Nice article on what we, physicians, can do to maintain or rediscover the joy in practicing medicine.  Enjoy!  -Ed

Physician Burnout: The Four Horsemen of the Burnout Apocalypse

by DIKE DRUMMOND MD

Physician Burnout: The Four Horsemen of the Burnout Apocalypse

Physician Burnout is a constant, prevalent, looming threat over doctors everywhere. Over the last 20 years surveys have shown an average of 1 in 3 doctors suffering from physician burnout on any given office day – worldwide, regardless of specialty. The question is why?

Yes, the nature of our work is difficult, stressful and draining AND there are other parts to this Venn Diagram of physician burnout – and some of them are hidden.

In my work with hundreds of over stressed physicians I have isolated one of the major invisible causes of physician burnout – the pervasive mental conditioning of our training process.

Call it the “brainwashing” of our medical education if you will

In this article I will show you four “flavors” of this conditioning – how and why they develop and how they contribute to our physician burnout epidemic.

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The Brainwashing of Medical Education

Yes, indeed, we are most certainly brainwashed by our medical education.There is a set of attitudes and behaviors that are expected of us while in training that become subconscious and automatic by the time we are board certified.  These automatic behaviors set us up for physician burnout in private practice.

Here are the four flavors I routinely see in my over stressed physician clients.

NOTE: None of our instructors, professors or attendings has ever tried to “brainwash” you consciously and on purpose. The expectations and attitudes that create this subconscious programming are built into nearly every facet of our medical education as NORMAL and “the way things have always been done around here”.  To most physicians in private practice the programming is invisible and unrecognized and the automatic behaviors it produces are dysfunctional and baffling. You will see in a second why this “brainwashing” virtually guarantees physician burnout in your 40’s and 50’s if it continues to sit in your blind spot.

The Four Horsemen of the Physician Burnout Apocalypse

Here they are in all their glory … see if they feel familiar to you.

=> Workaholic
=> Superhero
=> Emotion Free
=> Lone Ranger

These four behaviors are actually functional – even essential – when we use them to get through a rough night on call or a particularly onerous clinical rotation. However, they go much deeper than that in most doctors.

The process of becoming a doctor is so extremely challenging to most of us that we cannot help but feel our survival is threatened from time to time.So these four behaviors/attitudes get driven into our mental programming as a Survival Mechanism. We learn them at a deep subconscious level and can’t turn them off.

How deeply are we brainwashed?

Basic training in the military is 8 weeks. In that time they can condition an 18 year old to take a bullet on command. Medical education is a minimum of 7 years. (how long did it take you from your first day in medical school to your first day in private practice?) I believe there is no more thorough conditioning program on the planet than becoming a doctor.

If your only tool is a hammer, every thing looks like a nail

– and that is the problem. Not everything in a doctor’s world is a nail … especially after you graduate to private practice and the rest of your life. Physician burnout results when these four become “overused strengths”.

Being a workaholic superhero emotion-free lone ranger is an absolute requirement to make it through a 72 hour shift in your residency and it is NOT a great way to

- Be in a loving relationship

- Raise your kids

- Get your own needs met

- Or live your life

I help my clients see this conditioning when it appears as automatic behavior that is driving their physician burnout …

– when they are using this set of hammers to drive things that are NOT nails.

Here are a few examples:

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=> When your only response to a challenge or “problem” in your practice is to work harder — that is your workaholic programming. I can assure you there are other ways to address almost any practice issue that do NOT involve you personally working harder.

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=> When you feel like every challenge for your patients, your staff, your family and yourself sits on your shoulders and you “should” be able to solve them all — that is your Superhero programming. You are human. You are not a god. Learn to say, “I don’t know the answer to that” or “I wish I could help here, I wonder what you will decide to do?” and let things go that are outside your control. Breathe.

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=> When you have strong feelings of fear, sadness, anguish, helplessness, love, joy, compassion, empathy … don’t stuff them.That is just your emotion free programming . AND please don’t feel guilty for having them in the first place. You are human, you will have feelings. This is part of what makes life rich, juicy and worth living. Let them flow. Don’t bottle them up. And never be afraid to tell someone what you are feeling in the moment – especially your work team – it lets them know you are not superhuman.

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=> When you micromanage, can’t let things go and drive you and everyone around you crazy by having to do everything yourself — that is just your Lone Ranger programming. Yes, you are ultimately responsible for the outcomes in your practice (and your life) and you CAN ask for support. You can delegate and create systems that will take away some of your burden while delivering the quality you demand. It is possible.

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For most of us these four horsemen and their automatic behaviors are deeply subconscious. Remember that you spent a minimum of 7 years installing them in your psyche – deliberately, consciously, through thousands of hours of dedicated study and on the job training. No wonder they poke there heads into all areas of your life – and not always in a good way. AND this is not the only risk factor for physician burnout.

Our Brainwashing is only ONE of the Four Main Causes of Physician Burnout

So the way I visualize the causes physician burnout is like this — and it is a four part Venn Diagram

1) Physician Burnout Cause #1

The stressful, draining nature of the clinical practice of medicine. We have a tough job to begin with. Lots of responsibility and very little control. If clinical medicine was the only thing we had to worry about, physician burnout levels would be higher than a “normal” person — turns out it is only one of the big four.

2) Physician Burnout Cause #2

All the other demands placed on us in private practice that have nothing to do with clinical medicine.
Documentation/EMR, billing, the business of medicine, compensation formulas, practice politics, political uncertainty, our leadership roles we are unprepared for — and many other non-clinical hassles.

3) Physician Burnout Cause #3

The care and feeding of our larger life outside of medicine.
Getting our own physical and emotional needs met, our significant other and family relationships, our personal finances – everything outside of our career. We put this off throughout our training and now our ability to avoid physician burnout hinges on creating this work-life balance.

4) Physician Burnout Cause #4

And last, but certainly not least, our subconscious programming/brainwashing and the four horsemen I have laid out here. Their automatic behavior often throws gas on the fires created by stressors 1-3.  A recipe for physician burnout.

Next Steps:

Here’s a simple way to expose your own brainwashing and lower your physician burnout risk.

Whenever you find an area of your practice or life that is NOT WORKING the way you would like …
Ask yourself:
“How am I perhaps acting like a workaholic, superhero, emotion-free, lone ranger here?”

When you notice one of the four horsemen beneath your automatic behavior in this area …
Ask:
“What might I do differently that will get me more of what I really want?”

As a group serving a diverse community, we should work toward incorporating both models.  -Ed

Concierge Medicine will be driven by looming Doctor Shortage

by DIKE DRUMMOND MD

Concierge Medicine in Primary Care will be driven by the coming doctor shortage

I believe the projected doctor shortage caused by the Affordable Care Act will drive primary care into two opposite tracks

• The “Apex of the Pyramid” Track
• The Concierge Medicine Track

Each is a distinct and logical response to the patient overload from the doctor shortage that is rapidly approaching. Each points out gaping holes in our medical education that must be addressed. Concierge medicine has an additional powerful force acting in its favor which I detail below.

The coming tidal wave of newly insured patients

Association of American Medical Colleges  estimates that there will be a doctor shortage of 63,000 doctors by 2015 and 130,600 by 2025 in the wake of the SCOTUS decision to let the Affordable Care Act stand. This doctor shortage is caused by a tidal wave of newly insured patients has to be served somehow and US Medical Schools and Residency Programs cannot supply anywhere near these numbers of new physicians in this short of a time frame.

How will healthcare markets respond to this doctor shortage – especially with regards to primary care? I see two likely options  – please leave a comment with your thoughts.

1) Volume Driven:  Doctor as apex of a care pyramid

In the more traditional practice structure, the doctor shortage will force the primary care physician to become the leader of a care team supervising a number of physician extenders who provide the majority of the hands on services. The skill and experience of the physician will be saved for the more complicated and severe cases seen that day.

The majority of the doctor’s activity will be devoted to leading and coordinating the care provided by the pyramid of N.P’s and P.A.’s who are their direct reports.

The challenge to this model is the complete absence of functional leadership skills training in most medical school and residency programs. 30-50% of these physician’s time will likely be spent in leadership and management activities for which they are not prepared on graduation.

2) Service Driven: Concierge Medicine/direct care model

As the doctor shortage worsens, the typical patient will begin to notice they are only seen by a physician on rare occasion. A certain percentage will become willing to pay for that privilege. I suspect this will quickly grow to a huge new demand for concierge medicine services, where you pay a reasonable monthly fee to guarantee you are always seen by your doctor.

As the doctor shortage continues to worsens,  I believe a larger and larger segment of our population will become willing to pay to continue to see their primary care doctor as they do today and their only alternative will be concierge medicine.

The huge popularity of concierge medicine will have another important driving force – the office duties of the concierge medicine physician are exactly the opposite of those in example #1 above.

In a concierge medicine practice,  the physician is often seeing less than 15 patients a day, providing direct patient care and continuing to have meaningful personal relationships with their patients.

The challenge to the concierge medicine model is the absence of business training – and specifically marketing training – in most medical education programs. The concierge medicine model is inherently entrepreneurial and will always involve a fairly sophisticated marketing program to be successful.  This is not an insurmountable obstacle and I have yet to meet a newly board certified MD who understands the essentials of marketing.

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So if you have 10 years or more of practice ahead of you, I suggest you look at these models – the pyramid and concierge medicine – and get ready to be met by a fork in the road as the doctor shortage approaches. Will you choose to lead a team or build your cash/concierge medicine practice?

If you are leaning in one direction, I suggest you get started building your missing skill set – be that leadership or marketing. The wave of newly insured patients is coming.