October 24, 2022

FULL CIRCLE ENGAGEMENT

(IS IT REALLY WICKED?)

A chill is in the air, the leaves are starting to fall, and pumpkins dot the landscape. Fall is here and a time for reflection. For some, a time of melancholy, for others a sense that better things are coming. A time for all of us to reflect on the past months of the year and think about how we can improve, both ourselves and our relationships with each other. It is also time for the Annual Meeting of the Medical Society of Delaware. Believe me, I understand we all have competing priorities. Our time is seemingly more limited than ever. We seek down time as often as we can get it and look forward to sitting on a couch watching whatever, sleeping later, taking a nap or a walk outdoors and, in general, not doing much of anything. And that’s great because we all need a break from a world that is always moving, more polarized and angrier than ever, and just plain stressing all of us out. Our desire to be alone and out of the rat race is a goal many of us strive to reach. Yet is that what we really want or need?

During the semi-annual meeting of the MSD Past Presidents held recently, the discussion revolved around a number of issues focusing on the life of a physician. We spoke of ongoing frustrations regarding physicians being “constantly abused.” Abuse from administrators, patients, mistrust, misinformation, and more. We spoke about burnout from COVID-19 and many issues surrounding that to the very concerning feeling that “dreading the day” is now a fact of life for many physicians. How did we get to this point? What is driving all this? Clearly it is not just one issue but one thing heaped on another topped by many more. And just like a tower or sandwich or other structure not built to handle so much stress put on it…things will topple and fall eventually.

As physicians and people, we cannot succumb to the multiple stressors among us. Our lives are spent serving others and we need to take time for ourselves. It is critical for our wellbeing and those of our patients, families, and friends. We strive to do the best we can and have difficulty tolerating the mental and physical fatigue that is overwhelming at times. We have multiple demands coming at us continually. We struggle to find enough time to see patients in the inpatient and outpatient settings. We continue to be burdened with prior authorization, decreasing Medicare reimbursements, infringement on our practices by those claiming to be able to provide better access and more timely care. Who wouldn’t want to leave all that behind and just go sit on a beach?

Writing in JAMA Network Open, Sexton et al. studied emotional exhaustion among U.S. health care workers before and during the COVID-19 pandemic, 2019-2021. “Physicians specifically saw a decrease in emotional exhaustion from 31.8% in 2019 to 28.3% in 2020. However, the level rose again in the pandemic’s second year to a new high of 37.8%.” The drop is postulated to have occurred due to the rise in telehealth and fewer patients being seen overall, thus less stress and burnout. Yet Sexton noted “bite-sized interventions” for health care workers were noted to be beneficial and achievable in leading to a drop in exhaustion. Perhaps this can be seen as a sign of hope in a world in which many find hope lacking and resources “woefully inadequate."¹ For example, hardly a day goes by when another article is published about how physicians have been struggling for some time, how burned out we are, and how the pandemic only exacerbated things.^2-4 We hear once again about the utter lack of meaningful resources to help even though we are bombarded with potential ways of getting through things. We learn that an unhealthy physician can lead to unhealthy and unhappy patients, medical errors, and potential system reproaches. A vicious circle may then ensue. Some have decried the good-natured intentions of health care systems and have pronounced such intentions as systems simply doing their due diligence. The options of yoga, mindfulness, snacks, and more have popped up in our midst as ways in which health care systems try to deal with physician fatigue and the feeling that we have to take on more work and simply deal with it. We receive postal mailings, emails, and learn of online and phone app resources for ways to achieve wellbeing. Whether it be counseling, coaching, unlimited phone consultations about various issues in our work and home lives - all these are available to help solve our problems and become healthy and happy once again. We learn of ways to become more resilient in an effort to stand strong. Inherent in such offerings is the idea that as individuals we are responsible for our difficulties. The blame is placed on us for not having adequate resilience, fortitude, and strength to carry onward. Speaking at a Women in Medicine Summit recently, Dr. Jamie J. Coleman noted resilience needs reframing. “I think it leads to self-blame, which we already do. We’re already so bad about blaming ourselves for everything that happens, that it then says ‘okay, well I’m not doing enough and clearly I’m not doing it well,’ and then it leads to hopelessness.”⁵

Various recent articles have questioned whether physician wellbeing is achievable at all! Just this year, Sinskey et al., described physician wellbeing as a “wicked problem.”⁶ The term dates to the 1970s and refers to “social or cultural problems that are ill-defined and inherently unsolvable.” In addition to being difficult to define, the term implies traces are left that cannot be undone. Attending mandatory lectures or completing surveys on wellbeing, for example, can leave physicians feeling dissatisfied and demoralized, especially if there is no upside to their participation in such entities. The bottom line is physician health and wellness likely involves both individual and system-based approaches. Physician engagement, something I have commented about a number of times in different formats, and is a main platform for my presidency at the Medical Society of Delaware (MSD), is achievable. It may mean different things to everyone but there is no question it can only help us in these challenging present and future times.⁷ Medical societies can be very useful in the path to physician wellness.^8-10 Sharing frustrations, successes, and more in a group setting has been shown to be therapeutic in the short and long term. Encountering those with similar mindsets and ideas can be beneficial in leading physicians to become healthy and less burned out. Whether you actively engage on a committee, interact with legislators and provide testimony, or involve yourself in the many other ways available to you, just remember we’re all in this together. When we work together to listen, challenge and debate as MSD members, we all benefit and so do our patients and communities. How wicked is that?

Matthew J. Burday, DO

President

President@medsocdel.org

References:

1. Sexton JB, Adair KC, Proulx J, et al. Emotional Exhaustion Among US Health Care Workers Before and During the COVID-19 Pandemic, 2019-2021. JAMA Netw Open. 2022;5(9):e2232748. doi:10.1001/jamanetworkopen.2022.32748.
2. Pandemic pushes U.S. doctor burnout to all-time high of 63% | American Medical Association (ama-assn.org)
3. Shanafelt TD, West CP, Dyrbye LN, Trockel M, Tutty M, Wang H, Carlasare LE, Sinsky C. Changes in Burnout and Satisfaction With Work-Life Integration in Physicians During the First 2 Years of the COVID-19 Pandemic. Mayo Clin Proc. 2022 Sep 14:S0025-6196(22)00515-8. doi: 10.1016/j.mayocp.2022.09.002. Epub ahead of print. PMID: 36229269; PMCID: PMC9472795.
4. Ruzycki SM, Lemaire JB. Physician burnout. CMAJ. 2018;190(2):E53.
5. Gold J, Coleman JJ. Spilling the tea and all about "resiliency" with Jessi and Jamie. Presented at: Women in Medicine Summit; Sept. 16-17, 2022; Chicago (hybrid meeting).
6. Sinskey JL, Margolis RD, Vinson AE. The Wicked Problem of Physician Well-Being. Anesthesiol Clin. 2022 Jun;40(2):213-223. doi: 10.1016/j.anclin.2022.01.001. Epub 2022 May 4. PMID: 35659395; PMCID: PMC9066294.
7. Perreira TA, Perrier L, Prokopy M, Neves-Mera L, Persaud DD. Physician engagement: A concept analysis. J Healthc Leadersh. 2019 Jul 26;11:101-113. doi: 10.2147/JHL.S214765. PMID: 31440112; PMCID: PMC6666374.
8. Yewande Alimi, MD, MHS, Maria S. Altieri, MD, MS, Jeremy D. Kauffman, MD, Pridvi Kandagatla, MD, Patricia Martinez Quinones, MD, PHD, Madeline B. Torres, MD, Rebecca L. Williams-Karnesky, MD, PHD; A sense of belonging and community can mitigate physician burnout; Bulletin of the American College of Surgeons; Published August 1, 2019. 
9. PhysicianBurnoutReport2018FINAL.pdf (harvard.edu)
10. Panagioti M, Panagopoulou E, Bower P, Lewith G, Kontopantelis E, Chew-Graham C, Dawson S, van Marwijk H, Geraghty K, Esmail A. Controlled Interventions to Reduce Burnout in Physicians: A Systematic Review and Meta-analysis. JAMA Intern Med. 2017 Feb 1;177(2):195-205. doi: 10.1001/jamainternmed.2016.7674. PMID: 27918798.