02/04/12

Burnout is a dirty word to most physicians. Managing stress, juggling challenges, and overcoming obstacles are what good doctors do, they say. But all of medicine, and perhaps long-term care medicine more than most, produces stress. When your job is putting out fires every day, can burn- out be far away?

Every physician needs to understand burnout, even if he or she personally is handling stress well, said Dr. Michael Myers, clinical psychiatry professor at the State University of New York, Brooklyn. “Even if you are a pretty happy camper yourself, you can see burnout in other physicians in your setting, and you need to be aware of the signs.”

Ronald Leible Dr. Karyn P. Leible relieves stress by taking ballroom dancing lessons two to three times per week. “There’s no time to perseverate on your day when you’re trying not to step on your partner’s feet,” she said.

They include disengagement, blunted emotions, loss of motivation or hope, and feeling as if every day is a bad day and every task is dull. Burnout can happen when physicians feel overworked, underappreciated, and as if they don’t have control over their situation, said Dr. Myers. However, work isn’t the only reason behind burnout. Personal factors such as relationship problems and life- style changes also may contribute.

The signs of burnout can manifest themselves in various ways at work. “Physicians may say that they’re not feeling their best, their tasks and responsibilities take longer, and/or they can’t concentrate and have made stupid mistakes,” said Dr. Myers. “The saddest situation is when a physician tells me that a patient noticed he or she wasn’t paying attention during an examination or visit.” This is a huge red flag.

If a physician thinks that he or she or a colleague is showing signs of burnout, Dr. Myers said, the practitioner should seek an assessment. One reason is to see whether the practitioner might be slipping all the way into clinical depression. Distinguishing burnout from full-blown depression is important to sort out, Dr. Myers explained. “If someone is burned out, their solution may be to go to a new environment that isn’t so toxic for him or her. However, if you have clinical depression, you will just carry this with you to the new job.”

Unfortunately, Dr. Myers noted, some physicians attempt to self-diagnose. “Physicians sometimes tell me that they know the difference between depression and burnout. I agree, but we are not always the best diagnosticians for ourselves.

Even when physicians realize they have a problem, they may hesitate to seek help. “Some physicians have internalized a stigma about burnout. I’ve had patients who think I’m judging them on the first visit. They’ll say something like ‘You must think I’m pretty pathetic,’ ” said Dr. Myers. He added that some practitioners have legitimate worries about the impact of seeking help on colleagues’ attitudes, hospital privileges, and even medical licenses. Fortunately, he noted, most modern medical licenses don’t require reports of burnout-level problems even if they warrant some psychological treatment – as long as it doesn’t require medical leave. “This makes a case for early recognition and treatment,” said Dr. Myers. “If burnout is addressed early, the physician is less likely to have to take time off from work for treatment.”

Smart Kids, Savvy Veterans

Younger physicians seem to understand the importance of having a balanced life in order to avoid overwhelming stress. Robert Wicks, Ph.D., professor of pastoral counseling at Loyola University in Baltimore and the author of several books on fighting professional stress said, “Young physicians often are willing to give up the extra dollars and autonomy to have reasonable hours, week- ends off, and so on.” Perhaps they have learned life lessons by seeing veteran physicians make and pay the price for personal sacrifices, he added.”

“Most days, my job is fun, so I really enjoy life,” said Dr. Milta Little, who is only a few years out of medical school but already medical director at the National HealthCare Lake St. Charles assisted living facility in St. Charles, Mo., and attending physician for patients in an affiliated skilled nursing facility. She added, however, “I always take Friday evening off – unless I am physically in the hospital – to destress and take my mind off work. I don’t mind working late or on weekends, but Friday after 7:30 is sacred to me and my family time.””

Dr. Little said she gets energized by walks with her equally busy husband and relieves stress by playing with her cats. For pure relaxation, she watches television or plays solitaire on her iPhone.”

Dr. Greg Gatchell, who just started his first full-time job as a physician, said he surfs once or twice a week, plays guitar, and runs regularly on a treadmill. He preserves at least one-half of a weekday each week to be “completely off.””

While young physicians may enter the profession with a built-in appreciation of self-care, many older ones see the benefits of lives beyond medical practice too. AMDA President Dr. Karyn P. Leible, RN, CMD, chief clinical officer at Pinon Management in Lakewood, Colo., said, “I joined a dance studio and have become Ginger Rogers. Well, not really, but I do take ballroom dancing lessons two to three nights a week.””

She explained the therapeutic value: “There’s no time to perseverate on your day when you’re trying not to step on your partner’s feet.””

Courtesy of Dr. Smith Dr. David Smith relaxes by taking his grandchildren for a pony cart ride around his property in Texas, where they also hunt and fish.

Animals play a major role in stress relief for Dr. David Smith, CMD, president of Geriatric Consultants in Brownwood, Tex. “On a daily basis, I have horses and dogs,” he said. “Working with them – including training – is one of my biggest stress relievers. Animals are non­udgmental. They just like you because you are kind to them. There’s an expression, ‘There’s nothing for the inside of a man like the outside of a horse.’ That sums it up pretty well.””

Dr. Smith has two teams of horses that he hitches to wagons, and each family member has a riding horse. The physician also has several dogs, including a Labrador retriever that is a therapy dog and a hunter, and nine “Texas terriers.” Dr. Smith uses the terriers for hunting and maintains a breeding kennel.”

In addition to the horses and dogs, Dr. Smith has cattle and sheep. “We actually round up cattle the old-fashioned way. We rope and brand them.” And there’s fishing with his grandson for catfish in ponds on the property.”

Jacob Brubaker Dr. J. Kenneth Brubaker prunes one of the apple trees in his orchard, the tending of which is one of his stress relievers, he said.

Dr. J. Kenneth Brubaker, CMD, medical director of several nursing facilities in southeast Pennsylvania, is passionate about gardening. “I have a huge garden and a fruit tree orchard,” he said. One of his favorite pastimes is grafting trees to get better apples. He currently is work- ing on converting most of his orchard to Gala apples, which are favorites of his family.”

Controlling What You Can

Dr. Wicks endorses mindfulness meditation as a means of warding off stress. The practice focuses the mind on the moment and one’s thoughts and feelings, without judgment, he said. At its most basic, mindfulness meditation involves taking a few minutes each morning in silence and solitude. Choose a quiet place, sit up straight, and count your breaths from one to four while allowing thoughts to arise and pass through “without suppressing or entertaining them,” advised Dr. Wicks. He also stressed the need to take moments throughout the day to “center yourself.””

Dr. Wicks will deliver the opening keynote address at AMDA’s annual meeting, Long Term Care Medicine – 2012 in San Antonio, Tex., on March 9. He has titled his talk “Riding the Dragon: Psychological Approaches to Preventing and Limiting Secondary Stress in the Health Care Setting.””

While the long-term care physicians interviewed for this story described individual concerns about stress and unique strategies of self-care, they all emphasized that it helps to love your work. Dr. John Morley, professor of gerontology at St. Louis University and JAMDA editor, said, “I love doing all the components of my job. Going to nursing homes is relaxing for me because the residents are so nice to be around.””

Dr. Rebecca Ferrini, CMD, medical director at Edgemoor medical center in San Diego said, “I have never experienced burnout because the work I do is so very interesting. There are always challenges, each workday is different, and I can move from one type of activity to another, which keeps up my energy and enthusiasm.””

Dr. Timothy R. Malloy, CMD, medical director of the Hillcrest Health and Rehabilitation and Brookestone Meadows nursing facilities in Nebraska noted, “Part of the effort to ward off burnout is to remind myself that what we do is a privilege. We are in a position to really help folks at a difficult time in their lives. I remind myself that this is ‘my calling.’ I remind myself that what I do in long-term care is my ministry to the sick and their families.””

Dr. Brubaker, Dr. Ferrini, and Dr. Malloy are all past recipients of AMDA’s Medical Director of the Year award, Despite such positive attitudes, medical directors should watch their physician colleagues and all team members for signs of stress or burnout, said Dr. Myers.”

While a turn in that direction is unhealthy for the individual, addressing it is good for the person and good for his or her fellow caregivers.”

Dealing with burnout and stress results in a happier, more productive workplace and lower morbidity among physicians, said Dr. Myers. “Between 300 and 400 American doctors die by suicide every year. We have to be our brothers’ and sisters’ keepers in medicine. Physicians often need our support, encouragement, and assistance to get the help they need. It sends a message that we care.”

Senior contributing writer Joanne Kaldy is a freelance writer in Harrisburg, Pa., and a communications consultant for AMDA and other organizations.

Robert Wicks, Ph.D., will address professional stress in long-term care in the opening keynote address at Long Term Care Medicine – 2012, General Session, March 9, 8:00 a.m. – 10:30 a.m.