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Left Turns


 

Balance—that unrelenting chemistry project necessary to maintain our sanity. In its simplest form, balance means achieving harmony in work and life, job and home, career and family. However, as we move along the life continuum this straightforward linear equation can take on second, third, seemingly infinite dimensions.

Children need raising, marriages need cultivation, friendships need nurturing, lawns need mowing, books need reading, waistlines need shrinking, charities need volunteering, extended family need visiting, dogs need walking, minds need relaxing, beds need sleeping in, and so on and so forth.

Add to this concoction a full-time hospitalist job with its clinical demands, night shifts, long stretches of days, administrative or scholarly duties, and patients’ emotional needs and you have a volatile cauldron that’s nearly impossible to keep from boiling over.

Thus, the need to maintain perspective, keep even, and stay in balance. We all have our own means to maintain balance and methods to measure if we are in or out of it. For me, it all comes down to left turns.

I moved to Denver in the mid-’90s to do my residency in internal medicine. Prior to that, balance wasn’t something I thought much about. Certainly there were times when the work-life continuum strayed too far toward the former—especially during the doldrums of medical school. However, it wasn’t until residency that I began to feel the true equilibrium tug-of-war.

At the time, I wasn’t juggling nearly as many balls as I am now, but nonetheless it was easy to become discombobulated. With limitless work hours, every fourth night call with 36-plus-hour shifts, morning report preparations, and the occasional harrowing attending rounds, finding ways to let off steam became paramount. I had moved to Colorado partly to enjoy its natural bounty. With the foothills a mere 30 minutes away and the high country within an hour’s drive, I frequently recharged by heading west for a hike, snow shoe, or cross country ski. Driving north from my house in central Denver you quickly come to Interstate 70, which traverses the state of Colorado, east to west. For me, I-70 is more than just a means of transportation; it is the scale upon which I measure my life’s balance. A trip east takes me to the airport and the hospital at which I work. A trip west takes me to the mountains. Right turn = travel, work, stress. Left turn = recreation, exercise, relaxation. Reflecting on my ratio of right to left turns is a simple and sure means to gauge my level of balance.

Maintaining enough left turns is one of the key issues facing the field of hospital medicine. As a young, exciting, and rapidly growing field it’s easy to become overwhelmed in our jobs. For most of us, our first hospitalist jobs felt comfortable: basically residency with less hours and more pay. However, as it turns out, the hospitalist job’s similarity to residency is one of the biggest hurdles we face.

Studies of internal medicine residency programs have revealed that up to three-quarters of residents are burned out.1,2 This doesn’t bode well for a field that strongly recruits from this burned-out pool of applicants and shares many of the structural elements that make residents so prone to burn out. The common causes of burnout—extended workloads, limited autonomy and control over one’s work-life, ambiguous employer expectations, deficient support systems, lack of stability and predictability—are mainstays of many hospitalist systems.

The only study to systematically evaluate hospitalist burnout found 13% of hospitalists were burned out with an additional 25% at risk for burnout.3 While this is a noteworthy improvement over the residency rates, it is likely the rate has risen significantly since the study was completed in 1999. Even if it hasn’t, it’s concerning to build a hospitalist group (let alone an entire field) with about 40% of its base nearing or completely burned out. Burnout is associated with employee turnover, reduced individual and group morale, and—quite possibly—worse patient outcomes.

As such, it is incumbent upon hospitalists and hospitalist group leaders to promote healthy work environments. In most cases, this doesn’t mean making changes to reinvigorate a burned-out employee (although this may be necessary). Rather, it involves targeting the larger organizational structure to mitigate the factors that promote burnout in the first place.

A successful group must provide individuals control over its work environment to help offset the hefty demands the job levies on hospitalists. Individual hospitalists should have a voice in the group’s decision-making and scheduling process. This encourages ownership in the group’s future; ownership is inversely associated with burnout. Further, attempts should be made to reduce the unpredictability of the job as much as possible. This should include setting and maintaining clear expectations, having back-up systems to deal with unexpected spikes in volume or an ill colleague, and placing hard caps on the number of encounters per day. Finally, a group should strive to provide hospitalists with flexible scheduling so that, when necessary, they can care for a child or a sick relative, limit the number of consecutive shifts worked and ensure adequate time away from work.

Which brings us back to balance.

It ultimately falls to each of us to ensure that we remain on kilter. As the summer draws to a close, take a quick biopsy of your level of balance. If you’re a bit out of whack, make an effort to realign. Take some extra time with your kids, spend a night alone with your spouse, go to bed early and read by yourself. Take a left turn. TH

Dr. Glasheen is associate professor of medicine at the University of Colorado, Denver, where he serves as director of the Hospital Medicine Program and the Hospitalist Training Program, and as associate program director of the Internal Medicine Residency Program.

References

  1. Gopal R, Glasheen JJ, Miyoshi T, Prochazka AV. Burnout and internal medicine resident work-hour restrictions. Arch Intern Med. 2005;165:2595-2600.
  2. Shanafelt TD, Bradley KA, Wipf JE, Back AL. Burnout and self-reported patient care in an internal medicine residency program. Arch Intern Med. 2002;136(5):358-67
  3. Hoff T, Whitcomb WF, Nelson JR. Thriving and surviving in a new medical career: the case of hospitalist physicians. J Health Soc Behav. 2002;43(1):72-91

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