We all hear a lot about the effect of how physicians speak to patients affects patient satisfaction. Things you’ve heard from many others – sit down when you talk to them, introduce yourself to patient and family in room, listen actively.
Yada, yada, yada. Right? More corporate BS from someone who doesn’t have anything better to do. After all, doctors know how to talk to patients. What words to use. How to get our point across.
But let’s make it a bit more personal – how do our conversations with patients affect our malpractice risk?
I came across this when reading “Blink” by Malcolm Gladwell. For those of you who haven’t read it, Gladwell is trying to show how we can “thin-slice” decisions fairly accurately with very little information, and without conscious thought. One example he gives is of a veteran Lieutenant in a fire department who brought his men in to fight a kitchen fire. As they began to work, something felt strange to him. The fire didn’t go out with water, which kitchen fires do. It wasn’t as noisy as it should have been. And when they retreated to the living room, it was much hotter than it should have been. Now, the Lt. didn’t consciously think any of these things at that point – Gladwell reconstructed it with him later. He just knew something wasn’t right, and he yelled to get his men out of the living room. And the floor then collapsed because the fire was actually in the basement.
The thing that struck me in regards to us was a study Gladwell quotes on patients’ perceptions of doctors (reference below). The authors tape recorded 125 conversations between doctors (divided equally between surgeons and primary care) and 10 consecutive patients per doctor. ½ of the docs had been sued at least twice, the rest had never been sued. The docs who had never been sued spent more than 3 minutes longer with each patient and were more likely to make “orienting” comments, like “First I’ll examine you, and then we’ll talk the problem over” or “I will leave time for your questions”. These statements give a sense of what the visit is to accomplish and that the patients are expected to participate. The non-sued docs were also more likely to laugh and be funny. There was no difference in the amount or quality of information they gave the patients, though.
This is somewhat interesting, but the next phase is really valuable. Another psychologist listened to the same tapes just for surgeons and their patients. She took only 2 of the patient conversations for each surgeon, then selected two 10 second clips of each doctor talking, giving her 40 seconds of each surgeon speaking. She then removed the high-frequency sounds from speech so individual words could not be recognized, just tone, pitch, and rhythm with no content. Judges rated these slices of garble, looking for qualities of warmth, hostility, dominance, and anxiousness. By using these, she could identify which surgeons got sued and which ones didn’t.
Let me emphasize that – they could predict who had been sued ONLY BY ANALYZING UNINTELLIGABLE TONE OF VOICE!
That is astounding to me. But picture this – if you were felt to be “dominant”, you were in the sued group. Doesn’t that make sense intuitively to you? By being dominant, you convey a lack of respect for the patient, which they certainly perceive quickly – I know I can.
Burnout among physicians is an under appreciated, expanding and potentially disastrous issue in healthcare. Defined as a pathologic response to stress, it is manifested by a classic triad of symptoms:
Diminished sense of personal accomplishment
These particular symptoms certainly aren’t unique to the physician – some would say that these symptoms are already prevalent in American workers, and creating a crisis. However, studies have shown that doctors are at particular risk compared to the general public.
A 2011 study in Archives of Internal Medicine noted a 45.8% rate of burnout symptoms in physicians. In comparison to working U.S. adults, the study found physicians to be statistically more likely to experience burnout (p<0.001). This is true in spite of the fact that in areas outside of medicine, increasing education seems protective of burnout (T. D. Shanafelt et al. 2012). More concerning, this malady seems to be increasing. The authors of the 2012 study repeated their survey in 2014 and found that the rate of burnout has increased to 54.4% and satisfaction with work-life balance has declined significantly as well (T. Shanafelt et al. 2015).
Risks of Burnout
So what? Doctors hate their jobs just a little more commonly than the rest of us? What difference does it make?
A lot, it turns out.
Let’s consider their professional experience and their personal lives separately. At work, many negative impacts are noted, of which are of concern for patients.
Dissatisfaction with career choice (OK, that’s common)
Increased medical errors (Oh, oh – now, I’m listening)
Leaving medicine at a younger age (Depriving patients of experienced docs – not good)
Decreased commitment (Do you want to hear this about the person taking care of your illness?)
Poorer judgment (No comment needed)
Hostility & a negative attitude (Experienced by many of us at the hands of doctors already, right?)
Increased errors (Badness evident)
On a personal level, the doctor can experience depression (30% incidence among surgeons according to a 2009 study (T. D. Shanafelt et al. 2009)), sleep deprivation, alcoholism and other addictions, withdrawal from family along with greater conflicts with spouses/partners, poorer health, and, most concerning, increased risk for suicide (Gold, Sen, and Schwenk 2013).
Causes of Burnout
Why is burnout such an epidemic among today’s physicians? There are many reasons, according to a 2013 survey of physicians reported in Medscape (Peckham and Stelka 2013):
Too many bureaucratic tasks (The increased utilization of EMR is one such task that in and of itself seems to be contributing to burnout per a Chicago Tribune article in December, 2015)
Present and future impact of ACA (This is a 2013 study, so this issue may be looked at differently now)
Spending too many hours at work
Feeling like just a cog in the wheel
Increasing computerization of practice
Lack of professional fulfillment
Surgeons in particular are felt to have some unique stressors compared to other specialties, especially those surgeons involved in trauma work. They work long hours, have frequent call nights, often don’t have much control over their schedule, find inadequate resources and inability to access the operating room at their hospitals, and run the risk of surgical complications. Factors related to increased burnout scores in surgeons according to Shanfelt’s 2009 article include:
Number of nights of call per week
Hours worked per week
Having compensation based only on billing
What Can Be Done About Physician Burnout?
There are many alternatives, though none have been studied for their successful outcomes rigorously.
Physicians often attempt to self-treat their own burnout. Most common techniques are participating in exercise programs, spending more time with family, taking time off for vacations, watching movies, listening to music, reading or trying to get more sleep. Although these make sense intuitively, the amounts required and effects have not been documented.
Many healthcare organizations have realized the significance of this issue and attempted their own solutions. These include workshops and education, onsite exercise facilities and classes, Employee Assistance Programs and counseling. The problem with these from the physician’s view is that these efforts are generally only available during the day, when a physician’s time is at a premium.
General Principles In Support of Burnout Victims
It seems there are 3 principles that most experts agree can help combat burnout and stress:
More time – physicians simply need to build in more time in their lives for what is important to them. And to have more control over their time.
More opportunities for self-care – such as exercise and other wellness interests.
More support – to help them deal with burnout and stress. This is a complex, but consistent, thread found in interviewing doctors. Not just things like mentors, collegial support, and educational opportunities, but also support, respect and recognition from their administration.
So What Can I Do Right Now?
Limit call nights – some suggest 2 nights per week/8 nights per month maximum in trauma, where call is an essential part of the job. Even if the young doc wants to get paid for more – don’t let them!
For exercise programs
For weight loss
For health counseling
And don’t forget the power of teams – group exercise/weight loss/activities on a regular basis help doctors connect in a different way at work.
Formal mentorship programs – for ALL doctors, not just the young ones
Regular collegial interaction – either informal/social or work-related
Flexibility – Administrators should work with docs to identify how more flexibility can work to benefit both of them
Does your practice need more evening hours? Maybe one doc wants to do that and come in later in the morning.
How about early hours – see patients at 6:30 before patients have to go to work? This might allow Dr. Smith to pick his kids up from school.
Signing up for clinical time in blocks in a rotating basis, rather than having the same schedule day after day, month after month, year after . . . you get the idea.
Changing models of care
For surgeons, can they take call several days at a time and not do elective/clinic practice during those days?
Even better: establishing a formal hospitalist program for surgeons – both general and orthopaedic – can lead to improved satisfaction for both the one doing the hospitalist work as well as the docs who don’t have to do call anymore.
Our Biggest Challenge
Here’s the key, folks – we have to not just work to prevent burnout. We have to recognize it in ourselves and others. If you notice one of your formerly chipper doctor friends seems tired all the time, always seems to have a negative attitude, feels and looks hopeless – get your friend hat on! Talk to them about what you observe. And help them get help. Be a rock for them.
And if you feel that way right now? Get thee to a colleague, your hospital’s HR department, a mental health professional, or someone asap. Don’t wait until your burnout leads to a patient mishap that will define the rest of your life.
Gold, Katherine J., Ananda Sen, and Thomas L. Schwenk. 2013. “Details on Suicide among US Physicians: Data from the National Violent Death Reporting System.” General Hospital Psychiatry 35 (1): 45–49. doi:10.1016/j.genhosppsych.2012.08.005.
Shanafelt, Tait D., Charles M. Balch, Gerald J. Bechamps, Thomas Russell, Lotte Dyrbye, Daniel Satele, Paul Collicott, Paul J. Novotny, Jeff Sloan, and Julie A. Freischlag. 2009. “Burnout and Career Satisfaction among American Surgeons.” Annals of Surgery 250 (3): 463–71. doi:10.1097/SLA.0b013e3181ac4dfd.
Shanafelt, Tait D., Sonja Boone, Litjen Tan, Lotte N. Dyrbye, Wayne Sotile, Daniel Satele, Colin P. West, Jeff Sloan, and Michael R. Oreskovich. 2012. “Burnout and Satisfaction with Work-Life Balance among US Physicians Relative to the General US Population.” Archives of Internal Medicine 172 (18): 1377–85. doi:10.1001/archinternmed.2012.3199.
Shanafelt, Tait, Omar Hasan, Lotte Dyrbye, Christine Sinsky, Daniel Satele, Jeff Sloan, and Colin West. 2015. “Changes in Burnout and Satisfaction With Work-Life Balance in Physicians and the General US Working Population Between 2011 and 2014.” Mayo Clinic Proceedings 90 (12): 1600–1613.