Editor's Note: This is part 2 of a short series. "Cynicism, Burnout and the Search for the Ideal Patient" ran in the November issue.
Trying to achieve fulfillment as a doctor in today's health care environment is a "rigged game" and physicians are programmed to burn out. At least this is the opinion of Dike Drummond, MD, in his thehappymd.com blog. Cynicism and burnout among physicians are two of the hottest topics in medical periodicals these days. Much discussion addresses the recognition of burnout, the prevention of such, and treatment options for it.
In part 1 of this article, I discussed how "fighting back" against stressful patient interactions and administrative chaos necessitates that physicians have coping skills. Practiced tolerance, humor and downright cynicism are routinely used to prevent and survive the specter of burnout in their daily work. I also focused on how health care providers react to patients who have damaged their health with poor lifestyle choices or addictions. These patients have been identified as "self-abusers," and physicians commonly form cynical attitudes about the difficulty in offering them treatment.
In part 2, let's discuss how mild cynicism should just be considered healthy skepticism, how burnout is really an existential conundrum caused by competing forces – and finally, how chiropractors fit into the mix.
How to Use Cynicism for Good
Cynicism has been defined in medical literature as "an attitude of scornful or jaded negativity, especially a general distrust of the integrity or professed motives of others" (Becker, Boys in White; University of Chicago, 1961). I carefully define this in order to differentiate it from "skepticism", which is uncertainty, doubt or suspicion. Edwin Leap, MD, in Emergency Medicine News, March 2014, impressed me with his take on this subject. His opinion is that cynicism gets a bad name because we associate it with judgment and intolerance. And these days, "Who am I to judge?" can be an excuse for a crippled health care system. Dr. Leap reminds us, "We can't function that way. Judgment, discernment ... are critical to our work."
"The tool cynicism must be honed" he explains, "wielded by an experienced worker who understands its uses and its dangers. Cynicism requires an apprenticeship of sorts." I prefer to call this "clinical skepticism," meant to arrive at a reasonable diagnosis and appropriate treatment options.
Mapping the Road to Burnout
Every patient deserves a physician who uses "judgment and discernment." But it appears unbridled cynicism can be a gateway attitude to burnout. But what is burnout, really? It has often been defined as physical and emotional exhaustion, depersonalization and a reduced sense of purpose. The apparent "queen" of burnout research, Christina Maslach (the Maslach Burnout Inventory) defines it as "an erosion of the soul caused by a deterioration of one's values, dignity, spirit and will." Sobering.
In Dr. Drummond's blog, he outlines and discusses many of the causes of burnout. A primary factor is the administrative burden physicians face. One hour of face-to-face time with a patient results in two hours of electronic health record (EHR) charting. Mistakes in coding or documentation can evoke a financial penalty in light of a payer's audit. Fear, then, becomes a factor in treating patients.
Additionally, the tyranny of preauthorization by insurance companies for labs or procedures is often mentioned. Physicians see the process as stealing their authority, the clinical decision-making skills they have worked so hard to learn. As I said earlier, every patient deserves a physician who uses "discernment" – they can get a chance to use it.
All of this may lead to the cynical depths of "What's the use?" That said, an article by Talbot and Dean in the online STAT magazine (July 26, 2018) took a fresh take on burnout. They call it "moral injury" and state that the failure of doctors to meet patient's needs has a "profound impact on physician wellbeing." Doctors are expected to be tireless and resilient, but few anticipate how our broken health care system is going to negatively effect them.
The authors put it simply: Being a doctor is a "calling, rather than a career path." When the "system" regulates the time one can spend with a patient, controls referral pathways because of financial interests, and rates and reviews all aspects of a physician's life ... burnout may be inevitable.
The Chiropractic Experience
We chiropractors have not been forgotten in the study of burnout (although almost). Thankfully, Shawn Williams from CUNY York has written about emotional exhaustion and burnout among chiropractors since 2011. His studies can be found in the Journal of Chiropractic Humanities, and more recently Chiropractic and Manual Therapies (2016).
He agrees that DCs experience most of the known stress factors in practice, but have unique stressors of their own: increasing market competition (both internally and externally), a high prevalence of work-related injuries, and a high student-loan default rate. But above all these, Williams identifies the lack of cultural authority and internal consensus in the profession as the most reported stressor revealed by participants in her research.
Now that's something to mull over. "Poor public perception inconsistencies," she calls it. Can it be true that the No. 1 factor leading to burnout in chiropractic is our lack of a clear place in society?
