Crozet Annals of Medicine: Burnout, or Not

Many thanks to Dr. Sudhir for covering for me during my summer hiatus, my annual head-in-the-sand sojourn while the new interns flood the hospital with their good intentions and utter inexperience.

But one can only hide for so long. I am back from vacation and settling in with the new interns. Another cycle begins. For the next three years the new ’terns will work harder than they ever have in their lives in service to some of the poorest and most vulnerable people in our community. In return they will learn the ancient and modern art of medicine. A fair trade.

And it is a fair trade for me, too. My jaded cynicism will be remitted by the idealism and energy of the newest generation of physicians, the future of medicine. Indeed in these late afternoon days of my career, I remind myself that perhaps some of these very physicians will be caring for me in my dotage. This is good motivation for me to teach them something we usually overlook in medical education, how to care for the caregiver.

We caregivers are facing an epidemic. Burnout. Burnout is characterized by emotional exhaustion, depersonalization, and feelings of futility. The ICD 10 has a code for it: Burnout- Z73.0- State of vital exhaustion. Burnout leads to poor patient care, lack of empathy and compassion, depression, early retirement, substance abuse and suicide. Almost half of all practicing physicians report burnout, a far higher percentage than the general population of workers. Many are dropping out of practice altogether.

Far from being a product of too many years treating patients, burnout is widespread among medical students and residents too. In fact, in a recent large study half of all medical students reported burnout out and ominously 11 percent reported thoughts of suicide.

Our system of medical education and practice is broken. And the ER is the most broken, with the second highest rate of burnout of all medical specialties. (Critical care is highest by one percentage point.) As a teaching physician I need to help fix this. And I need to address it in the ER in particular.

So what are the drivers of burnout in the ER? The poet Robert Frost once described home as that place where, when you have to go there, they have to take you in. Now that place is the ER. We have to take you in. The ER is the one clean, safe, always-open place that will allow everyone patronage even if they threaten violence and openly declare their refusal to pay for their care. This can on some days produce what seems like a steady stream of angry, seemingly unreasonable, often irresponsible, difficult-to-like, demanding patients. The problems our frustrated patients bring to us are often longstanding and have proved unsolvable despite years of evaluation and treatment. Many are mentally ill with personalities refractory to all treatment. Too many argumentative encounters with these patients can lead to compassion fatigue, the first sign of impending burnout.

There are many other drivers of burnout in the ER, but these difficult patient encounters are among the most visible and also the most amenable to reframing to avoid the frustration that compounds burnout.

I have been watching the new interns and the newly promoted residents struggling this month with these encounters. Their compassion comes naturally to them; they are fresh and idealistic. When it becomes apparent that no reasonable medical therapy will satisfy these patients, frustration finally sets in and they come to me for solutions. And I often have a solution because I have a secret weapon.

My simple secret is that I know most of these patients. After 18 years in the same ER, I have treated them many times. I know where they live, I know their spouses, their kids, their pets. I know their drugs of choice, their favorite beverages and I know when they are acutely sick and when they are merely reporting chronic problems. And they know me, too. They ask after my dog, Bandit, who they have met in front of the ED when my wife picks me up from work. Bandit is always happy to see me and usually brings a smile to their faces. They know my habits and my limits, and they know what I won’t do in the ER (like narcotic prescriptions for chronic non-cancer pain). Even when I don’t actually know them, I know of them.

So I go to the bedside with the interns. I inquire briefly for any changes in conditions, but rarely is anything new. Have you gotten disability yet? No? Well, good luck. Bandit is fine, thanks. All right then, nice to see you. Come back if you need anything else. I know it is hard, but we have talked about this many times and there is nothing we can do in the ER.

Back at the main desk as we discuss discharge instructions and follow up, the interns want to know my secret. Specifically, how I remain calm and upbeat despite the provocation of these patients. I tell them two things. One, most of these patients just need a hug. While I am unlikely to hug them, respectfully asking how their life is going and being interested in the answer is a good professional substitute. Two, I remind the ’terns of an old rule in medicine: the patient is the one with the problem. This can be interpreted in many ways, but here it means that the doctor must maintain professional distance and not take the patient’s frustration and hostility personally. Your reaction is your choice, doctor.

And so the cycle begins again. In three years they will graduate and go, hopefully among the 50 per cent who choose not to become burned out. Time will tell and I will report back then. In the meantime it might not be a bad idea to get a dog.