Physician Burnout Podcast Audio – the 4 Causes of Physician Burnout and Slaying the EMR Devil

Physician burnout podcast- 4 causes and slaying the EMR devil

Dr. Dike Drummond
So if I may can I give the folks on the line and you a model for understanding what causes physician burnout? Would that be cool?

Participant:
That sounds great, yeah.

Participant:
And I would say actually just very briefly that I think what you’re saying on some level about having a bit of a gerbil wheel especially for those who are still working with the insurance system – that seems to generate a lot of concern and stress –

Dr. Dike Drummond:
Well and we can look at the outside causes but a gerbil wheel is happening any time you feel like it’s a gerbil wheel no matter what’s causing it. So you may feel like it’s a gerbil wheel because you’ve got two kids under the age of four.

Being a physician is not the only stress in your life. So let me give you this physician burnout model and I think it will really help and this is a model I’ve developed in my work one-on-one with burnout doctors.

So imagine a Venn diagram that has four circles. These are the four causes of stress and physician burnout.

They’re arranged in a square pattern and they don’t overlap each other. There’s no sweet spot in the middle here. If you draw four circles on a piece of paper and you label one on the top left if you want clinical medicine. You label the second one top right if you want nonclinical medicine.

Bottom left go ahead and put medical conditioning and if you want you can actually use the word brainwashing. Bottom right put having a life. So here’s the way I understand physician burnout and the way that my clients tell me helps them understand things really quickly.

So when you are in your medical training and going through medical school and residency and things like that what you’re being taught is simply the top left circle, clinical medicine. So you’re being taught how to be a clinician. In most cases because you’re like neck deep in your training program, you don’t have much of a life outside of medicine, you have really no business pressures on you right and you’re in the process of being conditioned.

But clinical medicine is what people think about when they think about well what are the stresses of being a doctor and what causes physician burnout. Well you’ve got sick people and you’re dealing with disease and you might make a mistake and all that kind of stuff. Those are the stresses that the popular conception is that’s what’s stresses people who are doctors and are the only cause of physician burnout most people think about.

But then when you graduate from your medical program, you realize there’s a whole bunch more and here they come. The top right circle is nonclinical medicine. So these are all the stresses of practicing medicine that have nothing to do with seeing patients. They’re piled on top of everything that comes with being a practicing doctor and actually taking responsibility for diagnosing and treating new patients.

So this top right circle is everything that is not associated with seeing a patient so the business of medicine, so your electronic medical record or documentation system whatever that is, malpractice risks, the culture of your group, political uncertainty of the reimbursement whether or not you opt into or out of Medicare. These are all nonclinical stresses that contribute to physician burnout. Does this make sense?

Dr. Dike Drummond:
And they pile on top of everything you were taught to deal with in medical school and residency and most people emerge from their training completely unprepared and completely unaware of this additional layer of stress. This is a physician burnout cause most are unprepared for.

Participant:
That was funny. I was talking to the – just one second – your medical students last week in their clinical foundation course and I was completely shocked and it’s so I guess how different worlds are that not one person of the 90 people knew what the Medicare donut hole was. It was just kind of funny because to people on the end lister that you know, you can’t imagine not knowing about it. But you’re right in medical school they have no reason to know about that yet.

Dr. Dike Drummond:
Well and just so you know, it’s not their job. It could be an additional task that they take on but it’s not the job of a medical school or a residency to teach you about  physician burnout or about anything other than how to diagnose and treat.

Participant:
Right.

Dr. Dike Drummond:
So for instance ideally in a residency program, they would teach you about stress and how to release it in a moment and about physician burnout and how to prevent physician burnout. Ideally, they would teach you about how to find your ideal job and how to do an interview.

Ideally, they’d teach you about the business of medicine, reimbursement rates, electronic medical records, documentation requirements. They teach you about all these things that don’t really have anything to do with this is the symptom, what’s the diagnosis ideally but that’s not their charge. Their charge is to turn out a clinician, to drop that clinician into a delivery system in the form of their first job and blam like a clown hammer in comes … A whole bunch of additional stresses, right?

Add on to that now they’re out of medical training right. There is no objective for them. They’re not focused on a graduation date or passing their boards, they’ve got it all, right. So now all of a sudden they have this freedom and this unstructured space and in comes the bottom right circle, having a life outside your practice.

So now you’re married and now you’re pregnant, right? It’s like, oh my god, I’ve got kids, I’ve got a family, I’ve got a spouse and now I have to have some of me left over for them. Actually, it’s incredibly important that you build a boundary of physical and emotional, psychological, kinesthetic boundary between your practice and your life outside of medicine and you know how to defend that boundary and you know how to actually have time with your kids and your spouse and your own health.

You have to learn how to not be the crazy person who did what they could to survive their residency program, right. So here comes life piling in. So there’s two more stresses and then the problem that really makes all of this difficult and a visual that may help is that I see doctors as being like a gold fish in a bowl.

Inside that bowl which is your practice so when you’re in the office, you’re in a fish bowl and you’re surrounded by this water that’s invisible to you that is the way you learn how to do things as a resident. If we want to, we can call it conditioning. I call it conditioning or brain washing and here’s what I mean. Each of us in some way has a piece of us at some point during our training process that wondered whether we’d be able to make it. That makes sense?

At some point in some incredible shift or rotation that you did, you felt like your survival was threatened. Now you may not have put words to it but subconsciously you did. You developed a certain set of programming, certain ways that you work in the world to get you through that 36-hour shift or that 140-hour week or when you lost that baby unexpectedly.

If I put words to the programming that we all learn and you might want to write these down too because when you recognize them in yourself, you can recognize them as programming. I see a lot of people say these are character traits of physicians and I say no, no, no, no, they’re not character traits, they’re conditioning just as an example.

Dr. Dike Drummond:
Basic training in the military lasts 8 weeks. in 8 weeks I can condition a recruit to take a bullet just by asking him to. Medical training last a minimum of 7 years and in that time here’s the survival mechanism that is burned into your subconscious that becomes the water you swim in at work.

I characterize it like this, workaholic, superhero, emotion free, lone ranger. If you want to add one more in there, I would add perfectionist.

Dr. Dike Drummond:
You’re not meant to get close to your patients, why? Because somebody told you. Why did they tell you? Because somebody told them. You’re not supposed to feel for your patient, you’re not supposed to get close to them, what a bunch of poppycock. That’s just a tradition handed down from generation to generation that makes no sense.

You have to feel empathy. I’m going off on one of these right now, right. You have to feel empathy, you have to put yourself in the patient’s shoes, it has to happen. It’s going to happen automatically but you being told that you’re not supposed to makes everything so much more difficult and drives it underground.

What’s supposed to happen is you’re supposed to be able to feel for your patients and be involved with them and learn how to release it. Learn how to create a boundary, learn how to be healthy about it, not try to avoid something that’s impossible. Does that make sense?

Participant:
Uh-hum.

Dr. Dike Drummond:
You know you’re being workaholic especially if you’re going to create your own little practice like an ideal medical practice. You’re being workaholic when you see something that needs to get done and you go do it without giving any thought to it perhaps being delegable or something you can systemize or get somebody else to do. That’s a combination of workaholic and lone ranger, right?

Participant:
Yeah.

Dr. Dike Drummond:
So these coping mechanisms are installed as a survival mechanism in your subconscious and we run them and automatic pilot. So when I’m talking to a doctor, I say I’m talking about the conditioning. It’s like talking to a fish about the water in their bowl. At some point in time, the fish will stop me and say Dike, what’s this water you keep talking about because it’s invisible to the fish, doe that make sense?
Participant:
Uh-hum.

Dr. Dike Drummond:
So this conditioning is how we operate inside our practice but because it was installed as a survival mechanism, nobody ever showed us the off switch. We tend to operate the rest of our lives that way too.
It was meant to be something you used in the office and you used to see patients in the hospital and then there’s meant to be an off switch in the back of your head where you turn it off. Just like normal people punch a clock and then they’re able to let work go, we’re supposed to be able to do that too. But because of the intensity of the training process, first of all nobody ever taught you how to turn it off. Nobody ever told you you were being conditioned until I did probably and it’s something that it’s meant to be turn off-able so that you’re not using these overused strengths in your life outside of medicine.

So in my mind those four circles are the four stresses that I see in working with hundreds of different folks who are doctors who have career-threatening physician burnout.

Let me just say them again. Here are the four causes of physician burnout.

It’s the stresses of being a clinician, clinical medicine top left.

Top right the stresses of being a doctor that have nothing to do with clinical work that come with the practice model that you choose. You’ve mentioned one for that IMP model, ideal medical practice, you’re taking on business skills you were never trained in. So it’s one of the stresses that has nothing to do with being a doctor that is part of being in an ideal medical practice setting.

Bottom right, having a life, how do I have a life at the same time.

Bottom left is the conditioning of your medical education, workaholic, superhero, emotion free, lone ranger and having somebody help you install an off switch on that.

That’s a framework that I use to help understand physician burnout. When I offer up that framework you can name something that fries your bacon, you can name something that sticks in your craw, you can name something that is stressful for you and you can point to the circle where it lives in.

Participant:
Uh-hum.

Dr. Dike Drummond:
Most of the time people will point top right as the things that are part of your practice model that don’t have really anything to do with diagnosing and treating the things in your practice that don’t work. That is often the biggest cause of physician burnout.

So for instance, one of those that everybody always complains about is whatever system you use to document is going to be “spawn of the devil”. I mean I even have this vision, you know Marcus Welby right? Your whole medical history even if you had been to Marcus Welby for 40 years was contained on three index cards.

Participant:
Uh-hum.

Dr. Dike Drummond:
And I bet he hated those index cards.

Participant:
[Laughs]

Dr. Dike Drummond:
Well and here’s the dynamic that I see doctors doing. So doctors also have a huge chip on their shoulder, right? Because they survived residency, they think that they should have a pass on certain things. So what I see doctors doing is they will take a documentation system and rather than learning how to be expert in it, they will demonize it and refuse to learn how to be good at it.

Participant:    So is that because we think we’re good at everything automatically–

Dr. Dike Drummond:
Here’s what I see and again this is – much of what I’m talking about is deeply unconscious, okay.

It’s the water with the fish. Okay. But I’m assuming that for anybody who’s made the transition from a standard medical model to an ideal medical practice like practice setting you’ve thought about some of these things. You may not have given them the actual words that I’m giving today but these things will be obvious to you because you have gotten yourself out of that old fishbowl and had a chance to look at that water a little bit.

Participant:
Right.

Dr. Dike Drummond:
Doctors’ lament is always the same. I just want to see patients. I just want to see patients. What they’re saying is I was trained to do the top left circle, I was trained to diagnose and treat. Why don’t you just let me diagnose and treat? Keep the patients coming, but take all of the other stuff away, please.

What doctors are looking for is what in the science fiction world is called wet wiring, right? Do you remember the movie the matrix? They had the big thing they shoved in the back of your head right and you experience –you know, doctors would love to have a wet wire in the back of their head that instantly transcribed their thoughts during the patient encounter.

Dr. Dike Drummond:
Now that will probably come at some point in time right but until then as physicians we have to acknowledge that there has to be some way to translate what we’re thinking and saying into some sort of record right.

Participant:
Right.

Dr. Dike Drummond:
That will always be a necessity if for no other reason that there’s basically two reasons, malpractice protection and so that anybody who picks up the chart can catch up with the patient’s narrative at that point. You can see their history and see where they came from. There’s always going to be that necessity.

So whatever system you’ve got, it makes no sense to do anything other than be as efficient and skilled and expert in the use of that particular system as you can possibly be. If you fight it and you demonize it and you make the sign of the cross and hope it’s going to go away, that just gets in the way of you being a better doctor. Again, I think Welby was probably pissed at the index cards. I have to write a whole sentence here with my blue Bic pen, this is outrageous. I just want to see patients.