Yes, burnout existed 30 years ago – but how today’s hospital culture is making it worse… aka the “Twitter effect”

Burnout, burnout, burnout.  It seems like that is all anyone wants to talk about these days.  And I admit, some days, I can get burnt out on burnout.  But, all the attention on the subject got me thinking… did burnout not exist 30 years ago? Why is this such a hot topic now?

And that is what brings me to this post – I came to the realization that burnout very much existed 30 years ago, but that the current “write-up” culture, and what I affectionately refer to as the “Twitter effect”, that is now prevalent in healthcare and most US hospitals has made it infinitely worse.

Let’s face it.  Surgeons have a reputation – bossy, mean, rude, impersonal, hard to work with, and difficult.  And, this reputation, just like Rome, wasn’t built in a day.  It wasn’t even that long ago (during my training years) that surgeons would throw instruments, throw nurses, medical students, even anesthesiologists out of their operating rooms, or yell, scream, and curse to their heart’s content.  Infidelity and extramarital affairs were rampant, paperwork wouldn’t be completed on time, and bad outcomes only had to be discussed at a weekly Morbidity and Mortality (M&M) conference and only with other surgical colleagues.

Clearly, most of the above described behavior is unprofessional, inappropriate, and unacceptable.  But, what it did do was provide a mechanism, a valve so to speak, with which to vent anger, frustration, sadness and fatigue.  And, for a very long time this behavior was viewed as a fact of life.  Nurses would talk amongst themselves, junior residents would get stuck having to operate frequently with the most malignant personalities, clerks and environmental services staff would just look the other way.

But then, over time, we became enlightened.  We became proactive in empowering any and every one to speak up against unprofessional behavior, sexual harassment, or profane language.    We began to focus more and more on ways to measure performance. How long does it take for a physician to complete their paperwork?  How many patients are you seeing in a day compared to your peers?  Hospital complications are now labeled as “never” events.   M&M’s have become Disney World vacations when compared to having to re-live bad outcomes over and over again in hospital-run root cause analyses and peer review sessions to examine the role of the physician in bad outcomes.

But somewhere in all this enlightenment, we have lost the true message of healthcare.  

Healthcare is about relationships, not write-ups.

We have now cultured a culture in which having a bad day, losing one’s patience, or not smiling enough can now lead to getting “written up” by anyone in the hospital – student, resident, nurse, clerk, patient, etc.  The filling out of paperwork, and the careful coding of certain physical conditions so as not to get dinged by the hospital for providing “suboptimal” care, are now fodder for write ups.  Physicians are held captive and measured by the electronic medical record, NSQIP, 360 degree evaluations, and quality metrics.

So what does being written up mean exactly?  It means meetings (often multiple) to discuss said incident or incidents, papers being placed in personnel files, and sometimes poor job evaluations.  I call this the “Twitter effect” – anyone can say anything at all about you, true or false, whether you have worked somewhere for 15 years or 15 minutes… and it gets attention.

Don’t get me wrong here. Professional behavior should be expected at work, and we should always strive to be better physicians, nurses, healthcare workers and humans tomorrow than we are today.

But, punitive attitudes and actions are NOT going to result in any of that.  I have never written anyone up in 11 years, and I pride myself on that because it does not change behavior.

Bottom line, if someone is an a**hole, writing them up is not going to change that.  And, if someone just had a bad day, or is having a rough week, having a relationship with them, being able to engage them in a conversation, will change their future behavior. A piece of paper will not.  Most times, people already know when they messed up, giving it undue amounts of attention only lead to feelings of defensiveness and self-doubt.  And the truth of the matter is bad days happen to all of us.

I am human.  Am I at my best after 36 hours of call inside the hospital with 60 patients on service, back to back emergency surgeries and emotional discussions with families about poor outcomes for their loved ones?  Absolutely not.  But am I still expected to smile, teach residents, make the medical students feel comfortable, get daily paperwork done within 24 hours, have the patience of Gandhi and not make any errors in clinical judgement?  You better believe it.  And, for the most part, I’m 100% okay with that.  I signed up to be a surgeon, I didn’t draw it out of a hat.  However, the feeling of walking on eggshells, the inability to have a bad day, lose one’s patience, or be anything other than perfect is soul-crushing.

I feel this especially as a trauma surgeon.  Surgeons in general are at a national shortage, and especially so with trauma surgeons.  Most institutions are not running fully staffed, leading to more call nights, longer hours, and more fatigue.  And no, this isn’t subjective. Being a trauma surgeon and the amount of call a physician takes have both been directly associated with the development of burnout.

Gone are the days where a surgeon can throw an instrument or curse out an entire operating room… and good riddance, quite frankly.  But also gone are the days in which anyone can have a bad day, get frustrated, or maybe say the wrong thing, and have it understood or handled without a paper trail.  The relationships we form at work are meaning less and less, and paperwork is meaning more and more. And, until we change this – until we change the punitive and negative culture within healthcare – we will continue talking about, and becoming, burned out.

2 thoughts on “Yes, burnout existed 30 years ago – but how today’s hospital culture is making it worse… aka the “Twitter effect”

  1. Excellent post and very well written. Got the wheels turning for me for a couple of days and now finally have a chance to respond.

    Whatever reporting system your hospital claims not to be punitive – that it’s the best way detached hospital administrators have for identifying physicians who are abusive and may need help or remediation. If you have a pile of complaints, you probably need to be on the radar. Caught in the crossfire, however, are physicians who occasionally “lose their cool” under stressful circumstances. This launches a series of meetings and talks, all over a misunderstanding or a bad day. For the generally well behaved physician who just “cracked” for a moment, this takes a situation about which they probably already feel not and launches them into a downward spiral of feeling worse about their behavior, concern about their reputation, lost time in these meetings, questioning their self worth and worth to the organization, etc. For a group of people who already teeter on a dangerous tightrope between depression, anxiety and substance abuse, a single “reported event” can be internally devastating.

    But I would postulate that these reporting systems exist as a symptom of a much bigger set of problems. As you say, true abusers need to be parsed out and remediated for clearly unacceptable behavior. But why do the rest of us occasionally “crack,” or “lose their cool?” Why is this happening to those of us who are otherwise generally well adjusted, functional individuals?

    Awhile back, a video circulated the Internet, showing people getting on and off an elevator in a hospital, with little bubbles over their head saying things like “just got diagnosed with cancer” or “up all night with sick baby” or “just lost their mother.” The video shows that you never know what’s really going on with other people, and sometimes we all need to cut each other some slack.

    So what would be in my bubble? On any given day, it would say at least 5 things, such as: “just told a mother her son died of a gsw,” “worried about her child’s problems at school,” “hasn’t slept in over 40 hours,” “patient has complication and she wonders what she could have done better,” “worried about money,” “academic deadline approaching.” And on and on and on. Things that even my team has no idea are going on, we aren’t allowed to talk about to our subordinates, and might cause us to snap at a team member for a missed order, incorrect lab, or some other minutia. Promoting a write up.

    Stress in our lives is like APRV ventilation. The peep of 28 is the stuff that’s constant – frustration about being caught in bureaucracy, not enough resources for patients, hospital inefficient (shout out to you, HS), political system broken and we see the effects of it in our ED. And our daily stress – a bad patient outcome, an approaching deadline, etc, are like the patient generated breaths above the pHigh – they ebb and flow and that’s just life.

    Where we need to focus is on the things that make the peep if 28. Because if we can drop that peep, we lower the overall minute ventilation (volume of stress). These are the big problems that seem too big to overcome, and we need our hospital, political systems and the like to do it for us. Bring down our baseline stress by making sure our systems work efficiently, we have the resources we need to take care of patients, and that we have time to maintain our personal well being. But you’re right, the “write ups” only bring peep up to 29, effectively worsening the problem, when instead, getting rid of them could bring your peep down to 27.

    What’s your peep today? 🙂

  2. Pingback: From Fizzling to Burnout... - Roadmap to Professionalism in Academic Medicine

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