Burnout isn’t just an issue for physicians; it can surface at any point throughout an individual’s medical career. If you’re experiencing burnout, it’s important to keep in mind that you’re not alone and you will get through it.
In the first of two “AMA Moving Medicine” podcast episodes featuring a panel discussion on burnout, some of the AMA's foremost experts on burnout research share their personal experiences managing burnout and address potential systemwide solutions. Kathleen Blake, MD, MPH, leads the panel with an Marie Brown, MD, a senior physician adviser for the AMA, internist Jan Kief, MD, emergency physician Ryan Ribeira, MD, MPH, and emergency medicine resident Hunter Pattison, MD.
Dr. Blake: This question would go first to Dr. Kief and it is to ask, have you experienced—at some point in your medical career—burnout? If so, how did you address it?
Dr. Kief: I guess I would reflect back to the time when I first came out in practice. I was in solo practice working five days a week, three or four more hours of administration and rounds at up to four hospitals, taking call every third night. But we had great teams at my office. We were innovating, we were doing fun things, I loved the patients. We were great at preauthorization, billing. We had an excellent staff and then as we expanded, being owner of the practice, we had new medical equipment, new docs.
I actually had to moonlight on the weekends so I could take home a paycheck because I had to pay everybody else first. That's not what put me into burnout. What did was when we sold to the hospital.
The teams disintegrated, our staff got taken to every other different clinic around the city, and we got leftovers. There were all sorts of complaints. I was scheduled very badly. I was always behind because they didn't know how to schedule me.
We always just did sick care, trying to transport or feed their tertiary clinics. No time to do prevention care.
In these 12-minute visits, you felt like you were putting out fires with a squirt gun, and it's just you felt like you were drowning and there was no end in sight. You dreaded going to work. You just were getting some recurrent nightmares, and you could not speak up about it. You were afraid, just like in internship, you were afraid you'd get fired. You couldn't trust anybody. How could you even talk about this?
Two of our practices that were experiencing this, we merged and bought ourselves back and got back our staff, got back to the innovation again, a manageable schedule, good technology, good equipment. We were finally able to do some preventative care, which is so satisfying, and not to just see the ravages of people that have not had preventative care.
It was diverse. I was doing some surgical assisting. I did a lot of my ER rotations, and you got back to the joy of it and finding medicine as a calling again. That is so important that it's a calling. It's something we really do.
The other things I think that helped me then over the next couple years—I'm married 41 years, I've got five kids—just that joy of being with them and in the moment, taking your vacation time, unplugging from the system, whatever. Spiritual and emotional health. I am a singer. I was in a choir and played guitar, and that was wonderful.
Also, I always had, in my office, medical student teaching. It keeps it so fresh and it energizes you. It's a very two-way street. You hope you can teach them something, but I'm always energized by students. That's why I'm in academic medicine today. Also, I did a couple medical mission trips, and to be able to take care of people without the billing and all the administrative stuff. And you had grateful patients and you really were able to make that difference.
The other thing was being involved in organized medicine. I started that early and that's where you really could talk amongst the colleagues in a safe place. And you could fix things, from some of the problems that you're having in the office to big legislative issues that can help us all. Those are the things I did to combat the burnout.
Dr. Blake: Pretty impressive. What I was hearing was “know thyself” and “to thine own self be true.” Dr. Brown?
Dr. Brown: I had a similar journey. I finished at Rush and went to work. I felt it also as a calling and worked out of a federally qualified health center not far from here called Mile Square, serving a square mile of underserved on the Near West Side of Chicago. That closed the last time Illinois had no money, and my colleague and I looked at each other and we said, and this is in the ’90s, "Do you want to go into practice together?"
So, we just went down the bus line so that we could continue taking care of our patients, and it really turned out to be probably the most wonderful decision, because I remained in control of my day, and I barely made a budget, barely made my salary. But I could spend as much time with my family and as much time with my patients as I needed to because that interaction at the end of the day to say, "I made a difference and I enjoyed what I did."
I've been in practice for 35 years, and I can't say that there isn't a day that I didn't enjoy going to work to see patients. The other thing that helped was staying in organized medicine and my educational home; my professional home was the American College of Physicians as an internist.
Once I had begun my family, I started working part time, so I had a wonderful work-life balance, but staying connected to something that you're passionate about throughout your career was very important. I found that when I started listening to my patients and learning why they weren't taking their medicine.
My passion became medicine adherence, and I wrote a paper. It got published and then Mayo Clinic said, "Will you send a video of why you wrote this paper?"
I said, "Well, sure, I'm a Kardashian. I'll just have my videographer come over to my little two-person practice."
But I found a nice gentleman, and he came and helped us and that turned into an idea to ask our patients, who we'd taken care of for 10 or 15 years, why they weren't taking their medicine.
That launched another whole career for me so that I'm a self-proclaimed expert in medication adherence, because I listened to my patients and my patients have taught me so much, and they are just fabulous. And I've gotten to know them for 10, 15, 20 years. That joy, that calling, that very longitudinal relationship with patients was critical.
I also found that, even when I was busy, going to one meeting once a year—which was my American College of Physicians, for you it may be the AMA Annual Meeting—where you recharge, you see people that you know; it is a very safe place. And you talk about things that you wouldn't necessarily have time or feel comfortable talking about back home.
I'll end by saying I would give my receptionist, who was my employee, the school schedule and I'll say, "When there's a day off for the children, don't book me that day."
That made my life and being able to raise three beautiful daughters—one who is a nurse in health systems management, one who's an immigration attorney in California, and one is a mechanical engineer—all loving their profession. I just celebrated one wedding last weekend, so it can be done.
It's hard work, but looking for that work-life balance and keeping it in mind is critical all along the way.
Dr. Blake: I'm going to give each of you one minute to finish this question out and then we're going to go to the next question.
Dr. Ribeira: I'll be quick. I experienced burnout and the interesting thing was I didn't realize it at the time. ... Halfway through my third year of residency, we all did one of those standardized burnout surveys and 100% of my class was burned out. This was only about two years ago. I was surprised to find out. I wasn't even close by the numbers. I was quite burned out.
It was more around the depersonalization and the cynicism. And that was the thing that made me realize that the degree of cynicism I feel in shift is perhaps not normal or the daily distress that I feel about the fact that I don't see my kids while they're awake for weeks at a time is perhaps not normal.
It was an interesting experience for me to reflect back on how burnout itself was normalized through the training process, and this is maybe not the most optimistic answer, but I didn't really deal with it during residency. I just graduated and then it got better and that was my personal experience, and we'll expand on that a little bit more as the questions go forward, I think.
Dr. Blake: Hunter?
Dr. Pattison: OK. I have experienced burnout a couple times in residency, and I've only been in residency for two years. I think the first time that I really, truly experienced burnout, I was on an off-service rotation on my medicine wards rotation, which for those of you who have done medicine wards, it's not the most energizing month of your life. But it was a particularly hard time, I think, because I was on over Christmas and New Year’s where a lot of things in the hospital were shut down.
I was getting really burnt out over the system and trying to take care of my patients because I couldn't get them to get particular procedures that they could get because other workers in the hospital were on vacation or on holidays and things like that.
So, I think after finishing that, I really was kind of cynical about my role as a health care provider and within my hospital system and just treating my patients. For a while, I think it carried over into my other shifts and my other rotations and even in my personal life, too.
It really didn't change until you kind of start taking charge and recognize burning out is just a reaction to the system: the restrictions that you have in your life with residency and with your medical training.
So, I actually got involved in our QI [quality improvement] committee with the hospital and kind of started telling my experiences and my story, and I realized that there are other people who had similar experiences. And we were able to identify different ways to try and help alleviate some of the restrictions that we have, especially around holidays and things like that. It was a way to take charge and recognize what was causing the burnout and not necessarily just react to it.
Dr. Blake: Thank you all four. And I think a common theme that we're hearing is that it's common to have burnout. Secondly, what I'm hearing from all four of our panelists is that by having colleagues, friends and family, that part of the antidote is going to be with the help and involvement of other people. But that's not the whole answer, because burnout is not an individual issue, it's oftentimes a systems issue.
Our next question; we'll start with Dr. Brown. ... Is there a way to enable health care systems to provide what we might call mandatory or expected trainings, workshops and activities, to be sure that everyone within the system has the space and the tools that they need to prevent burnout? This goes to our [session] title, is there a vaccine—not just individual, but systemwise—for burnout? So, Dr. Brown.
Dr. Brown: I think Stanford and Mayo and Colorado have all led the way in changing the system. And I will echo what Dr. Blake said, which is what we think at the AMA ... in the professional satisfaction and practice sustainability section—about 80% of burnout is due to the chaotic environment in which we work. And about 20% is due to maybe not having the resilience or taking care of yourself.
I was giving a talk in Boston, kind of a think tank, and one of the hospitals there said, "Well, we're handling burnout. We have tea at 2 p.m. on the first Tuesday of every month. But then we just go home an hour later. Tea is lovely, but then we just go home an hour later."
StepsForward.org is open-access. You don't need to put an email. You're all AMA members, but even if you're not an AMA member, there are tools there that you can use to evaluate the organization that you're maybe even thinking of doing a residency in.
One is: What is your leadership doing?
And there is a beautiful article written about and summarized on the organizational approach to addressing physician well-being. And Stanford is leading the way. Tait Shanafelt is there, who was at the Mayo Clinic. If the top level is paying attention to this, then it is probably going to trickle down to the experience that you're going to have as a student or as an intern or resident.
What we find is that if the people teaching you are burned out, and if the people teaching the residents are burned out, and the residency clinic is the worst run, under-resourced clinic in the entire organization, well then that just adds to the chaos and the misery.
It really has to be a systemwide approach. None of you—nobody that goes into medicine—is afraid of hard work. It isn't about the work. And it usually isn't about the salary.
We are engaged. We really want to be enabled.
So, to your point, Dr. Blake, what can we do? When you go into a rotation, you need the training to get the job done. I think you experienced, that what burned you out, was if you have worked 12 hours a day, but at the end of the day you said, "Darn, I saved lives. I did a great job." You're home, and you're happy and you bring that positive energy back to our family.
But if at the end of the day, because of the system, you haven't been able to do the job you were called to do, that's problematic. So, be enabled.
If you need more trainings on the EHR, if you need more education to do your job well, then ask for it. Nobody is going to complain about that. You're not whining. You're saying, "Give me more so that I can do my job better." And you want to do the job that you went in to do, not to do an administrative or clerical job that somebody else could do.
Then, make sure that the organization is even measuring. Not all organizations are measuring the physician well-being.
And we find that if the C-suite is paying attention, they're looking at the cost of replacing one of your teachers or faculty. We know that it takes $500,000 to $1.5 million to replace a doctor. And they can see recruitment and ramp up time. That's where talking to administration has been some of our message so that the administration understands the business case, because we've hired our administrators to make sure that the lights stay on, and they're just doing their job.
And lastly, some leaders have tied their leadership compensation to the wellness of the workforce. And that is really leading the way. But if organizations start on this path, they start with attending to personal resilience. As they become beginners, novices, and then more competent, they move to measurement. And then tying that to compensations. So, it really is a journey.
Dr. Blake: Other panelists?
Dr. Ribeira: Sure. The part of this question that stood out to me was asking whether or not mandatory wellness, luxuries and activities can really be a successful strategy. And I had some personal experience with this.
Building on the story that I told you last time, our entire class came out burned out. So, our program director came back and said, "Hey, so it turns out that you're all burned out. And I noticed that almost all of you happen to be off next Tuesday. We're going to have a mandatory event Tuesday night where we're going to have a psychologist come in and talk to you guys about how you can stop being burned out."
And we had already previously planned a barbecue for ourselves. So, it was as big uproar. Eventually, at the last minute, she backed off of that because I think there was recognition that there's a certain irony in replacing actual activities that build wellness with mandatory wellness events.
I won't say it's impossible, but I think it's very unlikely that you can construct a wellness program based on mandatory activities that is going to add rather than detract. At least for residents and for those in training. Because I think there's a lot of job dissatisfaction that comes when there is a mismatch between what you are asked to accomplish and the amount of control you have over your life. And in residency, you're just way off on that already.
There's so much that is mandatory about your life. You have very little that you have any control over. Anything that adds more mandatory activities, I think, is going to decrease your wellness.
Now, there are a lot of nonmandatory ways that I think that you can provide wellness opportunities for people and kind of give them the tools and skills that they need to navigate that challenging environment that I think, specifically on the question of mandatory activities, is not a good way to go.