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Welcome to another installment of the X-ray Beam series.
I hold the subject of physician burnout near and dear to me as it has had its grips on my medical career in the past.
In the Burnout Continuum, I introduced some of my thoughts on physician burnout as well as some of the statistical data showing the prevalence of burnout in the current medical climate.
Today I am thrilled to have Dike Drummond, M.D., a true expert on the subject of Physician Burnout and the founder of The Happy MD website, step under the X-ray Beam and give us some insight on his mission as well as address burnout and its effect on the medical profession.
I had the pleasure of attending a 2 hour live presentation by Dr. Drummond recently as part of a 10% premium discount incentive offered by my medical malpractice insurance company with an added bonus of receiving 2 CME credits.
Immediately after the presentation, I reached out to Dr. Drummond and he willingly agreed to be interviewed by phone (it ended up requiring two separate 30 minute time slots with the first conversation being the subject of today’s post).
So without further ado, I present to you, The Happy MD:
Although the term “Burnout” was first coined in the 1970s describing severe stress in the “helping” professions, it is only now starting to appear more and more frequently in the medical lexicon.
Do you think burnout is a new phenomenon or has it always been present but never publicized before?
Well if you look at Christina Maslach’s work, she is an industrial psychologist and developer of the Maslach Burnout Inventory which is typically the gold standard for measuring burnout, she’s been doing this work since the 70s.
So this is not a new phenomenon.
The way to understand it is that in any profession there will be disengaged employees, people that are disengaged from the work that they do.
And when that disengagement is something that affects them personally we call that burnout.
I use the following definition to describe what is considered to be a “helping profession”: Any place where you put the customer or client interest ahead of your own in a situation.
For instance it starts in retail and the restaurant industry where the customer is always right.
It goes into places like priests and pastors, teachers, nurses and doctors (where the patient comes first).
When we go up that scale then we go to the people that make the ultimate sacrifice and have the highest burnout rate:
- People in law enforcement that serve and protect.
- War fighting military.
- They have the highest burnout rate.
- They are expected to lay down their life in the service of other people that they represent.
Because the natural inclination of the helping professionals is to serve their client no matter how they are feeling at the time, they run the risk of overextending themselves and draining their energy levels.
At that point when you become burnt out what will happen will be:
- It will start to affect your physical health.
- It will start to become portable and affect your relationships back home.
The symptoms are exhaustion, becoming cynical and sarcastic about the people you are meant to serve, and then the last one is to doubt the purpose of the work you do.
“What’s the use?” is the phrase that often comes up in your head.
Now it is important to note that if I survey any non-healthcare/general population of employees, I will find the rate of burnout is 20-28%.
So burnout is not physician specific.
If you look at burnout studies that were done with doctors prior to EMR (prior to about the year 2005-2010), what you will find is that the background rate of physicians when measured by the Maslach burnout inventory is about 1 in 3 (33%).
That is the historical background rate prior to EMR.
But since the advent of EMR, which basically doubled the physician’s daily workload if they don’t have a scribe or some other way to deal with it, what happened is that ratio has gone up.
Most studies have burnout rates above 50% since 2014.
So burnout is indeed higher currently than it has been in the past.
Burnout has always been higher than normal with physicians, just like physician suicide rates that have always been higher than non-physician suicide rates (its actually been double for both men and women).
What are some of the factors you feel current physicians face, that their older counterparts did not , that might be exacerbating burnout?
Every doctor has a stress matrix, meaning there are a handful of things that play a large role in the stress of a particular physician.
EMR is not stressful for everyone.
There are people who love EMR, who get home on time with all their charts and everything and would never go back.
Amongst millennial and “digital native” physicians that ratio is higher than with Baby Boomers.
I am definitely not a digital native.
I learned to type when I was 30 (I am 60 now).
What we found out was that there are patterns on what will cause a doctor to become burned out.
Its always multi-factorial.
The five universal causes of burnout are:
- You chose to be a doctor.
- That is stressful in and of itself.
- We are working with people who are sick, hurting, scared, and dying.
- Bad things happen all the time.
- Thus most of the time when you go into work you will put energy into that work.
- You will put in energy and you will come home with less energy than when you went.
- You worked your whole 20s to get certified to be a professional in your particular specialty and then you got a job.
- Any job is going to add to the stress to the fact that you practice medicine in the first place.
- So it adds in things like EMR, your compensation formula, your call schedule, your booking template, and whether or not you have control over it.
- Poor leadership.
- If you have any conflict with the leader of your organization or if you don’t have a leader when you need someone, that will affect your burnout profile exquisitely.
- Any one of a number of things that can be happening in your life outside of your practice that can get in the way.
- Birth of your first child.
- Special needs child.
- Twins in drivers ed.
- A parent that can fall and break their hip and you still have not been able to convince them to move in with you in the mother-in-law apartment.
- Life can make it impossible to recharge.
- Any one of a number of things that can be happening in your life outside of your practice that can get in the way.
- The programming of our medical education.
- We are programmed to be workaholics, superheroes, lone rangers, perfectionists.
- Those kinds of personality traits drive automatic behaviors.
- For example, the workaholic only has one coping mechanism, work harder.
- Workaholics are not creative.
- They can double down on the same things that are not working.
- A Workaholic is actually someone who is inside Einstein’s insanity trap just running around on that gerbil wheel not getting anywhere.
- Perfectionism is a trait that is difficult to turn off.
- I often say if I ask your kids about your perfectionist tendencies do you think they will think that is always a good thing?
There is no such thing as a single source of burnout.
What you are looking for is a magic pill [that doesn’t exist].
It is always multi-factorial in its origin and those factors change over time.
Therefore it is always multi-factorial to build your strategy to either reverse or prevent it.
So you cannot take the multi-factorial nature of burnout away from its essence.
Going through the gauntlet of medical school and residency has created physicians who endure adversity as a badge of honor.
Because of this do you feel there is an under reporting of burnout in the medical community as physicians do not want to show any signs of weakness?
There are 2 prime directives in healthcare.
One that everyone knows and that is the patient comes first.
The other is one that everyone understands but never says: Never show weakness.
The challenge of burnout is born in the fire of our medical school and residency education.
Those are actually survival contests.
I call residency the educational equivalent of waterboarding.
It is not the same now as it used to be.
Prior to work hour restrictions there were no limits on how hard they can work you.
It is interesting to note that that is now illegal.
The reason it became illegal is because patients died and they died directly because of resident fatigue.
The work hour restrictions were a response to clearly adverse working conditions for residents.
What ends up happening is that residency is still a survival contest but it just isn’t as long and hard as it used to be.
Baby boomer doctors like me are more powerfully conditioned than millennial doctors who have graduated from work hour restricted programs.
So there are differences in the generations on how they are deeply conditioned.
It is interesting to look at the difference on how rest and the need for rest is perceived amongst high performing teams but from different areas.
For example, special forces military teams view rest as a weapon: It is valuable and in battle, the most well rested team is expected to prevail.
In residency education, we would say that the need for rest is a sign of weakness.
The other thing that is interesting is that, as you proceed into value based care, it is going to be super important to offer care to the patient as a multi-disciplinary team.
If you look at the difference between military elite teams and medical education it is different around the concept of supporting team based care.
In special forces and the Marines, it is no man left behind.
All for one and one for all.
You don’t compromise the effectiveness of the team and we work as a team and we have each others back.
In medical education what do we call collaboration in medical school?
It is a gladiator-style survival contest with everyone trying to be the lone winner.
When it comes to the concept of rest, the respect for rest, the respect for teamwork, those cultural pieces are fundamentally different when you compare military training to medical school/residencies.
In your very informative presentation, you yourself admit to being in the grips of burnout and had your medical career shortened.
What were some of the factors in your case that led you to burnout?
Everybody’s burnout story is different.
I will tell you mine, but I don’t believe that you can draw a trend from it.
My story on how I became a doctor goes back 3 generations.
My maternal great grandfather was a GP during the depression.
I was the first born male grandchild and it was my destiny to fulfill the family vision of having another doctor.
I got into Mayo Medical school.
Med school and residency were crazy.
The reason I got through was I played rugby that allowed me to blow of enough steam to survive the training process.
I was then a full service family doc for 10 years, I delivered 500 babies and in that time I loved being a doctor.
I considered it to be half detective and half teacher.
I loved having long term relationships with my patients.
By the time I was 40, I had seen about 35,000 patient visits.
At that time, as a family doc, one of the things that contributed to burnout is when you don’t see new things in your practice as frequently as you used to, and that comes with experience.
Usually about 10 years and 30,000 patients in, all of a sudden that, “I have never seen this before,” experience becomes more and more rare.
The newness in my practice started to wear off.
I just walked straight into a brick wall.
For me my burnout felt like someone choking me at work every time I started to see patients.
It didn’t go away with a 30 day sabbatical so I just quit (which I don’t recommend to just walk away from your career as a transition strategy).
It took me about 10 years to learn new skill sets and I subsequently launched the Happy MD in 2010.
Sometimes the physician/individual suffering burnout is the last to recognize it.
What are some of the signs/symptoms for an individual to look out for that may indicate that they are starting to, or are already, burning out?
I would say that it is extremely frequent for the doctor to be the last person to recognize it.
It is most visible to the folks that you are around the most.
People can see you go into survival mode, especially your staff at work.
But remember you out rank them so the chance of them giving you a reality check is very slim.
The staff at work may tell your leadership at work and every once in awhile the leadership person may reach out.
And then your significant other and your family at home are going to recognize it too.
Sometimes they will talk to you about it and sometimes they won’t.
Sometimes burnout is chronic and what happens is your spouse gets tired of talking to you about it so they will give up.
What ends up happening is if you are hearing a voice in your head that says, “I’m not sure how much longer I can keep going like this,” that is a sign.
There is another real frequent sign that is a huge red flag: In the morning on the way to work if you have any sort of fantasy that says, “if I’m lucky I might get hit by a car on the way to work so I don’t have to round on patients today.”
If you find yourself having to vent, that you have got to complain to someone before you see patients, that is a huge red flag.
If you find yourself doubting the purpose of what you are doing. or thinking, “what’s the use?,” then that is a red flag.
Those are the 3 cardinal symptoms of burnout.
It is time to look yourself in the mirror and then go ask somebody for help.
Tell us what the inspiration was behind creating the Happy MD website.
It was 10 years after I had quit medicine.
I had built with my ex-wife a successful training company in the leadership space.
That marriage and business went away.
I was burnt to the ground for a second time.
I had been a certified coach for a decade.
I got certified as soon as I got out of my medical practice as an executive coach.
I wondered if there was a way I could build a coaching practice working with doctors that are burned out like I was in 2000.
I went on the internet and I punched in the words physician burnout and the google results were accidental.
There were google results for that search term but none of the pages were there had been built to be there.
So I knew that I could, using what I knew about search engine optimization, write a blog post that would probably be on that first page pretty quick.
So I wrote a blog post that has been #1 on that search page for 9 years now and built a business on that as a coach.
As I started to coach more and more and see patterns I wrote blog posts and turned that into a book.
Then people asked me to train them and so now I have coaches that work underneath me.
I do a lot of training and consulting about helping doctors recognize and prevent burnout and helping organizations build burnout prevention into the way that organization functions.
I have about 2500 hours of 1 on 1 coaching experience.
I have helped several hundred doctors as a burnout coach and I have trained 30,000 doctors on 4 different continents on how to recognize and prevent burnout.
We have a team of 7 physician burnout coaches at the Happy MD that handle the volume that comes in for support.
A large portion of my readership subscribe to the FIRE (Financial Independence/Retire Early) philosophy.
Most feel that achieving Financial Independence is a great way to combat burnout.
What are your experiences/thoughts about the relationship between finances and burnout?
It is important to have always have an ideal job description and always be working to move your job to whatever that is ideal for you, so you don’t lose connection between purpose and passion in what you do.
In an ideal world people would say, “I can’t believe people pay me for this because I would do it if they didn’t even pay me.”
Most doctors are not in that situation.
The truth is that a piece of the vision that most people have is that one of the benefits of being a doctor has to do with income.
Doctor incomes are falling and will continue to fall for most primary care specialties.
There are certain high end specialties that are in the last stages of the gerbil wheel so that they are still making really good income.
But most people in my experience don’t go into medicine to become a high earner.
It is not all about money.
But the key is don’t take on $400k in debt in your education unless you have a rock solid plan for paying it off that you will complete.
Don’t make a deal with the devil, don’t run up the bills.
Educational debt survives bankruptcy, there is no way you are getting out of it.
Develop Ben Franklin’s habit of earning more than you spend.
Realize that when you get to the point where you have some savings and investment income, to always have a financial plan so that you know your financial trajectory.
You know how you’re doing and what your projected financial freedom date is.
At the point of financial freedom means you only have to do what you want to do.
You don’t have to work for more money.
It is a very powerful point.
For most of the primary care docs that point is reached relatively close to what is the traditional retirement age.
Sometimes people have difficulty disconnecting from working.
The old joke is the wife saying, “He can’t retire! That means I would have to spend more time with him!”
You don’t know what to do with yourself because you are so used to working.
When I have people in the 50s we always talk about what’s their net worth.
When they are at the point of financial freedom they need to switch the conversation to the topic of legacy.
What is your legacy?
Is there a legacy to what you have created in this lifetime.
In the current medical environment there have been disturbing trends of the rising cost of a medical education coupled with declining reimbursements.
This creates a financial pressure point on a physician who typically compensates by trying to see more patients in a day to keep financially afloat.
This practice can truly exacerbate burnout.
What is your advice to these physicians who see no way to escape the hamster wheel they find themselves in?
That is a workaholic response to declining reimbursements, just keep doing more of what you have always done faster.
Spin the same wheel faster.
My recommendation is that you look at all the different ways you can earn compensation, even with things that you don’t traditionally do that you can incorporate into your practice.
To see if there is a way you can change your practice mix to create more income without having to necessarily work harder to do it.
Perhaps becoming more efficient.
Perhaps widening the care team and getting a slice of income from a team of mid level providers that work underneath you.
Perhaps incorporating new procedures into what you do.
Perhaps being able to bill more effectively because maybe you undercharge like most doctors do.
Open up the creative side of your brain to open up new possibilities.
Work with your administration to figure out how to work the compensation formula rather than just doubling down on what you have always done.
It is amazing how quickly the 30 minute time slot evaporated as I found myself immersed in this question and answer session with Dr. Drummond.
As I mentioned at the beginning of the post, Dr. Drummond kindly agreed to another phone call interview which will form the basis of a second, follow up, post.
In the meantime, please visit his website, TheHappyMD.com where there are almost 300 blog posts with high yield information.
If you are interested in checking out previous individuals that were brave enough to expose themselves to the beams of the X-ray, please check them out here.
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Dike is one of the originals in the physician burnout space I’ve yet to meet in person, but you and WCI have referenced attending his presentations and getting a lot out of them. Appreciated the glimpse into his mind.
Thanks CD for dropping by. Yeah it was a great presentation and it was nice to hear it from the OG on burnout. He was super nice too
Thanks for a great interview. I enjoy reading the Happy MD and the Physician Philosopher regarding burnout. Life is hard and a physician’s life is even harder.
Thanks VP for stopping by. Both of those sites are great resources for burnout. There is definitely some progress in recognizing and treating it so hopefully these messages resonate with those at risk
I contend the hamster is invented to burn us out. We work in a mirage of free expression creativity and autonomy, when we are actually being manipulated by the C suite. We are taught that. I’m convinced you were not chosen for medicine because of your MCAT score in chemistry but because of a high degree of perseverance. you exhibit traits that you will take any shit and still show up the next day for 5 am rounds. We are used to performing a 2 SD above the mean, and the C suite sets the bar at 2.5 or 3… Read more »
Outstanding interpretation Gasem. I agree that the C suite keeps striving for profitability and thus the more they squeeze out of every doctor the happier they are. And when a doc burns out he or she gets replaced