It's the beginning of July, the beginning of a new academic medicine year, that strange entity that goes from July 1 to June 30 instead of January 1 to December 31, like the calendar year, or perhaps starts in September, like other academic years. The medical calendar has been so much a part of my life that I automatically think of a year as beginning in July, and my non-medical friends are often confused by this odd chronology. I started medical school in 1983, so I've been tracking time this way for over 30 years.
But this July
is very different for me. I will not be starting the new academic medical year along with my colleagues, students, and residents. I have stepped out of medicine, at least for the time being, as of the end of June. In fact, I left my position as a Primary Care Physician and Associate Professor of Clinical Medicine at a Philadelphia medical school a little early, on June 20th. I left, essentially, because the stress and ill health generated by my work had overtaken the satisfaction and other rewards it brought me. I made the decision, at 57, to step out of Primary Care, and to take a good, hard look at myself, my options, and the system. I made the decision to value myself and my wellbeing as much as I valued my patients and my career. I made the decision to take care of my own needs. I know, it's radical. It's selfish. People have told me it's brave, and at first I had a hard time accepting that, even though leaving was a very hard decision to make. But after a while, I started to understand that it is, in fact, brave to break out of a mindset that is deeply ingrained. One that we, as physicians are acculturated to early on and that we use to drive ourselves to be the very best we can be, but also use to punish ourselves and each other: the mindset that, no matter the cost, we must be good soldiers, that we must sacrifice ourselves to our profession.
I do not technically meet the criteria for burnout, if that's something you want to know. I happen to be one of the people who hates the term 'burnout', because it pathologizes and blames the physician instead of looking at the whole system. If half of Primary Care physicians (and a large percentage of doctors in most other specialties) are 'burnt out', according to the criteria of emotional exhaustion, depersonalization, and reduced personal accomplishment, then surely there is something wrong with the system, and it makes more sense to handle the systemic issues than to try to 'treat' the syndrome of burnout in an enormous number of individual practitioners. Besides, as Dr. Darilyn Moyer, my friend and the Executive Vice President and CEO of the American College of Physicians so eloquently put it at the National ACP meeting this year, we can't 'yoga ourselves out of' the problem. We've been talking and talking and talking about the crisis of burnout, depression and suicide in physicians for some time now. I'm glad we're talking about it, and I'm glad we're forming task forces and that our professional societies are taking the problem seriously. Yet in my own work, I only saw things getting worse, not better, over the last couple years.
Let me explain. So I technically don't meet the criteria for burnout. I did not experience depersonalization or loss of empathy towards my patients. If anything, I was overwhelmed by the empathy I felt. My patients seemed to be in more distress than ever, and I very much wanted to alleviate whatever suffering I could. I also did not feel reduced personal accomplishment. I was productive and effective, in my clinical work, in my teaching and in my writing. But I was truly reaching the limits of my physical and my emotional energy. I felt exhausted and depressed. I wasn't enjoying my life. I went home almost every day with a headache, and, after a day at work, had nothing left for other aspects of my life, which is sad, since I have a wonderful husband, two amazing young adult children, great friends and extended family, an adorable dog, and, ordinarily, a myriad of other interests.
I enjoyed most of the time I spent with my patients. I wanted to hear their stories. As a digital immigrant, I sometimes struggled to do all the tasks necessary on the electronic medical record while I was listening to my patients and discussing care and management with them. So I'd run a little behind just because of that, and I usually had a full schedule in any given patient session. That wasn't the problem. The phone calls and portal messages from patients would pile up while I was in session, but I could have handled that, too. Writing my notes on the EMR was formidable, since I had complex patients with multiple problems, and I could never finish a note until my patients were done for the day, but even that was manageable, though it was very time-consuming.
What became unmanageable was the stuff that seemed like constant, ridiculous roadblocks to what should have been the easy part of caring for patients. Every day I dealt with multiple prescriptions that, for what ever reason, patients had not received. Either they had been unable to reach our office, or the electronic interface to the pharmacy had malfunctioned, or the pharmacy had lost the order, or their insurance had denied the medication. Every day I did battle with several insurance companies regarding basic medications, such as antihypertensives, asthma inhalers, or insulin dosages because a patient had changed insurance or an insurance company had changed a formulary preference, and suddenly medications that had always been covered no longer were. Every day my electronic medical record inbox was flooded with messages regarding prior authorizations for medications and pre-certifications for tests, billing issues, referrals, and forms that needed to be filled out for various insurance companies in order for the health system to collect payment for patient visits. My email inbox often contained 'report cards' telling me about my productivity and how well (or poorly) I was doing at collecting health maintenance data on my patients. These report cards focused on comparing my 'performance' to that of other doctors. The 'compliance' department also sent report cards on our billing accuracy, and we were told that if we did not maintain an accuracy of at least 90%, we would be labeled as 'Error Prone Providers.' For me, the report cards and the punitive labeling were just insult added to injury. They were not motivating or educational or helpful in any way. I may not have been experiencing depersonalization, but the system was doing its very best to dehumanize me.
And there was the matter of the sheer volume of work that had to be done. Had there been adequate clinical or administrative support, many of these tasks would likely not have landed in my inbox, or could have been delegated to others once they did. My report cards would have always been excellent and my billing accurate, because others would have assisted in these endeavors. Unfortunately, as in many Primary Care offices across the country, support was not adequate. As a way to keep costs down, as the number of administrative tasks have risen, rather than increase the help given to physicians, the number of tasks falling on the physicians has risen also. It's the easiest place to put it. We can't really say no, because the care of the patient ultimately falls on us in the end. The report cards are our report cards. The patients are our patients. And so it goes.
We thought, back in the 1980's, that the insurance companies were driving us batty with referrals and prior authorizations and pre-certifications. Well, it's much worse now. And rather than make these tasks easier, technology has just made it less obvious who is behind the curtain. When a patient can't get what they need, it's hard to tell if the problem is at the level of the physician or the office staff or the pharmacy or the insurer, and entities will go in circles blaming each other, while the problem goes unsolved for days or weeks. So here we are, in quite a mess. I can only speak from my own experience, the perspective of just one primary care physician. But I know that it's not just in one practice, or one health system, or one specialty. From what I've read and heard, it's pretty ubiquitous.
Fortunately for me, I was able, from a financial perspective, to step away. And I had something else I wanted to do with my time. I wanted, first of all, to get my physical and mental health back. And I wanted to give myself space and time to write, and do it well. So I planned my exit months ahead, and applied to writing programs.
In this blog, I'm going to chronicle my road back to wellness, to study just what the last years of practice medicine have taken out of me and what I need to do to recover. I'm also going to explore writing as part of that recovery, as well as how it may be a useful tool for maintaining equanimity and humanity in the practice of medicine. Finally, I'm going to take the time to look at the systemic problems we are encountering in medical practice and the 'fixes' that have been suggested so far, to examine the question of if, and how, we can find a path back from a situation that has so many doctors unhappy, unwell, and even, in some cases, suicidal. Stay tuned.