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

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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.

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Mourning a Profession

This past week, an unimaginable tragedy fell upon a family. A wife lost her husband. (Nearly) four children lost their father. A mother and father lost a son.

Upon a circle of friends. A group of buddies lost their companion. A band lost their guitarist. A neighborhood lost the guy next door. A congregation lost their fellow worshiper.

Upon a highly skilled cardiac team. These heart surgeons, anesthesiologists, cardiologists, perfusionists, nurses, technicians, and many more team members lost both a colleague and a friend.

Upon a hospital. These employees across roles and specialties lost a visionary among them, slain in their own halls.

Upon current and future patients. These vulnerable humans lost someone who just might have saved their lives.

Upon a profession…

I did not personally know Dr. Michael J. Davidson, a cardiac surgeon from Brigham & Women’s Hospital in Boston who was shot dead by the son of a deceased patient, but of course the degrees of separation are few in our educational backgrounds and our chosen profession. Still, I am arguably low on this list of people mourning, grappling with the soul sucking grief of an utterly inexplicable loss of life. But I am feeling it nonetheless. I sobbed listening to the excerpts of the funeral on NPR yesterday. Sat in my car and sobbed after a long day at the hospital.

As a surgeon, I am prepared for a certain amount of risk in my profession. There are communicable diseases. I always double glove, never making judgment on a patient’s risk of Hepatitis or HIV. I am tested for TB annually. I take countless precautions everyday to protect myself (and my patients) from the spread of infectious disease. There are ergonomic risks. I woke up everyday for ten years with back pain. Luckily I was able to fix many of my issues with pilates but many a colleague has required surgery after years of contortion about the OR table. There are psychiatric risks. Rates of burnout are high in my profession. Burnt out surgeons have high rates of clinical depression, substance abuse, and suicide. One study showed the the highest rates of suicide were among young female trauma surgeons with children. That was a sobering statistic.

When I get asked by aspiring physicians, and particularly by medical students considering surgery, why I do what I do, my truly heartfelt answer has always been “Because I get to save lives and to experience the bittersweet joy of a family saying ‘thank you for trying’ even when a life is lost.”

I have lost many a patient. And I have never, not once, before this week, felt unsafe after losing a patient. Not once.

I am on call today. I have already had a patient die despite my best efforts.

And so I mourn. And I sob. For all those people on the list above me who knew Dr. Michael J. Davidson and are experiencing unimaginable grief. And I also mourn for the loss security of my profession, a profession I chose to help others in their darkest moments. I am left in one of the darkest moments of my career.