David E Bratt, MD

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.