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The Healthy Hospitalist


 

Hospital medicine often is regarded as a young person’s field. Because the specialty is so new, most hospitalists are young, bright-eyed, energetic, and seemingly invincible. But how will they feel after they have logged thousands of miles down hospital corridors, eaten hundreds of late-night fast-food dinners, and spent countless hours worrying about their patients?

How this generation of hospitalists takes care of itself may determine if the practice can be a healthy, sustaining career throughout a lifetime.

Michael Ruhlen, MD, MHCM, FAAP, who spent 18 years as a hospitalist before his declining health forced him into an administrative position, hopes young hospitalists don’t end up with the health problems he has experienced. Dr. Ruhlen, vice president of medical affairs at Toledo Children’s Hospital in Ohio, offers a cautionary tale illustrating the need for physicians to take care of themselves so they can have a long and fulfilling career in their chosen specialty.

A self-proclaimed stress eater, Dr. Ruhlen gradually gained weight over the years, mainly because of late dinners grabbed at fast-food restaurants—the only ones open when he finished night duties. The caffeine he consumed to keep up with his demanding schedule increased his blood pressure so much that he ended up in the cardiac cath lab with chest pains. The extra weight and miles of hospital halls he walked put additional stress on his joints, aggravated his arthritis, and led to sleep apnea.

“When you are young it’s easy to burn off the extra calories from stress eating,” he says. “But as you age, you find it harder and harder to keep your weight stable, especially when your cholesterol starts going up. Your joints get sore when you walk the halls for 24 hours straight, and shift work can produce sleep apnea and other stress-related sleep problems. Sleep apnea leads to hypertension. I pushed myself for the benefit of my practice and my patients. As an older hospitalist looking back, I can say that I didn’t stop enough to smell the roses.”

SOUND SOLUTIONS

Hospitalists can stay in shape by following the advice many give their patients:

  1. Have a personal physician you see regularly and get all the appropriate screening exams. “It’s amazing how many physicians don’t have their own doctors and how long they go between physicals,” Dr. Gunderman says. This leads to the ill-advised practice of self-diagnosis and self-treatment.
  2. Follow a healthy diet. You know the drill: lots of fruits and vegetables, whole grains, and water. Avoid fat, sodium, and sugar. Insist that healthy food be available in the hospital 24 hours a day, Dr. Gunderman recommends. If healthy food isn’t available at night, bring your own.
  3. Exercise. “Walking the halls doesn’t have many cardiovascular benefits, although it makes you tired,” Dr. Ruhlen says. Doctors should urge hospitals to provide a workout area where the entire medical staff can exercise. Dr. Gunderman also recommends taking the stairs instead of the elevator to work off stress hormones.
  4. Wear good supporting shoes to limit the wear and tear on joints.
  5. Get enough rest. Take short breaks during the workday to refresh and recharge. Take naps during a long shift. Perhaps more importantly, nap after a long shift before you drive home. “Sooner or later we’re going to hear about a hospitalist who died driving home after being up all night,” Dr. Ruhlen says. Studies have shown that sleep deprivation for 16 to 18 hours makes people perform no better than someone who is legally drunk.
  6. Insist on well-scheduled shift work. The U.S. Occupational Safety and Health Administration and the U.S. Coast Guard have developed recommendations that minimize the disruption of circadian rhythms in people who work at different times of the day and night. Rotating shifts clockwise has been shown to allow workers to approach healthy norms, for example.
  7. Balance your life with enjoyable leisure activities, meaningful relationships with other people, hobbies, and recreation. “Don’t be too busy making a living that you fail to make a life,” Dr. Ruhlen warns.
  8. Have control over what you do. Speak up so that there are enough people scheduled to handle the work in your hospital. Find things in your work that satisfy you.
  9. Get help for any abuse issue. “No substance is worth abusing, including food,” Dr. Ruhlen says. “Physicians get so caught up in being invincible that they don’t take advantage of the help that’s out there,” he warns.
  10. Act in solidarity with other physicians to improve the practice of medicine, Dr. Gunderman urges. “With a physician shortage predicted to hit 30 percent by 2020, physicians need to act now to assure that there will be enough doctors to take care of the sick in the future.”
  11. Make sure that you’re rewarded by the work that you do. “If you’re not rewarded by the work that you do, get out of the field,” Dr. Ruhlen says. Look for things within your practice that are satisfying to you.
  12. Don’t work too many hours. The Institute of Medicine in Washington, D.C., recommends nurses not work longer than 12 hours during a 24-hour period or more than 60 hours per week. Physicians can follow the same guidelines.

Stigma Persists

Dr. Ruhlen is courageous to openly discuss his health problems. An international study by the British Medical Association in 2007 found many doctors who are sick do not seek help because of the stigma of ill health or because of peer pressure. “This stigma attached to ill health reinforces the perception that ill health is akin to inadequate performance and unacceptable conduct,” according to the report. These beliefs lead many physicians to work through illness and self-treat.

Another danger as hospitalists take on more and more patient care and co-management is overwork. A case in point is the harrowing story from one hospitalist who shared his insights on condition of anonymity.

“I suffered from a multiyear bout of workaholism,” he says. “I used to laugh about it when initially diagnosed thinking, ‘How could this be a bad thing?’ As time went by I realized it follows the same stages of nearly every other addiction—and the consequences can be just as devastating. I lost 90% of my friends. At one point I was within days of losing my wife and family. My overall work performance significantly worsened despite increasing time devoted to work. My patient satisfaction scores dropped.”

The load also took a physical toll.

“My personal health deteriorated as I stopped making time for the gym and moved from a healthy diet to a quick-carb/junk-food diet. Work became my drug, and like all drug abusers—I suffered a great deal. During my second year as a hospitalist I developed hyperthyroidism. I’m embarrassed to admit how far it progressed before I made the diagnosis.”

Initially, the symptoms are positive ones, this hospitalist notes.

“I could get by on less sleep, always had bundles of energy, could dictate three times faster than anyone around me, and could eat anything and everything in sight and still lose weight,” he recalls. “My daily hospital rounds that typically take eight to 10 hours were often completed in four to six hours. Then came the sweating … followed by the tremors, which is not very conducive to performing delicate procedures such as inserting central venous catheters. The palpitations and eventual chest pains came next and prompted me to seek care.”

This hospitalist has since found a healthy balance—but it took hard work.

“Once I accepted that I had a work addiction, I began setting boundaries and had my wife remind me (which she needed to do often at first) when I was pushing the bounds,” he explains. “Over time I was able to resume a more balanced life.”

Having overcome his work addiction, he finds the signs easy to spot among his peers.

“Workaholics (unless you work under them) often look like super heroes,” he notes. “They say yes to every assignment. They always put 120% in. They are often the go-to person. On the rare occasion I do identify it in a colleague, I’ll let them know. I’ll tell them what it did to me and my family. Sometimes they listen—usually they’re too busy working to listen.”

A Hard Life

While hospitalists experience the same unhealthy stresses as other physicians, they may face unique demands caused by their chosen specialty.

“Hospitalists are at the forefront of an evolving new specialty,” Dr. Ruhlen says. “In order to create satisfaction with the specialty and help it evolve, you’re willing to extend yourself above and beyond what others in different fields might be doing. So you take the extra shifts when you don’t quite have enough people in your group. You get up early and go to meetings to promote your practice within the hospital. And maybe you stay up later at night than you ordinarily would have because you want to make sure you absolutely provide the best care.”

All this, of course, takes a toll at home.

“You slight personal relationships and outside interests, which adds to the stress in your life,” Dr. Ruhlen says. “Every time you miss a birthday party or a family activity you’re digging yourself deeper into an unsatisfying family life and giving up things that help you to relax and be healthy.”

Hospitalists also have more to juggle these days because they need to know a lot about both human beings and machines, says Richard Gunderman, MD, PhD, MPH, who speaks internationally on doctors’ health and its role in sustaining a medical career. Dr. Gunderman is associate professor of radiology, pediatrics, medical education, philosophy, liberal arts, and philanthropy at Indiana University Medical School in Indianapolis.

He is passionate about the need for physicians to take care of themselves because “we spend so much time focused on the needs of our patients that we often don’t pay attention to our own health. We spend millions of dollars on the latest equipment but we spend almost no time thinking about our most important resource—our people.”

Another contributor to ill health among hospitalists is exposure to more infections and serious illnesses in the hospital setting. “At the same time they are asked to take care of the sickest people, which puts them under more stress,” Dr. Gunderman observes. “We have new information on the role high levels of stress hormones (catecholamines) play in metabolism and the breaking down and tearing of muscle tissue which can make hospitalists more prone to injuries.”

Dr. Gunderman believes getting to know patients is one of the most fulfilling aspects of being a physician and a stress reliever. Hospitalists may miss out on developing long-term relationships with their patients because of the nature of their jobs, he points out. They also are pressured by financial concerns to minimize the time patients spend in the hospital, which does not promote developing relationships with patients.

As for Dr. Ruhlen, he struggles to follow his own advice. He doesn’t stay up all night anymore. He’s trying to get back into a regular exercise routine and eat healthier. He has a strong relationship with his wife, which keeps him grounded. He also enjoys golfing, spends time with his granddaughter, has taken up photography, and is traveling a little.

Although he still works many hours at the hospital, he is convinced that making time to take care of himself is the answer to a long, healthy career. TH

Barbara Dillard is a medical journalist based in Chicago.

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