Physician Burnout

Updated 3/2017 --  all links (except to my own posts) removed as many no longer active. 

Dr. Wes and Kevin,MD have both written reviews of the documentary film “The Vanishing Oath.”   I started the process rolling of trying to get the film shown locally.  No date yet, but looks like it will happen before the year is out. 

This is not a new phenomenon in medicine (or any profession).  Dr. Robert Goldwyn wrote a nice essay on the some of the issues that can lead to burnout though not once did he mention burnout specifically.  The title says much:

“I Bargained on Working Hard as a Surgeon,  Not Working hard to Be Able to Work Hard as a Surgeon”

The preceding title is a quote from a letter written by a resident in the last year of his training (S. A. Teitlebaum, August 20, 1994). It reflects the gloom besetting the young in particular but certainly not them exclusively. We all are uneasy about our futures, professionally and economically. Bandied in the corridors at a national meeting was a dismal figure: 1:100,000, the presumed proper ratio, as determined by Health Maintenance Organizations, of plastic surgeons to population. That 1 million Americans need only 10 plastic surgeons seems wrong and idiotic to me, but it makes good economic sense to health providers and insurance companies. Their coffers swell as they collect the same or higher premiums while curtailing what they provide.

When I started in practice 31 years ago, Massachusetts had a population of about 4 million and had 14 board-certified plastic surgeons. Now, with a slightly increased population, there are 104 plastic surgeons. If we go by the 1:100,000 rule, we should expect only 60.………

Lisa Chu, MD has an essay, Burnout is common to teaching violin and practicing medicine, in which she discusses the topic:

I’ve recently started reading blogs and articles about “physician burnout” and I can’t help but notice that there’s a lot of blame being placed on “the system”. Doesn’t this kind of storytelling just reinforce that physicians are victims? I’d like to see physicians adopt a way of thinking that will enable them to create the desired changes in their own lifestyles, levels of satisfaction, and ultimately patient care…..

REFERENCES

"I Bargained on Working Hard as a Surgeon, Not Working Hard to Be Able to Work Hard as a Surgeon"; Plastic and Reconstructive Surgery. 96(1):177-178, July 1995;  Goldwyn, Robert M.

"I Bargained on Working Hard as a Surgeon, Not Working Hard to Be Able to Work Hard as a Surgeon"; Plastic and Reconstructive Surgery. 114():102-103, October 2004;  Goldwyn, Robert M.

Consultations

Updated 3/2017 -- all links removed as many no longer active. and it was easier than checking each one.

Recently Dr. Debra Benzil (Women Neurosurgeons: Hearts and Hands) wrote a post suggesting doctors are often their own worst enemies.  As I continue to read through Dr. Robert Goldwyn  essays, “The Operative Note: Collected Editorials” (published in August 1992), I came across this one which suggest the same. 

I contend that his essay could apply to consultations for many different medical and surgical issues in how we physicians treat our patient and each other.  The bold emphasis is mine.

 

Consultation for Breast Reconstruction

The woman who has just heard that she has breast cancer faces not only the prospect of deformity and death, but also the quandary of having to decide among various treatments:  mastectomy – radical, simple, or segmental; node dissection; chemotherapy; or irradiation – alone or in combination.  Should this patient later want breast reconstruction, she must sort through another set of alternatives.  A few years ago, the choice for patient and plastic surgeon was relatively easy – an implant or nothing.  The advent of musculocutaneous flaps has allowed more latitude and, in may instances, superior results.  Even the implants have changed and now exist in a bewildering array:  saline- or gel-filled, in various sizes, shapes, and thicknesses, as well as the expander type.  My purpose here is not to list the indications, advantages, and disadvantages of each or to advocate one over another.  Numerous articles in this Journal have already done so.  This editorial is to make two pleas:  for each of us to take the time to explain to the patient the different methods for rebuilding the breast and the reasons for our specific recommendation, and for each of us not to denigrate the plan or person of another plastic surgeon who may have suggested something different to that patient. Results, though improving, are still not ideal and should not foster dogmatism.  The fact that the number of plastic surgeons has increased makes it easier for patients to obtain additional opinions.  In my own practice, I have heard such statements as “Dr.  ____ says that the flap from the abdomen is the only way to do it.”  Or “Dr.  ___ said that implants should never be used if you can avoid it.”  and “Dr. ___ told me and my husband that it is rarely necessary to use a flap because an implant can do the same thing more easily.”  One wonders whether that surgeon knows  how to do a latissimus dorsi or rectus abdominis flap.

I realize, of course, that patients misquote doctors; nevertheless, I am sure that much depends on what door a patient enters.  One surgeon may be in hsi Radovan expander phase; another in the flush of his first rectus flap; or a different surgeon may be fossilized, unwilling to try anything other than an implant.

Advising a patient about breast reconstruction involves the same principles as counseling in other areas of medicine.  What are the objectives and what methods are available for attaining them?  Am I capable of providing that treatment?  If so, should I proceed?  If not, I should refer.  In all these deliberations, the patient must be an informed participant.  Involving the patient and helping her choose a course of action is not the same as making the patient decide on her own.  The doctor who lists the serval ways of reconstructing the breast as a waiter would recite the entrees for the evening abrogates his or her responsibility.  The patient did not come to the surgeon to flounder in the sea of indecision while the surgeon sits comfortably in a nearby lifeboat.

Since reality is seldom perceived beforehand, photographs of average results of breast reconstruction, showing scars in the recipient and donor sites (if a flap is to be used), are helpful.  So is having the patient speak to or perhaps, see another patient who has already been through the ordeal.  One has to make clear in the record and to the patient that this does not imply guaranteeing a similar result.  In fact, on occasion, I have referred a patient to someone who is unhappy with the result if I sensed the new patient was screening out information about what could go wrong. 

Breast reconstruction is a challenging aspect of our specialty.  With several thousand plastic surgeons working in the world, ingenious developments will be forthcoming.  Tolerating ambiguity is necessary if we are to advance.  Is there unanimity in how to repair a cleft palate or how to treat cancer of the tongue or breast?  Breast reconstruction has come of age; there are now several ways of doing it.  Despite this variety, I expect that surgeons of the next generation will do better for patients than we can now.  Perhaps the need for breast building will have disappeared if an alternative to mastectomy proves effective and safe.  In the meantime, we must remain sympathetic to the patient, who bears the greatest burden. We should not make her lot more difficult by behavior that is unprofessional toward colleagues and damaging to those whom we are supposed to serve.

Find Your Inner Guru

Updated 3/2017 -- all links removed as many no longer active. and it was easier than checking each one.


Here is another essay from Dr. Robert Goldwyn (full references below).  It shows his sense of humor.

Be More Than You Are

Many years ago, I heard the legendary Mario Gonzalez-Ulloa exhort his audience with the words: Be More Than You Are. After the ovation, he left the auditorium but what he said has remained. I am still pondering its meaning. In the heat of the moment, the message seemed clear: rise above your perceived talents and personality; go beyond your supposed limitations, as did, for example, Schindler under more terrible circumstances.

In this world, where the haves possess much materially and little spiritually, a desperate need exists for guidance. Gurus, usually self-proclaimed, flourish in the vacuum. Some grow obscenely rich. Society seizes their utterances, which may be sentient or zany or both. The trick is to say something that combines the obscure and the obvious, the true and the false. If it has an inner contradiction (Be More Than You Are), it will stimulate thought or, at least, bewilderment.

Here are a few; readers will likely supply better ones.

Anticipate yourself (or, Be before you are.).

Live in the present, but remain in the past.

….….

A door can be open or closed.

We forget what we cannot remember.

Be extraordinary in an ordinary way.

………

Remember who you are even though it is of no consequence.

There are three steps to everything: one, two, three.

…….

Be yourself but not quite yourself.

This may be the end, but it could be the beginning.

So do any of you have an inner guru?  What “advise” or “wisdom” would you give to us?


REFERENCES
Be More Than You Are; Plastic and Reconstructive Surgery. 103(1):299, January 1999;  Goldwyn, Robert M.
Be More Than You Are; Plastic and Reconstructive Surgery. 114():136, October 2004;  Goldwyn, Robert M.

The Plastic Surgeon Knows Best?

Updated 3/2017 -- all links removed as many no longer active. and it was easier than checking each one.

I tend to agree with what Dr. Robert Goldwyn had to say in this essay from his book “The Operative Note: Collected Editorials” (published in August 1992). 

The Plastic Surgeon Knows Best: 

A Hazardous Assumption

Two incidents, within four hours, seemingly disparate, were instructive nevertheless.  The first was in the barber shop, where I paid a long overdue visit.  The hair stylist – there are no more barbers left in the world – was a woman, whom I had not seen before.  She was one-half my age and a hundred times as attractive.  She was sitting in her own chair, brushing Lady Godiva length hair muttering that her friend – another “stylist” – had “ruined” her.

“She cut too much off,”  she said.

My fantasy was that her hair previously must have trailed like a bridal train.

This is a good sign, I told myself.  She will not prune me excessively, something that is easier to do with each year.  To my request for a “light trim,” she replied, “Don’t worry.  I’ll take care of it.  You’ll like the result.”

That last statement triggered an iota of apprehension but I gave myself over to her obvious charm and flying fiingers.  I must have dozed and awoke to a World War II soldier staring back at me from the mirror.  I look like an old recruit, perhaps a General Schwarzkopf but without his girth or tanks.

Then a more primal fear seized me.  Maybe my modern hair stylist was really an incarnated Delilah.  That thought sent my strength ebbing as I went to my car and then to the office – for the second incident.

This was a new patient, a twenty-eight year old writer, who was displeased with the outcome of her rhinoplasty done elsewhere.

“I told him that I wanted surgery only on the tip,” she said.  “I even wrote him a note to that effect and also specified it on the operative permit.  I couldn’t believe what I looked like when he took off the splint.  He had given me a total nose job.  When I protested and asked him what he had done to me during the operation, he got very angry and practically yelled, ‘It’s none of your business.  I was the surgeon and I know what is best for you.’ ”

Her plastic surgeon and my barber have forgotten that my hair and her nose belonged to each of us respectively and not to anyone else.  They also shared the same deficiency:  not listening.  But there is more involved:  namely, arrogance.  After they have finished with their work, we are left holding the result.  Of course, I do not equate my Marine hair cut with her new nose.  With God’s grace, in a few weeks I will regain what I had but she will not.

I believe it was Osler who advised us to listen to the patient because he or she will tell us what is wrong and if we listen longer, the patient will tell us what to do.  I am afraid that each of us occasionally ignores or forgets that verity.  The patient becomes somehow incidental to our treatment which we impose without proper regard for that person’s sensibilities and desires.

This phenomenon of not taking into meaningful account what the patient wants I have observed more among older practitioners.  Perhaps they feel that they are beyond the restrictions that usually apply to other plastic surgeons.  This kind of megalomania is not without possible severe repercussions  -- the kind that take place in a court room.

In our specialty, more crimes are of commission than omission.  fewer problems result from doing less than from attempting more.  One would think that the older plastic surgeon would appreciate doing less in order to conserve his or her strength.  Maybe the issue is one of routine:  performing “the operation” instead of the right operation.  The patient who receives more than he or she requested is about as grateful as the diner who was served Beef Wellington when he wanted a green salad.

 

When breast augmentation and reduction patients ask me what size they should “go for.”  I tell them my opinion, but also tell them they should decide “what they want.” 

I have been known to use the example of me making them a dress in a lovely green silk.  The dress fits perfectly, the color suits their skin/hair/eye coloring, BUT I find out too late they hate the color green.

So while it is my duty to listen, my patients must tell me what they want.  Then we can have a discussion about whether it is possible, etc.

What People Think of Plastic Surgery

Updated 3/2017 -- all links (except to my own posts) removed as many no longer active. and it was easier than checking each one.

Another thoughtful essay from Dr. Robert Goldwyn’s book “The Operative Note: Collected Editorials” (published in August 1992).

What People Think of Plastic Surgery

In conjunction with the publication of my book, Beyond Appearance: Reflections of a Plastic Surgeon, I recently was on a number of radio talk shows. Through the wonders of modern communication, I was fortunately able to participate in most of these sessions without having to go to the studio. To relax in bed and to have one’s voice perpetrated on the citizens of Alaska, for example gives one an inkling of how easily those in high political office can abuse their power. To what extent these talk shows influenced the sales of my book I really do not know. But what I did learn was what many people are thinking about in relation to plastic surgery specifically and medicine generally. Although I was ostensibly on these talk shows to discuss my book, it was not long before larger issues and personal surgical events took over. What follows is not intended to be a factual survey of public opinion, but simply a series of impressions.

First, the good news. Most of those who called in were very much aware of the worthwhile achievements of our specialty. Many mothers expressed their gratitude for what plastic surgery had done for their children deformed from birth or trauma. Several men reported how well our colleagues had reconstructed their faces after removal of a cancer. Some callers wanted to know what I thought would be important discoveries in our field. A few asked specifically how close we were to perfecting artificial skin and methods to forestall aging. In that regard, aesthetic aspects of our activities soon dominated the reconstructive. Not surprisingly, many women phoned in to inquire about face lift, eyelidplasty, abdominoplasty, and liposuction. Men also described their experiences with plastic surgery, with most calling about hair transplants and rhinoplasty. Those who complained about what they considered a poor outcome of their aesthetic surgery admitted that they had been warned of that possibility but still thought that they should have received a better result, especially since, in the words of one woman, “I had been charged an arm and a leg for my face.”

A common question from the talk masters and listeners was how to find a qualified plastic surgeon. Many said that advertising had confused them. Why would a good doctor advertise? If he is as talented as he claims, why shouldn’t he be busy enough? Another question was whether a plastic surgeon would admit that he or she did not do a certain procedure and refer the patient to someone qualified. A frequent query was whether we “operated on everybody.”

What I gleaned from more than 20 talk shows was that the public believes that all plastic surgeons do cosmetic surgery and that anybody who say that he or she is a cosmetic surgeon is most likely a plastic surgeon. Credentials and board certification, though they are important to us and should be to the patient, are poorly understood. Almost any diploma on the wall will do. Availability, kindness, and cost are the determinants for a large group of people. Many regard an aesthetic operation as a commodity, a luxury item to be shopped for and purchased. A sentiment of many callers was that it is not really surgery since it can be done in the office and is not covered by insurance. Several vented their resentment at having something go wrong and then being unable to get to the doctor. One caller remarked (I was keeping notes), “He was there to take my money but not my complaints. He sent the nurse out to do that. Is that what you learn in medical school?”

The longer the talk show, the more likely the surfacing of disappointment and hostility. While almost every caller treated me with respect, undiluted, high regard was not what many had for the medical profession. The public is no longer our ally, if they ever were. A crucial factor, not surprisingly, was money. If we charged nothing for our services, our patients would undoubtedly like us more, but only if the result were perfect and we were kind. In this real world, however, most of us are not saints, most of our work is not perfect, and yet we charge for it.

I did receive one unusual call: Someone championed “genetic honesty.” saying that he was against any reconstruction that changes nature’s workmanship, even the most faulty, as in the instance of a child born with a cleft lip or a craniofacial mishap. Within seconds, the phones became alive with callers who verbally murdered that nihilist. They did my work beautifully.

As an aside, let me offer another fact: Nobody wrote me to become my patient. Many people did send letters asking how they could find a plastic surgeon in their area for a specific problem. I referred them to the Executive Office of the American Society of Plastic and Reconstructive Surgeons.

I did get a call, however, from someone who insisted he speak to me immediately, even though I was busy with patients. Finally, my secretary capitulated and I took the call: “Doctor Goldwyn,” the voice boomed, “I read your book, and I think it is one of the best I have ever read. Congratulations on such an achievement [by then, I was purring]. Sir, it would be an honor for me to sell you life insurance.”

So much for books and talk shows.