with work peers and family who show love and support. Look in the eyes of the nurses when you arrive at work or the eyes of your family at home. Are they glad to be at work with you or do they show agony and worry? Are your adaptive behaviors creating good or bad change? Help create an environment where it’s OK to show a range of emotions, but make sure to find humor and laugh.

Those who find happiness at work are the ones who surround themselves with quality collaborators and peers and show love and support for one another. You don’t always have to be right. None of us are. But you have to be willing to listen and love one another. Don’t just judge actions and results, but remember to judge intent also. Work life and home life is a long journey that has peaks and valleys. Most couples who stay committed through times of stress and struggle and stay together will generally respond years later that life is good. Work life is very similar. The work team is ever changing and we have to work through the valleys again. Forge trust and respect through trials. Character and commitment matters.

Is Your Work Site Toxic?

Four key questions to ask yourself to judge your work site are:
 

  1. Does my work match my values?
  2. Am I good at it?
  3. Do I like my peers?
  4. Do my peers, work family, and supervisors acknowledge my work and family and show respect and support?


Signs of burnout can be summed up into emotional exhaustion, depersonalization (numb emotions) and decreased sense of accomplishment.

11 Tips for Finding More Meaning in Your Life

What helps work/life burnout is finding MEANING to life. This can be different for each person, but examples are family, religion, hobbies, children and missions. Notice money is not one of the options.

Other proven strategies are:
 

  1. Find wonderment in old things. Try to find new ways to look at old problems. Be willing to adapt and embrace change.
  2. Rethink your life balance and take actions to change the ratio of work, time for family, time for self, and time for intimacy.
  3. Give compliments to your peers and to their families. The giver will be lifted up as well as the receiver.
  4. Give apologies. Stop all the unnecessary work arounds to avoid certain individuals.
  5. Find and write down three uplifts for every one hassle daily. This can be simple such as “I got a new recipe today.” Studies show this will change our attitudes very effectively in about six weeks.
  6. Find a place of serenity during the day for a few minutes. Take advantage of quiet times, laugh and let your mind rest.
  7. Find something to be inspired by.
  8. Find pride in what you do and who you are.
  9. Most importantly, find someone to love and who loves you back.
  10. Look for all the above and write them down.
  11. Be a hero. A hero creates a safe place for those we care about


I want to conclude this series by acknowledging all of our providers and the incredible work you do. That includes our nurses, unit clerks and other support staff. I have been in emergency medicine for more than 20 years and I am amazed at all that we are asked to do and we amazingly do it all.

Dr. Ronald Tompkins

Ronald Tompkins, MD, is the medical director of the emergency department at Parkridge Medical Center in Chattanooga, Tenn.

 

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Physician Burnout Is Prevalent, But Preventable

Posted on Wed, Oct 26, 2016
Physician Burnout Is Prevalent, But Preventable

This is Part 1 of a 2-part series.

By Ronald Tompkins, MD

When I attended EmCare’s Annual Leadership Conference, I heard several speakers discuss physician burnout, and while the conference covered a variety of topics, the sessions that addressed this topic stuck with me the most. I wanted to share what I learned, and some of my thoughts about burnout and resiliency.

ER docs must learn resilience. The burnout rate is more than 60 percent, the highest of all professions. Doctors in general work many more hours than any other profession. Studies show the number of doctors who often work more than 60 hours per week is seven times more common than any other profession. The intensity of work and new demands makes us try to adapt by working harder and harder. This is initially successful but eventually you hit a wall and can do no more. We all know the super human doctor who is always winning awards for juggling more than anyone else, and it seems they never struggle. They do. They just hide it and suffer in silence, and so do their families and the nurses who have to work with them.

Multitasking is a myth. We’re often praised for our ability to multitask, and the docs who do it best are often considered efficient. What’s really happening is some doctors handle interruptions better than others. We simply go from topic to topic every few seconds, handling only one at a time because our brains can only handle one thought at a time. Studies show that an ER doc is interrupted about 100 times per hour. Our brains get neuronal fatigue and need to recover somehow.

Psychologists who focus on treating physicians state that ER docs work under the most stressful situations of any profession, by far, due to the interruptions and unrealistic expectations. One of the presenters at the conference likened it to standing in the busiest intersection you have ever seen and trying to tell the traffic what to do, knowing you are going to get hit a few times a day. We are smart, controlling people by nature, but we control very little in our environment, leading to exhaustion and burnout. The burnout rate is more than 60 percent at any time, and expectations are growing steadily. They believe we handle approximately five times more material every day than just 20 years ago.

Tips for Recharging Your Resiliency

Adding to the neuronal fatigue is the use of computers and how we spend our free time looking at email and social media and worrying about trivial things. They believe that trivial thinking is nearly as exhausting to the brain as routine work is. The trivial computer and smart phone interactions every day account for the equivalent information intake of watching five full-length movies. They suggest that doctors take multiple short sessions a day to relax the brain, such as listening to music or walking. Of course, this is often impossible, but eliminating unnecessary tasks such as email and Facebook is helpful. Snacking during the day is helpful, too, as the glucose in the brain needs to be replenished. Caffeine, not so much. As the brain fatigues, decision making and performance suffers, making the doctor prone to mistakes. The end of the shift is often the worst. Be willing to offload the patients from the doctor you are replacing, as he is psychologically exhausted.

Offloading the brain of unnecessary material is very helpful. As mentioned above, limit your down time activities, but also make use of handwritten lists. Relying on memory is inaccurate and fatiguing. High performers have made use of external memory (handwritten lists of tasks) for generations, and it’s proven to be of great benefit. I’ve done this for years myself. Also make use of your peers, nurses, etc., to offload some tasks that they can handle. They have skills and we can’t do it all. Delegate duties when appropriate.

Limit information channels. They suggest making others communicate with you the way you communicate best and eliminate the other channels. Voice mail, snail mail, texts and phone calls are all OK and not as intrusive as email. Emails are abused and not very effective as we now get innumerable useless emails. Emails seem to suggest that everything is an emergency and worthy of interrupting you at any time. Most of it isn’t necessary and adds to the daily fatigue of your brain. They suggest telling your peer group of a special emergency way to contact you, but limit who has this contact.

Keep gatekeepers around you to protect you from unnecessary interaction. Create buffers to help create a “stress free zone.”

Change in medicine is inevitable and always has been. What’s different now is the rate of change and the energy and concentration required to keep up. It’s less stressful to accept the change and work with it than to fight it. Remember, do you want to be right or do you want to survive and pay bills?

The age old struggle of work/life balance concerns us all. Life is basically about work and love. Each effects the other. Stress at work equals stress at home and vice versa. There is no definition of life balance. It’s a myth. How much you are gone from the house at work doesn’t effect home happiness nearly as much as your attitude while you are at home. Be fully engaged with the family when with the family. Those who win the struggle of work/life balance have the love and support at work and at home.

Dr. Ronald Tompkins

Ronald Tompkins, MD, is the medical director of the emergency department at Parkridge Medical Center in Chattanooga, Tenn.
 

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