John Garvin may be the longest-serving emergency room doctor in the country. He can’t be sure—he started practicing in Virginia in 1971, before the specialty had residency programs to keep track—but it’s fun to speculate.
He speaks in clipped sentences, with a high-pitched Southern twang. “Medicine is a very demanding mistress,” he says, “and she won’t have you looking at any other woman.”
Doctoring is hard, and working on the front lines of patient care is especially challenging. Stomachs flap open. Blood bursts from where it shouldn’t. Children die. “You have to learn to put those griefs in saran wrap and unwrap them at the end of your shift,” Garvin says. “Whereupon, I hope you will deal with them.”
Most emergency room doctors don’t work full-time past 50, says Bengt Arnetz, a family practitioner and expert in organizational efficiency at Michigan State University. Garvin retired five years ago, when he was 68. He thinks he got out just in time. He knows plenty of colleagues who are cutting their careers short.
Many doctors are leaving medicine early because of how healthcare is changing. Levels of work-related stress among doctors are some of the highest of any profession in the US, even after adjusting for their crazy work hours, according to a recent review in the Journal of Internal Medicine. And it’s getting worse: Between 2011 and 2014, rates of doctor burnout increased by 9 percent, as reported in a widely-cited national survey from Mayo Clinic in Minnesota. Specialists working in emergency rooms and intensive care units top the list. Almost half report symptoms such as feeling emotionally exhausted, less empathetic, or disconnected from the meaning of their work, in a large national survey from Medscape this year.
The plague of burnout has been widely broadcasted in the medical community. “We know a lot about what causes it,” says Arthur Hengerer, a surgeon at the University of Rochester in New York. He’s lost nine colleagues to suicide over his career. “The problem is rectifying it,” he says.
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Doctors, educators, and administrators are experimenting with a heap of strategies to address burnout: promoting individual resiliency, changing doctor’s schedules, and shifting the deeply entrenched culture in medicine that encourages doctors to care for others and disregard their own needs. “This goes against the grain of most doctor’s training, which says patient first,” says Catherine Pipas, a primary care doctor at Dartmouth-Hitchcock Medical Center in New Hampshire. “We have to care for ourselves—that is very much foreign to medical professionals.”
There’s still a long way to go. “When it comes to strategies, that’s in its infancy,” says Marc Moss, a pulmonary critical-care specialist at the University of Colorado, Denver. But addressing this issue is urgent. Two years ago, the surgeon general called it the second-most pressing public health concern, after the opioid epidemic. That’s because burnout is not only bad for doctors, it’s dangerous for patients. Stressed-out doctors are more likely to make mistakes, their patients don’t recover as well, and they're less satisfied with their care, according to a large systematic review from PLoS One in 2016.
You don’t need to take a doctor’s word for it, either—you can measure levels of stress in their bodies, Arnetz says. His research team took samples of blood and saliva from emergency room residents before and after their shifts, and asked them about their performance. The team found that doctors-in-training with higher biological indications of stress reported more medical errors, in a study published in BMJ Open in August. This cycle feeds itself: Doctors who think they’re making mistakes feel worse about their job performance. Distressed doctors make more errors.
Burnout isn’t just bad for the health of doctors and their patients, it’s also costly. Every year, the healthcare system spends $100 million replacing doctors who retire early or take time off, Tait Shanafelt, Stanford Medical School’s first Chief Wellness Officer, told the New England Journal of Medicine in a January interview. And in a separate JAMA Internal Medicine article from December, he makes the case for why investing in solutions to combat burnout is good for business.
Implementing solutions isn’t exactly straightforward, however. “There is not going to be one strategy that fits all,” Moss says. One low hanging fruit is focusing on things that people can do for themselves, like mindfulness, talk-therapy, keeping a journal, and exercise, he says. Medical schools and residency programs across the country are embracing such approaches. Over half offer mindfulness programs to support wellbeing, according to a 2014 survey out of Harvard Medical School.
But efforts strictly aimed at individuals won’t cut it. “We have this culture of ‘pull yourself up by the bootstraps,’” says Annie Robinson, a wellness program facilitator at New York University School of Medicine. “That doesn’t work. We are influenced by the climate we are around.”
Arnetz agrees. ”Most of the intervention is not targeting the organization, it’s targeting the individual,” he says. “You need to look at the system.” As this issue gets more attention, medical centers are working to promote the wellbeing of their staff. Many have started surveying employee satisfaction and burnout, asking questions like if doctors use all of their vacation days, or how often they take their work home. Some offer peer-support programs as a resource after distressing patient events. And efforts to buoy a sense of community are growing, like book clubs and communal gathering spaces.
Even fixes within an organization do not tackle the roots of the issue, says Steven Rosenzweig, an integrative medicine doctor who also runs the student wellness program at Drexel Medical School in Philadelphia. “Burnout comes out of a system that harms its workers and also the people it is trying to serve,” he says. “If you want to start to address it, start looking at capitalism.”
The emphasis on production and productivity drives burnout. “That is the sad situation,” Rosenzweig says. “Practitioners are under enormous pressure to see more people in less time. What gets sacrificed is the relationship with patients.” As long as patient-centered care is undermined, he says, burnout will remain a problem.
The rewards of the doctor-patient relationship is a fundamental part of the job for many doctors. It plays a central role in John Garvin’s theory on how he lasted so long in the profession. He knew the reason patients visit the emergency room—to get treated for a broken arm or find the cause of unsteady breathing, but he wondered about the purpose. Every time he met a patient, he would ask, “Are you here to teach me something? Are we here to influence each other?” There was a magic in that anticipation, he says. Without it, the job isn’t worth it.
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