Physician behavior is important, and much can be dependent on it. (see Don’t Lose Your Cool). But often times the feedback given regarding a physician’s behavior is that it isn’t good, and a director is left trying to sort out what the root cause might be. Is it burnout? is it a psychiatric illness? Is it substance abuse?
It is difficult to differentiate anxiety from burnout in physicians. Both conditions lead the physician to have a very negative outlook of their practice and effect the physician-patient interaction. They also cause the physician to make negative assumptions when frustrated and to consider alternative employment due to job dissatisfaction. However, burnout improves with time off and less hours. It also is eased by process improvement and better system design (workflow). Anxiety due to self-confidence and competency can manifest at any time, but is more common in younger or newer attending physicians as they enter practice for the first time after residency. This kind of anxiety may actually improve with time as the physician’s experience grows. Generalized anxiety however, will move beyond the workspace into other aspects of the physician’s life and is unlikely to improve without treatment.
So how do you differentiate causes? Meeting with the physician in question is essential and should occur early. Do not put off the meeting hoping the problem will simply go away. Waiting will only allow more time to pass and more damage to be done to the physician’s reputation. However, be prepared with some information showing you have done a little investigation. Expect to answer questions like: Who is complaining about the physician’s behavior? Do these same complaints occur for other partners? Is there an unusual frequency of these complaints? Also, be sure to approach the physician from the point of concern for their well being. Physicians are difficult to recruit, take lengthy periods of time to acclimate and develop their own practice, and generally spend long periods of time with a practice they love and appreciate. So, be sure the physician in question knows that you value them and want to see them succeed and that you are ultimately there to help with their longevity in the practice. Also be sure they know you are not making accusation or pandering to the whims of a supervising administrator (a common retort from physicians who have their behavior questioned)
Once that is out of the way, ask some difficult questions:
Is the doctor young/new? Do they have concerns about their own performance? Most physicians will not openly admit this, but asking open ended questions like these will get the conversation started:
- How do you think you are doing?
- Have you had any surprises? Unusual medical cases or outcomes? difficult adjustments? Or difficult encounters with other physicians or staff?
Are they negative all the time? Even when away from work ? How are things at home? (Anxiety)
Do they have a history of anxiety? Formally diagnosed ? Currently being treated? Physicians are exposed to tremendous stress in many ways including internal feelings of responsibility for the patient’s well being. Even expected poor patient outcomes that are the natural progression of severe illness can weigh heavily on the shoulders of an involved physician.
Are they sleeping well ? Sleep disturbances are common due to schedule variations, night shifts, rapid cycling. Check to see if the physician has been making voluntary schedule swaps that are anti-circadian. Substance use is a common method of dealing with these issues. Is the physician regularly using caffeine, alcohol, or sleeping pills to compensate ?
Do they have someone to talk to ? Lack of an adequate forum to discuss stressors or problems is common because of over-exaggerated HIPAA concerns. We don’t need to be islands. There are appropriate places to discuss difficult cases and the emotional trauma we all experience in the ED.
Are they concerned about their medical knowledge or procedural skills ? This is also common in a new attending physician and can be combatted by adequate feedback. If there are legitimate concerns, simple observation will give you a better idea of the areas needing remediation. A multitude of conferences and educational courses are available to address all facets of our practice.
Hopefully this open conversation will demonstrate that you intend on being helpful and working toward a long term solution. As you discuss strategies for dealing with the problem, here is a short list of things to keep in mind. Though they are not absolutes, I have found them helpful.
- Rest makes burnout better. But if the problem is anxiety, long stretches away from work can actually worsen the problem.
- Time away can make confidence problems worse. Best approach in this case is observation, modeling and more work experience.
- Treating burnout with anti-anxiety meds doesn’t work.
- Treating burnout with confidence boosting or positive feedback doesn’t work
It is unfair to expect a rapid resolution to these issues. Long term treatment requires reassessments and typically encompasses occasional set backs. After all, we are dealing with human beings.