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A conversation with a renowned psychiatrist who reclaimed his personal life and learned to love his job.
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.
PP:But physicians are doing that because of the current realities of billing payers ...
CH: Exactly right, and I think every practice has to make some decisions about what they can and can't deal with. So I think that instead of an organizational principle that says at the outset, "If you have more than three questions, you have to make another appointment," I think it's much better for the doctor, looking at the patient face-to-face, to say, "You have a lot of questions, and I would like very much to be able to address them, and we need more time to do that. So I would like you to come back so that we can talk."
Sometimes you need to take more time with patients. ... I want physicians to feel good about that. Make patients feel that you care about them in a real way. In the current atmosphere, our patients are not sure whether we're making decisions based solely on what it is that their carriers will provide or what's in their best interest. And that is demoralizing to all of us in the practice of medicine - that our patients are no longer sure that we are making decisions based on their needs or on what's covered and reimbursable. That distrust essentially distorts the most important element of healing - the doctor/patient relationship.
PP:Is there anything specific the average physician can do to maintain good relationships with their patients and still make a comfortable, relatively stress-free living?
CH: They have to ask themselves the question, "Is this what I want to continue to do, or can I find another way to practice?" If it doesn't feel good, you can't be doing the work effectively, and it will kill you. That's the bottom line. If you're working in an atmosphere that regularly steals your joy, it's going to set you up to get sick. You've got to find a way to come to work every day with joy. ... You have to find a way to feel good about your practice, and if that means you're going to see patients for six minutes instead of four, then you have to find a way to charge them accordingly and see fewer patients, or you have to be willing to make less money.
And when you're not working, you have to find some way to replenish your sense of joy. I don't care how you do that, but it's generally something that fills you with a sense of appreciation and awe. It doesn't make any difference to me if you play with your kids, your grandkids, whether you go mountain biking, fly fishing, or just spend time alone reading, but you have to find some way to recharge your proverbial battery.
And practice in a community in which your ethics and values are shared. You've got to find a group that values what you value - or you'll always feel like the odd man or woman out.
PP:How can physicians guard against their employees burning out?
CH: I think that if physicians feel better themselves, the people who work for them are going to feel better, too. Mahatma Ghandi had what I think is the greatest line when he said something like, "You want to be the change you're trying to create in others." If your employees can see in you what reminds them of what they like best about themselves and why they are doing this work, they will stay. People are desperate to do work that has meaning - to make a difference - especially in this culture. ... People want to believe that the organizations in which they work and the leadership in those organizations operate from a position of some ethic of morality.
The work of medicine, the work of healing, is holy work. It's a sacred profession, and the current atmosphere is stealing the sacred, because we're always running scared.
PP:What keeps you enjoying medical practice after all these years?
CH: I love what I do, and I like to think I do it well. I see fewer patients because I can spend time with them. I'm a psychiatrist. I see people for an hour. I just don't dispense pills. ... But I had to supplement my practice by speaking, which is how I can afford to stay in business.
PP:You now practice part-time, while you also write and speak. Why did you make that transition?
CH: I knew that I was not going to be able to continue to enjoy doing my work prescribing pills and seeing eight hours of patients a day. ... I kept that pace from 1986 to about 1990. And I was hospitalizing patients then as well. And then I found I was getting seduced into the ease of hospitalizing them because then I didn't have to see them for 15 minutes; I could see them for shorter periods of time and it was still reimbursable under the standard rate. It's so easy to get sucked in, and I could feel myself become seduced by it. This is not something that fills me with pride.
I didn't want to do that. I wanted to give my patients the best I had, and I knew that if I could see four hours of patients a day, I would be much better. But to do that and keep my kids in school, I had to find some other way. So I did, and lots of doctors are also finding other ways. I would hope that they can do it in medicine instead of having to leave it completely and become entrepreneurs, because I think as a profession, everyone who enters medicine does so basically for wonderful reasons. We are a remarkable group of people who go into healthcare delivery, and we want to remind ourselves of that. And if we can feel that, then the people who work for us will feel it, too. We ought to work in a system in which we honor the sacredness of our profession. That's how we can prevent burnout and turnover.
PP:Do you run a cash-only practice?
CH: I don't take any insurance. My patients may or may not be covered, but that's between them and their carriers. They pay me directly.
PP:Do you have a sliding scale?
CH: I do. If I see a teacher who is divorced and raising three children and making what teachers make, which is a sin in this country, she'll pay me the same that she pays what it takes to get her nails done. So my scale slides enormously.
I also barter and trade. Somebody made the front door to my house out of stained glass - he happened to be a stained glass artist. There are people who send me cedar and sage; there are potters who have made pottery. ... I had a patient who once painted the walls of my house in exchange for their psychotherapy.
I speak, and my fees are high. So I can do it, but you have to find a way to balance your own life. It's critically important to find some balance. To achieve it, you have to pay attention to what you're feeling inside. This is what I talk about. If you're not feeling good, it will destroy you. The entire medical establishment gives scientific credence to what I'm telling you anecdotally. If you don't feel good, stress hormones will break down your immune system and ultimately make you sick. It's too big a price.
Barbara Gabriel, MA, is the managing editor of Physicians Practice. She can be reached at firstname.lastname@example.org. To learn more about Carl Hammerschlag, visit his Web site at www.healingdoc.com.