Burnout is defined as emotional exhaustion, feelings of cynicism and detachment, and a sense of ineffectiveness at work. The inverse of burnout is engagement — a persistent, upbeat sense of fulfillment characterized by vigor, dedication, and absorption. I haven’t seen that doctor in the hospital lounge in a long time.
I am a neurologist practicing for 25 years in both academic and community hospital settings. I have a busy outpatient practice, take calls at two hospitals and serve a leadership role within our regional health care system.
I found I was becoming less enthusiastic about the practice of medicine. I was rushing to stay on time, to finish electronic records, complete inbox tasks of patient phone calls, emails, result notifications, disability forms, pre-authorizations for MRIs and medication, and pharmacy requests. Daily practice was becoming a grind; I was neither burnt out nor fired up.
The tipping point was the introduction of Press Ganey patient satisfaction scores. My initial scores were abysmal. Patients didn’t like the long wait times, delays in responding to calls, and they felt I wasn’t listening to their concerns. This was not the caring and engaged doctor I thought I saw in the mirror every day. For the first time, I began to consider other avenues such as an MBA, a full-time administrative role or locum tenens practice.
But here is my confession: I love my job. At least most of the time. I love the sigh of relief when the patient hears the hand tremor isn’t Parkinson disease or poor memory may be due to depression and not dementia. I love the challenge of staying current on an ever-expanding knowledge base. I am grateful and honored to be in a respected and well-compensated profession.
I am a mostly happy doctor. Despite the frustrations of everyday practice, is there anything more fulfilling than caring for people? I had thought I was doing a good job, but my patients were telling me a different story. The body language of watching a computer is all wrong. Patients don’t believe I am listening if I’m glued to my screen. I needed to resolve the competing demands for documentation and the need to demonstrate presence to my patients’ concerns.
If you are one of the 60 percent of doctors who have experienced symptoms of burnout, here are ten changes I made that have helped reduce resentment and restore a sense of control, engagement and gratitude in clinical practice.
1. Patients complete a card with three questions for the doctor. I make sure we have addressed every issue on the card. No longer does the patient say, “one more thing” as my hand is on the doorknob because all issues have been addressed.
2. The two-minute rule. I spend the first two minutes with direct eye contact and try not to interrupt while asking the patient to tell me their story.
3. After a few minutes of listening, I ask permission to look away and take some notes on the screen.
4. I reassure that the patient is in the right place for their medical concern. I eliminate comments that suggest frustration with the EMR. I thank the patient for entrusting their care to me, offering email contact and regular follow-up and communication until the problem is resolved.
5. Optimize the EMR’s strengths. The EMR can gather data from other physicians, test results and can serve as an educational tool. Use the EMR to demonstrate images and reports to the patient, adding medical articles, online resources for exercise equipment, sleep hygiene courses, etc.
6. I end all encounters with the question: “Is there anything else I can help you with today?” Most of the time, the patient gratefully acknowledges that all questions have been answered.
7. Close the encounter before the patient leaves the room. The note, after visit summary (AVS), orders and letter to the referring provider are completed before the patient leaves the room. Avoid the temptation to complete records in bed or while on vacation.
8. I often finish with a request: “May I give you a hug?” While embracing, I will say a secular blessing, “Be well.” It is a simple act in the doctor-patient relationship that expresses empathy and support. There are caveats, especially in our current cultural awareness of sexual harassment: I always ask permission. An older female is generally safe; a younger female is embraced with caution or not at all, always with family in room; a male — generally not. A hug has the power to lighten the mood, to convey intimacy during a brief encounter and to share the burden of illness.
9. If the patient is smiling at the end of the encounter, I will encourage them to complete the survey. I may also request that they write a review on an online rating service.
10. I maintain resilience for the demands of practice with an intensive regimen of exercise. I became a group fitness instructor, teaching 3-4 classes a week of indoor cycling, including weightlifting and planks. In addition to the personal benefits, teaching has made me a more enthusiastic advocate for exercise with my patients.
What have I learned?
Since the electronic medical record and patient-driven quality metrics are unlikely to disappear soon, I have learned to use them to become a better doctor. The focus has become communication skills- demeanor, physical and emotional presence, listening and explanation of the evaluation and treatment plan. This has lead to a dramatic improvement in patient and physician satisfaction.
The physical contact has changed me more than my patients. I have moved from resentment to gratitude for a deeper relationship I thought wasn’t possible during a brief encounter.
Anticipating the offer of an embrace at the end prepares me to like the patient at the beginning. It opens me to want to know them personally, not simply collect data about their symptoms. Even though we may share hard truths about diagnosis, treatment, and necessary lifestyle changes, the patient may feel that we are in it together.
Laurence Kinsella is a neurologist.
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