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Physician Burn-Out: A Silent Epidemic

Physician in blue surgical scrubs holding her head due to a headache.
Burnout refers to psychological exhaustion and diminished efficiency from overwork or prolonged exposure to stress. Medical literature suggests practicing physicians are susceptible to Burnout. Common symptoms of Physician Burnout include worrying, particularly at night, sleep difficulties, feeling unappreciated at work, dread of going to work and feeling overwhelmed. Recurrent stress related physical symptoms, substance abuse, depression, irritability and anxiety are commonly seen in states of Burnout.
The following clinical vignettes (identifiable information disguised to preserve confidentiality) are illustrative of physicians seen in my practice who have suffered from burn out.

Doc A is a 46-year old male surgeon.

He is married and the father of two sons, ages 8 and 12. He reports that he works 85 hours per week, and has experienced a 25 pound weight gain during the past year. He states that he is consuming three martinis per evening and more on the week- ends. He is upset with loss of income related to managed care, and has two pending malpractice cases. The death of a patient one year ago precipitated a depressive episode. Additionally his youngest son was recently diagnosed with ADHD primarily hyperactive type. Doc A described a one year his- tory of depression, panic, loss of self- esteem, irritability, sleep difficulties, problems focusing, as well as elevated blood pressure. He described intrusive recurrent flashbacks of having to tell a family that their child died in surgery. He remarked “I dread going to work, I fear another bad outcome, I’m really hating medicine.” His wife, office partners and nurses at the hospital are concerned about his depression.
Psychotherapy utilizing a cognitive behavioral and psychodynamic focus helped this physician address grief issues surrounding the loss of his patient, which unconsciously stirred up unresolved feelings of death of his father when he was 16. Doc A began a formal exercise program, joined weight watchers and lost 20 pounds. He stopped alcohol and enrolled in a 12-step program. He became involved in AA for physicians and engaged with a sponsor. Dr. A modified his unrealistic expectations of himself, career and finances. He involved him- self in church and prayer life. He worked on a committee to reform malpractice law.
He negotiated with his partners to recruit another surgeon, which allowed him more time off. He planned regular weekend getaways with his wife. After six months of treatment, Doc A reported “I feel better about my career, my family and my health. I never realized that the death of that patient got me feeling things about my Dad.”

Doc B is a 40-year old divorced female, and a solo internal medicine practitioner.

She is the mother of a teenage daughter. Two office managers quit in the past ten months, and she has problems with billing and collections. Doc B describes a six month his- tory of anxiety and obsessive worry. She is preoccupied with making “a diagnostic error.” She comments, “I’m working longer hours and making less money; I feel burned out; I can’t listen to my patients anymore, they whine.” She reports that she is angry at men, and especially angry at her ex-husband for leaving her for a younger woman. She remarks, “Maybe I should switch careers, I have no social life.”

Doc B began weekly individual psychotherapy. Cognitive approaches were integrated into the treatment. She learned relaxation techniques including visual imagery.  We explored her anger toward men and subsequently understood how her deep and long standing resentment toward her father affected her feelings toward men. She hired a practice management consultant to help with billing and collections, and a new office manager. Two years later, Doc B stated, “my life is more balanced, my priorities are clear; I never realized how my hurts from childhood effected my relation- ships with men” - “I really enjoy my patient’s again.”

Doc C is a 52-year old male cardiologist.

He is married, and the father of an adult son and teenage daughter. Doc C was referred by the hospital executive committee for disruptive angry outburst towards nurses. He reports working over 80 hours per week. He is active in real estate deals, and participates in day stock trading. He goes to Las Vegas two times per month. He has had numerous affairs. Currently he has a malpractice case pending. Doc C felt criticized and unappreciated by patients and hospital administrators. He yearned for the “good old days” when doctors were appreciated. He hated paperwork and wanted to retire, but he didn’t have enough money. He yelled at nurses whom he thought were criticizing him, “just like my chief resident did and just like my damn father did.”
Clinical presentation, history and family history suggested Bipolar Disorder. Doc C was referred to a psychiatrist who confirmed the diagnosis and started the patient on a mood stabilizer. The patient participated in both individual and marital therapy. He was compliant with the mood stabilizers prescribed by the psychiatrist to manage his Bipolar disorder. Doc C began to limit his practice to an office practice. He took classes on anger management. He hired a financial manager to take charge of his finances. He joined gamblers anonymous and worked with a sponsor. He sold his investment properties and lowered his financial expectations.

Doc C became more involved in church and community activities. He developed more male friendships and began a yoga class. He began to explore the wounds of growing up with an alcoholic, Bipolar father who was emotionally abusive. He and his wife participated in marital therapy to recover lost intimacy. He learned to take time to listen to his patients with greater empathy. After one year of treatment, Doc C stated “I realize how much I love my family. Family is most important to me. I don’t love medicine, but I can do it well for at least another ten years if, I just slow down.”
Physicians around the country are experiencing stresses of time pressure, managed care, increased paperwork, decreased autonomy, malpractice litigation, high volume of patients, excessive and continuous direct contact with patients, inefficient office staff, billing and collection problems, conflict with colleagues, stresses of maintaining clinical competence, decreased compensation, government regulation, diminished image of physicians, limited access to social support systems and limited time to share feelings with colleagues.

Compassion Fatigue

Additionally, Physicians may also experience what has been referred to as “Compassion Fatigue”, or some- times “Vicarious Traumatization.” Transmission of traumatic stress through observing and hearing the stories of our patients’ pain often causes distress to the caregiver. Physicians who treat individuals who experience trauma, loss, pain, emotional hurt and disease become over- whelmed and may begin to experience feelings of fear, pain and suffering, similar to that of their patients. Doctors around the country are reporting increased emotional and psychological distress, dysfunction in their relationships with their spouses, family, children, and friends, and seemingly greater frequency of impairment due to addictions.

Where to get help

If these case studies resonate with your experiences, and if these symptoms sound familiar to you, you are not alone. In a recent survey conducted by U.S. News and World Report 75% of physicians reported less satisfaction with the practice of medicine over the past five years. Eighty-seven percent of physicians reported that overall morale within the profession has gone down in the past few years. Sixty percent said that their own morale had declined.
An organization like the Maricopa County Medical Society provides a wonderful opportunity to encourage preventative interventions for physicians. Members of the Society can remind colleagues of the importance of burnout reduction strategies. Colleagues can emphasize to each other, the benefits of regular aerobic exercise, appropriate nutrition, the mastery of relaxation skills; such as diaphragm breathing, progressive muscle relaxation, visual imagery meditation, yoga and biofeedback. Society members might sponsor workshops and seminars on conflict resolution, team building, communication skills and anger management. Colleagues can encourage each other to explore spirituality and prayer as a way to manage stress.
Decreasing physician isolation is the most effective intervention currently available to reduce the silent epidemic of Physician Burnout and Compassion Fatigue.

About the Author

Dr. Martin E. Keller, ED.D, ABPP, FAACP is a Diplomate in Clinical Psychology and a Fellow of the American Academy of Clinical Psychology. He is in private practice in Paradise Valley, Arizona where he provides consultation to physicians, as well as individual, couples and family counseling to adults, adolescents and children.