Editor's note: Part 1 of this two-part series reported that too many doctors are struggling with stress, and that too few organizations are helping them. Part 2 argues that temperament and training, while often making physicians their own worst enemies on the psychological firing line, might also be their best weapons for remaining happy warriors.
In 1999, Dike Drummond was 40 years old, a small-town family doctor in upstate Mount Vernon, Wash. He had a lucrative practice, a high-powered role as chairman of a 40-physician medical group, a loving wife and two children … and the glum, foot-dragging demeanor of "a guy going to chemo," he recalls. Although healthy enough physically, "All the joy had gone out of my life."
Like almost every doctor, Drummond had reached a point in the trajectory of a demanding career where internal and external stresses had become overwhelming. But there was no one to whom he could explain his misery, he believed, no one who could sympathize or understand what the "rich, successful, respected doctor" of their projections could possibly have to complain about.
"Nobody reached out," he says. "I decided to quit medicine."
Enough to Populate Pasadena
There are about a million physicians in the United States. Fewer than 400,000 say they're "very satisfied" with their professional life. That's according to a 2008 survey, which found that another 400,000 would consider themselves at least "somewhat satisfied" — which, for their families, patients and organizations, must be a bit of good news. But that left more than 150,000 who described themselves as somewhat or very dissatisfied — a population of sullen, disaffected doctors that could fill Pasadena, Calif., or Syracuse, N.Y.
The problem begins early. In the cauldron of medical school, according to a 2007 study, at least half of all students experience burnout at some stage, and each year 11 percent consider suicide (a tragic percentage follow through). During their grueling residency, anywhere from 41 percent to 90 percent of newly fledged doctors, depending on specialty, go through serious bouts of burnout. Among practicing physicians, numerous studies have calculated the burnout rate to vary from a third to as high as 60 percent at any given time.
Indeed, summarizes Drummond, "the lifetime prevalence of burnout for a doctor is 100 percent!"
Those were the kinds of dispiriting statistics Drummond confronted when he searched the Web for information on how to deal with his anguish. He was looking for help in understanding, contextualizing and coping with emotions even he found puzzling and shameful. Lack of enthusiasm for the work, indifference toward patients and colleagues, a sense of abject failure … those are the primary symptoms of burnout, and they contradict everything in the character and training that shape the self-identity of a physician.
"We're workaholic, superhero, emotion-free, Lone Ranger perfectionists," Drummond observes. Those characteristics are hard-wired into medical students by what he styles "the most thorough conditioning program on the planet." They're "actually functional — even essential — when we use them to get through a rough night on call or a particularly onerous clinical rotation." They are not, however, "a great way to be in a loving relationship, raise your kids, get your own needs met or live your life."
The toll of that dichotomy on the profession is apparent. In a 2012 survey of U.S. physicians, 16 percent said they were cutting down to part time, retiring, quitting medicine cold or seriously considering doing so. Half of those who actually planned to bail within the year were younger than 55. (That works out to nearly 600 exhausted, discouraged doctors potentially throwing away decades of productivity every single week.)
Before he cut the cord, Drummond tried a one-month sabbatical. It didn't help. Then he gave notice to his group and spent a year "developing tennis elbow" casting into fishing holes. He set about checking off items in the bucket list he'd fantasized during the bleakest moments of doctoring. Still unfulfilled and needing to return to breadwinning, he took part-time work in urgent care clinics. But he was truly burned out; the stints were soul-sapping. So when family financial circumstances at last made it feasible, he gave up ordinary patient care altogether and got himself a new credential.
"I'm still a doctor," he says. "My first loyalty is to save lives. Burnout kills people. Now my patients are doctors."
Reinvented, trained and certified as a personal life coach, Drummond today advises organizations on how to prevent burnout among staff physicians and counsels individual doctors who are in the throes of burnout, considering a change of career or who have been deemed disruptive by medical groups that want to rehabilitate and retain them. Through his website, theHappyMD.com, and an email list of almost 1,800 subscribers in 63 countries, Drummond offers tips on how to reduce job stress and recharge. Like many professional coaches, he gives free half-hour introductory sessions. And he leads small-group retreats for troubled doctors in Washington's San Juan Islands.
Peer Support at Brigham & Women's
More than half of America's major corporations provide personal coaching for leaders and emerging leaders — akin to the coaching athletes rely on even at the height of their careers — aimed at strengthening emotional intelligence, resiliency and self-awareness, according to Gail Gazelle, M.D., a professional coach and assistant professor of palliative and hospice care at Harvard Medical School.
Health care organizations? Not so much, she sighs.
One that does — as part of an extraordinarily broad and proactive program of professional and peer support for clinicians — is Boston's Brigham and Women's Hospital. Under the direction of Jo Shapiro, M.D., Brigham starts by requiring every one of its 3,000 physicians to attend a one-hour session on professional behavior — what's expected of them at Brigham and Women's as team leaders and team members, so as not to contribute to the burnout of colleagues or to endanger patients.
Next comes a half-hour program co-facilitated by Shapiro titled "Mindfulness and Work-Life Balance." Participants are on the clock, which, Shapiro points out to them, "really says a lot about the commitment of the institution. The reason they pay me and support your not working [while you're here] is an explicit way of showing this matters!"
Maintaining civility, trust and morale among clinicians at Brigham and Women's is deemed so important that more than 60 physicians have been trained as "peer supporters" to suss out and buttonhole colleagues throughout the organization who are even potentially subject to distress.
"We're normalizing the possibility that anybody can need help," Shapiro explains. The peer supporters — who are themselves doctors but not mental health professionals — respond to incidents and tips from concerned staffers by immediately "reaching out," especially after an adverse event occurs — an arduous but unsuccessful operation, perhaps, a medical error or a traumatic trial-by-gore for responders like the bloody terrorist bombing at the Boston Marathon.
"We're trying to be more upstream," declares Shapiro — not allowing causes of burnout to fester. "Physicians have been acculturated to be strong and emotionally resilient," she notes. "For a doctor to admit, 'I'm hurting,' is countercultural." They do, however, tend to open up to another doctor, she says — a peer trained to step forward and quietly suggest something like, 'I heard such-and-such happened yesterday. A lot of us have been in situations like that where we've felt it helpful to talk to a colleague. Do you think it would be helpful to you?' " There's no pressure," she adds.
Those who ask for more formal backup in figuring out how to juggle the apples and dodge the darts thrown at them by life may be referred to a coach like Gazelle. Her approach is "strength-based." That is, she explains, "Coaches don't 'fix' problems; instead they point clients in the right direction to find answers." (Drummond draws this distinction: "A therapist typically looks backward for causation. Coaching doesn't care. A coach asks, 'What do you want? What are you going to do to get that? See you next week.'")
"The coach's role is one of nonjudgmental advocate, ally, sounding board and champion," amplifies Gazelle. "Many times coaching is transformative!"
A Psychological Travel Service at Vanderbilt
Vanderbilt University Medical Center in Nashville, Tenn., has been another pioneering organization in promoting confidential help for physicians and faculty struggling with life-balance and burnout issues. The Center for Professional Health is highlighted in every orientation, notes Mary Yarbrough, M.D., Vanderbilt's director of health and wellness. Some 300 clinicians and researchers take advantage of its services each year — most of them, she says, on their own initiative.
"Physicians are like everybody else," she observes. "They have the same rates of depression, the same risk of alcohol and drug abuse … but what's problematic for them is the stigma. They're supposed to have all the answers."
In most health care organizations, she suggests, doctors come to the attention of the wellness committee only when they've surfaced as discipline problems. "The difference with us," she says, "is the majority of our staff see our program as a place they can go to get support and outside insight into how to be more effective in life." Bowed down by the weight of competing job and family demands, scrabbling for funding if they're doing research, caring for sicker patients with less time and taking on leadership roles where "all the rules meant to protect everybody else don't apply to you" — those are what impel clients through Yarbrough's door.
(Senior physicians especially, she worries, are losing the emotional safety net of caring for at least a few healthy patients and seeing at least some normal outcomes that let them say, 'This is work I've done well.' "Our organizations," she asserts, "have got to build in a way for physicians to get a smile during the day.")
Unlike Brigham and Women's, Vanderbilt relies on psychiatrists, backed up by psychologists and credentialed counselors, as the first line of contact when a doctor turns for off-the-record assistance from its Center for Professional Health.
Physicians are most respectful of the judgment of a psychiatrist, who is, after all, a doctor like them, reasons Yarbrough. And all physicians tend to have "VIP syndrome," she adds. "If you needed heart surgery, would you go to see an infectious disease specialist? The best diagnosis, for me, comes from the person who's best trained to make it."
After the initial psychiatric assessment, clients at Vanderbilt are referred to an appropriate, carefully vetted resource like a personal coach, a marriage counselor or, when there are alcohol or drug problems, a suitable program.
"My manager says we're a travel agency for psychological services," says Yarbrough. "Our goals are to get the right diagnosis, then connect the client with the right resource, and then follow through."
Maybe Spring for Coffee
For all the personal and professional traits doctors have that feed burnout, they can benefit from a couple of highly protective attributes.
First, they're smart.
"These are the best and the brightest," says Drummond. "If you show them something, they learn it really fast."
Second, they have a job that's also a career and a calling.
"A job," explains New York Times bestselling author Rachel Naomi Remen, M.D., a clinical professor of family and community medicine at the University of California, San Francisco, "is what you do to get money … . A career is what you do to get power, recognition, influence … to become a force in your field. A calling is work in which you get to express every day the deepest values you have as a human being. It's what you'd pay them to let you do."
Echoes of the calling that drew them into medicine will fade periodically for every doctor. That's when they need strong reminders of how to mute the daily cacophony that has drowned those echoes out. "If 50 percent of your work has deep meaning to you," Remen says, "the other 50 percent you can do without burning out. It's the experience, not the nature, of the work [that's the key]."
Radiologist Richard Gunderman, M.D., another physician writer who teaches at Indiana University School of Medicine, agrees. In an essay in The Atlantic last year, he argued that "if we are genuinely concerned about physician burnout, we need to focus less on reducing stress and more on promoting what is best in physicians: compassion, courage and, above all, wisdom."
Fine words. How can health care organizations give them substance?
In 1996, Remen, founder and director of the Institute for the Study of Health & Illness in Bolinas, Calif., invited four physician friends to join her one evening to exchange thoughts and anecdotes about what enables them to find meaning in their work. The group, which called itself Finding Meaning in Medicine, continued to meet for two hours each month — and they've been doing it for 17 years. What's more, they've expanded and split — "almost like mitosis in a cell," Remen reflects — eight times. Some of the splinter groups now have as many as 40 members, of whom perhaps 15 will show up at any one gathering with "the price of admission: a story from your work."
Initially, says Remen, "I didn't think hospitals would support something like this, so I worked out a way doctors could help themselves. All you need is four or five friends and a meeting room."
In fact, Finding Meaning in Medicine groups have proliferated across the country. [A resource guide for starting and running a Finding Meaning in Medicine support group.]
"Lots of medical schools now do it with faculties and residencies," Remen reports. So do many hospitals, despite her low expectations. Usually that's because a faculty champion or perhaps the head of a hospital division started the ball rolling, she notes. "You don't send a letter out to 100 people. You start with a single doctor and ask him or her to invite four friends. They tell other people and the group starts to grow … and splits when it gets too large.
"It helps if the hospital is willing to give dedicated time to it," she adds (that is, allow doctors to participate during paid hours). "But mostly it's people organizing on their own.
"In some ways this is more powerful than rocket science," she exclaims. "It's a form of self-care. Of caring for the soul of the doctor. We forget we are each other's strengths."
In Indiana, Gunderman derives the same sense of renewal from regularly hashing out thoughts about the history of medicine and philosophy with a group of physician colleagues who belong to one of two book clubs sponsored by the school of medicine.
"It sounds crazy," he admits, "but if we can help medical staff, associations and hospitals convene these kinds of discussions, I think we can make some inroads into the problem of burnout. People are often hungry, without knowing it, to talk about what's fulfilling in medicine and the impact we make on people's lives. A lot of us really benefit. And you don't necessarily need a million-dollar grant from the government to start a book club." He chuckles. "Of course, it's nice if the administration gives you a room and buys the books — and maybe springs for coffee."
A Business Case for Joy
A space, some books and a pound of coffee invested in reinvigorating exhausted doctors might be a health care organization's most cost-effective expenditure ever.
"It's really going to be a loss to the patient population if we can't figure out how to have more compassion for our physicians," frets Vanderbilt's Yarbrough. "But I don't hear that at the meetings I go to with administrators. You only hear it in the medical groups."
"Outside health care," says Drummond, "in almost any industry-leading corporation, the mantra is: 'The reason for our success is that we hire the best people we can find and we treat 'em great.' Inside health care we abuse 'em until they fall down. To administrators, turnover rates and whining docs are just the way doctors are!
"One physician," he continues, "put it to me this way: 'Every day we go to work, we go off into our little individual gerbil cages, we run like crazy on our little individual gerbil wheels … and every once in a while one of us drops. And the administration makes every effort not to notice.'"
"We have to sound the alarm!" asserts Brigham and Women's Shapiro. "That's what we're working on here. Even though we have a lot of challenges as a profession, it's also an honor to do it. We need to help reconnect people with the joy of being a physician."
"The workplace that creates a staff of happy doctors will immediately find itself with a significant competitive advantage," insists Drummond. "There's a massive business case for this. If you're not improving things on the front line, you're really missing the boat!"
David Ollier Weber is a principal of The Kila Springs Group in Placerville, Calif., and a regular contributor to H&HN Daily.