Joy in Medicine?

What 100 Healthcare Professionals Have to Say about Job Satisfaction, Dissatisfaction, Burnout, and Joy

Eve Shapiro

• Publisher: Productivity Press
• Year: 2020
• Print ISBN: 9781138328259
• eBook ISBN: 9780429828645
• Topic: Business
• Subtopic: Management
• Index: Business

Eve Shapiro has been writing about patient-centered care, physician–patient communication, and relationships between doctors and their patients since 2007. In Joy in Medicine? What 100 Healthcare Professionals Have to Say about Job Satisfaction, Dissatisfaction, Burnout, and Joy, Eve turns her attention to those on the healthcare delivery side of this "sacred interaction."

These healthcare professionals share their enthusiasm, joys, frustrations, disappointments, insights, advice, stories, fears, and pain, explaining how it looks and feels to work in healthcare today no matter who you are, where you work, or what your position is in the organizational hierarchy.

The healthcare professionals who provide patient care deserve our collective interest in their humanity. Without some insight into who they are and the forces with which they struggle every day, we cannot fully appreciate the obstacles to providing the care we all want for ourselves and our families during the best of times, let alone in the uncertain times that lie ahead.

part 1

What Promotes Joy

Taking care of others, helping others, ultimately is the way to discover your own joy…

The Dalai Lama

Introduction to Part 1

In this section you will meet people who express joy, satisfaction, and a deep sense of purpose and meaning in their roles as healthcare professionals. Simply put, these people exude thoughtful enthusiasm for their work. They are nurses, doctors, social workers, educators, psychologists, organizational leaders, an office manager, and a music therapist. They like talking to people and developing relationships with them. They respect their patients, their colleagues, and they cherish their roles because they are able to do what they most love: to help others. They are grateful to have found professions and organizations that enable them to use their varied skills in ways that are aligned with their own values.

Some took direct routes into professions they knew would be theirs from childhood, others took long and winding roads, and still others found themselves plunged into circumstances that led them to “aha!” moments when, suddenly, they knew, beyond all doubt, that this was what they were meant to do. Many of these people seem hard-wired for joy. Their glass is always half full. And they are strong, tenacious, and resilient in the face of forces that, sometimes daily, challenge their emotional and psychological well-being. If they feel joy in work it is sometimes despite, not because of, their leaders, their organizational cultures, their colleagues, or their circumstances—a tribute to just how deep their love of and commitment to their ideals and their professions run.

Several themes about what promotes joy in work emerged during the course of my interviews for this book. The first of these is passion: passion for the work, passion for leadership, and passion for treating the underserved globally and domestically. The other themes about what promotes joy in work, regardless of one’s professional status or affiliation, are autonomy and control; working in multiple roles; being part of a team; and finding work–life balance. When I realized I was hearing completely different yet remarkably similar stories and perspective over and over, regardless of who and how many people I talked to, I knew these categories would be the themes around which this section, What Promotes Joy, would be organized. I am privileged to present their stories to you now.

Passion for the Work

1.Sebastian P., MD, Primary Care Physician and Instructor of Medicine

Sebastian P. is a comprehensivist—a primary care physician and a hospitalist. He works in the same urban, academic hospital where he did his residency and was chief resident 22 years ago, and he works in the same primary care practice. Sebastian spends his time taking care of patients, teaching and mentoring residents, and, as he says, “thinking a lot about wellness.”

I remember growing up as a young adult thinking, I want to be a Marcus Welby. Not necessarily a country doctor but just like one. I want to go to people’s houses and know how they live. I like that role and it’s lovely to be able to do that now. I don’t exactly work in the country, but what I do isn’t far off in terms of the kind of relationships I’ve established: I go to people’s houses and hold their hands as they die. It’s an amazing privilege.

I’m moved and fueled and energized by helping people feel better and lead fuller, richer, more thoughtful lives with the bodies they’ve got. I like the detective work involved in finding out why people aren’t feeling well and figuring out how to make them feel better. If I couldn’t have been a doctor, I might have been a travel agent (seriously).

I’m a salaried employee of the hospital. My clinic looks like a private practice but of the six doctors, five are salaried and one is private. This hybrid model allows us to hire and fire our own staff and gives us some autonomy. I spend 70% of my time treating adults 18–102 and 30% of my time training residents and teaching.

My spouse and I share responsibility for our kids about 50–50, but I’m the primary parent. I shifted my hours when the kids came to make sure my schedule would be more in sync with theirs. I round at the hospital at 6:30 a.m. and take care of my patients. Then I go back home, make three breakfasts and pack three lunches for my three kids, and get them ready for school. Then I’m in my office. I pick my kids up from school when they’re done on Mondays, then I’m a dad. That’s why Monday is always a half day.

I work three and a half days in the office: Mondays from 9:00 a.m. to 12:30 p.m. are patient-booked hours. On Tuesdays I have a full day of work, starting at 8:00 a.m. and going all the way through, with no lunch break, so I can leave at 2:00 p.m. to pick up my kids from school. Wednesdays and Fridays are my full, long days. I round early in the morning on patients in the hospital and I see patients in the office from 9:00 a.m. until 5:30 or 6:00 p.m. Thursday is the day I teach. I chair the advisory system for the residency program, teach in the primary care center of a hospital, precept the residents, and run a wellness program for the residents. I think a lot about wellness.

I’m in the middle of my career. I’ve paid my dues and now I have some control over my time. I pushed hard to create flexibility in my schedule, so my work hours are more in sync with my kids’ school schedule. To figure out how to structure my time in the office I had to ask, first, whether such a schedule would be consistent with patients wanting to be seen very early in the morning or during their lunch hour and, second, what kinds of support systems I would need—and whether my medical assistant and secretary would be willing to work those hours, too. It turns out they were thrilled to work early and end earlier on Mondays and Tuesdays.

On Joy in Work

I definitely feel joy in work. I think you find joy in work when a moderate amount of work makes you feel good about yourself and about the difference you make—and that you want to do more of it. That doesn’t mean you feel like you’re on vacation the whole time or that every moment is happy. It just means that, overall, at the end of most days, you feel deeply positive about the work you’ve done and that you’ve made a difference.

I think people often feel, that was such a cool diagnosis, I just nailed it. Or, this is such a complicated case and I did really well. But for the most part, what’s important to me is the sense that people appreciate the time I’ve put in, or that I’ve made a difference in their lives, or that I’ve made them feel understood.

I do a lot of end-of-life care. When somebody dies, one of the most moving experiences is to hear the family say, “thank you so much.” At the beginning of my career I would respond, “Why are you thanking me? Your dad died.” Or, “Your mom died.” But obviously there are moving experiences all along that journey and I think those experiences fuel me. I feel engaged and energized when I know I’m making a difference.

When a young person dies, if it’s a young parent, it is so tragic. I’ve had two patients within the last year and a half commit suicide, and it was devastating. But even in such hard times, knowing that I have the capacity to feel so deeply and be so engaged is a good thing. Some people spend their whole lives desperate for a relationship. I have a relationship with people every 15 minutes.

I’m married to a physician. We’re a two-doctor household. My husband is a psychiatrist who is also deeply engaged in his work. I think he has a stronger drive to advance professionally than I do. In addition to patient hours he teaches and is a dean for educational programs, is involved in curriculum development, and so on. On top of everything else he has evening meetings and events. I don’t have that in my makeup. I do a lot of primary care and teaching and curriculum development—and I’ve been eligible to be an assistant professor for the last ten years—but I just don’t feel the need to climb through the ranks. It won’t get me more money, it won’t get me much more of anything, frankly. I’m doing exactly what I love to do, and I feel glad about it.

Promoting Joy: Wellness Programs for Residents

According to the literature on wellness in training programs published within the last three to four years, interns should have one day every two months or so to go to their dentist, see their doctor, get a physical, make sure they’re honoring their bodies’ need for sleep and restoration, that their nutrition is appropriate, and that their sleep patterns are compatible with humanity. There’s a lot being written about the need to make these requirements acceptable so they become the norm: “Well, of course you need those! Why wouldn’t you have that?” But that’s not the way it is right now. If you have healthy 26-year-olds I guarantee they haven’t seen a provider for a few years. They just don’t. There’s no space. There’s no time.

I champion a wellness program to ensure that residents are not only learning medicine and how to take care of people but learning how to take care of themselves so they can do their best work. This wellness program includes organizing social activities for residents. For example, I founded a corporate rowing league; in the summer, the residents are out on the water and they train one evening a week for six or seven weeks. It’s a wonderful time for residents to bond with each other and to be part of a team. There are lots of really good endorphins there! Our hospital competes with other companies and training programs. In the middle of winter, I organize a rock-climbing activity for residents. I also run a humanism program, taking the residents to the art museum every other month, which is fantastic.

I’ve also looked into how to offer confidential, non-insurance-based access to mental health treatment for residents. I’ve received funding for a program in which residents can access mental health services confidentially, without the knowledge of leadership. If residents feel overwhelmed, or if they’re having personal or marital problems and really need to talk, they should be able to talk to someone who isn’t responsible for grading or evaluating them. We fund three visits. After that, if they need more, whoever sees them helps them to use their insurance to find a provider for more extended treatment.

Maintaining Joy: Mindfulness

Mindfulness is helpful to me. For example, I have one work partner who whines a lot and he can easily get me into a whining mode. I’m particularly mindful of saying, “Don’t go there.” I have learned how to gently get him to stop whining—for himself, for me, and for the rest of the office. Deep breaths.

I ask him, “Why are you whining and complaining so much? Nothing is quite right so how can you make it right?” Or “Can you worry less about it?” Or “How can we change your attitude toward what’s wrong, if we can’t change what’s wrong itself?”

I’m mindful of the fact that some problems can affect the other moving parts of my day so I want to nip those in the bud whenever I can. When I’ve had a really crazy, complicated day I’m less patient with my kids at home. I’m acutely aware of that.

What Diminishes Joy

Difficult patients, the electronic medical record (EMR), and exhaustion diminish my joy in work.

Difficult Patients

Patients who are very difficult make me feel imbalanced, depleted, and exhausted. There are some people who, no matter what you do, will not be pleased. Nothing is ever good enough. Often there’s an underlying psychiatric problem with some of these patients. Sometimes patients like that diminish my joy.

The Electronic Medical Record

No question, the other huge factor in diminishing joy is the administrative burden of our work, by which I mean the EMR in general. Our world is codified. Everything has a code; we have to write our notes in way that is dictated by the billing system. Sometimes we spend a chunk of time in front of a computer that we could or should be spending with a patient. I’m 51 years old and I grew up in the era of paper charts but, even then, there was a sophisticated coding and billing system in place. I think this administrative burden has arisen from the need to do something with the incredibly expensive healthcare system we have.

Historically, we would bill for the amount of time spent with a patient—so for more complicated patients, we would bill more than we would for less complicated patients. During the last 30 years we began to bill for the complexity of thinking about the disease process. How do you document that complexity? Out came complicated billing systems to explain complexity, required by the Center for Medicare and Medicaid Services (CMS).

When I first started working, I would inherit charts from really good doctors who were on their way to retirement. There might be a little postcard stapled to the paper chart that said, “Made a house call. Pneumonia. Gave this antibiotic. Will follow-up in four days.” That was the note. With undoubtedly excellent care. You can’t do that now. You would be fired for fraudulence.

Fast forward to today. Let’s say I see 20 patients on any given a day. If it’s a particularly crazy, complicated day for whatever reasons my notes are not completed by the end of that day. We have a fairly new EMR system called Epic that enables administrators to see how many incomplete notes there are. They look at it every Monday. If I have a hard day on Friday, my notes will be done by Monday afternoon. But I occasionally have gotten an email from the administrators on Monday morning saying I have 20 incomplete notes. Sometimes I ignore that. Sometimes I say, “Do me a favor. Look at productivity. I don’t want you sending these emails, they just piss me off.” And sometimes I’ll just answer tongue-in-cheek, “Thank you for letting me know. Appreciate it.”

Exhaustion

I have felt exhausted. No question. But I’ve never felt exhausted to the point where I’ve thought I’m just not cut out for this. Or I need to go and be a travel agent. I love what I do. But at the end of the day, after seeing 20 patients in the office and I have 20 phone calls to make, I just don’t have it in me to call some patients back. I need to go home and get a hug from my kids. When I’m not calling people back that tells me I need something, so I have to think about what I need. I need to remind myself I’m not a bad person and it’s ok not to call certain people back. I let my secretary know, “just tell her I cannot call her back right now, but if she needs me, I’m happy to see her.” This is how I cope.

I tell people that telephone medicine is not good medicine. “I can’t see you, you can’t see me; if I ask you whether anything is worrying you about your headache, I can’t look in your eyes and see you look away. Is there a tear I’m missing, because this is how your mom presented with brain cancer? And is this why your migraine is worrying you? You don’t have brain cancer. But I can’t see that on the phone. Come in and see me so we can do this right.”

Reflections

I started my professional life at a time when people knew who Marcus Welby was, and at a time when a lot of our learning was done through mentorships. I think mentorships have gone away and should come back. The 80-hour work week for residents and the shift work, the focus on teamwork rather than individuals, diffuses responsibility for the patient. When there’s a whole group of people taking care of someone as opposed to when it’s just you—you and your patient and you’re on, and if you mess up it’s up to you to worry about and fix the problem—the sense of personal responsibility for the patient is diluted.

On Control

The blue-suited people watch the white-coated people’s bottom line, so you do have to work hard. But, in general, I think physicians believe we have less control than we actually do. I th...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Dedication
• Table of Contents
• Preface
• Part 1 What Promotes Joy
• Part 2 What Diminishes Joy
• Part 3 What Destroys Joy
• Part 4 What the Experts Have to Say
• Index