By Ravi Parikh August 5
We are in the middle
of a well-documented epidemic of physician burnout. Doctors report
more dissatisfaction than ever, and data presented at this year’s American
Psychiatric Association annual meeting shows that physicians commit suicide at twice the rate of the general population.
But as hospitals address this by appointing “chief wellness officers” and as medical
schools revamp their curriculums, the health-care system as a whole is ignoring
one obvious remedy: doctors seeing more healthy patients.
I recently had a busy
day at the clinic where I see people with cancer. My first two visits were
challenging: During the first, I explained to a patient and his wife that his
kidney cancer was no longer responding to therapy. Next, I recommended that a
patient delay his vacation to undergo treatment for an aggressive malignancy. I
was already dreading my last appointment, when I would tell a Vietnam veteran
with liver and heart failure that he would not be able to withstand the
chemotherapy needed to control his Stage 4 cancer.
It was going to be a
long day.
But sandwiched
between these appointments, a familiar face showed up in my office. About a
year ago, he had undergone surgery to remove a lung tumor. I hadn’t seen him in
months. He looked healthy, having regained most of the weight he’d lost. He was
happy to get back to fishing and taking long walks. Afterward, I gave him a
clean bill of health: “Your labs and scans look great. Why don’t you come back
in three months?”
He looked somewhat
surprised: “If things look good, do I need to keep seeing you?”
This didn’t mean that
he disliked me. (I think.) Rather, he explained that every visit to the
oncology clinic was a reminder that he had once had cancer. Besides, he lived
more than an hour away and he trusted his primary-care physician to review his
scans. And it was very possible that his lung cancer would never return. He
would be happy to never have to come back to see me.
I told him that,
while I sympathized, most patients in remission should see their oncologist
periodically after finishing therapy to monitor their cancer and address
possible side effects. He agreed and scheduled an appointment.
What I did not say —
or even consciously realize at the time — was that I needed to see him as much
as he needed to see me.
Staying connected
Cancer specialists
call these appointments “survivorship” visits. They’re where we generally
address treatment-related side effects and screen for other cancers and
diseases such as diabetes. Survivorship visits are a way for us to stay in
touch with patients, and many feel reassured that the doctor who beat back
their cancer is continuing to keep a close eye on them. Perhaps that is why
women with breast cancer say they prefer their oncologists to stay connected with
them even after therapy.
But there is a
movement in medicine to push healthy patients out of the doctor’s office,
propelled by the 20 million newly insured patients who got
increased access to the health-care system after the Affordable Care Act passed
in 2010. Recent articles in major consumer and academic venues argue against the annual
physical, noting that healthy or asymptomatic patients may not benefit from
these visits, which, of course, cost our system money. Telemedicine and home health services
also replace in-person care.
Even in cancer care,
patients who are cured or in remission often don’t see their doctor regularly.
Survivorship becomes the domain of providers such as nurse practitioners and
physician assistants. As a result, most of the patients we physicians see have
new cancer diagnoses or are receiving treatment.
In other words,
nearly every one of them is sick. That’s undoubtedly what any doctor signed up
for. And the value of a clinic visit is much higher for a sick patient than for
a healthy one.
But as one who treats
people on the verge of life and death every day, I am starting to recognize the
emotional toll. Between the gut-wrenching conversations about mortality and
managing life-threatening complications of a treatment that my team prescribed,
a full day of clinic can leave me drained, guilty or, even worse, depressed.
That feeling is amplified for patients with diseases such as pancreatic cancer,
where the chance of long-term survival is bleak. And I am still in training;
imagine how exhausted a seasoned cancer specialist or critical-care physician
must feel at the end of their day, after seeing 25 sick patients and answering
10 phone calls from worried family members.
Even among
oncologists, who self-select into a profession that is emotionally charged,
rates of burnout are high. In a 2014 study published in the Journal of Clinical
Oncology, nearly 1,500 oncologists surveyed reported at least some burnout, and
it was worse among those who saw more patients. These numbers were higher among critical-care
doctors and internists in the most recent Medscape Physician Lifestyle report,
which surveyed of more than 15,000 physicians practicing in 29 specialties.
Surviving the tough days
On most of my tough
days, I don’t think of seeing a healthy patient as a waste of clinic time. On
the contrary, when I saw that my patient who had survived lung cancer was on
the schedule, I felt relieved. With patients like him, doctors can afford to
spend 15 minutes discussing a child’s graduation or a recent vacation. These
interactions remind doctors that treatment can let someone lead a normal life.
These are the
patients who prevent me from burning out.
I went into medicine
to make sure that sick patients could return to living a normal life. Even if
that’s not always the outcome, it is nice to see it happen.
Even in less-critical
situations than cancer treatment, “well visits” can be important. Doctors can
focus on smoking cessation, exercise counseling and mental health — important
topics that are often ignored during a sick visit.
Of course, if a
healthy patient does not wish to go to the doctor, that’s their prerogative.
And I understand that either patients or their insurers must pay for in-person
visits, transportation, medications and lab tests. But I believe those costs
can be justified by the improved value of care that refreshed, happier doctors
provide.
As more physicians
become burned out and apprehensive about practicing medicine, we must realize
that there are limits to what chief wellness officers, counseling, and pep
talks can accomplish. Only systems-level changes in how doctors treat and see
patients will curb the rise in physician burnout. Perhaps healthy patient
visits can be therapeutic for everyone.
Parikh
is a fellow in hematology and oncology at the University of Pennsylvania and is
an adviser at the Coalition to Transform Advanced Care. Twitter: @ravi_b_parikh
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