There is a video on the Internet that has gathered 6 million views as I write this article (so likely millions more by the time you read it). The video is of a doctor in an ER mocking a patient who is extremely weak and distressed.
Samuel B., a college student, was found collapsed on the grass outside the school gym by his basketball coach. Taken to El Camino Hospital in Los Gatos, Calif., he waited with his father for four hours before being examined by "Dr. K." What begins then is the drama of a doctor who isn't listening to the patient or his father, and her failure to carefully read the patient's chart.
Sam had a history of anxiety attacks and had not taken his antidepressant medicine that day. He had been at that ER on an earlier date for the same problem. Dr. K. decided that Sam acted like a drug-seeker, wanting pain killers. That's when Sam's dad starting using his phone to record the scene. I watched the video online, and the doctor's mocking, cutting sarcasm and profane insults are disturbing. Yes, the hospital system made a PR apology and the doctor was fired. But what made Dr. K. "break bad"?
Physician Burnout: A Hot Topic
Speculation would suggest that maybe she was overworked; or maybe she just "snapped." It is an understatement to say that ER work is stressful. But I was surprised to find that cynicism and "burnout" among physicians are hot topics in the medical literature and journals. For instance, Medical Economics has an annual "fighting back issue" specifically addressing management of the more intimate physician challenges. "Beating Burnout" was the featured topic in August 2018.
Some of the articles I came across certainly did not beat around the "burnout bush"! "Taking Care of the Hateful Patient" by Groves, in the April 1978 issue of The New England Journal of Medicine, and "What Do Doctors Hate Most About Their Patients?" by Singh on Quora.com, both discuss the patient types that can drive physicians' negative reactions.
In 1978, Groves wrote in NEJM that "dependent clingers, entitled demanders, manipulative help-rejecters and self-destructive deniers" often evoke feelings of "aversion ... malice ... a wish to counterattack ... and lowered expectations" of success in physicians.
By 2018, Dr. Singh added types such as the "doctor shopper, "the liar," the obsessive "I have an agenda" person, and "the quick fix" patient. It makes one wonder why physicians don't just off themselves immediately and save themselves from all this confrontational anguish!
What Makes an "Ideal" Patient (and How Does It Influence Burnout)?
Physicians, nurses and other health care providers would prefer the "ideal" patient, of course. A study by Mizrahi, et al., in 1986 ("Getting Rid of Patients") defined the ideal patient as "intelligent, cooperative, and compliant; they had diseases that could be helped; they were clean, didn't talk too much, and were good historians regarding their health." But this is seldom the case, since patients are sick to begin with, in pain, scared, impoverished, etc.
Among hospital residents, Mizrahi and colleagues found that "patients whose afflictions were the consequence of self-abuse were evaluated as less 'worthy' of care than those whose pathology was perceived as no fault of their own" (such as most cancer patients). Self-abusers included those who used alcohol, tobacco or drugs to excess, or the morbidly obese.
At this point, it may be important to note that the "fight back" against the causes of burnout and cynicism is not a fight targeting the patient, as much as this discussion so far might imply. The definition of burnout given by many authors describes it as including physical and emotional exhaustion, depersonalization (with development of a cynical attitude), and a reduced sense of personal accomplishment.
"Letting Off Steam" or Belittling the Patient? The Conundrum
A review of measures used by health care providers to reduce the burnout risks includes many ego-defense mechanisms, but none is as common and complex as humor.
A seminal article by Wear, et al., "Making Fun of Patients: Medical Students' Perceptions and Use of Derogatory and Cynical Humor in Clinical Settings" (Academic Medicine, 2006), is worth visiting. The authors state: "It has long been known that medical students become more cynical as they move through their training." Dr. Wear originally thought this trend could be due to the stresses of medical school, e.g., long hours of study, lack of a "life" and mounting debt. But his conclusion was that the cynicism was part of the increasing realization that healing people and changing the world is far more difficult than a neophyte, idealistic freshman student might suspect.
Humor then, as Dr. Wear puts it, is a "safety valve for 'letting off steam,' a way to criticize patients who create stress perceived as unnecessary" in the effort to render health care.
Of all the patients considered "fair game" by medical students, the obese are at the top of the list. Many patients are off-limits to what I call "therapeutic doctor humor." They include those with most cancers, the terminally ill, women who've suffered a miscarriage, and children. Don't play around with jokes here. But even psychiatric patients are treated more gently than the obese.
Teachman and Brownell, in the International Journal of Obesity, 2001, found that negative attitudes are not just directed at the condition of obesity, but also against the patient who is obese. The reason? Big people make treating them more difficult; or as a surgical intern commented: "Obesity makes an easy 20-minute surgery a difficult 80-minute surgery." (I remember sitting in a surgical group case management meeting once and hearing the speaker ask the group if spinal surgery on a patient who weighs over 400 pounds could be considered malpractice.)
Burnout among health care workers, especially doctors, is an increasingly dangerous trend, pure and simple. There are high rates of suicide, depression, doctors exiting the profession, and many more factors involved with our chaotic and complex health system. But I think we all "get it." Burnout may be the result of the lack of ideal patients. That said, a patient is a patient - we can't make them "ideal," and as "Dr. K." failed miserably at, we need to treat them all with an equal level of respect and expertise.
In part two of this article, I'll focus on the positive use of cynicism, the deeper causes of burnout, and where chiropractors show up in the mix.
