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Practice Made Perfect | June 2019

Strategies to Avoid Burnout

Find the right balance to mitigate personal stress.

Burnout occurs in all professions. Ophthalmology, although reportedly lower on the subspecialty list for burnout, definitely has its share of personal and professional stressors. In the following interview, CRST asked ophthalmic practice management experts John Pinto and Corinne Wohl, MHSA, COE, to discuss strategies to avoid burnout.

CRST: How prevalent is burnout in ophthalmology?

John B. Pinto and Corinne Z. Wohl, MHSA, COE: As stressed out and burned out as one can become working in the ophthalmic field—whether you are a physician, an administrator, or support staff—the incidence of burnout is reportedly lower than in other medical specialties. According to a 2016 report, the physicians who most reported being extremely happy were dermatologists (43%), closely followed by ophthalmologists (42%). Therefore, although ophthalmologists are more stressed than the average person, they are doing fairly well compared with their peers in medicine.

CRST: What are some common causes of stress and burnout?

Mr. Pinto and Ms. Wohl: Everyone who works in ambulatory care is under stress for a variety of reasons. Those reasons could be divided into a list of excesses and a list of insufficiencies. For example, a surgeon experiences stress because of an excess volume of work and hours worked, or because of an excess of perfectionism.

Personal financial considerations can also cause burnout and depression. Ophthalmologists are paid per unit of work, and it can be addictive to say, “I am seeing 20 patients this morning. I wonder if I can see 25.” That sort of competitive behavior, if driven or exacerbated by financial stressors, can lead to a slippery slope, and individuals can lose control over how much and how intensely they are working. Common insufficiencies can also cause burnout, such as not eating or sleeping well, not exercising enough, not maintaining healthy relationships, and not keeping one’s finances in balance.

When physicians have an excess of some of these things and an insufficiency of others, it leads to stress and burnout.

In our firm, we use a model developed by Canadian researcher Hans Selye to discuss stress with clients. Many years ago, Dr. Selye said that stress is generated in an environment of change, and it does not matter whether it is distress, like the distress of getting a parking ticket, or eustress (eu-, ie, good, as in euphoria), relating to positive change such as buying a new home, getting a new job, or getting married. Whether change is positive or negative, it’s the change that can lead to a state of stress. Dr. Selye developed a useful scale for charting this. If one experiences enough changes, especially if compressed into a short time span, they will experience higher levels of stress until it starts to manifest as burnout. Burnout really can be thought of as stress sustained over time.

CRST: How can one recognize and alleviate burnout?

Mr. Pinto and Ms. Wohl: Think of any medical condition. It presents with certain impressionistic, subjective findings, and is then examined with objective tests. A diagnosis is made, and a treatment plan is put in place. The same methods can apply here.

Stress-related burnout has various subjective manifestations, which as management consultants—not psychologists—we are in a position to observe, but obviously not diagnose. In more challenging settings, where a client’s stress interferes with the business entity we are trying to help, we refer out to a mental health professional. Ultimately, it is something that can be diagnosed, and a treatment plan can be developed by the appropriate professional. Interestingly, we are often the front line of discovering and discussing stress and burnout with a new client because they are comfortable discussing their problems with a business consultant but feel embarrassed (unnecessarily, obviously) to seek out a psychologist.

The diagnosis of stress and burnout can be made through observation of factors (eg, emotional detachment or depression) and unhealthy stress mitigation behaviors (eg, abusing alcohol or drugs). Personality shifts can lead to social isolation as friends or spouses pull away. This creates a feedback loop because, if one’s social support systems fall apart, one will be even more stressed and find it harder to emerge from an adverse cycle. (See Ten Common Feelings Indicating Burnout.)

Once a diagnosis has been made, whether through self-diagnosis or by seeing a mental health professional, it is important for an ophthalmologist to realize that a big part of treatment involves setting limits and, if necessary, establishing an external source of discipline to stay within those limits.

Examples of limits include reducing the volume of patients seen in a given work session, the number of surgeries in a day, or the amount of money one tries to generate in a given month. It is appropriate to consider setting time limits. How many hours per day do you work? Do you include an hour-long break in the middle of the workday?

CRST: What is the greatest source of stress for ophthalmologists?

Mr. Pinto and Ms. Wohl: A lot of the stress and the burnout associated with stress that we see in ophthalmology is financial. Several years ago, we conducted a modest study with Craig N. Piso, PhD, which identified that the greatest correlation of unhappiness for surgeons was their perception of what percentage of their income that they lived on. Surgeons who thought they were living on 100% or more of their income scored very low on a standardized life satisfaction and happiness questionnaire. By contrast, doctors who believed they lived on 50% or less of their income had much higher happiness scores.

In our consulting work, we go into settings where doctors are living from day to day on a significant majority of their income. They feel like gerbils on a wheel. For these doctors, easing their stress can be a matter of getting them to work with financial planners and with their spouses to make sure they have reasonable budgets in place that are in balance with their comfortable earning potential.

It is not unusual to come across surgeons whose lifestyles were established at a time when their earnings were very high, but, as the years have passed, their income has slowed but their lifestyle costs remain the same. This can happen either because their practice is not doing as well or because they are simply older and not so energetic as in youth.

It is important for surgeons experiencing this to harness all of their resources, including their administrators, colleagues, spouses, and professional advisors, to overcome this. A personal financial planner can work with these doctors and their families on budgeting to relieve the stress of trying to spin faster on that figurative wheel when it is no longer possible.

CRST: What are some signs of stress and burnout?

Mr. Pinto and Ms. Wohl: Like exposure to too many x-rays, exposure to too much work can sneak up on a surgeon. Years of slow accommodation to work and stress builds until a breaking point is reached. It’s too bad we haven’t yet invented a stress safety badge—like an X-ray technician’s dosimeter badge—that can register when stress levels are too high or too prolonged. If you notice any of the following common markers in your providers, they may be at or beyond the point of burnout:

  • Arriving chronically late or at the last possible moment to the clinic or OR.
  • Asking for an early payday or extra personal withdrawals, obliging that practice vendors be pushed off.
  • Canceling clinic sessions on short notice or excessively, often with no more excuse than, “I really need a break.”
  • Avoiding staff and literally (or at least figuratively) flinching every time a staff member approaches with a question or request.
  • A collapse in professional growth, withdrawal from new clinical or surgical opportunities, and backing off from continuing education responsibilities.
  • Relatively good energy in the mornings followed by a weak finish toward the end of the day, and then dragging home.

CRST: What are some stress and burnout prevention and treatment strategies?

Mr. Pinto and Ms. Wohl: It is important to cultivate support systems in one’s life before getting to the stage of burnout. When we meet healthy, relaxed doctors, the thing that they seem to do the best is to cultivate support systems—friends, spouses, partners, and professional caregivers. The wisest doctors stay on the right side of burnout by realizing that seeing a counselor, psychologist, or religious leader at regular intervals can help them avoid burnout. It is important to discuss these things openly.

A smart practice administrator can also help doctors stay balanced in the midst of a hectic professional life. We think it’s important that the administrator be tuned in to the potential for stress and burnout in their providers and to develop a positive, open, safe, and trusting working relationship with each doctor so that, when stress or burnout start to occur, it is easier to initiate that conversation. If a surgeon keeps his or her administrator and partners at arm’s length, he or she will be more susceptible to burnout when stresses pile up.

Sometimes burnout is hard to recognize; it creeps up on you. That is why one of the great values of a support structure is that it gives you an outside warning system—people who are comfortable coming to you and saying, “It looks like you’re experiencing more stress than usual. What can be done to improve that?”

Every profession, whether it’s education, law enforcement, or medicine, brings its practitioners moments of acute stress. Our discussion here is not so much about how to respond to the acute stresses that are embedded in every professional life, but how to recognize and deal with the effects of the drip drip drip of the enduring stress that can lead to burnout.

CRST: What are the dangers of burnout?

Mr. Pinto and Ms. Wohl: Studies show a connection between physician burnout and a decrease in patient satisfaction.1 Additionally, they show an increase in reported medical errors and earlier retirement of physicians, among other things.

Burnout and the stress that leads to it don’t just have a personal impact on the doctor. It also has a secondary impact on patients, staff, the financial vitality of the organization, and cohesion among the practice’s partners.

ten Common Feelings Indicating Burnout

1. I feel that I do not have time to do many ofthe things that are important to me.

2. I feel that there is more work to do than I have the ability to do.

3. I feel that I am achieving less than I should be.

4. I feel that I am under an unpleasant level of pressure to succeed.

5. I feel that I am not getting what I want out of my job.

6. I feel that politics or bureaucracy frustrate my ability to do a good job.

7. I feel that I am in the wrong organization or the wrong profession.

8. I feel run down and drained of physical oremotional energy.

9. I feel increasingly irritated by my doctors or coworkers.

10. I feel thatI have no one to talk to about these feelings.

CRST: What actions should a surgeon consider taking to avoid burnout?

Mr. Pinto and Ms. Wohl: For any active ophthalmologist who is fully engaged in his or her work, there is a kind of connectedness between personal and professional life. It can be difficult to divide mitigation strategies between one’s personal and professional lives, but the key is to remove as many stressors as possible and add as many stress mitigators as possible, including exercise, massage, meditation, counseling, friendships, hobbies, religious practice, good sleep hygiene.

Remember to not cluster too many changes into a short time span, even if the changes are positive. If a practice is going to close one office and build another in the course of a year, that might not be the year when one would want to also add a new partner, get into a new service line like dry eye, and do a mission trip to South America. That would be a lot of change packed into a single year.

Likewise, if a surgeon knows that he or she will be changing jobs, moving his or her family to a new community and having another child—all in the same year—it might not be the best time to try to master a complicated procedure or start volunteer teaching at the university.

We each have a certain quantity of stress and change that we can accept. It’s different from individual to individual, but one should try to anticipate changes and limit the amount of change occurring in the aggregate dimensions of one’s life.

1. Panagioti M, Geraghty K, Johnson J, Zhou A, et al. Association between physician burnout and patient safety, professionalism, and patient satisfaction: A systematic review and meta-analysis. JAMA Intern Med. 2018;178(10):1317-1330.

John B. Pinto
  • President, J. Pinto & Associates, San Diego
  • pintoinc@aol.com
  • Financial disclosure: None
Corinne Z. Wohl, MHSA, COE
  • President, C. Wohl & Associates, San Diego
  • czwohl@gmail.com
  • Financial disclosure: None
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