Physicians Practice spoke with a physician renowned for his sound advice and calm demeanor about how you can do the job you love and still remain sane.
An author, speaker, and Yale-trained psychiatrist, Carl Hammerschlag is a self-described proponent of "mind-body-spirit" medicine. He has authored three books ("The Dancing Healers," "The Theft of the Spirit," and "Healing Ceremonies") that chronicle his more than 20 years living with and caring for American Indians, cultivating his expertise on how to survive within rapidly changing cultures. He is highly sought after as a gifted speaker and storyteller who has addressed innumerable audiences across the globe. Between speaking engagements, Hammerschlag maintains a small practice near his home in Phoenix, and he is a faculty member at the University of Arizona Medical School.
Physicians Practice: What originally attracted you to the practice of medicine?
Carl Hammerschlag: I suppose I was programmed to become a physician from the time I was small. My mother had great respect for our family doctor and viewed him with a kind of awe usually reserved for theological figures. ... I was always interested in somehow working with people because I felt an obligation to make a difference.
PP: How did you come to practice psychiatry?
CH: I served in the Indian Health Services as an alternative to going to Vietnam, and I was seeing sometimes a hundred patients a day in clinics on reservations. I was like the proverbial shoemaker whose children had no shoes. I was working so hard I couldn't even take care of my own business. It was exhausting. My wife was saying, "Hey, we need some time here as well."
I was always interested in the workings of the human mind and thought maybe I could study psychiatry and learn something about why people behave the way they do.
I went into private practice in 1986. I still have a smaller private practice and I still see patients. It's an unusual practice. I am different from most of my colleagues. For example, I do not carry malpractice insurance, so I do not have hospital privileges. But I feel it's a very important statement that I choose to make to my patients. I tell them I don't carry malpractice insurance, and I ask them to sign a form acknowledging that. I'm sure it's not legally enforceable, but I want to make a statement about how I see the world, especially in contemporary life when the practice of medicine and the relationships between doctors and patients have become more adversarial than communal. It is my strong feeling about healing that doctors and patients need to be in it together. It's a shared partnership — people themselves must become the principal agents in their own healing.
PP: What do you think are the chief causes of physician burnout?
CH: The prime cause for burnout among physicians is that there are enormous demands on the profession but little support or reward. Those are the elements that are the predicates of burnout. We live in a situation now in which the demands placed on physicians are intense. We have to see patients quickly in order to be cost-effective. There are payers that don't renew contracts with doctors because they are seeing patients for six minutes instead of the four minutes the rest of the practitioners in their specialty average.
There is always an urgency to do more in less time — especially within the fixed-cost, managed-care setting. And so the expectations placed upon physicians are enormous. Yet we've always prided ourselves on relationships — that we have to make connections with people to heal them. The current atmosphere precludes making those types of connections.
Combine that scenario with an environment that dramatically over-emphasizes procedures and pills for anything that ails you. It's further complicated by direct marketing to consumers by pharmaceutical companies that suggest that anything you feel has a pill that could cure you. ... This has created the current atmosphere in which patients come and demand the drugs they see on TV. ... If you want to sit and talk to your patients about what's really ailing them, you don't have the time. All of this colludes to lead to burnout. A lot of demand in the absence of any reward or support.
PP: Those problems are endemic to modern medicine, aren't they? What can physicians do, given those realities, to avoid feeling alienated?
CH: I think they have to establish relationships with their patients, and I think you can do that by looking at them face-to-face. ... Today, when many doctors interview their patients, they are simultaneously typing on a keyboard, so we're losing that eye-to-eye contact. I think we can learn more talking to patients in five minutes face-to-face, eye-to-eye, than we can by having them fill out all sorts of questionnaires or entering their information into a computer while they are in our examining rooms. The critical issue is you have to reach out and touch patients in a way that touches their hearts.
The critical area of medicine in the future is not more pills and procedures, but preventive medicine. To do that, you have to spend some time with patients. Most chronic diseases are not better treated by pills and procedures, but by patients changing their behavior. From heart disease to diabetes to mental illness, to get well, patients need to shed stress, eat better, exercise more, drink less, smoke less — you get the idea. And in order to get people to change their behavior, you have to touch their hearts. That doesn't mean you have to spend 20 minutes with them, but you do have to make a connection. I think you can do that in five minutes. I also believe it's antithetical to good healthcare to tell people when they come into offices ... [that they] can't ask more than three questions ... That interferes with relationships.
