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Confronting the doctor paradox

Doctors have incredibly meaningful jobs and enter medicine as dynamic individuals with ambition and expectation. Why, therefore, are so many unhappy in their work and what can be done about it?

Irishman Dr Paddy Barrett, a Clinician Scholar and Cardiologist at Scripps Translational Science Institute, US, is broadcasting a popular podcast series called The Doctor Paradox to investigate and interrogate these critical issues for the profession and their patients.

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Dr Paddy Barrett, creator of The Doctor Paradox

The series comprises of interviews conducted by Dr Barrett and focuses on achievable means by which doctors can tackle burnout. It also explores an evolving model of medicine where what it means to be a doctor surpasses traditional dimensions.

Episodes have included an interview with Medical Independent (MI) columnist and consultant rheumatologist Dr Ronan Kavanagh on embracing creative interests in medicine; US family practice physician Dr Dike Drummond on how to deal with physician burnout; and Dr Zubin Damania (AKA ZDoggMD) on finding one’s passion in life and novel healthcare solutions.

In the first podcast in September 2015, Dr Barrett said many medical professionals would criticise him for embarking on the series, but that such was life. Speaking to MI from the US, Dr Barrett said that within medicine there is “an ingrained culture” to not expose deficiencies in healthcare systems or physician vulnerability.

Doctors are often viewed by patients and society as “invulnerable” and the profession is “as guilty as anyone of projecting that image”.

Lost

The reaction to the podcast series has, in fact, been “very, very supportive” and relatively uniform from doctors in Ireland, America and elsewhere.

Dr Barrett was in Ireland during the spring, when he spoke at the National Intern Conference in Cork. MI asked him what type of atmosphere he gauged among doctors while back home.

“Somewhat a sense of despair,” answered Dr Barrett, who noted that this had been the case for several years.

“You have people who are truly passionate and genuinely want to do a really good job and enjoy their role as a physician, but they feel somewhat lost at sea without any obvious avenue to find a way towards a successful career path. They are looking at their career paths in Ireland and they are nervous as to what exists in the future. And they look overseas and some of it looks more appealing at times, particularly New Zealand and Australia, for Irish physicians because of the ease of transition.”

However, in tandem are the conflicts of emigration, “leaving family and friends and ultimately leaving home, so they feel quite conflicted in terms of what decisions to make. And that is a scary time, particularly for younger physicians.”

Solutions

In the series so far, what theories and solutions are espoused in relation to avoiding and addressing burnout?

“I think the first thing is recognising and really opening your eyes up to perspectives that are causing you these challenges,” he said. “We somehow have managed to be very persistent in just tolerating poor work and life conditions. It is something we have been ingrained to do across the world as physicians insofar as we are, in general, very resilient individuals and we will tolerate a lot for the benefit of our patients. And in doing that, we ultimately become the casualties and by proxy then, the patients do.

“We understand that you have to hustle at times, you have to pull out all the stops at times, there are occasions when you have to stay up all night and all day and that is implicit in what we do. That is not going to go away ever, but the reality is, to do that repeatedly is very much unsustainable. And ultimately, what happens is your care of yourself diminishes and if you can’t look after yourself, you are not going to be able to look after your patients…

“Say, here in the United States, there is a huge emphasis on patient satisfaction scores… that is becoming much more of a global phenomenon, but I think and I would argue that the sure-fire way of having happy patients is by having happy healthcare workers, and you can see that reflected in companies like Southwest, which is one of the largest air carriers here in the United States. They look after their employees and if they have well-taken-care-of employees, they have well-taken-care-of customers, and it works very much that way.”

Does he recall any particular focus on maintaining resilience and avoiding burnout during his own undergraduate and basic specialist training?

“Essentially none,” answered Dr Barrett. “Medical school in general is six years of very arduous scientific training for the most part. We lack a very comprehensive development of the ‘soft’ skills, insofar as how we are actually prepared for the challenges we face. And I think the medical schools in general are really only beginning to learn this. They are trying to squeeze in a huge amount of scientific knowledge and learning over the period of six years and they do that very successfully, with us ending our training very well versed in being clinicians.

“But in terms of the overall skillset of being a physician, an actual practising doctor, there are a whole set of skills that are only kind of picked up on an ad hoc basis by virtue of osmosis, and not uniformly by all.”

At the 2015 National Intern Conference, MI columnist and consultant gastroenterologist Dr Anthony O’Connor strongly advised younger doctors to maintain their hobbies. According to Dr Barrett, this subject has frequently arisen in the series.

People who train to be doctors generally have a broad set of interests, but the high commitment required to practise good medicine often sees hobbies and interests fall by the wayside. However, Dr Barrett emphasised that maintaining one’s interests is also a part of improving one’s performance as a doctor.

“It has been one of the recurrent themes in the podcast, whereby people really try to integrate a lot of their non-clinical interests with their practise of medicine,” he said. Dr Michael Gibson, a Harvard cardiologist, “has been a practising artist for a long time and it was actually his understanding of a lot of the principles of art that allowed him to make certain creative discoveries within medicine that have become standard practice today.

“There are physicians like Adam Gazzaley, who is a neuroscientist and psychiatrist at Stanford who ultimately wanted to spend a period of his life being a photographer and in doing so, learned a somatic language of how to creatively express the human condition, and in doing so was able to integrate that into later studies of neurocognitive performance for patients with dementia. It is about making those connections between often disparate areas that really lead to unique discoveries.”

Aviation

Aviation is one of Dr Barrett’s interests. “I think that has been super-important for me. I think I have become a better doctor because I have trained to be a pilot. I think it really lends itself to very substantial crossover in terms of applying yourself in a very systematic way, and also in terms of how you do crew resource management.”

Healthcare professionals train in silos, whereas training in commercial aviation is much more team-based, he said.

“There is individual training of course, but there is actually then collaborative training. So it makes total sense when you are dealing with very high-stakes environments that training as a team, despite having very different titles, is crucially important. That is something that we lag behind in medicine. The reality is that mistakes are made and mistakes will always be made in general, because we are human beings.

“But if you look at aviation, there tends to be a mistake made and then very substantial efforts to reduce the likelihood of that mistake happening again; it doesn’t eliminate the chance but it very substantially reduces it. In medicine, we seem to be making the same mistakes repeatedly without a great emphasis on trying to reduce those future mistakes, or certainly not to the same degree as in aviation.”

Why so?

“I think the complexity of dealing with an entirely human environment is much more challenging, but it doesn’t eliminate the systematic training that can be put in place,” said Dr Barrett.

“I think we have seen repeated examples of, we will say, actual power gradients that exist between different levels and that has been reflected in aviation and has been the cause of major disasters. And we see it in healthcare every day — when either a junior physician or an allied health professional will see there is something going wrong and will not speak up and potentially it will result in an adverse outcome. I think there is a lot to be learned.”

Medicine’s hierarchy serves a purpose with regard to delivering safe patient care, he added.

“But what matters is the actual degree of a power gradient…If it is very high, the other team members find it very hard to integrate and have their opinion matter within that. It is about setting an appropriate gradient and I think it has somewhat improved in recent years. The historical very, very authoritarian consultant figures are becoming less and less, and those power gradients are becoming less of an issue.”

Dr Barrett spends one-quarter of his working life in clinical practice and the rest on research, predominantly in digital medicine. 

“Digital medicine is one of those niche areas that is beginning to capture attention on a much more global scale. It gives us the opportunity to really do at a patient level, at point of care, a lot of the medical testing and diagnostics, and patient care that was historically only able to be delivered in very advanced healthcare systems.”

One of the benefits is more active involvement of patients in their own management. “I think there is huge opportunity for us to embrace that and incorporate it into healthcare today.”

See www.thedoctorparadox.com.

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