Rethinking Burnout: 3 Suggestions to Reduce the Stress of Practicing Medicine

Why, then, ’tis none to you; for there is nothing either good or bad, but thinking makes it so.

William Shakespeare, Hamlet

John Doe is a 43-year-old physician who has been practicing internal medicine for 10 years. Like many physicians, Dr Doe is a high achiever: He finished near the top of his class in high school and then graduated with honors from a state university. After medical school and residency, he entered private practice, where he now sees 23 patients or more each day.

He describes himself as a compulsive Type-A physician, with little tolerance for mediocrity. For the past few years, he has become exhausted by excessive documentation requirements, inefficiencies in the electronic health record (EHR) system, and increased pressure to see more patients in less time. He often spends several hours in the evening completing his charts.

Early in his career, Dr Doe trained for marathons and rode his mountain bike for exercise—but not these days. Now, he rarely eats lunch and snacks on candy bars. He has gained 14 pounds in the past 2 years. The nurses with whom he works report that he is irritable and short with the staff. He has become emotionally detached from patients. His engagement scores have progressively declined. He complains to his physician colleagues that he feels helpless to change a health care system that has become anathema to him. He frequently questions his ability to make a difference anymore.

Dr Doe is going through the motions of doctoring. He is chronically stressed, or burned out. And he is not alone: A recent study revealed that more than 50% of physicians currently experience symptoms of burnout—a number that has increased by 10% since 2011.¹ Dissatisfaction with work-life balance has also significantly increased, especially in specialties such as general internal medicine, family medicine, and emergency medicine. In ambulatory practices, physicians are spending less face-to-face time with patients and more time working after hours at home (1-2 hours each night) doing clerical work and documenting patient encounters in the EHR.²

Burnout is a chronic stress syndrome that is characterized by emotional and physical exhaustion, loss of meaning, feelings of inadequacy, and emotional detachment from patients.¹ When burnout is severe, it can lead to depression and an increased suicide risk. Many factors contribute to physician burnout, including individual factors (eg, compulsive personality traits, poor coping skills, emotional inflexibility) and systemic factors (eg, office inefficiencies, EHR hassles, regulatory and reimbursement demands, production pressures).^3,4

Although systemic issues are huge contributors to the problem, they are not the focus of this commentary. Instead, I offer 3 suggestions on how health care providers can reduce the stress of practicing medicine today.

Don’t believe everything you think.

Several months ago, I saw this line on a bumper sticker in the doctor’s parking lot. I now have that sticker placed prominently on my office bookshelf, to remind me to think twice about the stories I tell myself.

For example, my electronic charts are rife with misspelled words and incomplete sentences. One story I could tell myself about this fact sounds like this: My charting is really poor. I’m not living up to my own high standards of care. I cringe when I think about my colleagues reading these notes. 

This story makes me feel embarrassed and inadequate. These feelings lead me to doubt myself and will certainly affect my future performance.

A more positive and equally plausible story about the same fact sounds like this: I’m fine with getting a C in medical charting—it’s good enough. It’s a small price to pay to achieve my primary goal: to excel in my relationships and the actual care I provide to my patients. 

Telling this story makes me feel very good about my work. The more positive stories I tell myself, the better I feel. The better I feel, the better I perform as a physician and a team member. As my performance improves, so do my patient outcomes.

Am I being naïve, or ignoring the facts? I don’t think so; I’m simply choosing to interpret the facts in a different, more optimistic way. The fact that I can choose the story I want to believe is a very powerful remedy to negative thinking, and it is a preventive step in overcoming feelings of burnout. Choosing positive stories to tell about the facts requires frequent, deliberate practice.⁵ Read the bumper sticker again to help you remember what to do.

An attitude of gratitude builds fortitude.

Before I start each day, I write down in my journal what I’m grateful for. Gratitude for health, family, and friends, of course; but also for the simple pleasures: hot coffee, a great pen, a blazing fire, or a brilliant sunrise. It only takes a moment between patients to recall these and the many other wonderful things in my life. To make gratitude a habit requires deliberate practice and thinking differently about your life, which can be not easy to do. An active prayer life reinforces and supports my attitude of gratitude.

Build real and meaningful friendships.

One or two will do, as long as they are authentic friends with whom you can comfortably share deep thoughts and feelings about life. For example, let’s say you’ve committed a medical error. You think it’s your fault, and you cannot shake the guilty feeling. Because of the error, you begin to contemplate a career change. A good friend can provide another, more expansive view that points to systemic factors contributing to the mistake. A friend can remind you of your many career successes: high patient satisfaction, a fine reputation among colleagues, and numerous teaching awards. In other words, a friend can help you not to believe everything you think.

There are other things physicians can do to reduce the stress in their lives: Practice mindfulness, breathe deeply, exercise, and get regular physician checkups; find a life coach⁶; and smile and laugh more. Some physicians are reenergized by using their gifts for advocacy to change organizations and systems of care. Others are renewed by teaching the next generation of physicians. Of course, none of this will happen unless physicians change the way they think about their work and life.

In other words, the first place to start is not to believe everything you think.

Dean Gianakos, MD, is the director of medical education at Centra Health in Lynchburg, Virginia.

References:

1. Shanefalt TD, Hasan O, Dyrbye LN, et al. Changes in burnout and satisfaction with work-life balance in physicians and the general US working population between 2011 and 2014. Mayo Clin Proc. 2015;90(12):1600-1613.
2. Sinsky C, Colligan L, Li L, et al. Allocation of physician time in ambulatory practice: a time and motion study in 4 specialties. Ann Intern Med. 2016;165(11):753-760.
3. Gabbard GO. The role of compulsiveness in the normal physician. JAMA. 1985;254(20):2926-2929.
4. Huff C. Fixing the system to fight burnout. ACP Internist. 2016;36(10):1,9,12.
5. Patterson K, Grenny J, McMillan R, Switzler A. Crucial Conversations: Tools for Talking When Stakes Are High. 2nd ed. New York, NY: McGraw-Hill; 2012.
6. Gazelle G, Liebschutz JM, Riess H. Physician burnout: coaching a way out. J Gen Intern Med. 2014;30(4):508-513.