Retired Doc Fears Burnout for New Recruits

Where are the doctors, nurses and medical staff to be found for these 32 million people?
June 16, 2010 -- Dear Mr. President,
Perhaps my experience as a psychiatrist now retired could be of help as you develop effective health reform services.
On March 30, when the evening news announced that you’d signed the health reform legislation into law, I found myself of two minds. My left cortex celebrated the promise of healthcare for the underserved, while in wonderment, my right cortex asked how the medical profession might address and relieve so great a plight as the present inadequate medical care of our poor.
Studying the fine print offered no specific plans for health reform at our local level but led to a larger question. How can the medical profession, buffeted and disparaged for delay and error in integrating the promise of medical technology, fill the pressing need for physicians that accompanies reform?
Perhaps our government expects the medical profession to reorder its established patient-doctor relationship while expanding the present physician workload to accommodate 32 million more people who now lack full care. This prompts the question, where are the doctors, nurses and medical staff to be found for these 32 million people?
Another question concerns the plight of our primary care specialists. As you know, with aging and relatively low level reimbursement, primary care doctors are disappearing. Will reform protect and sustain our essential front-line physicians?
Inevitably a point is reached where the elemental issues of insufficient and overworked staff diminish the quality of delivered care. Organizational stress, non-negotiable for both the patient and their doctor, can become an alibi for poor care.
The medical profession’s basic question asks how the overwhelming medical needs of millions of new patients can be addressed. There is a real and present hazard existing within any reform that simply passes the added burden of difficult patients onto caring, civic-minded physicians – known as overload. With overload, difficult patients can lead the conscientious doctor to develop the diminished medical morale syndrome – burnout.
Mr. President, I encourage you to consider the danger of burnout as a real and formidable disease capable of threatening reform. Burnout is a contagious social-psychological disease that manifests itself in a constellation of signs and symptoms affecting a physician’s mental, emotional and physical effectiveness in utilizing their clinical skills.
Importantly it surreptitiously diminishes and then destroys the physician’s working relationship with both patients and colleagues. Burnout afflicts conscientious clinicians by slowly and silently destroying professional morale. Without diagnosis and treatment, burnout frequently leads to death by suicide.
Few organizations anticipate the real and present danger of burnout. Ironically, organizations often consider the burned-out employee an inadequate employee, a slacker, seeking sympathy. The final result can be suicide, which often goes unrecognized for what it is – a symptom of disease.
A plague of physician suicides taught me how quickly civic capitol can be trashed, even when measured in human lives. It’s a process I’ve come to recognize as organizational homicide.
A number of years ago a snippet in a local newspaper caught my attention. It reported that eight physicians had killed themselves while two other physicians had attempted unsuccessfully to do the same. All ten had been under investigation for unprofessional behavior by the Oregon Board of Medical Examiners. The newspaper report said no more. By telephone the Board confirmed such was the fact. As to my question, “Why?” no one had an answer.
I invited four professional friends to form a team to find out why. What we uncovered I’ve since labeled as “organizational homicide.” For each of these physicians, their world began falling apart the day the notice arrived that one of their patients had lodged a complaint against them with the Board. Each doctor became suspect and was ordered to immediately cease all medical practice until cleared by the Board.
Their worlds crashed. Months passed as the Board’s investigations dragged on. Some of the physicians simply stopped getting dressed, choosing to spend the days in their pajamas, mindlessly starting at the television set. Some fought back ineffectually. All stumbled down a personal path to the same conclusion – their lives had become meaningless.
Subsequently our community of physicians recognized the need to save the lives of physicians suffering from burnout. Dr. George Robbins, a past president of the Oregon Medical Association and as fine a physician as ever practiced in Oregon, established The Friends of Medicine, a group of caring physicians dedicated to reaching out to colleagues in trouble. Over the years, the Friends repeatedly demonstrated the healing quality of a hand extended to help.
But I digress. Will our historic reform develop the organizational strength to recognize and help staff members who may be burning out? Will we cease talking about better exchange of information as the key?
Patients are not cured by exchanges of information. Patients are human beings who are reached and cured by caring physicians willing to do more than convey the words,  “shape up,” to burnt-out colleagues.
Mr. President, this isn’t a plea to refrain from asking physicians to do their best. Rather it’s a caution to remain alert to the vulnerability of physicians who find themselves on the edge.
My plea is for our government to see the work of patients and doctors working together as a unique form of democracy. As administrators consciously understand the limits of the doctor/patient relationship, they can see the healing relationship as a civic trust.
I appeal to those who are respected for their civility and humane insight. As we work together for effective reform, I appeal to you President Obama!
Dr. Crawshaw is a retired psychiatrist in Portland and co-founder of Oregon Health Decisions.


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As a retired primary care doc, I much appreciate Dr. Crawshaw's comments although I am quite doubtful that they will be heeded. While the recent health care reforms are a major step in providing health care to all our citizens, they do little to change the pathological approach to the provision of medical care in this country. Medicine will continue to be a business, insurance companies will continue to view the money spent on caring for patients as a "loss" (as in "medical loss ratio"), and primary care doctors will continue to be devalued because of their inability to "produce" compared to their specialist colleagues. Youthful idealism is a wonderful thing but years of being told that one's "production" is the ultimate measure of one's value can lead to cynicism and burnout. I feel privileged and relieved to be able to retire from what was an increasingly frustrating and stressful career in primary care. I certainly would not in good conscience recommend that any young physician choose to be a primary care doctor. Leigh Dolin

Leigh and Ralph, as I sit here in Mexico, marveling over the clarity and significance of your words, I cannot help but reflect on the lack of progress that has been made since the days when I worked with you in Oregon, pursuing the same dragons. I hasten to add that the lack of progress is not due to a lack of effort on your behalf, and that of many, many others. For the past four weeks, a dear friend of ours has been in a Puerto Vallarta hospital battling bacterial meningitis. The care he has received has been phenomenal, and the doctors attending him are truly exceptional. Certainly, the monetary rewards that they receive are far less than their earning potential in the US. But practicing in a country where most residents have access to basic health care, and malpractice cases are settled through an arbitration process may provide them with more satisfaction than we can imagine. I certainly have not discovered any magical answers to the dilemma faced in Oregon and the US, but I am so gratified to see that Diane is still out there, telling the truth, and that voices like yours are still saying what needs to be said. Saludos, Karen Whitaker Knapp ([email protected])

Excellent letter, Dr. Crawshaw. I cannot disagree with a single word. Christina Peterson, M.D.

It always seems that "doctors will find a way". that is find a way through or around most anything depending on their committment to quality and to receiving an adequate income. If they concentrate on "income" they will find as many of my fellow surgeons have found, that in the last five years a procedure that was always despised as a indelicate, frustrating, cosmetic operation with marginal results i.e. vein stripping has suddenly become something that could be done with new technology, take about 45-60 minutes(as an outpatient) and pay MORE than I would get paid to do an aortic valve operation or a coronary bypass. WHY there seems to be no explanation but the "restrictions" that the veins be symptomatic (by the insurance company" have been gimmicked by cleverly designed history sheets the patient fills out with obvious things that need to be checked if the insurance company is going to pay. Dozens of good vascular surgeons, radiologists, cardiologists in the NW have begun to spend significant amounts of time caring for these cosmetic procedures now listed as medically necessary and doing something for basically healthy people that have all of a sudden developed a PROBLEM that is associated with poor health. Give me a break. the new influx of patients will find a way to be seen by PA's, NP's, Paramedics, supervised by robots or those overstressed physicians, burned out but not to burned out to collect a pay check if someone will pay and they will organize the care. Careing physicians? not hardly. duane bietz

A cogent article. However, when OHSU is unable to fund faculty at the Nursing School, that also speaks to the serious problem of providing trained nursing staff around Oregon and beyond. It is regretful that we all have to face the possibility of the need for more healthcare, but unable to train and provide the staffing necessary for the need. Anthony Thurston