Date November 16, 2023

Medicine@Brown: You’re Not Alone

Facing unprecedented levels of burnout, clinicians are working together to topple systems and reclaim the joy of a career in medicine.

“ I can’t do it anymore,” Tammie Chang ’03 MD’07 thought to herself, over and over, one night in 2019. For months, the pediatric hematologist/oncologist in Tacoma, WA, had endured short staffing, record numbers of patients, and sleep deprivation; now, as she was driving home, after a long end-of-life discussion with a patient’s family, she couldn’t imagine ever going back to work. She nearly steered her car over a cliff.

Around the same time, Chang’s old PLME friend Luisa Duran ’03 MD’08, an endocrinologist in the Bay Area, was feeling isolated and exhausted. She was seeing more than 20 patients a day, had three small children at home, and only one older, male colleague who couldn’t relate. Just five years out of fellowship, “I was looking actively for a job outside of clinical medicine, this career that I felt called to as a kid,” Duran says.

After a conference in Seattle a few months later, Duran got together with Chang before her flight home. Though they hadn’t seen each other in years, they immediately rekindled their friendship. “We felt that trust and safety to openly share with each other,” Duran says. Months after Chang’s near-suicide, Duran was the first person she told.

They knew other physicians were suffering from burnout, and not getting help. They wanted to change that. Within months, Chang and Duran cofounded Pink Coat, MD, to promote women physicians’ success and well-being, and keep them in the field. “We want to bring back joy to medicine and not lose physicians to burnout,” Duran says.

Countless American physicians have struggled with burnout over the decades; in a recent survey one in five said they plan to leave their practice within two years, while tens of thousands more have already left. Hundreds of academic papers have sought to define burnout, quantify it, offer solutions, and test them. Yet it remained “a dirty secret in health care,” Chang says. It took a worldwide pandemic, and one physician’s suicide, to finally get everyone talking about it.

Lorna Breen, MD, took her life in April 2020, after weeks of nonstop work and worry (and contracting COVID herself ) in a New York City emergency room. She had no prior history of mental illness, but fear that she could lose her medical license or hospital credentials if she sought mental health care prevented her from getting help. She was one of an estimated 400 physicians who died by suicide that year, and every year. In Breen’s memory, and in recognition of the incredible stress and sacrifice so many health care workers have endured, President Joe Biden signed into law the Dr. Lorna Breen Health Care Provider Protection Act, which provides federal funding to address burnout, substance use disorders, and suicide.

“Lorna Breen was not the first physician to kill herself because of how stressful and challenging this work can be, and she certainly wasn’t the only person who killed herself as a result of the pandemic,” says Scott Pasichow RES’19 F’20, MD, MPH, an emergency medicine physician and mental health advocate. “But she was the one that was able to galvanize a movement and get a law passed to try to help address this. And I’m glad that her death was able to be honored in that way and that it will help prevent others.”

Chang adds: “One of the silver linings of the pandemic is that it really exacerbated all the issues that were already existing and have been around for over 20 years, and brought them to the forefront. And now there is a movement … of really passionate people that’s growing.”

Fix the Doctor or Fix The System?

One day during his second year of emergency medicine residency at Brown, Pasichow arrived at work to learn a patient he’d admitted the night before had died. A longtime EMT before going into medicine, he’d had patients die before. But for some reason this one pushed him over an edge he didn’t realize he’d been on; he knows now he’d been ignoring warning signs of burnout for months. After his shift, he intentionally mangled a traffic cone with his car. “I was like, OK, this is too much,” he recalls. Yet he initially resisted going to a therapist, fearing what his program would think and how it would affect his medical license.

Duran says she and Chang both, at first, blamed themselves for how they felt. “We thought we were the problem. Clearly, we didn’t get trained well enough,” Duran remembers thinking. But when she began researching burnout, she learned that systemic factors were the problem—and they especially impact women physicians, who report considerably higher rates of burnout than their male counterparts (63 percent vs. 48 percent); 40 percent consider quitting medicine within just six years of finishing training. “We don’t have systems that support our well-being,” Duran says.

While personal resiliency is important we’re not telling the full story if we don’t include the systemic kinds of things that are happening.

But it’s incumbent upon systems to do so, because “burnout is fundamentally a work phenomenon,” says Kelly Holder, PhD, the chief wellness officer for the Division of Biology and Medicine at Brown. Yet much of the wellness advice offered by employers to combat burnout—exercise, meditate, eat better, sleep more—places the onus on employees to solve their personal problem (usually on their own time). “While personal resiliency is important,” Holder says, “we’re not telling the full story if we don’t include the systemic kinds of things that are happening.”

There are many, many causes of burnout for physicians, and they differ by workplace and by specialty, but increased workloads and responsibilities, coupled with declining resources and autonomy, are considered near-universal stressors. Women physicians and doctors from underrepresented or marginalized groups suffer higher rates of burnout. “It’s hard to be well in a system where you’re being systematically oppressed because of an identity,” Holder says. Her work shares close ties with diversity, equity, and inclusion efforts, she adds: “We’re not going to be able to do our best work if folks are uninvited to the table, or don’t feel like
they belong.”

At Brown, Holder’s first order of business is to understand the Division, and each area’s challenges, before devising system-wide solutions. “If we just go and change something”—EHR management, scheduling, policies and procedures—“we’ll invariably create some other kinds of problems,” she says. Since last summer, Holder has been meeting with the Division’s departments and offices and is creating wellness focus groups open to students, trainees, faculty, and staff to identify sources of burnout. “No matter what we find,” she adds, “we know that access to mental health treatment is paramount.”

So is reducing the stigma among physicians around mental health care. Pasichow received support and understanding from his residency program when he finally asked for help, and therapy didn’t affect
his licensure. Now an assistant professor of emergency medicine at Rutgers New Jersey Medical School and the assistant medical director for University Hospital EMS, he’s never had to answer questions about his mental health history. But many state licensing boards and employers still ask, and 40 percent of physicians report that they wouldn’t seek care because of such questions.

In addition to advocating to remove mental health questions from all states’ licensing and credentialing applications, Pasichow wrote about his burnout experience in a 2021 essay for ACEP Now. As the publication date approached, “I was terrified,” he says. The response was nothing but positive, with some people telling him, “I actually started going to therapy because of your article.” Now he regularly shares his story with colleagues and trainees, and points them to resources. “Being honest and vulnerable creates a lot of buy-in,” he says.

Chang went public with her story as well. In a TEDx Talk last year she told the audience, “Asking for help never even occurred to me, because as doctors, we don’t do that.” Like Pasichow, she believes coming forward about her struggles and the care she ultimately received will help reduce stigma—and deaths. “There’s one in five physicians who’ve had a thought like mine,” Chang says.

Upfront Investment

Physician burnout is too costly a problem to ignore. Burnt out doctors are often less productive and make more mistakes, which means higher risk for patient dissatisfaction, malpractice, and damage to a practice’s reputation. It’s also expensive if a physician leaves: the AMA estimates that, depending on specialty and rank, it can cost from $500,000 to $1 million to replace a doctor—two to three times the salary of the person who left.

“We recognized early on that this is the cost of doing good business,” says Kenneth Lynch Jr., PhD, APRN, the director for surgical education for Brown’s general surgery residency program. His department, concerned by high burnout rates in surgery, established its wellness program in 2018; in response to feedback, it has grown over the years to include a wellness coach, a robust curriculum for faculty and trainees, and structured mentoring. The investment’s paid off, in the form of recruitment and more diverse intern classes. “It’s not OK that people have these feelings of not wanting to be in health care anymore, or change careers or just going home stressed,” Lynch says.

For other departments, COVID was a wakeup call, as physicians quit in droves. “We lost a meaningful number of faculty,” says Lauren Allister ’97, MD, a pediatric emergency medicine physician who became Brown Emergency Medicine’s director of wellness last year. The practice reduced her clinical hours so she could take on the role and, hopefully, change the culture that was driving people away. “Investing up front is going to be a huge payoff and allow us to avoid the tremendous cost of attrition,” she says.

Assistant Professor of Medicine Stephanie Catanese RES’14, MD, initially focused her wellness work on her area of general internal medicine, but quickly realized she’d have more impact at the department level. “It’s really important to have someone whose focus is on physician well-being at the table when big decisions are made,” she told her chair, who agreed. Catanese now leads the Department of Medicine’s Committee for Physician Wellbeing, and is offering physician coaching while trying to tackle issues related to workflow, schedules, and inclusivity. But in such a large and sprawling department, there’s no one cause of burnout—and “there’s no one answer,” she says.

Holder, who became BioMed’s chief wellness officer last year (she arrived at Brown in 2021, as CWO for the Medical School—see sidebar, page 33), meets regularly with a group of wellness leaders at the hospitals, including Allister and Catanese, to collaborate and coordinate their work. “If we [work]in silos, we’re not really going to move the cultural needle very much,” Allister says. The group is now planning a 2024 wellness symposium, where they can share ideas more broadly.

Last year Dean Mukesh K. Jain, MD, named wellness a core priority for the entire Division, not just people with “wellness” in their title. Chang, who in 2021 became the medical director of provider wellness for MultiCare Health System in Tacoma, says that’s the right approach. “Wellness-centered leadership … is putting the individual’s well-being first, and that means every leader in any system knows that it’s their job to take care of their people,” she says.

That said, having someone to oversee wellness efforts, and ensure they reach everyone in the organization, is essential. Chang predicts it will take many years for every health system to create a role like hers or Holder’s, but finds a comforting analogy in the decades-long quality and safety movement; now every hospital has a chief quality officer. “I hope during our lifetime [a CWO]will just be the standard,” she says.

A Place For The Arts

Many wellness leaders speak of the need for a cultural shift in medicine: around bureaucracy and scheduling, around work-life balance, around mental health most of all. While Allister is addressing these intrinsic issues, “there’s this other, much more ephemeral element,” she says. “What does it mean to be well? What does it mean to be better?”

She’s partnering with writer and Professor of Emergency Medicine Jay Baruch, MD, to bring small groups of faculty and residents to the RISD Museum to view and discuss works of art. For people who instinctively compartmentalize difficult emotions, this is not easy. “They’ve worked so hard to create that compartment, which is the survival skill, but it borders on the maladaptive,” Allister says. A chaotic abstract painting, which even she didn’t like, evoked visceral reactions to the disorder. “It was a discussion about art, but we could all tell that we were also talking about work,” she says.

As an essayist, Baruch regularly reflects on his feelings around medicine. During the COVID surge of early 2021, he pretended to write a resignation letter to see how it would make him feel; the exercise revealed, to his surprise, a host of reasons to stay.

In emergency medicine, Baruch says, “we have all these different emotions that we’re feeling, and often we don’t have time to process them.” The arts—like the RISD programs, or the writing workshops he leads—present a safe, nonjudgmental opportunity for colleagues to grapple together with complexity and messiness. “People share stories they never would have shared otherwise,” he says.

“Connection is the antidote to burnout,” says Mariah Stump RES’15, MD, MPH, an assistant professor of medicine who leads narrative medicine and writing workshops for the American College of Physicians. Writing can “give you a sense of control over your own thoughts,” she says, while the workshops themselves support “inclusion and a sense of belonging.”

Self-compassion goes hand-in-hand with connection. “We just keep beating ourselves up,” says Stump, a primary care physician. But “we are set up to fail in this health care system.” Being kind to yourself means “giving yourself the grace of saying, this job is really hard, and I’m actually doing the best I can; knowing that I’m not alone, that other physicians are struggling too.”

Narrative medicine won’t solve her profession’s problems, Stump acknowledges; she’s working on that as chair of the Rhode Island Department of Health’s Primary Care Physician Advisory Committee. But by heightening doctors’ listening and observation skills, narrative medicine can make too-short patient appointments more meaningful. “Rather than … turn our attention to the computer, we turn our attention to the patient and say, what’s going on, and actually listen and get to the root of the problem.”

The 15-Minute Atrocity

With relatively low pay, high administrative burdens, and absurdly short patient visits, primary care has become a “revolving door,” Catanese says. Already, most communities contend with a shortage of primary care providers, and it’s only expected to grow. One small change she’s made at her practice is “desktop time,” an unscheduled slot in each physician’s workweek where they can catch up on paperwork, phone calls, or other administrative tasks—so they don’t have to bring work home. “It looks like it doesn’t actually affect productivity or your bottom line,” Catanese adds.

But it’s a drop in the bucket. “Fifteen-minute visits are an atrocity,” Catanese says. “The reason I went into this was to cultivate [patient]relationships, to have that rapport.”

Last year, researchers reported in the Journal of General Internal Medicine that primary care providers following recommended guidelines would need nearly 27 hours each day to properly care for their patients. The finding gives Lauren Hedde RES’14, DO, “chills.”

The goal is happy satisfied physicians, because if we lose that, we’re just doing what everybody else is doing.

“I’ve seen my colleagues wonder, what am I doing wrong?” says Hedde, a family medicine physician in East Greenwich, RI. “Most physicians have a strong moral compass and want to do the right thing. … So it’s the perfect population of people to be squeezed to the max.”

During residency at Memorial Hospital, Hedde and Mark Turshen RES’15, MD, became so disillusioned by the churn of patients and crush of bureaucracy that they decided to start their own practice, Direct Doctors (see Brown Medicine, Spring 2018). They offer direct primary care, which charges patients a flat monthly fee for unlimited access to their physician, and doesn’t take insurance. With no office staff, they need fewer patient appointments to turn a profit—at most eight per day, which can last up to an hour each.

“A physical at a traditional practice would be 20 to 30 minutes, which I spend the first 30 minutes of the physical just talking,” Turshen says. “I don’t even know how you’d properly get through everything.
And the answer is, a, you don’t, or b, they have to come back and then people are lost to follow up.”

In addition to spending the time they need with their patients, the physicians at Direct Doctors (there are five now, all graduates of Brown’s family medicine residency program) enjoy a level of flexibility and autonomy that would be alien to many of their peers. They decide what days they’ll be in the office, take parental leave and vacations, and “never miss one thing for our children at school,” Hedde says. And while they are technically on call 24/7, Turshen says patients respect their boundaries. “I think when people have a really deep relationship with a physician, they really are more cognizant of not bothering you off hours, unless it’s really important,” he says.

Hedde says they are often “pinching themselves” that they’ve achieved such great work-life balance in a difficult field. “The goal is always happy, satisfied patients, happy, satisfied physicians,” she says. “Because if we lose that, we’re just doing what everybody else is doing.”

The Front Lines of Change

Professor of Family Medicine Jeffrey Borkan, MD, PhD, says while the Medical School didn’t establish its Primary Care-Population Medicine Program in 2015 with burnout in mind, “it’s precisely the kind of systems issue that we anticipate students will take on and work to solve.”

The program includes coursework on the US health care system, scholarly and advocacy work, leadership training, and a longitudinal clerkship that embeds students in an outpatient practice throughout third year so they can truly understand its day-to-day operations, and the system’s flaws. By the time they graduate, says Borkan, the program’s assistant dean, they “don’t just know the system but know how to make changes in the system.”

Even without such big-picture training, today’s medical students know the system is broken, and their risk of burnout. When applying for residency, they look for programs that will take care of them, Lynch says. And once they join his department, they’re empowered, he adds: “They will speak up if they feel like there is something missing from their support system or the curriculum.”

Allister says for many young physicians, medicine is no longer a calling, no longer worth sacrificing one’s well-being. “I don’t necessarily think that’s a bad thing, but we still then have to think about, well, how do we get people to want to do this job?” she says. “We have the potential to be on the front lines of helping to change the culture of medicine.” Chang calls today’s physician wellness leaders “the transition team,” who may not get to fully enjoy the fruits of their labor, but will inspire the next generation to carry it forward. “They’re the ones who are going to really change it,” she says.

For Pasichow, prioritizing his wellbeing has allowed him to balance a fulfilling career in health care, education, and advocacy with plenty of time for his family and himself. He’s learning to cook, reading fiction, and being the father he wants to be for his two children, ages 6 and 1. “Being able to take time to turn off everything else and just focus on what my daughter’s imaginative play is at that moment and what dinosaur I’m supposed to be,” he says, “it’s everything to her right now.”


Taking Care of Future Caregivers

More than half of medical students report symptoms of burnout. That rate is even higher for students who are underrepresented in medicine or from other marginalized groups. (A 2021 study in JAMA Network Open, led by Elizabeth Samuels RES’16, MD, MPH, MHS, reported that students who identify as lesbian, gay, or bisexual are more likely than their heterosexual peers to experience burnout.)

Today’s medical students know the risk, thanks to social media, news coverage, and doctors themselves. “Older physicians try to warn us about burnout … and even tell us not to become doctors because of the bureaucracy,” Sonja Kapadia MD’26 said in May, which was Mental Health Awareness Month.

Kapadia had just finished a yoga class on the rooftop of the Medical School taught by Assistant Professor of Medicine Mariah Stump RES’15, MD, MPH, who also led the students in a self-compassion meditation and encouraged them to set boundaries. “You can’t care for others until you take care of yourself,” Stump said.

Cultivating good wellness habits among medical students is an important first step toward building a more resilient physician workforce, says Chief Wellness Officer Kelly Holder, PhD, who organized (and participated in) the yoga class. “In order to sustain a medical career over the long term and give their best to their patients, it’s critical they figure out what they need to stay healthy and happy,” she says. If students carry this practice into residency and beyond, “we can aid with improving the culture of wellness in medicine.”

Since arriving at Brown in 2021, Holder has instituted “well checks” for first-year students—20-minute appointments where they meet with Holder, talk about how they’re doing, and get referrals for resources—and regular wellness programming for all students. She sits on committees to advise on policies that affect students’ well-being, and meets with third-years to find out what issues in their clerkship rotations she might help address.

One major change last year turned out to be a pioneering one. Prompted by student advocacy and with the support of administration and clerkship directors, preclinical students can now take one day off, no questions asked, each semester; third-year students get one such day each rotation. In June, the AMA House of Delegates seemingly followed Brown’s lead: because compelling students to explain their absences could deter some from seeking mental health care, it required every medical school to better define time-off rules and encouraged them to allow days off without explanation.

“I think that it’s a really good policy,” Holder says. “We don’t have to play catch-up with that.”

Holder also organized the Medical School’s first suicide prevention conference last month, focusing on suicide in health care and science. While burnout and depression share symptoms, they are not the same—but burnout can exacerbate underlying mental health conditions, and if left untreated can heighten some individuals’ risk for suicide. This reinforces the imperative to provide confidential mental health services, and reduce associated stigma.

“Burnout has to be linked hand-in-hand with mental health and mental well-being,” says Alaa Elnajjar, MD, MSc, a clinical assistant professor of psychiatry and human behavior. Earlier this year she piloted Buddies Space, a digital platform for physicians that offers peer support and access to mental health resources. In virtual meetings during the pilot, she focused on dispelling myths about and destigmatizing therapy.

“We lose around 300 doctors every year to suicide,” Elnajjar says. “We’ve got to make treatment accessible and stigma free, because if we punish people for being mentally ill, then we are really far away from getting a healthier community.”

Reprinted from Medicine@Brown.