I am asked to multitask instantaneously and without warning, disrupting what I find sacred about the bond between patient and doctor.— J. Gregory Mears, MD
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In my 45 years of practicing hematology/oncology at a major urban academic medical center, I have observed a sea change in daily practice that contributes to physician burnout. Although the emotional stresses of caring for seriously ill people play a part in physician burnout, I find the daily niggling and frequent, unnecessary intrusions into my professional doctor-patient interactions most troubling.
I am asked to multitask instantaneously and without warning, disrupting what I find sacred about the bond between patient and doctor. The doctor-patient relationship is currently under siege by modern regulations, disruptions in insurance coverage, the need to rely on an electronic health record (or four in my case), the hefty cost of therapies, and the increasingly corporate environment that the medical industry has fostered. Many of the interruptions are a result of the need for instantaneous gratification stemming from the expanding era of electronic communication. As physicians, we cannot control these modern-day institutional and social constraints. However, we can learn to modify our reaction to these events through the practice of mindfulness.
My day starts: I turn my Mac on and log on to review my schedule. My secretary tries to protect my time, knowing I get stressed when I fall behind, which is almost a daily experience. Since she is kind and responds to the pleadings of my patients to be seen immediately for a perceived threat to their health, double-booking has become the norm. A stressor! I know many patients will have inordinate waits and so feel the pressure to pay short shrift to some who are seeing me for what I sometimes describe as a “well baby visit.” The daily schedule is a stressor!
I began to rely on the electronic health record about 10 years ago and promised myself I would do my best not to let it disrupt the way I was taught to care for patients. I do not use a computer in the exam room. I take a notepad, sit down, and begin a conversation with my patient. I listen intently and remain focused, asking the appropriate questions to gather the needed health information. I escort the patient to the exam table and perform a directed exam using my senses to gather objective information about my patient’s state of health.
I step out to retrieve the results of the previously drawn lab tests from my computer. I do this knowing the lab turnaround time is often slow—as it is today. I wait for the results. I return to the patient explaining the delay and am interrupted by an urgent phone call. I know most of these calls are not urgent, but I must stop and take them. This one announces that the patient I am seeing has a critically high white blood cell count of 106,000/μL. Of course, this is not a critical value for my patient since he has chronic lymphocytic leukemia and his white blood cell count was 112,000/μL 3 months before. If only the algorithm for reporting critical values took this into account. These frequent interruptions to my workflow are a stressor!
I present the lab report to my patient and summarize my findings. I am pleased he is in a steady state and not currently in need of therapy, so we plan a follow-up in 3 months. Both my patient and I are happy and satisfied. These moments are the highlights of my day.
I return to the office to type up my notes, and halfway through my secretary interrupts to say that a Dr. B (whom I do not know) is on the line in urgent need of my thoughts about Mrs. A, a patient I barely remember, having seen her once about 2 years ago. I quickly query the electronic health record for any information about this patient. I search and find my initial visit note, recollect the issue at hand, and then feel comfortable fielding the call from Dr. B. I do my best to provide appropriate medical information. Several more phone calls need to be dealt with. I feel stressed with each one; a mini-crisis may be in the offing.
May we all live in the present moment, practice loving kindness, and celebrate the beauty of the cracks in our lives.— Leigh Leibel, mSc
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The day proceeds apace. Further critical lab calls—one patient has a creatinine of 3.0 mg/dL, as he always does. The caller asks me to spell my name. I think this is a bizarre request but a reflection that nobody knows anybody anymore at my workplace. I understand the legal principles behind critical lab value calls. However, I find it odd that truly critical lab values assuredly identify a critical change in a patient’s health requiring urgent medical attention, but it is not called in as a critical value.
And Still More Stressors!
Near the end of the day, after the last patient has been seen, my secretary approaches with a mountain of paperwork and phone callbacks. I remain surprised that in the era of electronic records so much paperwork continues to accrue. All stressors!
One is an insurance precertification request for a patient of mine who has been on dasatinib for 8 years, with excellent control of his chronic myeloid leukemia. The form does not allow me to state that this should be a routine recertification. The questions are arcane and unnecessary.
Then there is the need to get approval for a PET-CT scan for a new patient found to have lymphoma. Her insurance seems to have restrictive indications for this necessary test. I need to take time for a peer-to-peer review; after many wasted minutes getting connected, an equally tired sounding doctor hears my plea and agrees with my request. More wasted time and another stressor!
I don’t have much time during the day to review e-mails, so I do that later in the day. One states I need to take a test mandated by my university regarding violence in the workplace. I’m given a strict timeline to complete the task. I add this command to the many other online courses and tests now demanded of me every year.
I return to my phone messages. Could I renew Mrs. S’s hypertension drug prescription? I see her for myelodysplastic syndromes and do not even discuss her hypertension when I see her. Do I make a fuss and refuse, or just get back into the electronic health record and do it?
I remain surprised that in the era of electronic records so much paperwork continues to accrue.— J. GREGORY MEARS, MD
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I look forward to the weekend. I am not scheduled to be on call, and the weather forecast suggests I might play a round of golf. On the seventh tee box, as I am about to hit my driver, my phone buzzes. It is a patient texting me that he feels fatigued and short of breath. What should he do? Thanks to modern technology I am on call all the time!
It may seem that my burnout will derive from my daily interactions with patients and loved ones facing mortal illnesses. Yes, there is an emotional toll, but the emotional rewards are great. Peace and the satisfaction of doing a good job outweigh the emotional stress. The stressors outlined here have no rewards for me.
Strategies for Coping With Stress
The word stressed spelled backward is desserts. This heteropalindrome is a keen reminder that each of us reacts to our environment in profoundly different ways; it is the maladaptive reaction to an event—not the event itself—that leads to pernicious chronic stress and allostatic load.1 As the previous vignette illustrates, we can’t always control our external environment; however, we can learn to modify our response and disruptive habitual behaviors through mind-body practices that promote better cognition, concentration, relaxation, and a more positive outlook.2
Mindfulness is one such evidence-based intervention well worth cultivating to mitigate stress and improve high-level functions such as attention and memory.3 Informed by ancient Eastern introspective practices, Jon Kabat-Zinn, a founder of the field, describes mindfulness as “paying attention in a particular way: on purpose, in the present moment, nonjudgmentally.”4 It is a skill to be learned and honed, like studying a musical instrument.
Here are a few suggestions to help establish a daily mindfulness practice for wellness:
Briefly, STOP stands for stop what you are doing for a minute; take a breath; observe your thoughts, feelings, and emotions; and proceed with something that will support you in the moment. In short, become aware of what’s going on internally and externally, ground yourself with some conscious breaths, and proceed with more clarity from a place of choice.
In brief, RAIN stands for recognize a strong emotion is present; allow or acknowledge it is there; investigate the inner experience; and nonidentify with your thoughts and feelings. Allow emotions to come and go—like weather patterns crossing a mountain.
Practicing mindfulness throughout the day helps create new healing habits of mind and body, not only for ourselves as health professionals, but also as holistic healing ambassadors for those in our care. May we all live in the present moment, practice loving kindness, and celebrate the beauty of the cracks in our lives.
For more on physician wellness and burnout, look for a special series of articles coming soon in the JCO Oncology Practice, April 2020.
DISCLOSURE: Dr. Mears and Ms. Leibel reported no conflicts of interest.
1. McEwen BS: Protective and damaging effects of stress mediators. N Engl J Med 338:171-179, 1998
2. Gotink RA, Chu P, Busschbach JJV, et al: Standardised mindfulness-based interventions in healthcare: An overview of systematic reviews and meta-analyses of RCTs. PLoS One 10(4):e0124344, 2015.
3. Sharma M, Rush SE: Mindfulness-based stress reduction as a stress management intervention for healthy individuals: A systematic review. J Evid Based Complementary Altern Med 19:271–286, 2014.
4. Kabat-Zinn J: Wherever you go, there you are: Mindfulness meditation in everyday life. New York, Hyperion Books, 1994.
Dr. Mears is Professor of Medicine at Herbert Irving Comprehensive Cancer Center, Columbia University, New York. Ms. Leibel is Clinical Director, Integrative Practices at Herbert Irving Comprehensive Cancer Center, Columbia University.
Disclaimer: This commentary represents the views of the author and may not necessarily reflect the views of ASCO or The ASCO Post.