ARTICLE IN BRIEF
In response to burnout, some neurologists are dropping out — at least temporarily — before reconsidering their career options.
Neurologist Melinda Burnett, MD, was burning with anger. Mayo-trained as a movement disorder specialist and working as a solo neurologist in an academic community practice, she was angry with insurance companies for developing complex formularies, coverage policies, and appeal procedures. She was angry at pharmaceutical companies and the many layers of profit-seeking middlemen and unregulated maneuvers, which resulted in seemingly arbitrary swings in drug pricing so that she was unable to advise her patients if they could afford their seizure medications on any given month. She was angry at the government for addressing the morass of medical economics with more bureaucracy. She was angry at her physician leaders for wielding their newly-acquired economic jargon like a weapon, and distancing themselves from the fellow doctors they supervised. And she was angry at multiple electronic health record vendors, which placed doctors' time and effort at the bottom of their priority list, all of which she chronicled in a post on the blog site KevinMD.com.
The mother of two children, aged eight and ten, Dr. Burnett had been working 12-hour days running to three different remote sites in rural Minnesota since 2010. “My clinics were often overbooked and I had a six-month waiting list, and so three years ago, after my supervisors failed to find a viable solution, I decided to call it quits.” Over time, she explained, the administrative duties of her practice had escalated substantially and there appeared to be no end in sight. Dr. Burnett needed a reboot, so she and her husband prepared intensively for a year, then sold their belongings, provisioned a Catamaran, and the family of four, who had never sailed before, went off to travel the world.
GOING ONLINE FOR SUPPORT
Burnout statistics for neurologists are startling in and of themselves: Six out of ten neurologists in the US experience some form of it, according to a study published in Neurology earlier this year. A majority, 53 percent of neurologists, had high emotional exhaustion, 41 percent felt high depersonalization, and 21 percent had a low personal accomplishment score.
But even more jarring are the repercussions of those numbers; the degree of dissatisfaction has reached such high proportion that many doctors want out. And they are getting together on social media and other digital platforms to talk about it and to find new jobs.
The Drop Out Club (DOC), www.dropoutclub.org, is one such site. The idea was sparked in 1999 when six former physician classmates from the Columbia College of Physicians and Surgeons who had left traditional medical careers to pursue jobs in business gathered for drinks and to exchange notes. Over each subsequent meeting the group size grew larger, so two of its original members decided to create a website for the group. Employers soon found out and submitted job opportunities. As the online community thrived, the site was built out, and the job posting process was formalized to meet recruiters' needs.
Perhaps it's no surprise that with the changes in health care delivery over the past decade, the business has thrived. Today, it has around 40,000 members across the US — approximately half medical doctors, one quarter PhDs, and one quarter dual graduate degree holders. And it offers opportunities in strategic consulting, startups, health care IT, health plans, biopharmaceuticals, medical devices, medical communications, government and public service.
DOC is not alone. Another site, www.nonclinicalcareers.com offers job postings as well as conferences and books that provide instruction on alternative or supplemental careers. A recently established Facebook group aims to meet a similar need. Since its founding last year, Physician Nonclinical Career Hunters has almost 6,000 members. “There is a lot of dissatisfaction today with traditional medical careers,” said Derek D. DuBois, MD, one of the founders of DOC. “Folks who are looking to explore alternate careers are surprised to see the degree of options.”
Although the DOC site doesn't track specialties, a search reveals multiple pages with long lists of neurologists who have joined as members. They not only look for job postings, but to air their grievances and take solace that they are not alone.
In 2013, one member, Smriti (Simi) N. Wagle DO, posted, ”After being in private practice as a general neurologist for the past 10 years, I have seen the medical landscape change and in my opinion — not for the best. While treating patients is rewarding, I find myself most excited about teaching medical students and training other physicians and staff on electronic medical records efficiency and technique.”
Dr. Wagle's disillusionment, echoed by many who have joined, sounds familiar. At the time, she was traveling three hours a day covering five hospitals and rounding for eight hours, and she said she got burned out. Although she ultimately returned to clinical neurology after leaving her job, she said she did so partly because she felt a change would be risky. “I had $140,000 of student loans I was paying off, I am a single mom, and felt the timing wasn't right.”
For now, she really likes the group she is working with, a large health system with nine neurologists. “I also feel a sense of obligation to patients,” she admitted. “I did train in neurology and feel a responsibility to the profession since there is a nationwide shortage of neurologists.”
That shortage — estimated to be 19 percent by 2025, according to a 2013 AAN study in Neurology — is indeed threatened by neurologists leaving medicine. It's further compromised by the contagious nature of burnout. As many researchers have noted, doctors who are experiencing burnout can have a deleterious impact on those they work with, by causing greater personal conflict and by disrupting job tasks. According to research by Levin et al. reported in Neurology, burnout is common in neurology trainees: 73 percent of residents and 55 percent of fellows had at least one symptom of burnout. As Erin Barnes, MD, an intern at Boston Medical Center who is going into neurology, can attest, the contagion can result from the example set by superiors at work.
On her second day as a sub-intern (fourth-year med student) at Lewis Katz School of Medicine at Temple University, Dr. Barnes called a community doctor to let her know that her patient was admitted with anemia. The response was a verbal assault.
“Well,” the doctor said, “Let me tell you about this patient. She is a lazy [expletive]. She will not do in-home rehab. She will go home, dismiss the services, and then end up back at my office or your emergency room. It is ridiculous. I'm sick of it. Tell her she needs to be sent to a nursing home. I'm done with her.”
Dr. Barnes, who was getting ready to start a neurology residency, wrote about her experience in April in StatNews, a digital news service produced by the Boston Globe: “This doctor was once a student like me,” she wrote. “Now she is using vulgar language to describe a patient and flying into a rage because a sub-intern called her. The interaction shook me, mostly because I knew I wasn't immune to becoming a doctor like her.”
“Even worse, I was sitting next to a third year med student on his first day of clerkship,” recalled Dr. Barnes, “and I could see the look of horror on his face.” Two days later, she was on rounds when the same doctor called her attending to reprimand him for allowing Dr. Barnes to have called her. “At the time, I was seeing a patient who was very, very sick and rounding on her every day...how could I tell her that her that her doctor was angry and that she did not want to accept her back?”
Dr. Barnes recognized that her experience was due to burnout and began to do research, reading about empathy and resilience. “As a young physician moving forward in this field, I know that neurology in particular has been plagued by burnout,” she said. “I don't think that the doctor had started out angry, and it made me wonder, what will I be like in twenty or thirty years?”
The experience changed her. “When I started out in third year med school, I wanted to get into the ‘best’ residency I could find, but it helped me redefine ‘best’...for me.” As Dr. Barnes began her quest for neurology residency, she paid attention to what the housestaff said about the faculty at the pre-interview dinners, and at the end of her interviews, she asked the faculty what they did to avoid burnout in their careers – and listened carefully to their responses.
“Burnout is absolutely contagious,” she said. “If you're grumpy at work and complain all the time, it trickles down to residents, interns and medical students and sets the example that it's acceptable to behave like this.”
Although Dr. Barnes' experience began with one physician, her story is not meant to point fingers. In fact, the descriptor “burnout” has numerous critics who believe the very term places the blame on the individual, rather than multiple external factors, and is part of a culture which causes doctors to feel unfit for the profession they once loved. The most vulnerable spiral into depression, contemplate suicide or leave medicine.
TAKING A ‘COMPLETE BREAK’
Dr. Burnett recognized that her crisis called for a complete break. “I needed more than a ‘support group’ or yoga classes,” she said, “the implication being that the problem lay within myself and not the system.” But having reached the conclusion of her two-year journey, she is grateful for the experience, which included two Atlantic crossings and visits to 35 different land masses. (For those readers who want to take vicarious pleasure in her family's adventures, read her blog posts on BurnettsAhoy.com.)
“The first year, I wanted nothing to do with neurology and abandoned all journals and updates, and it took me another six months to rediscover my ambition,” she admitted. “At first I was consumed with learning about sailing, but after 18 months I grew starved for intellectual stimulation,” she confessed. “I love neurology and did not quit because I did not love it. I quit because it didn't feel like a career.” At the end, she decided to return to neurology, and she took the time to search for a position that checks all the right boxes for her. She ultimately found a job in movement disorders with a focus on teaching at Creighton University, and will be starting there as soon as she is credentialed.
Neurology Today will continue to cover burnout in neurology. In the next issue, we look at its impact on neurologists in solo and group practices, and how they transformed their practice or career paths to address the pressures.