Physician Burn Out and Suicide

I often feel alone.  Like a soldier on the front lines.  I’m working in clinical medicine with patients increasingly desperate with the lack of physicians and waitlists.  Of course I sometimes believe we have the largest bureaucracy in the history of health care with Committee Cancer and all the other waste of mismanagement.

Pamella Wible MD has been studying physician suicide.  Apparently our ‘perfectionism’ and ‘conscience’ are problematic especially when we aren’t given the support to achieve the unreasonable expectations of patients and leaderships. Increasingly the patient wants us to heal them while the authorities want us to do the least at the greatest saving to the system.  It’s like being a soldier again, on the front line, and they are handing out 3 bullets and telling us not to shoot.  The patients always turn their attack on the physician they see because the elite are so far removed in Space Stations feeling their Ivory Towers were no longer safe.  

It was great to learn too that the ‘disruptive physicians’ are indeed being scapegoated in most cases for the broken system. The principle problem is indeed the ‘blame and shame’ management of administration. Rather than address the crisis they persist in their antiquated 19th century management approach to law and administration by standards ‘cover your own ass’ bureaucratic strategizing and looking for an ‘indivdual to blame and shame’.  

The burnn out figure for physicians is 40% and often more than 50%.  That means there are literally hundreds of thousands of burnt out physicians functioning all across the US and Canada.  These are primarily the people in the front line. The worst hit are emergency doctors. The quip on the tape was ‘you don’t see many 60 year olds practicing emergency medicine’.  Dermatologists are by contrast fairly happy like pediatricians because of job satisfaction and reasonable re imbursement. As long as I’ve worked their has been ‘wage control’ on doctors with all the savings of our increased training education and skill being skimmed off to pay the outrageous costs of swaggering smiling CEO’s.  Burnt out physicians are at highest risk for making mistakes, depression, suicide and alcoholism.  No surprise, the ‘stress’ of the work causes addiction behaviours.  Not vice versa. PTSD is prevalent and it was found in the military the guy who bayoneted the other guy was at highest risk of developing PTSD and a third of these front line folk got addiction disease without any genetic contributions being found.  So despite what the ‘suits’ say it’s tough seeing patients.  The least likely to suicide are those in administrative medicine and doctors who have least contact with patients like radiologists or lab doctors. I expect pathologists have a pretty good gig too. 

But of course, the ‘blame the victim’ mentality prevails.  Instead of compassionate consideration that there is an endemic and epidemic stress level individuals who speak out about the gross inadequacy in leadership and often actual corruption these ‘whistle blowers’ are literally hounded and punished severely to maintain the delusions that the ‘emperor has new clothes’.  A brilliant study of the last Liberal Ontario Provincial government showed that the administration literally wasted ‘billions’ of health care dollars  by having a little chair shuffle on the Titanic.  No improvement in health care before or after the several years of changing names and meeting places for the duplication and triplicating of self serving leadership.

The suicide rate in the military was considered an epidemic when it rose past  23/100,000 but doctors are dying at a rate of 40/100,000.  And all they get is ‘blame and shame’.  They are also encouraged to exercise. 

The reason I’m happy to hear this is because I’ve been reporting the ‘systemic’ problem and the gross mismanagement of resources for years with constant back lash sometimes by individuals actually diverting clinical care money into their own pockets.  All the while I’m told I’m a bad doctor and that I shouldn’t  swear.  (I’ve been known to pull out my hair and scream ‘fuck!’ Or “I”m not going to take this shit anymore.    I love my female colleagues who have taken to keening in the hallowed halls.  We’re considering consulting those fellows who have learned to talk with gophers, chimpanzees and dolphins and such in the hope that they might learn how to communicate with management.   We need a Star Trek Unversal Translater or a Hitchhikers Guide to the Galaxy Babblefish because they don’t seem to be hearing the screams on the people.  “Give them cake,” is no longer a good answer even if today the new twist is  ‘Give them pot’.   There one skill appears to be pointing fingers and apparently they are selected for this one quality.  These are people who haven’t seen a patient in decades, see selective patients from Potempkins Villages  and are surround  themselves with echoing sychopahts., so out of touch with clinical reality as to be deemed psychopathic or psychotic, all the while Rome burns and Nero plays his violin.

Yesterday I listened to this presentation driving the 1/2 hour commute to and from work that because of the construction and bike lane chaos in Vancouver is now 2 hours making my previous 9 hour day job 13 hours a day.  

So I have hope.  Maybe physicians can finally stop metaphorically pouring gas over themselves and setting themselves on fire to bring attention to the systemic failures. Dr. Robert Hare studied Corportate Leadership to address the tendency for certain types of systems to promote sociopaths to leadership. The problem too was ‘bullying’ by physician leaders of physicians. This same problem had been noted in police organizations.  Wow.  Someone is  seeing the envy and petty small mindedness for what it is and naming it and actually looking for the ‘identification for the aggressor’ types who make the best ‘Capo’s’,  a term used to describe management strategies used by the Nazi’s. 

  

One step a head of the crowd and you’re a leader, two steps ahead of the crowd and you’re a martyr. I was thankful hearing the presentation as I felt less like a voice crying in the wilderness. The American Medical Association is putting millions into addressing this problem now and the take home point was simply that the whole of the present health care system was about to collapse unless management did something to address their own inhumane abuse of physicians.  In my minds eye I saw the German Army in Russia in winter and Hitler shooting the ‘messenger’ who told him ‘you have to send the troops overcoats.”  It was said that the British won the war because they cared for their people.  

I have hope.  Despite the commute, tt was a good day in the clinic.  

Translating Cochrane Reviews to practice - Linda Gowing - ISAM 2013 - Kuala Lumpur

Systematic reviews are focussed, respond to a specific question
Grading - assesses the strength of evidence - high, moderate, low, very low

Eg. Buprenorphine vers adrenergic - completion of treatment

Who do you defer to, Doctor?

I was asked the question, "Who do you defer to, Doctor?" by a lawyer in a court case.  It caused me to pause.  I was being asked about the care of my patient.  I was a generalist, a specialist and a sub specialist.  I knew that the lawyer seemed to consider some 'hierarchy' applied to doctors as it presumably does among lawyers and certainly is a matter in the military.
It probably pertained when I was an Assistant Professor at the University too.
But it wasn't relevant in that way to clinical medicine.
I said, "I don't defer to another doctor, unless he is willing to take responsibility for the patient and assume full accountability."
Indeed, that's what clinical practice is about. It's all in the relationship.
I thought about the question overnight.  Clearly I defer to God.  I defer to authority in a governmental sense but in regards to patient care, again it's different.
The lawyer asked specifically about someone who is high profile in the court system.  I found that interesting because again clinically the lawyer couldn't grasp that 'big guns' and 'little guns' weren't a matter of much substance in my clinical world.
I do have a constellation of characters who I admire and respect and would on specific questions seek their advice and probably accept this though in the end it would be a consultation. In a consultation I can disagree and go my own way with greater risk and responsibility once I'd asked for advise and chose not to follow it.
I have a host of doctors, though fewer as I've grown in years and experience, who I consider have more specific experience than I do in a particular area.
I am a psychiatrist in the general sense but am a subspecialist in the area of addiction with certification and extensive experience.  I routinely seek advise of colleagues who have more experience with a particular kind of patient. I have a half dozen doctors who are certified in addiction medicine, some of them psychiatrists even, but I don't think of them as 'superior' to me.  I think of their individual training as comparable in many instances as mine but think more about them in terms of numbers of cases diagnosed and treated.  I also think of their outcomes and most importantly the complexity of cases.
One fellow is particularly good with heroin addicts, but of two doctors I know one is more experienced with abstinence while another is more experienced with harm reduction therapies.  Another doctor has far more experience in sex addictions than me and there is one character locally and another in the next province who know more about gambling addiction than I can ever hope to know. Yet I don't think any of them know more about 'addiction' and the diagnosis and treatment of addiction than I do in my addiction psychiatry work.
In my psychotherapy practice I have subspecialised in trauma and especially with those in recovery, the 'dual diagnosis' group and don't really know another psychiatrist who shares my particular approach to this group, a mixture of 12 step facilitation, dynamic spiritual therapy focussing on the anxiety and isolation components.  I know others who work with a similiar population but their particular approaches to treatment are often different but I think they may get similiar results.
I have another niche where I am commonly sought for advise and that's where patients have major medical problems coupled with psychiatric disorders. The psychopharmacology of this subset of patients is particularly difficult.  Patients with head injury and an anxiety disorder or depression and a seizure disorder, kidney disease and psychosis.  These are a particular group of patients who I found that a colleague was also commonly seeing and I've benefitted from his specific insights.
I don't 'defer' to these colleagues in a 'deferential' sort of way except one lady doctor who has specialised in the treatment of pregnant patients with psychiatric disorder.  And come to think of it I would defer to her and do. It's an area of psychiatry that I really have limitted experience to hers.  There's definitely some areas in psychiatry in which I probably do 'defer' now that I think of it but they're areas like that.  Child psychiatry and Geriatric Psychiatry. The latter is a subspeciality area that requires more training certified geriatric psychiatrist would see far more patients over 75 years old than I do. Right now I only have a half dozen in my practice and may have seen less than a hundred in my lifetime.  In contrast my female colleague in geriatric psychiatry is not only a great clinician but she's my age and has being seeing old people as long as my other colleagues has been focussing solely on children.
So yes I do 'defer' in these cases and would surely and do surely defer to other specialists outside my own area of specialization. Hence I'm forever deferring to orthopods, surgeons, cardiologists, endocrinologists, rheumatologists, and urologists etc.  There are however some areas of overlap in neurology for instance. I do defer to neurologists commonly but there's some areas where my own experience and expertise cause me to feel that the area of overlap might be more in my peculiar bailiwick than that of a neurologist. This is true for pain specialists and occupational health specialists.  There are little overlapping territories where I acknowledge that the two of us might have equal expertise despite coming from wholly different backgrounds.
The matter of responsibility and accountability is always at play. There are commonly alot of 'adjunctive' players in the field but when the ball is dropped I'm very much aware of whether I'm going to be stuck holding the ball.  Alot of people who refuse to carry the ball really want to tell you how a ball should be carried. I'm more aware of these with age and experience.  Monday morning quarter backs and and arm chair philosophers.
The question was a good one. Lawyers are astute and I am thankful for the questions they raise and the opportunity their questions give me for self examination and further learning.  When personally I've need a lawyer I've been rather deferential to him or her though know that in the end I'm going to be the one who is ultimately accountable.