Physicians need to set up a system of care to support well-being, reduce burnout and help fellow physicians deal with the pressures, and create boundaries with patients.
Physician Noriko Anderson writes in JAMA Neurology:
The angry voice of the patient’s partner bellowed at me. The frustration boiled over and they rapidly fired words at me. This was not because of my actions; rather, it was a response to our healthcare system.
I understood where they were coming from – their beloved was suffering without a clear path to respite. I imagine I would feel similarly if my husband were in the same situation. But in the moment, it was difficult and hurtful to experience.
I had been working diligently to diagnose and treat their loved one’s condition. Relationship-centred communication with PEARL (partnership, empathy, acknowledgment, respect, legitimisation) statements did not diffuse the situation. I had to set a boundary, so I gathered my resolve and said that I was feeling attacked.
In this moment, despite my compassion and empathy for their situation, I could not and would not take any further belittlement. Immediately they backtracked and said they were not attacking me but the situation. I acknowledged how tough the situation was and encouraged us to work together as partners to investigate and manage the situation. They agreed, and we continued the appointment in a productive way.
Boundaries are necessary for all relationships, and sometimes physicians need to be brave enough to set them with patients. Interpersonal relationships refer to reciprocal social and emotional interactions between the patient and other people in the environment.
The physician-patient relationship is a unique interpersonal relationship that has multi-layered dimensions. Historically, physician-patient relationships have been one-sided, but recent years have seen the emergence of collaborative and patient-centred care.
While this generally leads to better care, I, as a multi-racial African American and Japanese female neurologist, have experienced many patient-initiated interactions that negatively affect me. Sometimes a patient can make statements that tax me emotionally. Comments like “Your hair is nappy” or “You’re the doctor?” (said in disbelief), or other comments about my appearance, weigh on me.
I can now identify these as micro-aggressions, which are everyday verbal, non-verbal, or environmental slights, snubs, or insults, whether intentional or unintentional, that communicate hostile, derogatory, or negative messages to target people based solely on their marginalised group membership.
Micro-aggressions happen frequently and accumulate over time, like tiny cuts. As a human being, I have an emotional response to these. But, for patient care, I am expected to ignore those emotions and care for others like a well-tuned robot.
I am required to lock my feelings away and proceed as if they do not exist.
Healthy? I think not.
I am honoured to care for patients and realise it is a privilege to promote individual health. However, I have come to the point where I also must balance my own emotional and physical health and well-being.
I realise some of my attitude may be consistent with burnout. Burnout is a state of mental exhaustion, depersonalisation, and a decreased sense of personal accomplishment.
Since the Covid-19 pandemic, physical and mental burnout has increased dramatically. Rates of burnout symptoms have been associated with adverse effects on patients, the healthcare workforce, costs, and physician health. Burnout symptom rates exceed 50% in studies of both physicians-in-training and practising physicians.
Emotional exhaustion describes what I experience at times, and it is a major component of physician burnout.
I would argue that my emotional exhaustion is different from, say, a white male physician’s potential burnout etiology.
As an African American woman in the United States, the micro-aggressions I experience on a routine basis greatly contribute to this emotional exhaustion.
LaFaver et al, reported higher rates of burnout in women, and being under-represented in medicine also is associated with higher rates of burnout. Burnout affects groups differently, and while our health system is now beginning to support building skills for well-being in training and in practice, for many decades burnout was ignored.
In the era before the pandemic, it was commonly accepted that physicians push through and work when sick.
I came to work sick because I felt remorseful about cancelling on patients the same day who were driving quite a distance to see me and had waited longer than three months (more like 6-12 months) for this neurologic evaluation.
I wore a mask and practised good hand hygiene while I pushed through my clinic day.
Although my malaise was heavy and my fatigue was increasing, I was proud that I was considerate of the patients and provided care – until I received a low patient rating and a comment complaining that I came to work sick.
What?!?!
First, shock ran through my system, quickly followed by devastation. After I forced myself to work for the consideration of the patients and their situations, the same consideration was not afforded to me. I felt angry. Should I have cancelled on the same day and not considered their commute or their wait time for another appointment that would probably be rescheduled to months later?
At this pre-pandemic time, there was not as much professional support for not working when sick as there is now (post-pandemic), although at times it seems presenteeism may be creeping back into the expected work mentality.
Televisits were starting but were only used for follow-ups and not for new patients.
This experience made me create a boundary that focused on my well-being: I would not come in when I was sick.
It felt like a no-win situation for me. The patients would be dissatisfied with a sick physician but also with a cancelled appointment.
The pandemic highlighted the need for physician well-being. It increased awareness of physician suicide, early retirement, and an exodus from medicine compared with previous years. Furthermore, chaotic clinical environments exacerbated by Covid-related work conditions added to underlying time pressures, lack of work-home balance, work overload, and perceived lack of organisational support: these have all contributed to the Great Resignation in healthcare.
In this spirit, I argue for my well-being. Sometimes I will have to say no, as I am human and need to support my emotional and physical well-being.
Linzer et al noted that the explicit understanding of the unique challenges faced by women and people of colour is crucial in demonstrating that all workers are valued, and in creating a culture of equity and inclusivity.
Acknowledging that physicians are human too, and that women and other under-represented clinicians also face unique challenges, is vital for health systems to target areas of support for clinician well-being.
It is crucial for us to see this as a problem not just about women or people with diverse backgrounds needing to change to be tougher or only setting boundaries to take care of themselves.
Also needed are accountability, resources, support, and intentional action at the structural level, integrated into how things are done, so we can all more perfectly do no harm as professionals and not be harmed ourselves.
My profession is privileged to serve and help others; but, in this service, I still hold the right to be treated with kindness, compassion, and respect as a fellow human being. I now recognise that it is ok to say no.
I am not a bad physician if I do.
In fact, this helps me to be a better physician who values and supports my humanity. If we could remember the humanity of the physicians – of all of us – we can all create a system of care that mutually supports well-being, reduces burnout, and helps physicians with historically under-represented identities feel less ‘othered’.
We could return humanity to medicine for patients and ourselves as physicians. So, let us all commit to remembering humanity in healthcare and that physicians are human too.
Noriko Anderson, MD, MPH, Department of Neurology, University of California, San Francisco.
See more from MedicalBrief archives:
How physicians can cope with burnout
Insomnia, disrupted sleep, and burnout linked to higher severe Covid-19 risk
Primary care physicians experience more burnout and anxiety
Close to a third of UK doctors may suffer from burnout
Solutions to physician burnout — US National Academy of Medicine report