Doctors

For many, burnout is always around the corner. How can you keep your life in balance when your job is a black hole?

It took a freak accident to get pediatrician Betsy MacGregor to do something about a life on the verge of breakdown.

MacGregor had always been passionate about her job, and for 15 years she thrived as head of adolescent medicine at Beth Israel Medical Center in New York Center. Working with teens, she says, taught her that medicine should treat the whole person, not just the disease. So engrossing was the job that she was routinely putting in 60- to 70-hour weeks, bringing home paperwork at night and on weekends -- to the dismay of her husband and two children. "The problem was that I loved my work too much," MacGregor says. "It was too demanding. I was obsessed with it."

MacGregor realized her life was perilously out of balance. She felt increasingly guilty about not spending enough time with her family, but tried to shrug it off as simply part of being a physician. "In the back of my mind, there was a little voice saying, 'Slow down, slow down,'" she says. "And I kept telling myself, 'Yes, I will, just not right now. I have too much to do.' "

Then, while riding a bicycle in the country with her 6-year-old daughter, the physician took a nasty spill. She recalls flying over the handlebars and blacking out; she came to in a pool of blood, her distraught daughter by her side. She had broken her jaw in three places, an injury that took two months off work to heal. Her jaw was wired shut, and it was weeks before she could even talk. But the long healing period finally forced her to take stock of her frenetic life. "Before the accident I wasn't listening to my body," she says. "But after I broke my jaw, I felt life had confronted me. It gave me the time to reflect on things."

In that sense, MacGregor is grateful for her accident. During her rehabilitation she received some sage advice from fellow physician and friend Rachel Naomi Remen, who began her career as a pediatrician and now works with cancer patients as well as doctors. "I remember her telling me how important it was to take the time to replenish myself so I'd have the resources to give to others," MacGregor says. Struck by Remen's words, MacGregor resolved to make some changes in her approach to work. "I was on the road to burnout," she says. "If the accident hadn't stopped me, something else would have."

Under pressure

Medicine is a dangerous business. Infectious diseases, violent patients, accidents on the job, and other hazards have shortened the careers -- and, in some cases, the lives -- of many physicians. Doctors take steps to stay safe on the job, but stress is one threat that can never be completely avoided. Loss of autonomy, longer hours, heavier workloads, shrinking paychecks, greater bureaucracy, and less time for patient visits -- all hallmarks of recent changes in the field -- have all contributed, observers say. And even if doctors have all the time they need, treating critically ill or dying patients --- and breaking bad news to their families -- takes its toll. No matter how well they're trained, no matter how careful they are, no matter how committed and idealistic they may be, most physicians are going to face extreme stress.

Research on physician stress shows just how widespread the problem is. Case in point: Of the 1,205 doctors surveyed by the American College of Physician Executives in 2006, 46 percent rated their morale as 5 or less on a scale of 1 to 10 (10 be very high morale). The same survey showed that close to 60 percent of doctors have considered leaving the practice of medicine behind. Nationwide, physician insurers have also seen disability claims by doctors soar. Says Donald Rosen, director of the Menninger Leadership Center and its Professionals in Crisis program: "The level of dissatisfaction in the profession is tragic."

Physician Brian Burke didn't feel that way when he started his career. From his first days of medical school, he felt he would thrive where other doctors failed. He would run a family practice, see a few dozen patients a day, make brilliant diagnoses, win battles against insurance companies, and come home satisfied after a job well done. He knew other doctors buckled under the strain of modern medicine, but he wasn't other doctors. "I was convinced that I had the gift to surmount any problems," he says.

Burke started working as a family doctor in Portland, Oregon. Two years later, he quit. "I was working 11 hours a day, and three or four of those were paperwork," he says. "My personal relationships were suffering, and I started blowing up at people in the office. After a lot of soul-searching, I decided I had to leave." He is now thriving in his job as an occupational medicine specialist.

Battling burnout

Burke's story is nothing new to John Christensen, PhD, a clinical psychologist with Legacy Portland Hospitals in Portland. Christensen helped found the Northwest Center for Physician Well-Being and has counseled doctors for the last 18 years. In that time, he has seen many become very ill and burned-out from stress. He's also seen many doctors who conquered the stress and stayed at their patients' bedside, doing what they do best.

According to Christensen, the root of the problem often comes down to one thing: control. Whether you're a doctor or a secretary or a piano tuner, your stress level is directly related to the amount of power you have (or at least perceive you have) over your workload. In a survey of more than 600 physicians published in the Western Journal of Medicine, the perception of control was the single strongest predictor of burnout.

In today's practices, many doctors can feel their control slipping away, Christensen observes. With administrators and insurance companies calling so many of the shots, doctors "have less control over their schedule and the management of their patients," he says.

The toll of stress

After countless therapy sessions with physicians, Christensen can quickly spot the hallmarks of stress. Early signs of trouble include sleep problems and irritability. More than a few physicians start snapping at their staff for no good reason. If the stress isn't brought under control, it can quickly lead to burnout -- the point where it's hard to face another day of work. Doctors in this stage tend to think of themselves as objects instead of people, Christensen says. They may robotically go through the motions, but, in a sense, they've already checked out.

Like anybody else in a high-pressure job, physicians are vulnerable to a wide variety of stress-related health problems, from colds, headaches, and stomach trouble to depression. As reported in the Western Journal of Medicine, 8 to 12 percent of health professionals develop substance abuse problems at some point in their lives. And, shockingly, suicide rates among doctors are two to three times higher than average, according to a report in the Annals of Internal Medicine.

When doctors suffer, so do their patients. On-the-job stress is driving many talented, compassionate doctors out of the field of patient care. And according to a report in an issue of the American Medical News, the newspaper of the American Medical Association, stressed-out doctors are more likely to make poor medical decisions or even outright mistakes.

Heal thyself

It's easy -- and often justifiable -- for stressed-out doctors to blame the system, but many of them also need to look inward, Christensen says. The personality traits that brought them to medicine in the first place and helped them excel in medical school can drag them down in the real world. Specifically, many doctors are saddled with doubt, guilt, and an exaggerated sense of personal responsibility -- what Christensen calls the "compulsive triad." "They are rewarded for being compulsive, but it comes at an enormous personal cost," he says.

But there are definitely things that doctors can do to help protect themselves and even rediscover the joys of medicine. For starters, Christensen recommends the classic stress-busters: getting enough sleep, eating right, and exercising. Ironically enough, doctors also have to be encouraged to see a doctor regularly. "At least one-third of doctors don't have a primary care physician," he says.

Many doctors also need a readjustment in outlook, Christensen says. Instead of trying to control everything from their patient's lifestyle to office policies, they should strive for "influence." They also need to develop a tolerance for change and uncertainty. To counter feelings of guilt, they need to be generous with forgiveness, both to themselves and to others.

And ultimately, many of them need to find some help. Whether in the form of one-on-one therapy session with a psychologist or a retreat with hundreds of their peers, a little support can go a long way. "Many physicians can restore the balance between their personal and professional lives," Christensen says, adding that that often rekindles their passion for work.

Betsy MacGregor can attest to this. After she recovered from her accident, she eased back into her job at Beth Israel, but never returned to her previous hectic pace or to carting work home. "The kids were much less irritable and there was less tension when I was around," she recalls. "I wasn't constantly disappointing them by postponing things."

She also made time for herself, pursuing stress-reduction techniques such as meditation, relaxation, and biofeedback, and has incorporated them into her practice. She founded a complementary medicine program and resigned as chief of adolescent medicine to focus on end-of-life care, collecting stories from dying patients to better understand what they go through.

"The opportunity to become a student again, to learn from people at the end of life, is very exciting for me at this point in my career," MacGregor says. "For me, doing something different like this helps to keep my profession alive." Every day, she says, seems new and fresh.

Further Resources

Resources for doctors are now available across the country. For more information on getting help, see these sites:

Center for Professional Well-being

919-489-9167

Center for Physician Renewal, 253-351-8577

Professional Renewal Center

Physician Wellness Foundation, WellDocs@aol.com, 805-528-7586

References

Interview with Brian Burke, an occupational medicine specialist

Interview with John Christensen, a clinical psychologist with Legacy Portland Hospitals in Portland, Oregon

Interview with Betsy MacGregor, head of adolescent medicine at Beth Israel Medical Center in New York Center

Physician, heal thyself: Survey of users of the Quebec Physicians Health Program. Oct. 1, 2010.

Steiger, Bill. Survey Results: Doctors Say Morale is Hurting. The Physician Executive. November December 2006.

Burnout. The Doctors Page. http://www.doctorspage.net/satisf.asp

Gundersen, L. Physician Burnout. Annals of Internal Medicine. July 17, 2001. 135(2): 145-148.

American Medical News. Cost of Living: Stress is the price you pay for being a physician. April 22/29, 2002.

Freeborn, D.K. Satisfaction, Commitment, and Psychological Well-being Among HMO Physicians. Western Journal of Medicine. January 2001. 174: 13-18.

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