Changing Doctor’s Attitude

Wistful reminiscences of life in medicine years ago are recollections of what was best and easiest well pruned of all the shortcomings.

None of us like to be told we need to fix our attitude. With me it’s like hearing a nail on a blackboard – all my defenses are instantly brought to bear; I want to grimace and put my hands over my ears to ward the effect off. We feel undervalued, unappreciated, misunderstood. It takes a pliable ego to stand one’s ground, hear out the criticism or complaint and give it a fair appraisal.

Much that ails the medical profession these days is about how we choose to perceive the world about us. We’ve never had it better in terms of the number of clinical, technological and scientific advances that allow us improve the lives of our patients. We’ve never had easier access to information whether that be tapping into new knowledge, or reaching colleagues who may advise you on a clinical dilemma. We can communicate more easily with our patients who are also better informed.

For these and many other reasons, we should be thankful and optimistic. Many doctors are. Others, though, are dismayed by their perceived loss of autonomy and authority, by our being held accountable, by medico-legal pressures albeit that objectively there is a downturn in lawsuits nationally, by more modest compensation although we remain extremely well paid, or by having less time to spend with our patients.

We can all assemble our own lists of pluses and minuses as I’ve done with a few examples above. But no matter how your list comes out looking, what is going to count in the end is how you decide to view it. I said a few days ago that it was for us to view these times as the best of times because they were our times. It’s sheer folly to pretend that “things were better back then”. What lies ahead, or if it will include us is an unknown.

Over the long haul, a change in attitude is less taxing than a radical career change or even an inter-disciplinary change.

Defining Physician Burnout

Operational Definition of Physician Burnout

A condition of over 3 months duration where previously high functioning physicians experience physical and mental exhaustion, disengagement from the human service component of a doctor’s work, and diminished accomplishments at home and at work.

Over the past two years I’ve read many different definitions of burnout, most of them fine, thoughtful and considerate of the complexity of the problem. I offer my own definition as an effort to refine the impact of burnout on a doctor’s life more clearly, to be as specific as possible, and to attach a temporal dimension. I regard my definition as a work in progress.

I’ve chosen brevity over additional descriptive features, acknowledge that clarity is often provided by saying what an object or phenomenon is not as much as what it is, and emphasize that a real understanding of physician burnout and its implications must be rooted in an awareness of the culture of the medical profession.

With those stated caveats, I’ll expand.

First described by HJ Freudenberg in 1974, though assuredly there were burned out cavemen, career burnout is considered to consist of a triad of (1) emotional exhaustion, (2) depersonalization and (3) diminished personal accomplishments.

I agree with these features but feel that additional clarity is provided by stating that the manifestations of exhaustion may be mental, physical, or both; by explicitly stating that the notion of depersonalization is one applied to those whom we physicians serve in our work; and, emphasizing that the manifestations of diminished personal achievements occur at much at home as at work. These elements arise de novo, in persons whose previous work record was exemplary, and are not signs of a pre-existing psychological disorder.

Each element feeds back to reinforce the other two, a true chicken and egg tandem effect. It is my experience that diminished professional accomplishments are more subtle than the literature would suggest. The exceedingly high level of performance that each physician provides on a daily basis allows for some slippage that is below the radar screen of the outside observer, though not to the affected individual themselves.

I have attached a timeline. My selection of 3-months is not arbitrary. I believe this is long enough to indicate that the problem is not likely to go away on its own or be a part of any of the natural seasons that occurs within our natures that we so poorly understand. It is (or should be) short enough to permit correction of the problem if definitive steps are taken by the affected individual.

While burnout may be triggered by stressful circumstances, it is much more than just a reaction to even chronic stress. I could graph this more easily than I can describe it. In response to stress each of us will manifest acute or subacute physical or mental changes from our baseline state to which we recalibrate. Burnout causes persistent deviation from baseline – it is therefore a product of unsuccessful adaptive mechanisms. Implicit here is that there are personal characteristics that make some more prone to burnout.

What are those characteristics?
Christina Maslach, a sterling researcher and writer on burnout identifies six primary personality characteristics of the individual predisposed to career burnout. These include low levels of stress hardiness, a locus of control that is more externally than internally derived, an avoidant coping style, low baseline self-esteem, compulsive perfectionistic behavior (your average type A), and being more a feeling than a thinking person. I see lots of doctors in the mix here.

How does the culture of our profession impact physician burnout?
The impact is profound as cause, trigger of specific manifestations in physicians and as a barrier to resolution. Tomorrow’s comments are devoted to this matter.