Three years ago, Julie Wei, MD, realized she had hit bottom.
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November 2012After months of plugging along in her life, balancing an academic career as a pediatric otolaryngologist, along with her marriage, infertility and, finally, the opportunity to have and raise a child, Dr. Wei wasn’t happy. “I felt like everyone constantly demanded something from me, and I had nothing left to give,” she said. “I was booked out three months ahead, and I couldn’t take a day off if I wanted to.”
Dr. Wei, now 42 and an associate professor of otolaryngology-head and neck surgery at the University of Kansas School of Medicine in Kansas City, even hoped to become a patient at times, as a way to get off the treadmill her life had become. “During my darkest moments, I prayed for terminal illness. I did not understand why, after years of training and finally living my dream life, I felt so angry and exhausted all the time,” she said. “I lost all joy in my work and life despite having a great husband, child, family, friends and career. I also experienced physical symptoms of constant body aches.”
While otolaryngologists overlal report lower burnout rates in comparison with other some other medical specialties such as emergency medicine, family medicine, general internal medicine or obstetrics/gynecology, there are still pockets of the population who, like Dr. Wei, report feeling at least moderately burned out.
Who Is Burned Out and Why?
Burnout, characterized by high levels of emotional exhaustion and depersonalization and low levels of personal accomplishment, is measured using the Maslach Burnout Inventory. According to research published in August (Arch Intern Med. 2012;172(18):1-9), doctors work 10 more hours a week, on average, than those who work in different fields, and physicians are more likely to say they are unhappy with work—as measured by emotional exhaustion or overall burnout—than are other professionals.
For those who have studied burnout specifically within the otolaryngology field, a few elements seemed to contribute to higher burnout levels. In a 2011 study of 115 otolaryngologists who were alumni of the University of Iowa Hospitals and Clinics and who worked in either private practice or academic medicine, researchers found that those who were at an earlier point in their careers, worked longer hours, had more children and were newly married were more likely to report feeling burned out (Otolaryngol Head Neck Surg. 2012;146:234). But only 16 percent of respondents reported high levels of burnout. Overall, “otolaryngology tends to fall on the lower end of burnout,” said Aaron Fletcher, MD, resident physician at the University of Iowa Hospital and Clinics in Iowa City and the study’s lead author. “It’s the nature of the specialty. There aren’t a lot of catastrophes or devastating complications that occur. For most of us, the outcomes are pretty good.”
Ted Teknos, MD, a professor of otolaryngology at The Ohio State University in Columbus, agreed that otolaryngologists tend to be a happier group than other physicians, based on the nature of the job. “I think otolaryngologists have a high level of personal accomplishment,” he said. Dr. Teknos, who co-authored a 2010 study on burnout among microvascular and free-flap head and neck surgeons in the United States (Arch Otolaryngol Head Neck Surg. 2010;136(10):950-956), added, “We’re doing some very minor interventions at a relatively low cost in terms of stress to the physician, such as giving someone a hearing aid or even cleaning wax out of their ears, and it makes a huge difference to the patient. It’s pure speculation, but so much of what we do is related to the senses, so our interventions really improve the quality of life in our patients in a visible way.”
The Changing Health Care Landscape
Physicians now need to juggle more administrative and bureaucratic tasks than they have at any other time. Health insurers are putting more responsibility on doctors to ensure that proper paperwork and documentation are in place prior to approving and paying for patients’ medical visits and procedures, and doctors need to keep abreast of changing billing and coding requirements, as well as new Medicare and Medicaid requirements. Physicians who work in private practice must earn a living while also potentially hiring staff to ensure that things run smoothly. It’s a far cry from the days when a doctor made house calls and health insurance companies didn’t exist. And, with uncertainty about how national health care reform may play out in years to come, it’s no surprise that morale among all physicians can be affected.
“I think all physicians are facing those issues and, in my opinion, that is why we are seeing many physicians becoming ‘employed physicians’ working for systems, physician groups or hospitals,” said Robert Ossoff, DMD, MD, CHC, the assistant vice chancellor for compliance and corporate integrity at Vanderbilt University Medical Center in Nashville and the co-author of several studies on burnout in otolaryngology residents, academic chairs and faculty.
“Morale for all physicians is challenged these days, and otolaryngologists are no exception,” said Dr. Wei. “It’s near impossible to keep up with constant changes in coding and billing requirements and, in fact, there are a few [otolaryngology] procedures that do not even have updated surgical billing codes. The increasing administrative burden and compliance related to electronic medical records continues to challenge our work flow, efficiency, energy, time and availability to actually provide care.”
And providing such care is what attracted most physicians to the field in the first place. “There is no doubt that physicians feel overburdened by the regulatory environment that dictates medical practice,” said Dr. Teknos. “All of these factors take physicians away from what they really love—caring for patients—and it forces them to deal with bureaucracy, which definitely erodes morale.”
Being in control of one’s own time is a key factor in determining burnout levels, said Michael M. Johns, III, MD, associate professor of otolaryngology at Atlanta’s Emory University, director of the Emory Voice Center, and Dr. Ossoff’s co-author on the burnout studies on otolaryngology residents, academic chairs and faculty. In their research, they found that, for residents, the number of hours worked mattered in terms of higher burnout rates, while it didn’t matter for academic chairs, even though the number of hours worked was similar. “Chairs can decide if they want to work extra hours or not, while residents have to do the work they’re assigned,” Dr. Johns said.
How to Fix the Problem
Developing work-life balance is crucial for physicians who want to avoid burnout altogether or who want to fix their current high burnout levels or low morale.
“Learn how to balance your life, and have stress relievers,” said Dr. Ossoff. “I personally recommend having a stress outlet and, for me, it’s exercise.” Others may find balance in having date nights with their spouses or getting involved in community activities or something else that speaks to them besides being on the job. “You get involved, and you start to meet other people and develop friends outside of medicine,” he said.
Drawing boundaries is also important, he added. “Turn off the BlackBerry or the laptop when you are at your kids’ events or at home.” If you don’t, “you’re there, but are you mentally present?” he said.
It’s also important to identify burnout and low morale, both individually and on an institutional level. “Tools for management and self-assessment would be a valuable area for development,” said Dr. Johns. Mentoring programs can also be helpful for residents trying to reduce burnout, said Dr. Teknos.
For Dr. Wei, attending an Association of American Medical Colleges conference for mid-career professional women when she was 39 changed everything. “For the first time, I had time to think about what I hadn’t had time to think about and reflect on what was going on with my life,” she said. “I realized that I was on autopilot all of the time just to get through the demands of my professional and personal life, and I lost awareness for living in the moment. At the conference, I learned by listening and by talking to others, and thinking that whatever had been going on with me must change—and I was going to fix it. I came back on fire.”
Dr. Wei reached out and engaged a few other women faculty at her medical center who were committed to transform the culture so that others wouldn’t have to experience the high degree of burnout she had. She began teaching a course on how to identify burnout, potential low morale and other problems that can contribute to a lower quality of life as an otolaryngologist, and she resurrected the University of Kansas School of Medicine’s Women in Medicine and Science organization. She’s been president of the group for the past three years. “I am now passionate about fighting the realities of what my life and career demands are and want to help others,” she said. “But most of all, I am constantly aware that I am so close to reaching a high degree of burnout again. The more you do, the more you do, so it’s a constant battle.”
Next Steps
Burnout can manifest in personal or professional dysfunction, resulting in medical or surgical errors, drug and alcohol dependency or leaving or changing one’s career, said Dr. Wei. “We must work on supporting ourselves and colleagues by increasing awareness and including it as a competency so we can protect our field.
“Many of us are overachievers and give 100 percent to our patients and everyone else except ourselves,” she added. “We have to educate our trainees, and we must continue to measure degree of burnout through research. Get educated; learn about it. Take courses. Talk to those who have studied, written and—most of all—experienced it. Self awareness is the first step to healing.”
Academic Burnout
A 2009 study found that the factors that contribute to physician burnout tend to vary based on career type and practice setting, as well as on which aspect of work a physician finds most meaningful (Arch Intern Med. 2009;169(10):990-995). Researchers found that 34 percent of the faculty physicians at an academic medical center they surveyed met the criteria for burnout.
Further, the researchers found that these faculty members may be able to avoid burnout if they spend at least 20 percent of their time—typically one day a week—on an aspect of their work that they find most personally meaningful. Those who were able to do so had a rate of burnout roughly half that of those who spent less than 20% effort in the activity that was most meaningful to them.
“These findings have important implications for the administrative leadership and department chairs at academic medical centers. These centers are responsible for training the next generation of physicians, for serving as the primary origin of scientific discovery and advances in the fields of medicine and health care delivery and for providing tertiary medical care to patients with complex and unusual health care problems. Their physician faculty is the most critical resource for academic medical centers to discharge these responsibilities to society,” the authors concluded. “These findings suggest that efforts to optimize career fit among the physician faculty members at academic medical centers may be important elements of programs to promote physician satisfaction and to reduce attrition from academic medicine.”