Get a Life!

July 15, 2004

STriking a balance between practicing medicine and practicing life

When Dana Chambers, MD, of Hickory, N.C., e-mailed Physicians Practice earlier this year, her frustration with medical practice sounded like an alarm bell for the profession. "So many [of us] are worn down by the day-to-day drudgery," she wrote. "As a 34-year-old family physician, I often daydream about what my next career will be. Certainly this isn't the way it should be."

That Chambers feels this way at a relatively young age is hardly
surprising. Career disillusionment and burnout among physicians appears to know no demographic boundaries.

"The frustrations that clinicians face -- changes in insurance billing, particularly Medicare guidelines, problems with getting patients admitted, length-of-stay issues -- those concerns are pretty universal," says Devin Nickol, MD, an assistant professor of internal medicine at Nebraska Medical Center in Omaha.

Moreover, some physicians contend that medical school and residency encourage workaholism at the expense of physicians' personal lives. "When I went through training it became so obvious to me how unhealthy and anti-self-care the whole process is,Ó says Ahnna Lake, MD, a family practitioner who now runs a counseling-based practice for "people working in high-stress, high-responsibility professions."

Hanna Sherman, MD, recalls her own frustration over "what I had lost of myself over the years of being in medicine and feeling disillusioned ... ." She spent 10 years in private practice as a pediatrician and developed an after-hours telephone care program at Children's Hospital in Boston. "It was during that time that I developed an interest in physician well-being. My work put me in touch with almost 350 practices in the Boston area, so I was hearing from a lot of physicians about what their quality of life was like. The biggest thing that I have heard -- and continue to hear from physicians -- is that they don't have the right balance in their lives."

There is no doubt that the current healthcare environment is a major contributor to physicians feeling overwhelmed, burned out, and out of balance. The overriding themes are working harder for less pay and decreased quality of time with patients.

"We physicians do not work in a healthcare system," contends William Clark, MD, FAAPP. "We work in a fragmented insurance industry that does its best to make sure that its investors make a little money, that denies care where possible, and that makes doctors spend a huge amount of time justifying what they do. It's driving us nuts. It's totally different from what it was 35 years ago when I started practicing."

Clark, an internist and addiction medicine specialist, is also course administrator for the American Academy on Physician and Patient, which presents seminars on communication skills and professional renewal.

"The enjoyment [of practice] is in the interaction," says Lake, "and that takes place in the present. A lot of physicians tell me they have seen that erode with the changing system. Part of it is because of rapid turnover in seeing patients. When you're always in a rush and going on to the next thing, it's harder to enjoy. You have a whole group of people dying to get out [of practice]. A lot of physicians feel like they're stuck because of financial obligations."

Finding a balance between professional and personal lives will mean different things for different people. It will certainly mean making difficult choices, many having to do with time and money -- and making changes, in yourself and within your practice or organization. But if it can help you ward off that feeling of disillusionment and regain your appreciation -- your enjoyment -- of practicing medicine, isn't it worth a try?

A changed landscape

The fact that it's harder than ever to make a good living as a physician is a big part of the rising stress levels. It's one thing to work like a dog and make good money; it's another when you're barely making ends meet. The changing healthcare economy has especially frustrated older doctors who remember the good old days, explains Mary Jo Gorman, MD, MBA, chief medical officer for IPC, The Hospitalist Company.

"In the '60s and '70s, with little effort, you could be very successful," Gorman says. "There wasn't that much competition. Those people are the ones I hear in the doctors' lounge who are the most frustrated. They just thought that money train was never going to end."

But younger physicians like Chambers are feeling the pinch, too. "The day-to-day business issues, all of these things like managed care came into being before I even thought about being a doctor. You have CPT codes, ICD-9 codes ... but there's still that art of being human. You can't just boil it down to a code on a piece of paper. Then you've got increased costs to do the business of medicine, but [insurance] companies are paying less and less. So what happens is young physicians [are asking], 'Hey, is this what I signed up for?'"

Indeed, there are many physicians who are ready to throw in the towel. To them, Clark and others point out that stepping back and thinking about what you're doing  -- and how you're doing it -- can help you regain your enjoyment of practicing medicine, and give you back your life outside the office.


"You wonder why you should bother keeping up this work, dealing with ill people who are badly behaved sometimes," says Clark. "It gets to you unless you spend time thinking about your position in the world and in life, and balancing your work and life, your inner self and outer self."

How do you work?

To start, take a look at your own practice or organization, where you spend the bulk of your time, and where so many of the frustrations emerge. There are some practical, eminently doable things that can help.

First, consider your schedule and how much autonomy you have to change it to meet your needs. "People who feel like they have some flexibility over how their day or week unfolds usually feel a lot less stressed. That's the essential piece where practices can really help out," Lake suggests.

She recalls one physician who found a way to set aside time midday for exercise. "The ability to say, 'I like to run at lunch and I don't want any patients after 11:30' -- 'a profound difference from just making it through the day. If I can run, then I start my day over again from a fresh perspective in the afternoon. Having that flexibility built in to say no to something or influence the schedule is essential."

Chambers says she likes having a consistent schedule with the freedom to alter it if she anticipates a backlog or has a commitment outside the office. "Physicians have a lot more control than they realize. In the course of a busy day they don't think, 'Hey, I could check my schedule a few days ahead, or let me block 15 minutes if I have to leave for a meeting.' Just open your eyes and look at what you can do to help yourself during the day."

Completing today's work today helps keep work from interfering with home life. Chambers says her practice cuts documentation time by using templates for common types of visits, making it easy for her and her colleagues to document the physicals and sniffles without having to face stacks of files at the end of the day.

"As much as you can, complete the work while you're still in the office so when you're at home, you're truly present," says Sherman.

Second, consider whether your patient load is reasonable or out-of-hand. Many physicians may reject the idea of reducing the number of patients they see as impractical, a way to guarantee an even smaller paycheck.

But, says Sherman, "The problem we've fallen into is many physicians carry a patient panel where the demands exceed what we are able to do within a reasonable period of time." She points to the open-access scheduling model, in which patients are scheduled the same day they want to be seen (or within a day or two) as a good alternative to schedules that are set weeks or months out. It allows physicians to identify "how many patients they can effectively take care of in an appropriate timeframe and limit their panel size. Otherwise, you're never quite done and you're overwhelmed. The key is knowing how much work you can do and knowing your limits," Sherman says.

Edgar Nace, MD, a psychiatrist and chair of the Texas Medical Association's Physician Health and Rehabilitation Committee, recalls a colleague who purposefully curtailed his practice so that he sees only eight to 10 patients a day, and is satisfied living within his means.

"He's not generating the income that he might if he had a more typical practice, but it's working for him," says Nace. "Maybe you don't need the most expensive sedan and your children don't need to go to the most prestigious private school. These are things that people get caught up in" and that contribute to physicians feeling overwhelmed by work.

What stressed-out physicians (and other professionals) might need to consider is whether making a little less money is acceptable if what they get in return is a more satisfying life. Your answer to that may be no -- and that's OK. It's all about making choices.

"Someone once told me you can consider lifestyle, money, and job satisfaction and pick any two. You can't have all three," says Nickol. "If you're looking to get rich, medicine isn't the easiest field to do it in, but I don't know very many physicians who don't make a reasonable living. It depends to what extent you're motivated by [money]. The fact that I'm much more interested in doing medical student education than I am in driving a Porsche gives me a little more flexibility."

Practice culture is key


Next, consider the roles within your practice or organization: are physicians doing clinical work and staff doing what they should to support that? Is the care of the business as strong as the business of patient care?

"The number one thing a practice can do is have a medical director who can be the liaison between medical care and the financial stuff, who will take responsibility for making sure you have employees who are doing their work and that physicians are focusing on giving care," says Clark. "Number two is to separate giving medical care from taking care of the business. Every practice needs to develop mechanisms for everybody to do what they're supposed to do."

"It helps you focus on patient care if you know your staff is stable and well-trained, and that there's a good system for capturing your charges and getting those submitted," adds Gorman. "If you don't have an EMR, make sure there is a good system of medical records. The better those back-office functions work, the [fewer] headaches the physician will have."

In other words, doctors need to be able to be doctors, not practice administrators. That doesn't mean the physicians shouldn't keep an eye on the business -- on the contrary, they must -- but the right systems and people should be in place so that, for the most part, the business runs smoothly without much physician micromanagement.
Sherman urges practices to "plan for flexibility," whether it's for a physician who wants to decrease his workload temporarily or needs to take leave for family reasons.

Providing opportunities for physicians to support one another is also important. "The people I work for try to take a mentor role and aren't focused entirely on trying to wring every last dollar out of practitioners. They focus a lot more on making sure people develop their careers in a productive way and are moving along the path to success," says Nickol. "In turn, they get a lot of loyalty."

Practices can be creative with meeting time, too. They don't always have to be about how to cut expenses or increase productivity. Clark suggests physicians in a group can get together for as little as 15 minutes a week, to talk "about the practice of medicine, how you relate to patients, how you relate to your colleagues -- not how to run the business better. Remember what you're really there for."

 "It would be a huge benefit if we took a deeper interest in our colleagues," adds Lake. "I was talking to one physician who worked side-by-side with another physician for years. In conversation I found out he was going to sing at Carnegie Hall and these other physicians knew nothing about it. This is how we function."

Certainly time is tight in most medical practices, but these physicians -- who devote part or all of their professional time to helping colleagues avoid burnout -- insist that even a little more personal interaction and reflection about the work go a long way toward a healthier approach to practice.

Take good care of yourself

Remember the old story about the shoemaker whose children went barefoot because he was too busy keeping everyone else in town in new shoes and boots? It seems as if many physicians do the same.
Staying in good physical and emotional health is essential to balancing the demands of work and home life, and finding satisfaction in both. Lake reiterates her philosophy that neglecting oneself is part and parcel of the medical profession.

"A person can carry an intense physical and emotional load only so long before it starts to deplete them. In a profession like medicine, you can't avoid stress, but to be able to handle it you have to build in recovery. This is not part of the model of being a physician. There's very little self-care," she says. On the contrary, "all this self-neglect is worn as a badge of honor."

Lake urges physicians to "learn how to identify when they are headed into burnout, [looking for] changes over time in their energy, their general health, their satisfaction with their work and home life, and the quality of their close relationships."

Reluctance to take time off also is apparently part of many physicians' psyches. Gorman points out that "many physicians have a benefit package that includes vacation and CME; [but they] don't make use of the time they are allotted to get away from the practice, turn off the pager, and get a change of scenery. Some of it is a work-ethic thing and some of it is feeling like you don't want to leave your patients. Physicians are fairly compulsive sometimes."

And that compulsion can lead physicians to take on too much. Chambers, for one, realizes limits are important to avoid becoming stretched to the limit. She's medical director of the eight-practice group owned by a local hospital in North Carolina, serves as county president of the state medical society, and sees patients four days a week. "I'm starting to think, 'How much more am I supposed to take on? I can't fix the world. When do I just say stop?'"

Chambers and other physicians agree that regular physical exercise is part of maintaining a balanced life -- one that includes working hard and playing hard. Sherman adds that time for reflection and contemplation is important. For example, she suggests, "On your drive home, don't turn on the radio -- think about what you've experienced during the day so you can close your day and think about what you're coming home to. Know what activities nourish you. It can be physical exercise, listening to music, a creative outlet like painting. You're serving yourself by allotting the time to do it."

Try something new

Say you've set some limits to your schedule and started a moderate workout routine. You're feeling better, but still don't feel energized by what you do every day. Maybe it's time to add some variety, a slightly different approach and focus to your practice. Many physicians have done so and found it works wonders for them.
Harry Wilkins, MD, arranged a unique work schedule that helped him spend time with his family and regain the joy of practicing medicine.

Wilkins moved from a busy trauma and critical care practice in East Texas to a private general surgery practice in Kansas -- a location that his wife preferred. But, he says, "At the end of 18 months, I was ready to leave the medical field entirely. I completely lost the ability to enjoy my work and I felt I had no connection with my patients."

His solution: he would return to his practice in East Texas for two weeks a month, and the other two weeks, he'd spend in Kansas and be "a househusband, complete with PTA duties." Wilkins reports that after about three months, he discovered what he calls "an interesting phenomenon: At the end of my two weeks at home in Kansas, I began to look forward to getting back to my patients. I discovered a renewed interest in my work. I've been doing this for three years now, and at age 43, I feel healthier, more relaxed and less stressed than I have in the last 20 years."

Other physicians are looking toward the burgeoning hospitalist model -- either as a career change or as a way to take control over their time in the practice they're in. Gorman points out that the hospitalist setting tends to be somewhat less paperwork-intensive -- "and it's more satisfying, from what we've heard from physicians."

Chambers' practice uses hospitalists with good results. "I don't think it's efficient to do rounds in the morning and try to handle things during the day while you're seeing patients in your office and then try to go back and discharge somebody at night."

Another possibility is to expand your practice to include so-called "alternative medicine." It has the potential to add income (many payers now cover treatments such as acupuncture) as well as a new outlook toward treating patients.

According to Lake, it can be "very gratifying to get out of the standard medical model of when the body breaks down, we do something to fix it -- and instead to look at the body's innate capacity to heal. That has been a big revitalizer for a growing group of physicians ... [adding] a little more creativity and connection with the patient."

She points out that what's considered alternative has changed over the years. "When I was training, cardiac rehabilitation was considered to be a fringe-y thing without any true basis for us to believe in it. Now look at it. It's a totally accepted part of cardiac care."

And whether you believe alternative therapies can be beneficial or that they are a sham, more patients are demanding them. The National Center for Complementary and Alternative Medicine of the National Institutes for Health reports that in 2002, 64 percent of adults in the U.S. reported using "any complementary or alternative medicine" in the preceding 12 months.

"Patients are leading the way," says Lake. "The model is changing, and without [physicians'] participation."

Making choices

Whatever you do to achieve a healthy balance between your professional and personal lives is going to involve making some decisions about what's really important to you. Think about your work habits and what kinds of changes you could make --personally and as a practice -- to make your work more gratifying.

Set aside time for yourself -- schedule it as you schedule patients, if you need to -- for exercise, a hobby, time with your family, or whatever you need to do for a more balanced lifestyle. And give some real thought to your financial needs -- is it possible to forgo some income in exchange for time for yourself and your family?

"It's very possible to make a good living in medicine and have a job that you love. You have to pay attention to what your personal priorities are," says Nickol.


"Most physicians love what they do," says Lake. "If that's the case, they can recapture that. But not without some experimentation."

Joanne Tetrault, director of editorial services for Physicians Practice, last wrote about practice marketing techniques in the May issue. She can be reached at
jtetrault@physicianspractice.com.

This article originally appeared in the July/August 2004 issue of Physicians Practice.