Burnout and Taking Back Control – Dr. Paddy Barrett

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Dr. Paddy Barrett is a trained Interventional Cardiologist. He is also the host and creator of The Doctor Paradox, a podcast committed to addressing the issues of burnout in healthcare and understanding how to make it better. He has worked internationally–practicing in Ireland, Sydney, New York, and San Diego. His work has been featured in TimeHealth, Business Week, the New York Academy of Sciences, the New England Journal of Medicine, and many other media outlets and journals. This interview with Dr. Barrett discusses the many aspects of finding joy and satisfaction of a career in medicine, and ultimately, the importance of taking back control of your life. Please enjoy this very wise next guest: Dr. Paddy Barrett.

Website: http://thedoctorparadox.com/ 

iTunes: https://itunes.apple.com/us/podcast/the-doctor-paradox/id1043836086

Top Points

My personal take: listen to the entire conversation. It is filled with great wisdom to be utilized actively in your life today. 

1. The roots of physician burnout is not in the physicians themselves, it is primarily in the environment in which they work. The issue is that the ecosystem that exists has changed very dramatically over the past couple of decades and this environment in which people work, is what’s driving these issues of discontent and dissatisfaction within the physician community.
2. What matters most, and this is a key thing, in setting up an ecosystem in that people feel they are cared for and heard. People will work incredibly hard (physicians are not strangers to hard work). But, if you have an environment where they are not appreciated and cared for, it doesn’t matter how hard working they are, they will be dissatisfied with their work. Yet, in the setting of long hours, if people feel heard, appreciated, and cared for, they will enjoy their work.
3. If you are working somewhere and you feel burned out, look at your organization’s mission statement. Read the first line, and if you throw your eyes up and say that’s kind of nonsense, you have a personal value conflict with the way that you believe the organization delivers care, the way you believe people should be treated. And this is the problem.
4. Ultimately, and this is one of the distinctions when you look at the actual happiness scores whether having children make you happier or not, compared to people who don’t have children… if you survey people at the time and ask them are they particularly happy, a lot of the time they are not, they are in the middle of some crazy situation, they are stressed, and just want free time. But when you ask them in an overall sense, are you happy that you had children? Are you happy in life and the way things are? They are happy. Understand the distinction between the weather and the climate. The weather will always change, that is part of life. You need to try to pitch to where your climate is, and whether you are generally happy with the world.
5. Change your attitude or change your geography: Sometimes it just requires you change your geography: either who you spend your time with, where you spend your time, or how you spend your time. But sometimes you can’t, if you are in a medical school and you simply can’t leave…you need then to look at how you change your attitude and how you respond to the world…
6. As you move through your training to your own independence, it is up to you to define what are the components of your job, the parts of your work you want to do most of, and you do that. Because, then you can craft your life and your work that you truly had envisioned it to be.
7. One of the most fundamental things I like to reiterate to myself or would try to reiterate to a younger me is: “it’s going to be okay,” and things will just be okay. Because, it’s a matter of how you view it. I think that would be the most important thing for me.
8. Understand that you can take back that control of the direction of what you are doing, and to dictate that you will have a satisfying and engaged career. To understand there are certain things you cannot change, and if you cannot change them, you cannot worry about them. But understand that you are the one who is in control, and you can have items to give yourself the toolkit to achieve it.
9. And much more…

Transcription

Introduction

-Paddy Barrett, Interventional Cardiologist and Clinician Scholar at Scripts Translational Science Institute in San Diego, California

The Doctor Paradox Podcast

-Two major tenets for the podcast

-One is understanding – the increasing and worrying trend of burnout and mental health issues associated with working in healthcare today.

-Secondly – How will we make that better?

-That has really been a journey for me, I have learned an immense amount.

-Additionally we cover interesting and novel medical careers, things that people may not have considered.

-You hear people’s stories, and they may come from different places, but everyone’s core journey is effectively the same and has gone through challenging or difficult times.

What commonalities have you found through your research and learning through your interviews with physicians?

– When you are in early career – you see older physicians and attending, and think everyone is doing fantastic.

-A lot of people went through challenging time during medical school training, internship, residency, attending, and retirement periods. It’s incredible common, but not talked about.

–People tend not to disclose this [challenge/pain], and because of that there is somewhat of a perception that this does not exist amongst their peers and colleagues.

-It’s a feeling and a journey that people are going through individually, and when we hear about physician burnout and depression… it tends not to match up to what you see largely in personal experience.

–You will see pockets of it, but these figures quoted of 50% don’t seem to match up. There is obviously statistical nuance…but it’s important that we have these conversations and understand what the true causes for it are and it’s only when we understand the problem better can we look at addressing it.

In reference to burnout: How does one expose themselves or allow that vulnerability and create dialogue within the community?

-I think it’s an issue of having a more global conversation and an individual conversation

-When you speak with your friends and colleagues frankly, you will find you can have these conversations.

-One of the more challenging parts of this is the fact that how physicians reflect on themselves or how students reflect on themselves if they feel they are going through a period they are challenged. They feel there is a very significant stigma.

–Physicians also have a feeling of being invulnerable, that we don’t get the diseases our patients get, and we tend to avoid disclosing it. In terms of, how we might be judged by our peers. But in close conversations and mentors, you will find that this is something that has touched almost everybody in their training.

-The understanding of the problem is key here, because, what you will see and have seen is a huge growth in articles about physician burnout. Additionally, how we are as a group will likely be a performance indicator. There have been many honorable moves in institutions to “cure” physician burnout. But what that does is really speaks to our core principles of finding pathology and to treat that pathology.

-And this is what I’ve found in the literature, It’s not something you treat as an individual. So when a hospital goes to put in place a physician wellness program, what they put in place is often resisted by the physician group and it is ineffective. The reason for that is because the roots of physician burnout is not in the physicians themselves, it is primarily in the environment in which they work. So if you try and treat and cure the physicians, you really achieve very little. While I think these are really critical components, they are only useful if layered on top of an understanding of the problem.

–The issue is that the ecosystem that exists has changed very dramatically over the past couple of decades and this environment in which people work, is what’s driving these issues of discontent and dissatisfaction within the physician community.

-So trying to address it by sending them to a mindfulness class or resiliency training is simply not going to work. It’s about the true root-cause analysis and understanding the problem, then you can work towards a solution. Some healthcare systems want to address the problem, but if you have a solution which implies the problem is with the individual, and the individual doesn’t get any better (and why would they because that’s not the actual way to address it), you find that the ownness of responsibility is on the person. And when that doesn’t work, they say well we tried, but this is a problem with the individual. But when you look at it from the other way around, and see it is the ecosystem in which they operate, so it’s people in a high-risk environment, then the responsibility is on the people who actually provide the environmental structures.

-And that gets a lot trickier because now we are looking at institutional organizational change, that cultural shift amongst institutions and how people interact with each other and how they interact with their roles in general. That’s much trickier, but now the responsibility is shifted more on the organization.

Have you conceived or seen a healthy or happy environment that doesn’t provide this sense of burnout that we have seen?

-I think of you are going to see elements of it everywhere, however it doesn’t have to be ubiquitous

-I’ve worked on three different continents, you will see it exist in various forms, in various different healthcare systems.

-The key component for me is that if you simply accept that there will be challenges and difficult organizational structures… we have to part of the solution and once you feel you can at least attempt to influence change, it makes a huge difference (in terms of your psychological approach to it).

–What matters most, and this is a key thing, in setting up an ecosystem in that people feel they are cared for and heard. People will work incredibly hard (physicians are not strangers to hard work). But, if you have an environment where they are not appreciated and cared for, it doesn’t matter how hard working they are, they will be dissatisfied with their work. Yet, in the setting of long hours, if people feel heard, appreciated, and cared for, they will enjoy their work.

How do we implement appreciation on a system level, and how do we on a personal level take ownership in a mission like that? (Please Read… I would have bolded the whole thing)

-This is fundamentally down to leadership and when people think of leadership, they tend to think of people sitting in some elevated structure away from the clinical floors, and not seeing patients.

-In reality if you are working in healthcare, if you are CEO of a hospital, if you are the head of a department, if you are a fellow, a resident, a medical student, you are playing some leadership role… because someone looks up to you in guidance in what you do, and that’s important.

-It’s not about a very extensive complex solution, it’s about sitting down with the people whom you are responsible for, and asking them and paying a genuine interest in what they are doing, asking them if they are okay, and maybe how we can work better. With that as a cultural ethos in place, the solutions will naturally find their way.

-There is no one size fits-all to this problem, because the individual drivers of dissatisfaction, vary from place to place and person-to-person.

-We can see vastly different rates of burnout in physician specialties, but we understand implicitly that different specialties operate in different ways, and have different personalities, that would attract them. There is something to do with the environment we work and the dynamics of that environment, and the fact they are different between specialties and areas, that are driving more dissatisfaction amongst those. But we all know of a particular person in the past, who was a leader and a mentor who allowed you to do the work you wanted to do, to be closer to the physician that you had wanted yourself to be, and you didn’t mind working incredibly hard. Because that was your purpose, that was where you find agency in what you do.

-That is the key is finding a cultural ethos change – understandably there are core features that are somewhat out of our control as physicians in health care groups and organizations. When you have top-down regulation of certain things you need to do with the EMR. The issues with the EMR aren’t that we have to tick boxes or fill in forms, it’s the fact that it takes us away from doing the thing that we feel what it means for us to be a doctor. There will always be issues with the EMR, but it’s about trying to work together and minimize those, and there will never be a perfect solution. Each individual in an organization has to do a root-cause analysis of what is driving the dissatisfaction within their organization.

The job of medicine versus the art of medicine

-This is something that really has been described in philosophy…

-it was very much a revelation to me, that we tend to put it in one category in terms of “this is what we do”. It is not one thing, it’s two things: it’s the art of medicine and the work of medicine.

–The art of medicine is the thing that truly drives you, it’s the passion you have for those times when it’s just fantastic to be a physician, and to intersect with patients at a time that is so critical in their lives and it is such a privileged opportunity to have that

-The work of medicine, is a lot of the stuff around that. It’s the call, it’s the EMR, it’s the board certifications, and maintenance of certification.

-Ultimately we truly love the art of medicine and continue to do so, but we dislike a lot of the elements and the work of medicine. But when we start to feel a disdain for this, we put the two of them together and we have this dislike or disdain for the art of medicine, and we feel huge guilt around that.

-And we can’t understand why we feel guilty for disliking something that we hold so dear. And it creates huge conflict because we don’t understand.

-But when you begin to parse out the problem of recognizing that the art of medicine is always there and something that you truly love, and nobody can touch that, but the elements that exist around your job, where you work, how you work, the type of specialty that you are in, the people you work with, the call rotation that you, these are elements of your job that are modifiable. And, when you start out of your training, you have less scope and less flexibility, but as you move through your training to your own independence, it is up to you to define what are the components of your job, the parts of your work you want to do most of, and you do that. Because, then you can craft your life and your work that you truly had envisioned it to be.

-So when you look at your job as a whole then, there are elements that you truly love, and elements that you don’t love, but the aggregate is worth it. You learn to craft your ideal job, and it’s a constant process.

On finding Control in Adversity

-I think that a general philosophy in life, is you will always face adversity. If you look at the Buddhist fundamentals of where people derive suffering is in this expectation mismatch. If you always expect things to be good, you will find you encounter painful times in your life, and therefore you have an expectation mismatch. Because of that, there is suffering. Pain is mandatory, and suffering is optional.

–This reminds me of the two-arrow theory discussed by the Dalai Llama: the first arrow is pain which is unavoidable. The second arrow is our reaction to the pain which we do control.

-This has been reiterated in literature, and if you read, Man’s Search for Meaning, he’s basically paraphrasing Niche in this, he describes that we control very little in our lives except how we respond to the situation. So that is fundamentally always up to your control. Shakespeare writes that in the tempest, so far as he says that nothing is right or wrong, only thinketh make it so. So you have the control in how you respond to situations, and we always have that no matter what situation we are in.

How do you define happiness?

-Everybody describes happiness as something you find, but that’s not really possible. Happiness is something you create, you build, and work towards.

-It is fundamentally a byproduct of the way you live your life. People describe this as a sense of finding meaning in life and that implies that there is meaning to be found.

-You need to look at it another way in that you bring meaning out of the world in what you do. You bring happiness out of the world in what you do.

-When people describe happiness, there’s how we are in the moment (in terms of your immediate moment to moment, and day to day happiness), then there is your contemplation of how you feel you are in general.

–Ultimately, and this is one of the distinctions when you look at the actual happiness scores whether having children make you happier or not, compared to people who don’t have children… if you survey people at the time and ask them are they particularly happy, a lot of the time they are not, they are in the middle of some crazy situation, they are stressed, and just want free time. But when you ask them in an overall sense, are you happy that you had children? Are you happy in life and the way things are? They are happy.

-So it is to understand the distinction between the weather and the climate. The weather will always change, that is part of life. You need to try to pitch to where your climate is, and whether you are generally happy with the world.

-That is fundamentally up to you, because to find happiness, means that you must luckily stumble upon it (or it will select you).

–But when you take ownership, that you can work towards finding happiness, that you can really put a plan in place, that you can find a toolkit… the onus is on you, therefore you can take control of that.

-It’s about perspective and it’s a byproduct in the way you live your life.

The need for control

–Taylor: I think a common theme we spoke about earlier is this sense or need to find ownership or control…

–And that’s one of the key drivers of dissatisfaction in general and burnout. Which by means is not exclusive to physicians. When you look at the classic survey instruments used to describe burnout, the most commonly used is the Maslach Burnout Inventory. And that’s what you will often see quoted in studies or a variant of it.

-But all that does, is that it tells you if someone is burned out or is at high risk for becoming burned out or not. So effectively, it gives you a temperature, it gives you a binary “yes” or “no”.

-But it says nothing really as to what the root cause of the drivers are.

–This is important, because without understanding the root cause, it’s effectively just looking at a temperature of a patient, and not understanding the pathology of where that may be coming from (whether it is indeed sepsis or which organ it is coming from).

-When you look at the survey instruments for finding the causes, the most commonly used is again defined by Christina Maslach, and it’s the area of life survey. When you look at the rank order of these – excess work hours, or excess demands on the capacity that you have… that tends to be perceived as the number one driver, but, invariably it’s actually at the bottom. The reason it is perceived as the number one driver, is because the excess work hours are probably the number one issue when you are feeling burned out, so it’s the most obviously manifest symptom.

-The two biggest drivers are: lack of control. The lack of control of how you deliver care. The lack of control in how you live your life. The lack of control of where you perceive your future  and your career to be heading and this fear you are being railroaded into a life that you are terrified to have, and that you have no control over this direction.

-The second is, and it is equally important: is this concept of value-conflicts. What that means is you have a major conflict personally with the institution or organization and their own philosophies and beliefs. My acid test for this is, if you are working somewhere and you feel burned out, look at your organization’s mission statement. Read the first line, and if you throw your eyes up and say that’s kind of nonsense, you have a personal value conflict with the way that you believe the organization delivers care, the way you believe people should be treated. And this is the problem… is that if you are in a system, whereby you feel patients are being treated unfairly, or are being utilized to generate overuse for example or do certain things that, you believe are not the best for the patient, or that they deserve better… that creates huge value conflict.

-These are the deepest drivers of what actually causes discontent.

-The flip-side to that is, when we look at what is the most manifest, or visible symptom, an issue around working hours… and clearly working hours has tolerances if someone is working 120 hours a week, no one is going to tolerate that. But if you then solely and exclusively address that and reduce working hours you don’t actually tackle the true fundamentally drivers, which are likely autonomy and control and around value-conflicts.

-So you have reduced the time exposure to the adverse stimulus, but you haven’t taken away the stimulus.

-If you don’t fundamentally understand if those are the true drivers for you, you can never orchestrate or put in place, a role or a job, that will then be able to make you feel satisfied and engaged in your job as a physician.

Taylor: And this loss of control and loss of value-congruency, this is applicable in all fields.

-And burnout as I stated, is not exclusive to physicians, burnout was originally described by a German gentleman, and it was described by those caring for drug addiction. It’s most commonly seen in anyone in a role who cares for another. It can be seen in fields where anyone is dealing with other human beings. So that’s effectively almost all jobs.

-So we go in to our job having certain expectations, in terms of, we go into our lives as physicians wanting to do well for our patients, and sometimes we feel limited in our ability to do that, and that creates huge conflict. But burnout is seen across the spectrum, between physicians, teachers, lawyers, firefighters, police officers. It is something that is very ubiquitous.

What are your thoughts on the climate of fear in creating and expressing your own voice, within the field of healthcare?

-I think that’s having a confidence in your own belief structures that are sound and reasonable.

-I think it’s about using the right platform, at the right time, with the right voice.

-I think there is a way to have rational discourse and talk about sensitive topics, and I think what is often lacking in the world today, is the idea that we would have a rational discourse over a topic that is maybe not agreed on by two parties.

-It is only by having that discourse and having rational discourse that a reasonable solution can be found.

–I think one of the most valuable things is to try to understand where someone else is coming from, truly understand that, and you will recognize their fears. Often, where you are coming from is driven from fears, anxieties, and insecurities… and it is being met by the other side also. I think when we recognize those elements, then progress can be made.

-But don’t be afraid to voice your opinion, but think carefully about what you are saying, and how you are saying it. And the root of the motivation of saying that, if it’s born out of fear, and why that is.

-And understand that if someone retorts, to understand that is born out of fear also.

-But I would certainly encourage everybody to develop their own thoughts independently, read broadly, have an idea and an opinion about the world, not to be opinionated but understand why things are happening and the way things are set up. To basically accept nothing at face value and understand the rationales for the structure of things.

-I think it is so important to have your voice in the world, and if you don’t have your voice… if you simply standback and say nothing, and when the world collapses around you, and things don’t go the way you would have liked… you really are not in a position to complain.

-One of the things I like to say to myself and to others who are in a position that they don’t like is: you can change your attitude or you can change your geography… or both.

-but if you don’t do any of those processes or put those in place, and if after 6 months you are still complaining, you forfeit the right to complain.

-Because sometimes it just requires you change your geography: either who you spend your time with, where you spend your time, or how you spend your time.

-But sometimes you can’t, if you are in a medical school and you simply can’t leave…you need then to look at how you change your attitude and how you respond to the world… you need to look at building that toolkit, in terms of your psychological ability to operate in that world and understand that maybe changing your geography is something you can’t do right now, and you can put a plan in place to have a structured down the road (maybe one year, two years), whatever.

–But if in 6 months, you haven’t found a new approach to the problem, you are essentially suffering for yourself, and you have done nothing to help yourself.

Favorite Resources

-For me, I think there is a currently an obsession with the new… the problems we face are as old as human behavior.

-So the books I’m currently reading are older and older books. For me, it’s about philosophy and understanding, and having a framework to view the world, and how to operate within it.

-I think one of the most valuable resources that everybody should use, is watch there is probably hundred short videos by The school of life by Alain De Botton, videos on philosophy and how we look at the world. Although that is a new item, he is talking about very old ideas.

-In terms of a book, I think for anybody who is struggling with a dilemma, and a dilemma is something that doesn’t have an immediate and obvious solution. And we talk about touching the two horns of a dilemma, in so far as that if you touch one you are moving further away from the other, and I think everybody is struggling with that… the book for me that has been the most important is a book by Stephen Cope called the The great work of your life. And it’s effectively a modern day interpretation of an old Vedic text called the Bhagavad Gita, which is the story of Arjuna and Krishna on the battlefield.

-It’s about how to deal with a situation whereby if you think you are going to choose something, that you feel you will pay a penalty in some other way, and vice versa. It’s about how to rationalize that in your mind and ultimately all of that is driven by fear.

-So I think that the understanding of the core tenets of philosophy, The School of Life, anything in the stoic philosophy particularly Marcus Aurelius or Seneca, just unbelievable in terms of how to look at the world, and also Stephen Cope’s book.

If you could speak to a younger Paddy, let’s say ten years ago, what would you say to yourself?

-I wouldn’t change anything, I think where I am now is a result of all the good and bad things that have happened to me.

-I think the character and people we become are forged by our life’s journeys. I don’t think I would like to say anything particular because it would change potentially who I am now.

–One of the most fundamental things I like to reiterate to myself or would try to reiterate to a younger me is: “it’s going to be okay,” and things will just be okay. Because, it’s a matter of how you view it. I think that would be the most important thing for me.

What would like to say to medical community at large, something you would like us to conclude with

-I think my main message is that, although I have podcast that very much talks about physician burnout, is that… it was motivated by the idea that you can have a very fulfilling and satisfying career as a physician. That people do have incredibly satisfying careers as physicians, even within this environment and that opportunity is always there for you. That is why you have taken all the exams and put in all of this hard work. The reality is, to secure that you have to take control over your personal world, in terms of how you look at the world, and how you structure it. Understand that you can take back that control of the direction of what you are doing, and to dictate that you will have a satisfying and engaged career. To understand there are certain things you cannot change, and if you cannot change them, you cannot worry about them. But understand that you are the one who is in control, and you can have those items to give yourself the toolkit to achieve them.