Physician burnout: Don’t blame the patient

My daughter loves her career as a probation officer. She is very good at what she does, and finds the work both challenging and rewarding. Yet her client case load includes some of the most unsavory of individuals, found guilty by the courts of child abuse, domestic violence, sexual assault or worse, many of them  living with added complexities like addictions or mental health issues. She’s been insulted and screamed at by distraught clients. Police are sometimes dispatched to her workplace to intervene in potentially dangerous crises.

Yet whenever I ask my daughter what kind of day she’s had today, I marvel at her continuing ability to truly care about the work she does, despite the many challenges of working within the criminal justice system, dealing with an often-desperate clientele, and an almost overwhelming legal bureaucracy.

Contrast that perspective with the collective unrest among physicians who seem to hate their jobs.

An example is well-known Chicago cardiologist Dr. Wes Fisher‘s recent online essay: Hostile Dependency: The Real Reason For Physician Burnout.It’s a compelling exploration of his belief that “most doctors” are turning away from medicine.

He blames this trend on the serious challenges doctors face when caring for their patients.  He blames the many layers of bureaucracy and paperwork, both electronic and manual, that burden today’s physicians. But the brunt of his blame lands on one particular target:

As bad as these realities are, they are probably not the reason most doctors are turning away from medicine.

I think there’s another issue that is even bigger.

I believe the overriding reason doctors leave medicine is because there is a growing hostile dependency patients have toward their doctors.

Comparing the hostility of patients to what he calls the disillusionment felt by acting-out teenagers when they discover that their parents have feet of clay, Dr. Wes adds:

Most of us understand this behavior simply as “adolescent rebellion,” not understanding the powerful issues at play.  So when we spotlight doctor burnout or the lack of patient safety in hospitals without acknowledging the realities health care workers face — like looming staffing shortages and pay cuts — we risk fanning the flames of narcissistic rage against the very caregivers whom we depend on the most.

Thus the blame for this burnout among medical professionals is laid squarely at the feet of the very people who inspired physicians to enter the practice of medicine in the first place: the patient.  That self-absorbed misguided sod who just can’t comprehend the problems that one’s doctors are facing.

Why do some doctors blame patients for their discontent?

Dike Drummond, MD spends a lot of his time thinking about this question. He describes physician burnout as a downward spiral that has three distinct symptoms:

  • physical/emotional exhaustion
  • depersonalization
  • reduced sense of personal accomplishment

It’s that second symptom that doctors like Dr. Wes and others exemplify: depersonalization.

Depersonalization, according to Dr. Drummond, includes the development of a negative, callous and cynical attitude toward patients and their concerns (“my patients are so #%*&!”). The cardinal signs here, he warns, are cynicism, sarcasm and “feeling put upon by those patients.”

Depersonalization is not unique to doctors, of course. Whether you work in medicine or in a school classroom (teachers, for example, have the highest burnout rate of any public service job) or, like my daughter, in the world of criminal justice, depersonalization can rear its ugly head if given half a chance.

And pointing accusatory fingers at those who need you is very, very tempting.

Dr. Wes doesn’t mention his nurse colleagues in his essay, but studies attribute burnout rates among nurses to high nurse-to-patient ratios, long shifts, and, ironically, dealing with difficult doctors who, as a British Journal of Nursing study described, “regard nurses as their hand-maidens.” Another study conducted by VHA cited “disruptive physician behavior” as a contributor to the nursing shortage, after a whopping 92% of nurse respondents reported witnessing “inappropriate conflict involving verbal or even physical abuse of nurses.”

If you really want to avoid getting burned out, don’t work in public accounting where juggling heavy client loads, frequent business travel, crazy tax season schedules, and relentless quarterly filing deadlines throughout the year lead to prolonged periods of extreme stress and exhaustion.

And those who work in retail or the fast food industry suffer significantly high burnout rates due to very low pay, monotonous tasks, extremely high staff turnover rates, job-related depression, and “not feeling valued.”

But when the depersonalization of burnout happens in the traditional hierarchy of medicine, it may feel heightened by what sociologists describe as a dominant group holding power in a given society (doctors) being disturbed by those who have historically had little power to dare question that dominance (patients).

Jackson Katz is an educator, author, filmmaker, TED talker and author of The Macho Paradox. He had this to say about those who represent a dominant group in society:

One of the ways that dominant systems maintain and reproduces themselves is that the dominant group is rarely challenged to even think about its dominance.

It’s one of the key characteristics of power and privilege — the ability to go unexamined, lacking introspection, in fact being rendered invisible in large measure even in the discourse about issues that are primarily about them.

The dominant group doesn’t get paid attention to while they’re busy pointing fingers at others.

Is Dr. Wes correct? Are “most doctors” in this dominant group actually turning away from their chosen careers? And is this where the practice of medicine now finds itself?

The times they are a-changin’, just like Dylan warned us. And as I wrote previously, health care today from the patient’s perspective can look something like this:

It’s a pretty frightening time to be a patient, in fact. And if you think it’s tough these days to be a doctor struggling with the burdens Dr. Wes writes about, just try being sick.

No patient I know wants to be labelled as “difficult”, for we know to be so judged can demonstrably impact the quality of care received. An interesting study reported in Health Affairs last year found that even though patients voiced a strong desire to engage in shared decision-making about treatment options with their physicians, several obstacles inhibit those discussions, including:

  • even relatively affluent and well-educated patients feel compelled to conform to socially sanctioned roles and defer to physicians during clinical consultations
  • physicians can be authoritarian
  • the fear of being categorized as “difficult” prevents patients from participating more fully in their own health care.

When patients do dare to speak up on medical issues that matter, we risk being shouted down for our efforts by those in the dominant group.

A small example. Even in emergency while presenting with chest pain, nausea, and pain radiating down my left arm, I was scolded by a nurse to stop asking questions of the ER doctor: “He’s a very good doctor, and he does not like to be questioned!”

The unacceptable questions I was asking that day, as I was being sent home in mid-heart attack with a GERD misdiagnosis, feeling suitably chastised and embarrassed for making a fuss over nothing, included: “But doctor, what about this pain down my arm?”

Many patients who do try to speak publicly can be accused of widespread“doctor-bashing” – and now even called names like “narcissistic” and “hostile.”

Most patients are, in fact, concerned about our doctors’ professional frustrations. We hear them. We get it. We really do. We value and respect good medical care, and want to trust that the physicians who provide good care will be around for a long time. We certainly don’t consider physicians to be our enemies, and are puzzled to be considered or treated as such by any of them.

But the thing about being sick enough to seek medical care is that it’s often impossible to truly focus on the wants and needs of your physician when you’re very ill or hurting or scared. I guess that’s why Dr. Wes called us narcissistic.

Patients will not and cannot single-handedly address this burnout and depersonalization crisis.

We know, however, that not all doctors agree with Dr. Wes. That’s why we appreciate the doctors who can stand with their patients, not against them.

My daughter told me about a concept that those working in domestic violence prevention call the “bystander approach.” Instead of only seeing men as perps and women as victims, for example, their focus is on bystanders who have the power to interrupt. A bystander in this context may witness a comment, a victim-blaming remark, or any other word or behavior that might contribute to negative outcomes and then choose to interrupt the scenario. Thus, rather than silently observing a threat, bystanders dare to speak out to stop the cycle of silence.

The bystander effect can work both ways, however. We know, for example, that:

  •  the greater the number of bystanders who do nothing to interrupt a specific action, the less likely it is that any one of them will help
  • studies on altruism show that all helping behavior is more likely when there are similarities between the helper and the person being helped
  • when “us-vs-them” accusations begin, the resulting wedge widens the gap between the two

I wonder if it’s possible to get the doctors who don’t hate being doctors to speak up as bystanders, to be interrupters as this “downward spiral” accelerates within their profession?

There are many of them out there. I know this because I so often hear from them, meet them, read their words and best of all, I’m lucky enough to have three of the very best of them on my own team as my GP, cardiologist and pain specialist.

Another such interrupter is internist Zackary Berger, PhD, MD, who teaches at Johns Hopkins and is the author of the excellent book, Talking To Your Doctor. He chose to respond directly to Dr. Wes Fisher’s essay on “hostile dependency” and “narcissistic rage” like so:

I confess I have difficulty with this piece.

First, I am not sure what the author means by the term “hostile dependency.” It seems to mean patients who criticize doctors too much. But iatrogenic error and its attendant morbidity and mortality are real.

Patient criticism of providers’ failures and shortcomings should not be reflexively dismissed.

Perhaps the “growing hostile dependency” is a projection onto patients of our increasing realization that something is amiss with healthcare in this country.

If we doctors blame patients for pointing out what we all know to be the case, we will be shooting the messenger — pretty hostile, I think.

Yet another interrupter is physician Rick Lippin, MD, whose essay My New Adult Relationship With My Patients manages to avoid name-calling entirely:

My approach with my patients has evolved over 35 years of medical practice. The excesses of paternalism in my practice of medicine have been replaced by a much more rewarding adult-to-adult relationship with my patients. Not shaking my finger at them or scolding them as “children” has helped them and me more than you can imagine.

When my daughter first set her sights on working with criminal offenders, many of us worried about her career path. But very little of her current workplace reality has come as any surprise to her. Like all of us, she experiences good days and bad, but she knew what this life would be like right from the get-go, and has been well-trained to cope.

Eric Van De Graaff, MD has expressed similar observations in his column, Why Are So Many Doctors Total Jerks?  Another potential interrupter, Dr. Eric is, like Dr. Wes, a cardiologist — yet one who doesn’t feel the need to compare his patients to acting out adolescents.

He warns his colleagues:

We doctors have chosen professions that are inherently filled with stress, deadlines, and treading in deep emotional waters.  None of that grants us a free pass to behave like spoiled toddlers.

There well may be “narcissistic rage” boiling up out there, but sadly, much of it appears to be coming from physicians, not from patients.

Carolyn Thomas is a heart attack survivor who blogs at Heart Sisters.

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  • Whatever

    Thank you for your thoughts. We all, patients and physicians (I am the latter), have different levels of stress that we can tolerate and different battles that we fight every day. When we have bad interactions, we would do well to try to consider the situation from the other’s perspective, avoid blanket statements villainizing entire groups of people, and stop using “My life is harder than yours” as a pissing contest. Acknowledging our mutual difficulties is a powerful tool and can clarify almost any situation. I think it really is that simple.

    • DoubtfulGuest

      Yep…suffering is not a zero-sum game.

  • rtpinfla

    A mentor of mine liked to say, “When you point a finger at someone/something else, don’t forget your other three fingers pointing right back at you”.
    I always interpreted that as 1) If you think there is a problem you had better make sure you take a good long look at yourself first and 2) no matter where the problem is coming from, it is ultimately up to you to take the steps to fix said problem.

  • buzzkillerjsmith

    Post is too long.

    Multifactorial, Carolyn, multifactorial.

    Next case.

  • southerndoc1

    Patients blame doctors.
    Doctors blame patients.
    Insurers laugh all the way to the bank.

  • guest

    I’m confused by all of this back and forth stuff. Most doctors I’ve encountered have been very professional, have treated me respectfully, and have been great physicians. There will always be a few bad apples in any profession, but they’re the exception by far.

  • Changjie Han

    I understand Dr. Wes Fisher‘s point. As long as you are engaging in some kind of career that needs to deal with people, you’ll always have the chance to get misunderstood or blamed, that’s normal. The point is, as a doctor, it is still necessary to ask oneself is there something I did wrongly or is it possible for me to improve my work, instead of simply blame back or just ignore patients’ remarks.

  • May Wright

    Excellent post, Carolyn Thomas, and you and the other authors whose posts you link to express some absolutely vital points.

    I hope other doctors will take your rational and quite valid concerns and criticisms on board and not just dismiss them as the hyperbolic rantings of a hostile acting-out teenager — though if they do, that will rather be proving your point!

  • fatherhash

    i think it’d be interesting to see how most med students entering medicine view patients vs how they view patients towards the latter part of training.

  • Claire

    Agreed. I would add to that financial pressures. The cost of education is simply outrageous. The stress of being in your mid-20s, having debt that is well into the six figures and then work 80+ hours per week for only $50,000 per year [or thereabouts] as a resident is simply too great. Some people have the coping skills to deal with this, but many do not. It’s simply too much of a burden. Many stable well adjust people simply crack under financial strain.

  • rbthe4th2

    I’d say it also doesn’t help when we try to help you out and you knife us in the back. Some of us would help, but once we’re blacklisted, etc. you turn allies into enemies for no reason.

  • http://www.myheartsisters.org/ Carolyn Thomas

    Thanks so much Dr. D for your two cents worth, and particularly for reminding us right off the bat: “Blaming the patient is a SYMPTOM of burnout – compassion fatigue. It is NOT the cause.”

    I was hoping you’d weigh in here, as you have uniquely experienced burnout both personally in your medical career, plus as a person who now offers valuable and practical help for your colleagues suffering as you once did. For example: http://www.thehappymd.com/blog/bid/290248/Physician-Burnout-Pathophysiology-and-Treatment-of-Burnout

  • Rob Burnside

    It’s not the patient, it’s the patientS. There are just too many in the average doctor’s average workday, no matter what the specialty. They shoot horses, don’t they?

  • Mellanie True Hills

    Excellent perspective on this problem, Carolyn!

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