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Burnout and bias

Tuesday, January 26, 2016

Interesting article last week about two important aspects of a physician’s personal life that affect the care of patients, “burnout and bias.” 

It was a survey of nearly 16,000 American physicians and I think it has some relevance to us because our disease pattern is now that of a developed country. The problems that affect American physicians, the lure of Dr Google, the lab test generation, the alternative medicine movement, legal issues, are now part of Trini medical life.

Burnout is generally defined as loss of enthusiasm for work, depersonalisation, and a low sense of personal accomplishment. 

Research suggests that burnout is a form of depression. In that case, more than 50 per cent of American doctors are depressed because that is the figure arrived at in the survey. The figures varied a bit according to 25 specialties. The highest five (50 to 55 per cent of physicians depressed) were critical care, urology, emergency medicine, internal medicine and GPs. 

My specialty, paediatrics came in sixth. The lowest (40 to 45 per cent of physicians) were psychiatry, ophthalmology, endocrinology and dermatology. 

Burnout explains why many US doctors are retiring or leaving the profession. We are well on the way to similar numbers. 

There are too many local doctors not enjoying medical practice. As far as the specialties are concerned, you should know that there is no formal or legal definition of a “specialist” in T&T. 

That means any Dr Ram, John or Sheila can take a six-week course in something and claim specialty status. That piece of knowledge explains some of the mysterious goings on you read about in the papers. The situation is even worse than you think.

Top on the list of causes of burnout was having too many bureaucratic tasks, followed by too many work hours. 

Maintenance of certificate requirements came third followed by income not high enough and increasing computerisation of practice. Every doctor in T&T can attest to the first two. 

We are years away from re-certification, a must requirement. Income is tricky. 

The ease with which some people make millions by writing pre-action protocol letters or selling toothpaste has to be compared with the stress-filled hours worked by doctors, especially in the public sector. 

Computerisation of office records has been a failure and doctors are pushing back against it. It interferes with the doctor-patient relationship. How can you trust someone who spends a visit looking at a screen and not at you? 

For me, the ability to provide patients with the quality care they need because of the above reasons is the major problem with doctor depression. 

Another interesting finding was “too many difficult patients.” “Difficult” patients, as opposed to “good” patients, are the elephants in the medical room. 

They are often described as “distressed high utilisers of medical services.” 

This finding arose out of the question: “Do physicians have any biases towards patients?” Forty admitted they did. Emergency room physicians, orthopedists, psychiatrists, GPs and obstetricians topped the list with Paediatrics coming in at eighth.

When pediatricians who admitted biases were asked to characterise “difficult patients,” most picked emotional problems (anxiety or excessively dependent or the opposite, demanding and manipulative) as the patient factor most likely to trigger bias. 

Next came intelligence, which for me is simply a sign of doctor arrogance or the “difficult doctor.” Language differences were next but that is not a problem here unless we include the many Venezuelans now attending clinics or the foreign doctors attending them, and us! 

Weight questions, as in “he not eating, doc, he too skinny,” when the child is 20 pounds overweight, came in fourth. 

Other patient characteristics that evoked bias, were drug seeking (“She need an antibiotic, Doc”), and patients with a sense of entitlement (“The chile cah be so sick, we going Tobago tomorrow”.) 

“Good” patients usually means they agree with doctors, don’t bother them and let them be in charge. Such a definition runs counter to what we know about truly good care, which must be a process of collaboration. 

There will always be patients and families who are considered high maintenance, challenging, or both by health care providers. 

Among them are a few with evident mental illness, but most are simply trying their best to understand and manage their own or their loved ones’ illness and unless the doctor taps into that sentiment, which is a healing one, the outcome will not be positive.

There are also physician factors related to “difficult patients.” Physician-overwork may be related to greater numbers of patients being considered “difficult.” 

Less-experienced or younger physicians report encountering more “difficult” patients. Physicians who have greater need for diagnostic certainty are more likely to consider patients “difficult” when they present with multiple or vague symptoms, persistently fail to follow through with treatment plans or try to self-manage.

In the survey there was no relationship between spiritual belief and bias. That would be a difficult one to believe in T&T. Neither was there a relationship between political leaning and bias. No problem here, everyone has more or less the same political views. Race would be a factor though.

One interesting finding was that the longer a doctor resided in the United States, the more biased he became. Thirty-four per cent of pediatricians who came to the United States as adults said that they were biased compared with 38 per cent of those who had lived there since childhood and 46 per cent of those who were born in the USA. Preliminary findings, no comment is needed.


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