Patients Come First

Fatigue, Burnout and Poor Quality of Life Predicts Errors

At the forum in September we had an in depth look at the dimensions of physician health gone awry.  We focused on foundational issues such as the psychological make up of most physicians and risk factors for physicians engaging in unhealthy coping strategies such as substance abuse or being a “bully”.

In this articlefrom the New York Times,  the issue of residents in distress and medical errors is addressed.  The article tells the story of a resident that was clearly fatigued and depressed made an error.  The article references a study from JAMA that examined the association between residents self-reporting of medical errors during training and the level of fatigue, depression and burnout.   Sadly the problem is not limited to resident. As we learned in the forum depression and burnout happens in all areas of medicine regardless of the tenure in practice.  Dr. Colin West, the author of the JAMA study makes this comment:  “Most of us got into this profession because of passion for medicine, for taking care of people, but somewhere along the way, it gets drummed out. We have to figure out the best ways, the right way, for different individuals to t

Copy of the Presentations

Thanks to all who attended and contributed to a powerful event.  Below you will find the links to all of the presentations in one place for your convienence.  Please share with others  you know you might benefit from the information.

Physician Addiction, Impairment, and Suicide: Who’s Problem? by Mick Oreskovich, MD

Dealing with Problem Physicians by Paul Fletcher, MD

Legal Pitfalls and Protections by Barbara Shickich

Just Culture Decision Tree Discussion by Forum Participants

For your use…

Click here for powerpoint version

“I could finally lay down my own burden…”

“Perfect children become doctors”. This is clinical pearl I brought home from an amazing day I spent at “Healing the Healer”. And what is the price of that striving for perfection? I learned that plenty of us are also plagued by self-doubt, neglectful of self-care, have poor delegation skills, can be determined and rigid, and often carry an exaggerated sense of responsibility. We are consequently unable to reconcile critical events such as bad outcomes, and are vulnerable to burnout, depression and a lot of stress and sadness.

I found out that a disturbing number of doctors commit suicide, and struggle with bad coping strategies like drinking too much, and using prescription drugs. But doctors generally can’t admit they are depressed, and they won’t miss work. Almost all of the suicides had done shifts within the prior 24 hours. What they will say is “I can’t stop the pain. I can’t see myself as worthwhile.”

It was also transformative to learn more about addiction. Deeply rooted in my own stepfather’s alcoholism (I would guess) has been a longstanding impatience with people who have addictions. I have never had much empathy for people like this. But when one of the audience members, from the Washington Physician’s Health Program (WPHP), told his story, it opened my heart. He described driving past Lake Washington, seeing people in boats and on the beaches. Imprisoned by his addiction, he would look at those people and think “That will never be me. I will never have friends again, or laugh, or be happy. There is no way out.”

The most beautiful thing in the world, they say, is an intervention. Fortunately, this doctor’s staff amd colleagues did just this. They told him they suspected he was impaired and forced him to go and meet with WPHP. He had to drive to Olive Street, and find parking. And here is what WPHP did: They sat him down in one chair, but they also put an empty one beside him. In that chair was his disease. They told him that they loved him, but that his disease was telling him lies, and making him do terrible things. And he got into treatment.

And now? “Every part of my life is OK now. I have friends, I have happiness. My oldest daughter is getting married. I love being a doctor now more than any other point in my life.”

I got a little emotional on my drive home, feeling like I could finally lay down my own burden of trying to be perfect. It also felt good to find a source of compassion I didn’t know I had. It felt so good, I shared my story with my teenage daughter, and talked to her about the importance of not trying to be perfect. It must have worked, because she listened carefully and then had a question. “So, does that mean I can have cereal for dinner and watch CSI at the same time?”

What would be your answer?

Sue Taylor, MD

24 hours after the Healing the Healer event, some reflections.

First – a great meeting for me.  I was at the steep end of the learning curve, and the presentations and discussions were very helpful to me.  Powerful stories and experienced presenters, all comfortable with an uncomfortable topic.

Second -great to be a guest blogger/tweater from the conference!

Third – I recognize the debt that all of us attending owe to Dr Jeffrey Grice and Lauri Kutshia of Group Health Permanente.   We have had many leaders organize effective CMEs on myriad topics over the years – but never have we convened leaders of partner organizations so effectively to help us all work together on behalf of our patients.  This was the third time that they had the courage to engage us all in a challenging topic, and I look forward to their next event.

Barbara Allan Shickich is leading a discussion about the legal issues involved with working with physicians in difficulty.   Its hard work – if we do it properly we will not make it even harder.

Focus of the discussion:

- Discuss increased interest in addressing disruptive behavior
- Describe ways to protect and share information
- Summarize state and federal reporting obligations
- Provide guidance on responding to inquiries in light of Kadlec decision

Barbara Allan Shickich pt 1

Barbara Allan Shickich pt 2

Dr Paul Fletcher shared stories of how Group Health Permanente worked to improve the quality of the staff by being clear about the role of HR – is not transactional, it is transformational.  GHP improved the quality of the staff with deliberate attention to:
• Who we hire, who we fire
• Who we choose to lead
• Training and support for individuals and leaders

I really appreciated Paul’s respect for the involved physicians and efforts to help them be successful – and also value his establishing a high threshold for what it takes to be a part of our medical group.

Dealing with Problem Physicians

It seems to make sense to many people that the public should know about any clinician who has any impairment, or history of treatment.  Unfortunately, in states where legislation has been passed that has eliminated confidential treatment and monitoring for clinicians, the number of physicians coming forward for help has decreased considerably.  That means fewer practicing physicians getting treatment.  It does not mean that care is safer, and very likely means that care is less safe.  The WPHP provides confidential evaluation, treatment and monitoring for physicians with issues that impair their ability to practice.

Valuing the health of physicians is an important part of improving the health of our patients.  Right now patients are getting better care than those that provide care.  There are opportunities for improvement in both treatment and primary prevention.

At any given time in WA state there are about 22,000 MDs, DOs and PAs practicing.   About 8% are “troubled” (e.g., burnout, chronic stress, overwork, fatigue), and 3% are in trouble (e.g., severe depression, impaired judgment, disruptive behavior, substance abuse).

A challenging presentation about physician impairment.  Most every attendee has been touched in some way in their life by a physician with a serious impairment.  The charge of the WPHP:

“WPHP is the qualified provider for potentially impaired physicians, physician assistants, osteopathic physicians, osteopathic physician assistants, podiatric physicians, dentists, and veterinarians and whose objective is to motivate healthcare practitioners to enter treatment and to, and, in so doing, will serve to minimize the losses recover from their illnesses and other negative impacts that are caused by these illnesses”

Physician impairment is much more prevalent than I had ever thought.  A survey of the American College of Surgeons (8,000 responses) showed 6% of practicing surgeons were actively suicidal.  Professional prevalence (risk at some point during working career) of depression in male physicians – 13%.  Female docs – 20%.  Scary numbers.

Over 800 clinicians have been treated through the WPHP.  A great resource for the clinical community, and one that is likely significantly underused.

Dr. Oreskovich part one

Dr. Oreskovich part two

Dr. Oreskovich part three

Dr. Oreskovich part four

About 70 Medical leaders are gathering at Cedarbrook conference center this AM for a session led by Jeffrey Grice MD of Group Health Permaente.  The focus today is “Healng the Healer”, helping us take another step forward in building a safe and just culture.  The discussion leaders will include:

Mick Oreskovich, MD, Washington Physician’s Health Program

Paul Fletcher, MD Group Health Permanente

Barbara Allan Shickich, Riddell Williams P.S

And hopefully including the 70 other participants.

I have posted the main presentation and am looking forward to sharing some of the discussion online throughout the program.

Healing The Healer