You may wonder what this question is all about. Let me explain. There are many points of contact between a physician and a patient consenting to a procedure, when an informed consent can be obtained. The first point of course, is when the surgeon first informs the patient that they need surgery. Most of the time, patients agree to the procedure, and are put on the waiting list immediately. In many hospitals, the booking cannot even proceed, unless the signed consent for is sent along with the booking information. Usually, the pros and cons are explained to the patient right away, and the consent is signed.
I find that this may be too soon. I always give the patients a handout, containing detailed information about their surgery, and instructions as well. (I know that every other surgeon does this too). Should the patient not have the time to take this information home, read and assimilate it, before they sign their consent? Should they not also have the opportunity to do research on their own or ask others for advice, as I am sure everybody does?
Some patients need more time to think about the surgery, and sometimes about different surgical options, before they can decide whether to consent or not. They may just call and inform of their decision, or may want to come in and ask more questions. If they are seen at this point, the consent may be obtained then.
I personally feel that the best time to obtain informed consent is in the pre-operative room. This is when I give them the chance to ask any final questions, and have them answered, both about the surgery, and about the anesthesia. The also get to ask about post-operative care, if they have any questions. This also gives me a chance to re-familiarise myself with their condition, the reasons for operating, and any special considerations that may be required. In some instances, patients do change their minds about the surgical option, and this can be acknowledged as well. This way, I also get to make sure I have seen them and addressed any fears before they are wheeled into the operating room.
i do work in a small hospital, and I am able to do it this way, but I wonder what, if any problems other surgeons have had, when the consent has been obtained weeks in advance.
I invite anyone – physicians, nurses, other healthcare professionals or anyone who has had the experience of going through an operation – to send me their thoughts or experiences about the consent, and when it is signed.
Great post by a medical student (I rest my case)!
So recently I was approached by a medical student asking if she could guest post on my blog about burnout. I was more than happy to take her up on her offer, and not just because it has been WAY too long since I have blogged and her timing could not have been more perfect. It’s easy to forget that physicians in training are not in any way immune from burnout and compassion fatigue that affects so many of us out in clinical practice. Fiona shared with me that she had recently lost a classmate to suicide – something I unfortunately also experienced during my training when one of my fellow medical students killed himself during our first year. If anything, the pressures and difficulties have only seemed to have grown during the time between my and Fiona’s training.
I welcome Fiona’s piece on her experiences so far during medical…
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Stress and Burnout have been the main topic of interest to me recently. In any discussion about stress, I find the reference to gadgets made, usually describing the ‘assault on the senses’, and how to minimize this assault. There are so many reasons described, for recommending that you stay away from those evil screens! I have, however, been very impressed with how these screens have been a huge stress buster.
A few years ago, I travelled to Austin with my daughter, who was then a teenager. On our way back, there was a stopover in New York. For some reason, there was a long delay, in New York. After an hour or more, there came an announcement from the desk at the gate, that there would be a further 2 hours’ delay. It was quite the epiphany for me, when everyone paused for a moment, after the announcement, and then looked back down at whatever they all seemed to be doing on their phones/iPads/laptops! Not a murmur of protest! I automatically thought back to the days in the past, when screaming and shouting was the common response to such announcements! My immediate thought was – Thank God for Steve Jobs! (He was still alive then).
Fast forward to conferences I am at, today. Most of the conference material is sent out electronically, these days. That is a great way to save on paper. Most conference halls have Wifi, and people bring their laptops or other devices. Obviously, some topics are far more interesting than others, some speakers more passionate than others. If you look around, you see almost everyone has their head bent down – staring at their devices. A few actually look up at the speaker or the slides being projected.
In the olden days, if you were speaking and the audience was not making eye contact, you know they hate you, or don’t care for your topic. Now, if they are looking down at their device, you can tell that they are following, while looking at the slides on their devices. How nice! Except, most of them are actually on their social media, or checking out their email messages, or texting, chatting, etc. With a really boring speaker, when they have done all their mail checking and chatting, some people resort to playing games even! But the speaker can so easily be blissfully oblivious, and therefore, not go through the stress or the humiliation of Knowing that they are bored! Well, if that isn’t the best way to reduce stress, for the speaker, I don’t now what is!
As for the audience, I know how hard it is to try and stay awake, if you have to listen to a monotonous speaker. if the topic is nevertheless important, then the stress is greater, and tires you out that much more! Enter, the mobile device. No risk of falling asleep, no worries of getting caught out, no need to leave the room and that much less caffeine consumed!
The electronics are here to stay. We might as well reduce our own stress, by taking advantage of these devices!
On my radio show, Stress Busters’ Corner, on the Health and Wellness Channel of Voice America, (http://www.voiceamerica.com/show/2423/stress-busters-corner), I was discussing with my guest, Wayne Markell, who is a Platoon Commander for the Emergency Medical Service (EMS), the issue of Stress and Burnout amongst the paramedics.
Wayne talked about how he encourages his staff to “raise their hands” and be vocal about how they feel, and when they feel distress. He talked about how the staff are encouraged to seek help, for the sake of their own mental health.
As a coach, who believes in (mental) Health Promotion, I think that is precious little, and unfortunately, that is how it is with most healthcare professions. We are expected to seek help, if and when we need it.
If a person is not seeking help, the automatic assumption is that they are coping just fine. Indeed, many of us would say just that, if asked directly, how we are doing! Therein lies the peril!
I strongly believe that all healthcare professionals should be aware of their own vulnerability, and be willing to reflect on their lives, and be able to recognize signs of impending burnout, and seek help long before it happens.
I would actually go one step further, and say that we should target people who are seemingly doing just fine, and help them become aware of their own strengths and weaknesses, their own stress triggers, and help them develop more tools to deal with stress. That way, we catch them before the stress becomes a problem in their lives, and the negative consequences are kept to a minimum – just as I like to say, that the best time to stop somebody from hurting themselves by smoking, is even before they light that first cigarette!
I read the recently reported survey on Medscape, about Burnout amongst Physicians, and the findings are scary! Thirty seven to 53 percent of the physicians who responded, reported burnout! Looking at General Surgeons alone, it was 50%. The scarier part is that this number has risen significantly (almost 15%) from what it was, just 2 years ago.
Looking at some of the reported causes for burnout, I felt I had to make some comments – hence this blog post. The top 5 reasons cited are: too many bureaucratic tasks, too many hours at work, income not high enough, increasing computerization of practice, impact of the affordable care act, and feeling like just a cog in a wheel.
Too many bureaucratic tasks: In this profession, there is a certain amount of ‘mandatory’ bureaucratic tasks. It depends on the kind of hospital you work in, and what positions you hold. The question you have to answer is – which of these is really mandatory, and which ones can you let go of? Ultimately, we each have to prioritize, and decide how to handle these tasks. It is also up to us to say ‘No’ to anything we don’t absolutely have to do.
Too many hours at work: This is something, again, that most of us can decide for ourselves. If you are employed by a hospital, and find the hours too much, then you can decide what you want to do about it. I am sure there are regulations on hours of work, and you may have to negotiate with the hospital, to reduce your hours. For those who work in private practice, it is easier, since many of you can do your own scheduling. Either way, the reason many physicians don’t limit their own hours is that the remuneration does drop, when you work less. Again, it is up to us to decide what is important, and what is the price we pay.
Income not high enough: I wonder how much income is ever “enough”! While there is a huge discrepancy in remuneration from one country or state to the next, within any given geographical area, physicians earn a decent income. It is also true that some physicians live lavish lives. And the most important thing is that we do not get any training on financial management, during our training. It is up to each one of us to acquire the knowledge, or get advice, and learn to manage our own finances. It is no use if you use all your time working to earn more, and then have to spend all of it to either fix your health problems, or pay alimony and child support, or fix whatever other problems arise as a result!
Increasing computerization of practice: Well, like it or not, computers are here to stay! The sooner you get used to the idea, the sooner you can learn to use these computers to your advantage. They do save us a lot of time, and make our work more efficient. We just have to decide not to fill up any time saved, with more work!
Impact of the affordable care act: Living and working in Canada, I am unable to comment on this, because my knowledge of this is minimal. But going by the general principle of trying not to resist what is, and trying to work with the system, can certainly reduce stress.
Feeling like just a cog in a wheel: This speaks to me of low self-esteem. I admit I feel like that at times too, but only if I allow myself to. The truth is that we do have a great deal to offer – and this goes for every human being, not just physicians. If we can understand that every cog in a wheel is indeed important, for the wheel to work efficiently, we can make ‘a cog in a wheel’ feel pretty significant.
So, at the end of the day, I think it is what we tell ourselves, and how we interpret things that really cause the stress, to a great extent. There are things that are within our control, and there are those that aren’t. It is imperative that we recognize the difference, and not play victims of the system.
Which is why, I remembered the serenity prayer:
God, grant me the serenity
To accept things I cannot change,
The courage to change the things I can,
And the wisdom to know the difference.
Please let me know what is your top stress factor, and what you do to manage it!
I am back, with a year-end blog, this time. Today, the winter solstice has led me to do some reflection. I launched my new website, (www.stressfreephysician.com).
Is it really possible to have a ‘stress-free’ life at all? When I look around me, I see people who are complaining about the stresses in life, and in work. There seems to be no workplace today, that can be considered stress-free. No matter what people are doing, there seems to be this drive for efficiency, return on investment, better quality, greater quantity, and so on. The healthcare field – and in fact, any service sector – just seems to have a greater intensity of stress, because of the increasing demands, and the diminishing resources. There is the pressure from the business aspect, to get better results with lesser expense, while medical care is inherently more expensive. There are also increasing advances, and the pressure to do whatever it takes, to keep people alive longer. One very palpable effect of the global stress levels, is that people often take out their frustrations on anybody at work who does not have the power to fight back, or at home, on the people who are closest to them, and therefore often taken for granted!
So, the big question is: Can we really hope to achieve a stress-free state? More importantly, is any amount of stress actually good for you? My answer would be a resounding “No” to the first question, and an equally resounding “Yes” to the second.
Stress is the body’s response to a real or perceived threat. The purpose of stress is to get people ready for some kind of action to get them out of danger. The action can be the ‘fight or flight’ response. In other words, the action taken either helps the person overcome the danger, or helps them remove themselves from harm’s way.
Some stress can be a good thing. It can motivate us to focus on a task or take action and solve a problem. In this situation, stress is manageable and even helpful. In a questionnaire I remember doing many years ago, a wedding was described as one of the most stressful events in a person’s life.
When a person is unable to achieve either of those results, is when stress becomes a negative thing. This is perhaps the biggest problem facing people today. Often at work, they feel frustrated at not being able to perform in the way they feel is best, or feel that they are in an environment that clashes with some values they hold dear to their hearts. There are also feelings of not being appreciated enough, and the demand to do more and more, with very little emotional support.
It is when such stresses occur repeatedly in a person’s life, with inadequate recovery in between, that burnout occurs. Burnout is of course the stage where a person gets physically exhausted, emotionally drained, with a sense of detachment, and has a feeling of ineffectiveness. “What’s the point?” is often their attitude.
Instead of aiming for a stress-free life, I think it would be best if we accept the reality of life as it is today – the reality that stress is not something we really can avoid, unless we become monks and go into the woods to meditate!
Once we accept what is, then we can equip ourselves to deal with it. We can figure out methods to recover well from the individual stressful episodes and to protect ourselves from the harmful effects of stress, so as to prevent burnout.
It has been a long time since I posted anything here. Even for a life coach, life can get busy, and for those areas that are not visited often, cobwebs can collect! It is Spring already in many countries, whereas here in Canada, we are still praying for the snowing to stop. but the promise of Spring is there, nevertheless. (“When Winter comes, can Spring be far behind?” – P. B. Shelley).
It is therefore, time to do some Spring Cleaning. As we think of cleaning the physical spaces around us, it would serve us well to stop for a minute, and consider a ‘spring cleaning’ of our lives as well – both at work and at home.
One good method that I once learned, for Spring cleaning is to methodically go through the house, one room at a time, from one corner, all around, and look at or pick up every object there is. Then, to ask oneself: How is this serving me? If there is a reasonable answer in the present tense, then the next thing to do would be to look at the object, to see if it is in good shape, and functioning well. If it is, then we clean the item up, and put it back in place. If the object doesn’t serve us well, or if it is defective in any way, we get rid of it. As we do this, we clean the area as well, and move on to the next.
This method should work well in our lives as well. The different areas of our lives can be compared to the different rooms in the house. In each area, we take a tour of all its aspects. For example, in the Physical realm, we can check out our eating habits, our exercise schedule (or lack of it), our health check-ups, and so on. For each of these, we then can see if what we are doing is serving us well. Any habit that is adding to our health, we keep; anything that doesn’t, we give up. And we also assess what else will be needed, to improve upon what we are doing already, and we make plans to incorporate this into our lives;
On the mental or emotional plane, this will include our thinking habits. Beliefs could be examined. Standing back, it really will help to take a long look at which of our beliefs actually are helping us. Anything that is not enhancing our mental or emotional well being is better replaced with a more useful belief or thought. Anything that works can be reinforced.
The same applies to our financial affairs. If there was no saving habit before, that needs to be started. If there were spending habits that were excessive, those can be changed. the budget for different parts of our lives can be adjusted to match the current situation or the current financial climate – or even new changes to tax rules!
The same principle can be employed at work as well. It helps to go through the office to see what processes we are doing right, and are helping to further our growth, and keep us safe, and what practices are not as helpful. based on the changing needs, and the demands of the job, we may have to replace old behaviours and practices, and put in place new ones.
We will often find that what was good when it was first put in, no longer serves us, and are best let go of. This may include artefacts or furniture that we have collected, as well as behaviours or beliefs that we developed in response to situations that no longer exist.
If we can learn to do this process on a regular basis, three or four times a year, it will be of immense benefit to our well-being, overall. It is necessary to do this at a very minimum of once each year – and what better time to do it, that early in the Spring, which signifies a new beginning?
I was at the biannual CUSEC (Canadian Undergraduate Surgical Education Committee) meeting in Ottawa last week, where burnout was a recurring theme in many of the presentations and discussions. Dr. Judith Brown, from the University of Western Ontario, gave a presentation titled ‘Seeking balance: The Complexity of Choice-Making Among Academic Surgeons.’
A very poignant question that arose from the discussions, (thanks to Dr. Geoffrey Blair, University of British Columbia), was the idea of ‘work – life balance.’ Geoff (rightly) questioned the term, because it seemed to imply a separation of “work” from “life”! While seeking a balance between one’s personal and professional life is what people really mean to convey, we have, for long, loosely used the term, ‘work-life balance.’ For a person (like most physicians), who enjoys his profession, this instantly produces a subtle discordance,and its pursuit, even a sense of guilt! Isn’t work supposed to be a part of our lives, and a very important part at that? Isn’t work supposed to bring us great satisfaction? Isn’t it supposed to make us better people, through the challenges we face and overcome, through the miracles we see, through the joys and the pain that we see and share, through everything we learn and teach?
When inserted into this particular term, however, the word, ‘work’ has such a negative connotation! The part of this work that we really need to balance out is the repeated stress and the exhaustion, from which everybody should get adequate time to recover, if we should prevent Burnout. The important thing is to make sure that other aspects of life are nurtured just as well. Make sure that we do not sacrifice everything else for this work, especially those things that make us happy.
Let me know what your thoughts are, as you ponder over these terms and what meaning they hold for you.
It has been a long time, since I have posted anything here! I have been very busy, and for a person who warns people to guard themselves against getting burnt out, I often thought I was spreading myself out too thin! I committed myself to 2 new projects – one, a fundraiser for children with cancer (Masquer-Aid 2014), and the second, a First Lego League (Robotics) team in Cornwall. Both are going great, and are bringing me immense pleasure and satisfaction. The downside has been that I have not been able to keep up with the blogging, and the website updates. Also, my house sometimes looks like the tornado just passed through, and I do fall behind on many a chore. The one thing I do make sure I am caught up with, is my work. Thank goodness for EMR, I have very little paperwork pending, and I catch up with my billing quite regularly.
The one question I have been asking myself lately is, how can I keep myself from burning out? I do find myself physically quite exhausted, and often mentally drained too. As for work-life balance, there really is none, in my life. If I do well in one area, another definitely suffers. On a day that I do the robotics program, I do nothing at home. The day I do house cleaning and laundry, I cannot go outside the house. When I have meetings after work, I cannot attend the robotics meetings. With all these new commitments, my coaching practice has been a little slow. When I have a medical student with me, my paperwork piles up. Something always has to give way for something else to be done well. I do not believe in doing anything half-heartedly. So, whatever I do, I do well. I just put off those things that don’t have a deadline, until I can do it well.
If I were to try and ‘balance’ things out, and do everything equally, I would end up either not getting anything done well, or not completing anything at all. What is worse, if I believed it was important, I wold stress out over it, and that would certainly lead to burnout.
I have therefore, come to the conclusion that it is most important to do things that make us happy. It is certainly important to have something outside of work that excites us as well. How can we make the best of it all, and prevent burnout? Here are a few tips:
1. Make sure you always plan time off, well ahead. It is best to have the entire year planned, with important days for self, and the family set aside right at the beginning. These dates should be non-negotiable. if they are blocked off ahead, then it is easy to ask for these days off early when schedules are being made.
2. Try not to fill the day’s schedule to the brim. Always leave a little free time, to adjust for the unexpected – the urgent, unscheduled patient who needs to be seen, the inpatient who takes a turn for the worse, the flat that needs to be changed, etc.
3. Following the 80:20 principle, 80% of the satisfaction comes from only 20% of the things we do. Similarly, 80% of the things we do give us only 20% returns. We could take some time to reflect on those 80%, and determine which of them we could totally eliminate from our schedule – either cut out completely, or delegate, or hire somebody else for. We could then focus more on the 20% that bring us the greater satisfaction.
So, what are some of your strategies for staying sane in this life? Do send me your suggestions and comments.
- Harvey Bowden’s tips for keeping a good work life balance. Written for The Guardian. (harveywatersofteners.co.uk)
- How to: Achieve a work/life balance (reed.co.uk)
- Are You Struggling with Work Life Balance? New Study Suggests Gender is a Factor (projecteve.com)
- Work-life balance: all employers should encourage it [infographic] (sandglaz.com)
- Achieving Work/Life Balance Means Changing How You Think (lifehacker.com.au)
- The Key to Work-Life Balance: Delegate (blogs.wsj.com)
Just read yet another article on Physician Burnout (http://www.medscape.com/viewarticle/803968). This one compared burnout amongst physicians in China and the United States. In order to keep the groups comparable, only the responses of physicians less than 45 years of age were selected – there were 6000 Chinese, and 7500 US physicians. I was specifically intrigued by one of the charts presented, which is reproduced here:
|It is manageable and I’m not making any changes||36%||25%|
|It is manageable but I need to make some changes in hours/workload/etc.||52.2%||62%|
|I am thinking of leaving my current position||7.3%||7%|
|I am thinking of leaving medicine altogether||4.5%||5%|
Forty two percent of US Physicians, and 82 percent of Chinese physicians who took part in the survey reported burnout. Of these, 52% and 62% respectively said they needed to make changes in their working lives. This is very significant in that 3120 Chinese and 4650 US physicians know they should do things differently. It would be interesting to know how many of them are really doing something about it, and how many simply feel stuck, and will sooner or later end up either resentful or leaving their jobs.
What is even more disconcerting is that almost 12% of the responders in both countries were thinking of either leaving their current job, or giving up medicine altogether. This means, 720 physicians in China and 900 in the US – all under 45 years of age). If we consider the entire physician population in both countries, this number would obviously be much higher.
These physicians who report burnout must have put in a lot of time, money, and sacrifices to get to where they are. The government also would have spent a lot of resources, training them.
I wonder, what would it take for these physicians with burnout, to decide to stay? What would it take for them to re-discover their love for the profession that attracted them initially.
Please let me know your thoughts, either through comments on this page or by e-mail: email@example.com.
In my last post, I answered one important question that physicians often ask, when the question of looking after themselves is brought up.
Another question that was asked of me recently, was this: “OK, so, I recognize that I am burnt out, but it is such work (sic) to get help! When I think of seeing a coach/counsellor, I worry that they are going to give me ‘homework’ and that is added burden to my already burnt-out life! So, I prefer to just go on, hoping that things will get better. Isn’t it better to do that, than to jump into something (coaching) and then halfway across, find that I am treading on thin ice, and then be unable to turn back?”
Quite a poignant point, don’t you think? Well, there are many points raised in this question, which I shall try and address.
The first point is that it is, of course, important to recognize burnout – but what is more important is to figure out, what is it costing you to stay in status quo??? If you are already aware of your situation, then either you are very self-aware, or something is already going wrong, in your life/career. Chances are, based on the question, that the latter is more likely. What is the price you pay, for not fixing the problem? Is it discontent at work, disrupted relationships – with colleagues/family members/friends, lack of time for self, illness-physical or psychological, or is it lack of recreation time, or a lack of well-being? How badly does this affect you, make you unhappy? How badly do you want to change this situation? Once you figure out the value of change, and if that value is big enough, then you will have the motivation to change.
The idea of “hoping that things might get better” is really hoping against hope, if you do nothing about it. You cannot sit on the sidelines of your life, and ‘hope’ for things to get better. It just doesn’t seem to happen, at least, not with any reportable frequency!
As far as coaches giving you ‘homework’, I think the term itself conjures up a very negative emotion! While most coaching sessions end with the client making a commitment to an action towards their stated goal, it is entirely upto the client to decide how they want to get to the goal, and what the reasonable action is, to get there. For example, if a person decides that they want to have a positive attitude at work, a simple step towards this goal would be to become aware of one’s thoughts/speech, at least a few times during the day, and if it is negative, replace it with a positive thought. Writing things down would make this exercise more effective.
This does involve some work, indeed, but if the motivation is to change one’s thought pattern, and if you want it badly enough, then you cannot help noticing your thoughts, and you would not consider this as unpleasant ‘homework’. The only way to change your life is to change something that you are doing – to that extent, there is homework to do. There are habits to change, and this can only happen with conscious action, done repeatedly.
The idea of turning back is interesting. The whole point of starting a new program is to make a significant change for the better in life. People only do this when they feel unhappy enough with their current lives. Any change, however, is a step towards the unknown. It is a step outside your comfort zone. And a person would only do that when their current situation is uncomfortable or unsatisfying. To expect things to e easy is rather naïve. When considering the idea of turning back, the question is – towards what? The same situation you were turning away from in the first place? What good would that do? Most worthwhile successes in this world have happened when people have stuck it out just past the point where they wanted to turn back! So, one can only start knowing fully well that any change is going to cause some discomfort, but it will be worthwhile in the end.
Please send me any questions/suggestions you have, that I can address in future posts.
I recently gave a talk at my hospital Grand Rounds, about Burnout, which is one of my favourite topics. There were a few questions asked, which I thought I could try and answer here.
“If I take any time off, what will happen to my patients?”
I would like to clarify that I wasn’t asking people to all take lots of time off, and go away! On the other hand, I suggested that everybody needs rest, and that we should all be sensible about recognizing that need, and taking rest, before we become too fatigued, and forced to rest. If we wait until we have to go, then we will not be able to enjoy such time off. Also, if going away for any length of time is impossible, then make sure that the time that we get every day that we come home after work, be well utilized to recover as completely as possible, from the stresses of the day.
It is very true, especially in community hospitals, that there often is nobody else who shares the care of our patients, normally. We have a great rapport with most of our patients, and the sense of responsibility for their well being is also great. This can lead to a sense of guilt, even at the thought of having to make them wait longer to see us, or worse, having to cancel their appointment, for any reason.
On the other hand, we have a responsibility also to give them our best, when we are with them. If we work ourselves to the point of burnout, then we will surely be unable to feel the compassion that the patients need, and perhaps the good judgment we need in certain situations that call for more involved, critical thinking. This can lead to mistakes, or at the very least, misunderstandings and a loss of trust and that very rapport that we try to maintain, by not missing work!
To look at things from a broader perspective, imagine a freshly dug hole in the ground. At first, the hole will have very sharp banks, but slowly, the soil around it will shift, the edges will look blunt, and eventually, the hole will disappear. How long it takes to fill the hole will depend on how big the hole was, but fill up, it will.
Similarly, if a physician suddenly drops out of the scene – due to illness or (heaven forbid) death, there will be a void at first. The size of that void will depend on how well that physician was thought of. It is probably the physician’s own family who will be the most severely affected – let’s make no mistake about that. However, life will go on. Sooner or later, alternate arrangements will be made, others will move in, and the patients will get taken care of, the work will get done.
It is true that each of us is unique – and nobody will be able to do things exactly as you do it! But people will learn to adjust and even like the way it eventually gets done. That is how they will cope with the change themselves.
So, ultimately, it is in our own interests to not be forced to drop out of our working lives before we are ready to go. Also, we owe it to our patients to give them our best, when we are there, in front of them, giving them our full attention.
I will answer some of the other questions that have been raised, in future posts.
- Empathy in Clinical Practice: How Individual Dispositions, Gender, and Experience Moderate Empathic Concern, Burnout, and Emotional Distress in Physicians (plosone.org)
I had promised to write on this topic, a while ago, so here goes.
I was shocked to hear, in this day and age, that any medical educator can actually warn students to “never make a mistake!”
I can only hope that they did not mean it literally. I hope they meant to TRY to avoid mistakes. I hope they meant to say that in the business of human life and health, a mistake made by us can actually cost another human being their health, and therefore can be a very bad thing. I hope they meant that mistakes can be costly in many other ways as well. They can lead to litigation, immense stress, burnout, depression, and so on.
All of that would be right. But the fact remains that, despite everything we do, despite our best intentions, mistakes CAN happen.
What is most important to teach students and trainees is – How to avoid them, and how to deal with them, when they do happen.
Avoiding mistakes involves a lot of forward thinking, even play-acting in the initial stages, when setting up office. Work-flow has to be carefully analysed, and possible sources of error have to be eliminated.
For example, every lab report should be seen within a certain period of time, by the physician ordering it, and should only be filed away after it has been acted upon. In order to prevent mistakes in this sequence, it is necessary to make sure that every lab report is seen by the right physician, at the right time; there has to be some sort of code, that the physician puts on the report, that informs the staff of what action is required. there has to be a mechanism for the staff to see this, and then act on it, and follow up on those actions. Finally, the report has to be filed in the appropriate chart. A system has to be put in place, to ascertain that every one of these steps is carried out correctly, if mistakes are to be avoided.
Even after a system is set in place, and things are running smoothly, there have to be regular evaluations of these systems, to try and improve upon them, and make them more efficient.
When a mistake does occur, it can be a very scary thing. Mistakes can sometimes be small and inconsequential, and at other times bigger, and causing either distress or bodily harm of varying severity. It can also be the result of the action of any one person in the whole team of individuals involved in a patient’s care – and that includes clerical staff, as well as other support staff in hospitals. Often, however, the physician in charge has to take responsibility for it, anyway.
Whatever the cause of the mistake, early, full disclosure is always the best policy. It is of course, required by the law in Canada. There are plenty of resources, and workshops put out by the CMPA (Canadian Medical Protective Association), that help physicians understand what this means, and how to go about it. I am sure that such resources exist in other countries as well.
No matter what, the one thing that patients appreciate is a physician who tells them the truth. The majority of cases that go to court have been ones in which the patient felt that they were lied to, or not given answers to their questions in an honest and open manner. There will always be things we cannot explain when something goes wrong, however, and it is alright to say “I don’t know,” about such specifics. But overall, the patients and their families expect to see that the physician cares that something went wrong, and that they are not taking it lightly.
Perhaps the one thing that will be most appreciated when a mistake has been made, is an indication as to how this will be avoided in the future. If we can make it clear that we have identified ways to avoid it in the future, and put necessary mechanisms in place already, that will avoid a lot of conflict.
I do not know any physician who has worked for any length of time who can honestly say that they have not made mistakes. As far as I have seen, the person most affected, is always the physician, who feels guilty, and worries about making the same (or other) mistake again. They often find it hard to forgive themselves, especially when there has been a bad consequence. Over a period of time, however, they do learn to go on.
Ultimately, mistakes make us humble, they help us grow. They teach us forgiveness, and other valuable life lessons. When we do make mistakes, it is important that we try and learn everything there is, to learn from it, before we move on. And pray that we don’t make more!
According to Maslach and Jackson, who created the Maslch Burnout Inventory (MBI), the symptoms and signs of burnout can be grouped under three headings:
Depersonalization (or Cynicism), and
The cost of such a condition, in a physician can be immeasurable – not just for the physician, but for the family, the colleagues, and for the community at large! Unfortunately, when trying to be strong, in the face of repeated stress, physicians think they are doing the right thing, that has been taught to them, and is expected of them. They believe that everyone around them is looking up to them for strength and support, and any sign of weakness on their part would be harmful to everyone.
This, in reality, is far from the truth. We are doing nobody any favours, if we allow ourselves to suffer to the point of exhaustion, overwhelm and burnout. No patient would want to be served by a physician who is so emotionally depleted that he suffers from ‘compassion fatigue,’ nor would they be very understanding if a mistake was made by a physician who is exhausted, or didn’t really care enough! So, it behooves us to take care of ourselves, so that we can serve those whom we have committed to serve.
How do you prevent Burnout? Here are a few steps you can take, to avoid burnout.
1. Be Aware: Any change starts with self-awareness. We first need acknowledge that this is something we are all susceptible to, and that there is a certain courage in recognising problems and seeking help as required! If we think that we are in some way immune to the stresses, or that we are capable of handling it all on our own, we could be deluding ourselves.
It is important to know and detect the symptoms and signs early, and have an idea of what you are willing to endure, and for how long.
2. Be proactive: Smart people solve problems, by avoiding them in the first place. For example, every physician requests tests, and will receive the results in some form (electronic or paper). Isn’t it the smart thing to do, then, to set up a system, whereby the results will be looked at and acted upon, in a seamless way, least delay? Once this is in place, the chances of missing an important report can be minimised. Similarly, we can have different structures in place to deal with referrals, phone calls, etc. Maintaining a well organized and functioning office is perhaps the best thing one can do, from the professional point of view.
There are many things we can do on the personal level as well, like taking care of minor ailments to avoid major complications, clearing small misunderstandings in relationships to prevent build-up of resentment, and so on.
3. Be very clear of Your Values and Your Mission: You need to know what are the values that are most important to you, as a person, the violation of which will bring you pain. It will also help, if you know what you really hope to accomplish, through those values – in the near, and the distant future.
4. Prioritize: Once you know what is important, you can try to get more of what you want in your life. This includes knowing what is not important, that takes up our time and energy, that you can cut out of your life. This also means being able to say “No” to things that encroach upon your priorities.
5. Take care of your body, mind and spirit: Eating regularly, eating the right foods, and exercising should not be something relegated to when you have time. It would help to have some activity outside of work, that can help stimulate you in a totally different way, and make you happy. Volunteering is great, not just to balance out the stresses, but also to get some endorphins flowing! A spiritual practice helps to navigate the ocean of life, the currents of which can at times be very turbulent. Make sure you take time for renewal on a regular basis.
6. Build a support system: Have a good team around you. Choose your colleagues carefully, if you are in a position to do so. Make it a point to cultivate good relationships with supportive people, whom you can call upon, when you need help. It also means that you should have trusted people you can delegate all those tasks to, that you don’t really need to do yourself.
7. Learn to be a good team-player: It is important to try and understand that people are different, and that having different people is what makes a team strong. So, when conflicts arise, remember that it is most likely due to a simple difference in mental wiring or a difference in priorities. If you learn to understand the differences, and can learn to negotiate, and to work together – then you can avoid a huge source of stress in your life.
I have simply put together a few suggestions, many that have worked for me, and some, that I am still working on.
Please e-mail me with any comments, suggestions or questions.
While talking with a colleague recently, I was asked this question – and I realised that the word ‘burnout was used a lot, and the signs of severe burnout, the point where it hits you in the face, is easily recognisable. However, burnout is something that has to be recognized before it reaches this stage, and there are many people who seem to be functioning reasonably well, and yet, do have many of the symptoms of burnout, which they put down to stress.
There is a big difference between stress and burnout. The main difference is that a person under stress will feel better when the stress is relieved, whereas a burnout person has no hope that things will be any better, even if the current stresses are relieved. Burnout is the result of too much stress, often repeated, without enough recovery in between, over a period of time.
The term was first used by Freudenberger, who described it as a “state of mental and physical exhaustion caused by one’s professional life.” This is characterised by exhaustion, cynicism, and a sense of inefficacy.
Causes of Burnout: There are many factors that lead to burnout. While most cases occur due to stressful work environment, burnout can occur in a stay-at-home parent, or in a person working two or more jobs to make ends meet, without any vacation or leisure. It can also occur in the obsessive compulsive person who expects too much of himself- and everybody else!
Burnout can thus be due to a combination of work environment and responsibilities, lifestyle, and personality traits. Some of the factors are as follows:
Work Conditions: (anybody in the healthcare field know what these are like)!
Overly demanding job, with high expectations
Working in a chaotic or high pressure environment
Feeling a lack or loss of control over the work
Lack of recognition or reward for good work
Too much work, no time for relaxation or socialization
Too many responsibilities
Being too many things to too many people
Lack of or inadequate support
Perfectionistic tendencies – expecting too much from self and others
Pessimistic attitudes – related to self and the world
High-achieving, Type A Personalities
Need to be in control – reluctance to delegate
Burnout is something that happens over a period of time, and can be prevented, if the symptoms and signs can be recognized early enough. It is important to be vigilant and pick up these signs, many of which may be subtle.
The symptoms and signs may be categorised as follows:
Feeling tired and drained most of the time
Lowered immunity, feeling sick a lot
Frequent headaches, back pain, muscle aches
Change in appetite or sleep habits
Sense of failure and self-doubt
Feeling helpless, trapped, and defeated
Detachment, feeling alone in the world
Loss of motivation
Increasingly cynical and negative outlook
Decreased satisfaction and sense of accomplishment
Withdrawing from responsibilities
Isolating yourself from others
Procrastinating, taking longer to get things done
Using food, drugs, or alcohol to cope
Taking out your frustrations on others
Skipping work or coming in late and leaving early
In the next post, I will be discussing methods of avoiding burnout, as well as measures to manage burnout, once it has occurred.