Burnout: Quenching the Fire?

In two ways, I'm feeling a little guilty. First, I doubt I've provided any new insights in this burnout mini-series. And second, since I began by saying I'd heard from a few people that I've gotten them interested in a career in surgery, I don't want to have turned them off or discouraged them. So let's see what I can do about that.

In my core, I always loved doing surgery, and being surgeon to my patients. As I hope I've made clear in this blog, I was always amazed that I was allowed to do it, and awed at the mysterious beauty of it all. As much of a responsibility as it is, it's also an inexplicably wondrous honor and privilege. Those words aren't lightly written. But in a diabolical combination of being constitutionally unable to cut back, being hyper-demanding of perfection in myself and only slightly less so in those who touched my patients, mixed with a certain degree of paranoia which made me see any imperfection as an accusation, I got to a point where some sort of line was crossed. Every ring of the phone at home became a gut-shot; the emergency room was like a stalker, a heavy-breathing relentless destroyer of plans, a stealer of sleep, a wielder of a fearsome disrupter ray. Klingons, the lot of 'em.

The cold shower of new rules, the deluge of self-fertilizing forms, the insults and veiled threats of the latest memo from some bureaucrat or other, the inverted logic of convincing some insurance cubicle-denizen that I had a legitimate reason for recommending an operation she understood not at all -- I think I might have withstood all that were I better rested, had I not arranged my day for maximum continuous pressure nor added work upon work. So here's the bouquet-toss to future surgeons: don't do it like I did.* Give yourself a goddamn break. Good news: the system doesn't care if you work your ass off or not. So don't. Turns out, the world didn't stop turning, people didn't start dying left and right when I sheathed my scalpel.

That's, I suppose, the corollary of my obsession: the silly sense that I was indispensable, that only I could render proper care to my patients. Don't get me wrong: I think my judgment, my technique, and my rapport with my patients were above average (OK, OK: way above average!) But so would they have been, had I relaxed a little. I have no doubt that rounding, as I did, three, four times a day made a difference in length of stay. But it seems I was the only one who noticed. I kept office hours four (sometimes five) days a week, wanting to be there if my patients needed to be seen, hating to have someone else see them. That meant I always had pressure to get my operations done by a certain time. I could have arranged it differently. Making things worse, as much as I hated to be late I also hated to make others late. I almost never ran beyond my scheduled OR time. I almost always saw patients in the office EXACTLY at the time of their appointment. I helped move patients on and off their gurneys (I'd recommend that!), cleaned up my exam rooms, whatever it took to keep things going on time. Close to crazy. I never could say no to a request to work in a woman frightened about her mammogram, instead of making her wait a few days. Couple of days? Probably would have still been ok. As I said in the first two posts in this series, US healthcare as currently constituted is -- almost as effectively as if it were deliberate -- selecting against hard work and high quality, at least to the extent that it fails to recognize, encourage, or reward it. Consider it good news: don't kill yourself! I'm serious.

Want to have a better life? Don't schedule yourself into your office half an hour after your last case is expected to end. Cut yourself some slack, in all things. Rounding twice is enough. Letting your partners see your patients on weekends off is ok; I saw theirs, ferchrissakes! Take all the time off you're allowed. Avoid serving on any committee you can wangle your way out of. Get thrown off, if that's your only option. But be civil to the ER doc who calls at three a.m; and to the nurse who overlooks something, explain in non-angry terms how and why you think it could have been different. A "teaching moment," I believe, is what they call it. Chill. Had I done so more often, I might not be blogging.

And here's the happiest secret: there's always one place they can't get to you -- the operating room. (They can call you, of course; but they can't paper you, committee you, disallow you. Not while you're there.) If you love it, that will never change; so if you love it, go for it. The act of doing surgery, distilled to its essence, the condition of being surgeon to a fellow human being -- that will always be honorable and essentially untouchable, immutable. And wonderful. It's even conceivable that if "they" come up with meaningful ways to evaluate the quality of medical care, some sort of global, transferable, reproducible, over-arching and useful method that's neutral and rational (pretty unlikely but not unimaginable), then the piles of paperwork, reams of rules, confabulations of committees might actually become superfluous, and a doctor will once again be allowed to be a doctor. A physician. I like that word. It's almost as good as surgeon.

*Unless your patient is me.

Burnout: Embers

The medical director of my clinic once gave me a book on burnout. I never read it. Didn't have the time or energy.

Because a young reader considering a career in surgery referred to stories he's heard of depressed and disappointed surgeons and asked for my thoughts, I'll try to address it. Parenthetically, I've heard from more than a few readers that my blog and/or book has inspired them to consider surgery as a career. Don't know whether to smile proudly, or shoot myself.

I quit my practice much younger than I'd have predicted when I went into it. In thinking about the reasons, not all of which can I distill, I can't make the claim that one ought to generalize: I speak only for myself. In some things, the themes are universal; in others, maybe more particular to me than my colleagues. As with many others, it's true that my love for my work diminished over the course of my career: yet at its core, the rewards and pleasures remained. It's just that it was harder and harder to access them, as the layers of bullshit of all sorts increasingly hid it all from view. Maybe it's like this: early in my career a day of work had ten pounds of pleasure in it. By the end, it was still ten pounds (heck, maybe even twelve), but I had to wade through fifty pounds of crap to find it. Thirty years ago, it was only five.

Surgeons my age are transitional characters. When we first dipped our toes in the pool we were touched by ripples of the good old days: regulations were minimal, the default presumption was that we knew what we were doing, most of our time was taken up with actual patient care. The occasional meeting. Serving on a committee once in a while. And we could charge what we thought was a fair price for what we did. Let's get that last concept out of the way first. (Reality check: not everything about the good old days was good, especially for the consumer. I admit it enthusiastically. It's not necessarily better now; just different.)

I've yet to meet a medical doctor of any sort who went into the profession first and foremost for the money. (For some, that came later.) Nor would I claim that doctors deserve to be the highest paid of professionals. In fact, at the time I took up the scalpel, I thought many docs -- surgeons especially (general surgeons less so!) -- made way too much money. The public health would be much more adversely affected were garbage collectors to cease to exist than if doctors did. Yet there's a truism: most people willing to work very hard, who have an ethic of excellence, who take great and justifiable pride in what they do, expect some sort of reward commensurate with and in some way proportionate to the quality of their product. And money, for better or worse, is one of the vehicles for providing that reward. Not the only one; not, maybe, the most important one. But a very tangible one. Measurable. Whereas I recognize that speaking about it at the outset risks losing any sympathy (in fact, I'm not asking for sympathy: I'm just trying to explain, and to answer an honest question), I think it's central, symbolically, to understanding the unhappiness that I and many of my cohorts came to feel.

My brother is an attorney. A very successful one; a senior partner in one of the US's bigger international firms. I gather he's really good at what he does: the accolades he's received within his profession attest to it, as do (to the extent that I can understand them) the extremely complex cases he's guided to favorable outcomes. He charges by the hour, a hefty sum which has risen steadily over the course of his career. More, I gather, than many of his peers. And, I'd wager, his clients are happy to pay it: for their top dollar, they get a top echelon lawyer who can be counted on to work his ass off and most likely prevail in their cause. To them, he's worth it. (Makes four times more than I ever did, and is probably four times better at what he does than I was at what I did -- I'm thinking there may be greater divergence among good attorneys than among good doctors.) As in virtually every other profession, you get what you pay for. Not so, any more, with medicine.

Two things have happened to physician reimbursement, and both have had a perverse and adverse effect on professional morale. First, payments have steadily declined, to about a third of where they were when I started out. Second, fees have become standardized, meaning Doctor A gets exactly the same amount to take out a colon as Doctor B, no matter how much better at it one is than the other. By law and/or contract, doctors have no ability to establish their own charges or to collect the difference. In the first instance, the effect is that doctors have to work harder and harder every year just to stay even financially; in the second, it means there's no incentive -- financially anyway -- toward excellence. If money is a surrogate for acknowledgment of a job well done, the current system says "we don't give the slightest shit about whether you are doing your job better than the next guy or girl." Take it, and shut the f@*k up. Or so it seems. You may or may not believe this: doctors are, for the most part, altruists. The real rewards come from doing right by the patient. I love the relationship I have, as a surgeon -- especially and particularly as a surgeon -- with my patients. I love (except when all hell breaks loose) being in the operating room. (Heck, sometimes even then: as long as I can bail myself and my patient out, able to tell myself I did good, and seeing the instant proof.) But (or is it "so?") it's enormously deflating every year to get the latest announcement from Medicare, or Blue Cross, or for-profit Joe the insurer and its multimillionly paid exec, of the latest cut in what they'll pay me. Similarly, the notion that they'll be paying the same amount to some guy who I KNOW is not getting the results I am (or saving them the amount of money I am, by virtue of a passion for cost-effective care and willingness to work extra hard to achieve it.) Like I said, it's perverse. And my claim is that it's having an effect on who chooses to go to medical school, and who chooses to go into the most demanding specialties. My friends in academic medicine seem to agree. It's elsewhere that hard work and excellence are valued more.

Every year I was in practice I made more than in the previous year, despite the fact that in virtually every year, reimbursement declined. The reason is obvious: I simply kept working harder and harder. Partly it's because that's who I am: I never took as much time off as I was allowed, I always took call on my own patients, rounded whether I was on or off. So here's an instance in which my behavior contributed particularly to my burnout. But the milieu was the same for everyone. And it compounds itself: as you work harder and harder to stay even, you'd like to hire some help. But anticipating further cuts, you feel you really can't afford to. As I got older I came to think I'd be happy to trade time for money; but my younger partners -- with young kids and longer futures -- didn't want to take the financial hit. And whereas they were taking the same amount of call as I was, they (perhaps wisely!) kept fewer office hours, saw fewer patients, and took more vacation. And why shouldn't they? Coming along in the new era, maybe they saw that hard work wasn't recognized and rightly concluded it wasn't worth it. Yep, you get what you pay for.

So that's a foundational background. Money isn't an explanation, but it is sort of a microcosm. I'll think some more about the rest of it, and let you know what I come up with. Next.