From the May 14, 2021 issue of the Transformational Times (Suicide prevention issue)
Coaching is Vital to Preventing Burnout in Physicians
Brett Linzer, MD
My internal medicine/pediatrics friend, Alex Djuricich, MD, killed himself a few years ago. He was one of my resident partners and eventually became the internal medicine/pediatrics program director at the Indiana University School of Medicine. He was a mentor to many internal medicine/pediatrics physicians and a father of two teenage daughters. When he died, I promised myself that I would do what I could to help other physicians...
It has taken me a long time but, with some of the work I am doing, I feel as though I am making good on that promise. I spent years trying to figure out why doctors hurt themselves. I am not sure if I have figured out much, but I have learned a lot along the way.
One of the most important things I have learned is that I do not have all the answers to my life. But I found a lot of the answers through coaching.
Why is coaching important?
The idea that we, as physicians, can figure everything out on our own and not rely on others to help us is, at best, a poor strategy for success and, at worst, a dangerous myth. Physicians are highly trained and skilled in certain areas but may lack mastery in relationships and communication. After residency, there is little emphasis on personal growth and especially emotional development. Coaching can bring wide-ranging benefits to any organization. Most experts agree the cost of replacing one physician, including lost revenue, can be around $1M. A well-coached physician is more likely to stay in their current position and, therefore, save the cost of recruiting a replacement. In addition, there is less physician burnout, improved mental health, more effective physician leadership, and more balanced and engaged physicians. When physicians are at their best, everyone wins.
The struggles hit close to home
During my training, I was no stranger to suicide. A medical school classmate killed himself. Then, an international graduate with two children and a family in China hanged himself during the second week of our internship. We all knew he was struggling but had not known what to do. We were treading water ourselves.
The next morning, the residency program director brought our group of ten interns into a room and talked to us. "This is bad,” he said. “We care about you. Here is the card for the psychologist. Call if you need help." I looked around the room at the other confused faces and honestly thought, what does he mean by “need help”? I said to myself, Look Brett, screw your head on straight. You are on call and have a busy service. You need to get back to work.
Two years later, my chief resident shot himself. I thought he had all the answers. He was a smart guy and had a desirable GI fellowship lined up. At the funeral, I went up to people I knew. Do you understand this? Can you explain this to me? Can you please tell me he had some label or diagnosis or something that I do not have? Chronic depression, alcohol abuse, or schizophrenia? Something? Anything? How do I know I am not next in line? There is always a line.
On average, one physician commits suicide every day in America. Every day!
But I was not next in line. Next in line was my friend Alex. He was considered by many to be the ideal internal medicine/pediatrics academic physician. I went to his wedding. He met his wife when she was a fellow intern with me and Alex was our resident. He had a family. He even looked like me. How are they different than me? How close was I to where they were? Look Brett, I said to myself. Screw your head on right. You have a lot of … wait … it is not working. You cannot figure it out. Who's next in line?
Then, one of my best friends and close partners left our organization. I had difficulty understanding why he left and felt the effects even more acutely when I had to absorb a number of his patients. This was the height of the opiate epidemic and some of the patients were very difficult. I did not know how to manage them well. In addition, I had an unmotivated, depressed medical assistant working with me and I did not know how to communicate with her. The triage nurse in our small clinic was not motivated to do her job. I was not comfortable with conflict, so I avoided her and did extra triage work. The clinic manager was too scared to confront the problems. The administration was well-meaning but not helpful.
I felt like I was playing a new game and I did not know how to play it well. I did not even know how to tell if I was successful. Press Ganey surveys did not do it for me.
About this time, Epic came online, and I struggled with efficiency. My wife had chronic debilitating migraines and we had three teenagers at home with no family support. I had extended family challenges. I was cut off from my emotions and I unknowingly built walls to contain them, not knowing I was cutting off my good emotions as well.
A turning point and finding help
In 2014, my survival skills were not serving me. Life was closing in. I was tired, frustrated, angry, irritable, confused, fearful, and more. I took care of depressed patients and I prescribed SSRIs for them. Would an SSRI help me? I did not even have a doctor. Maybe counseling would help, but I did not know where to turn. I did not have the time.
I was too scared. During one particularly rough patch, I asked myself if I was suicidal.
One night, I was sitting at home and finishing Epic charts. My wife handed me a card that said, "I think you need some help."
I looked at the card that suggested I contact Dike Drummond, MD from the burnout prevention program, www.TheHappyMD.com I said to her, “Don’t worry. I just need more time. I can figure this out on my own. I just need to work harder.” My wife had heard me say this before. She was losing patience and my words were not as convincing to me as they had been before.
I asked myself, “Am I depressed?”
I called Dike and set up a discovery session. This is a free one-hour “get to know you” session with the burnout counselor. At that point, I still did not trust him or anyone else. More than once, I almost cancelled the call. I thought, he does not know me. I am a very private, introverted person with my special problems.
The next week, I completed the call and was shocked to discover within twenty minutes that he could see right through my walls and defenses. He saw the scared kid behind the walls. He saw and knew my patterns of behavior and thought. He knew where that place was because he had been there. I broke down and agreed to work with him.
Dike explained that many of my patterns of behavior and emotion were not unique to me. There are patterns that are unique to physicians and emerge from our training. Many of these are survival adaptations. This stunned me and was so reassuring. He told me I was not broken. There were patterns I could learn about and then modify. Here are some of the typical patterns and misconceptions that Dr. Drummond described that physicians adopt that lead to burnout:
- If I just work harder, things will work out.
- I am a smart guy/girl, so I will figure it out.
- I need to do it all by myself.
- I do not want to deal with this difficult patient, nurse, etc.
- Compassion is important for other people but not for me.
- My emotions are not safe. I need to protect myself.
- I feel like an impostor.
My work with Dike centered around twice-a-month one-hour coaching calls where we worked on emotional and skill development. We started every call with five minutes of gratitude and appreciation. What would I like to congratulate myself for? What did I do right? This was actually hard for me because I was more in the habit of beating myself up for what I had done wrong. I could easily list all the negatives, but I had trouble seeing the positives.
After that, we would complete the work for the day. Some of the emotional work involved processing difficult emotions like shame, fear, anger. I realized I had a lot of shame. For example, we discussed:
- How to gain better access to my emotions and feelings. How to trust myself and others.
- How to have more self-compassion and more compassion for others.
- How to absorb positive feedback and not deflect it away.
- How to have a soft front and a strong back.
The area of skill development was wide-ranging. Communication skills were huge. I realized if I could be a better communicator, I could save a lot of time and prevent a lot of negative emotions. As I became better, I noticed how ninety-minute disagreements could turn into fifteen minutes. Three meetings could be one if I was more effective. Three-day arguments could be resolved in thirty minutes with deep listening and full presence. We did in-depth personality testing and self-awareness, and I learned how to interact with different personality types more effectively. I learned how to deal with difficult people like the nurses and patients. We did role-play and scripting.
I realized that as I took more responsibility for the interactions, I developed new skills and the nurses changed their behaviors. In the past, I had believed that my role was to give the right answers, but I learned it was more important to develop the art of asking the right questions. I discovered how to run an effective meeting. What is the goal? How do we know if we achieved the goal? Can we stop after thirty minutes and consider it a success if we reached our goal?
I mastered Epic documentation techniques, created succinct, appropriate notes, learned stress management breathing techniques, mastered time management and batching approaches, practiced delegation, adopted marriage skills, enhanced my communications, and made firm dates on the calendar. I had been transformed.
Emerging from the other side
Coaching has changed me. When physicians are at their best everyone wins. As physicians, we need to trust, ask for help, and be supported along the way. We need good leadership that makes coaching easily accessible, affordable, and encouraged. We could spend one-tenth the amount it takes to replace one physician and invest it in the few hundred we already have. It is critical to understand that coaching programs are not just for impaired or problem physicians. These approaches are for growth minded, striving physicians who want to improvetheir lives and the lives around them. Highly achieving people in many fields have coaches. Every sports superstar has a coach. Most high-level business leaders have coaches. Every coach I know has a coach of their own. And the people at the top - the ones who train the other coaches - have networks of support and growth systems around the country.
It starts with each of us
Here is what you can do. It all starts with you. Take care of yourself and trust that others may be able to help you. Realize that you may not have all the answers to your life. Reach out to others for connection and for mutual support. Consider coaching for yourselves.
Brett Linzer, MD, is board-certified in both internal medicine and pediatrics. He has been in practice with ProHealth Care for over twenty years. He has been a part of the Medical College of Wisconsin for 18 years as a preceptor and mentor to fourth-year students in his ambulatory clinic in Oconomowoc. He is the recipient of the Marvin Wagner Preceptor Award, ACP Wisconsin Community Physician and mentor award and the Milwaukee Academy of Medicine award for excellence in teaching. He can be reached at balinzer@phci.org
