American College of Physicians: Internal Medicine — Doctors for Adults ®

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Re-discovering the need for personal renewal

From the December ACP Observer, copyright © 2005 by the American College of Physicians.

By Robert Calandra

Every Sunday morning from September through March, Michael D. Cirigliano, FACP, rises before dawn, throws a bulky bag into the trunk of his car and heads for downtown Philadelphia.

According to Dr. Cirigliano, age 45, his Penn Internal Medical practice in Philadelphia's University City area boomed last year after a city magazine put his name on its coveted "best physician" list. Add into the mix his position as a medical correspondent for a local morning newscast, and the only way he can keep his workweek down to 70 hours is by returning patient phone calls during his drive home.

But on Sunday mornings, Dr. Cirigliano trades his lab coat and stethoscope for a Montreal Canadiens' sweater and a pair of ice skates. Snapping on a helmet and grabbing his hockey stick, he spends the next 90 minutes bouncing off the boards like a 185-pound pinball.


For Michael D. Cirigliano, FACP, personal renewal means getting physical. Here, he assumes his position as right wing for his amateur ice hockey team.



"I love ice hockey," said Dr. Cirigliano, who has practiced medicine for 12 years and claims the sport is a crucial form of stress reduction. "If I don't play, I feel it. The other players are HMO executives—that's what it means to me."

It also means that Dr. Cirigliano may be leading a healthier, more balanced life than many of his peers. Unlike some physicians who work equally long hours, Dr. Cirigliano said he consciously carves out time to exercise and pursue non-medical interests—a program of personal renewal he claims makes it possible for him to sustain a demanding practice.

"I just get into other things," said Dr. Cirigliano. "That is the absolute key. If all I had to think about was medicine, then I would lose it."

Years after studies first flagged the dangers of physician burnout, evidence continues to point to a growing number of physicians at risk for burnout. That pervasive threat led ACP's Board of Regents in 2003 to expand the College's Mission Statement to include "support[ing] healthy lives for physicians" as one of ACP's core goals.

A better work/life balance is also behind many of the College's revitalization of internal medicine efforts. "We are trying to help physicians rediscover the joy of practice," said Mary T. Herald, MACP, former Chair of the Board of Regents, who helped organize internal medicine's revitalization summit in 2003. "To do that, we have to help them with support and tools for the basics of their practice, sharing innovations and a vision for a better way to do things."

It remains to be seen, however, how many physicians are heeding the message about the need for better balance.

"Too many people my age equate the quality of the doctor to how many hours you are available," said Lawrence G. Smith, FACP, who is age 56 and chief academic officer and senior vice president for academic affairs at North Shore Jewish Health System in Great Neck, N.Y. "The biggest challenge will be to stop confusing the delivery of excellent medical care with working 80 hours a week without going home."

The burnout factor

Recent studies cite the growing number of doctors who complain of at least one classic burnout symptom: emotional exhaustion, cynicism, ineffectiveness and a sense of depersonalization in relationships with co-workers or patients. An article published in the Feb. 4, 2004, issue of Student JAMA, for instance, found that "components of burnout may be common among practicing physicians." The study, based on a small, localized sample, said that between 46% and 80% of practicing physicians reported moderate to high levels of emotional exhaustion.

"Burnout is still pervasive," said Peter Moskowitz, MD, a career life coach for health care professionals and executive director of the Center for Professional and Personal Renewal in Palo Alto, Calif. "As a result, unfortunately, many people end up in various degrees of burnout, and it is very hard for them to ask for help." His typical physician client, Dr. Moskowitz said, is a 50-year-old man who works an average of 60 or more hours a week and has no interests outside of medicine.

"They have no reserve, they are depressed, they have lost their ability to be empathic with patients—and it often spills over to their family life," Dr. Moskowitz said.

Tragically, burnout can translate into a higher rate of suicide among physicians than among the general population. A study in the June 16, 2005, issue of New England Journal of Medicine found that the suicide rate among male doctors is 40% higher than among men in general—while the rate among female physicians is 130% higher than the general population of women.

Many factors can lead to burnout, including low pay, long hours and less control over patient care—all factors that threaten internists.

"The problem with internal medicine is that doing the same thing we did 20 years ago is much harder now," said J. Fred Ralston Jr., FACP, a general internist practicing in Fayetteville, Tenn., and Chair of ACP's Board of Governors. "There are more things to follow on a patient and more paperwork and regulations. I know too many physicians who went into this field who feel their time and talent don't appear to be as valued as they were in the past."

Add to that frustration a pervasive medical culture where physicians are trained to equate relaxing with wasting time. Too often, experts say, doctors don't know how to pull back from patient care and look to their own personal needs. That learned behavior often begins in residency, with workaholic-attending physicians who consider those not willing to spend endless hours at the hospital as less dedicated to medicine, says Michael F. Myers, MD, clinical professor of psychiatry at the University of British Columbia in Vancouver.

In his private practice, Dr. Myers said he has to tackle the guilt physicians feel when they take personal time. "Instead of saying to their colleague, 'Yes, I finished my work and I don't need to hang around here another hour,' " or 'I'm going to the gym,' they worry that a colleague will think they are less of a doctor."

New blood—and priorities

Fortunately for older colleagues, the new generation of young physicians, like Alan C. Jung, ACP Member, serves as a strong reminder that work/life balance counts. From the outset of his career, Dr. Jung, now age 38, has worked less than a 40-hour week, dedicating the rest of his time to other interests, including woodworking.


Alan C. Jung, ACP Member, regularly works less than 40 hours a week and has crafted most of the wooden furniture in his home. He poses here with a bench he displayed at the 2005 Annual Session's "Internists as Artists" exhibit.



"Seven years ago I was the exception," said Dr. Jung, a senior partner in the Permanente Medical Group, the physician network for Kaiser Permanente, in the San Francisco Bay area. "But physicians coming out of training in the last four years have a greater sense of not immersing themselves in their career and have it be the be-all and end-all of their lives."

New York's Dr. Smith tackled that generational difference in the April 2005 issue of APM Perspectives from the Association of Professors in Medicine. In the article, Dr. Smith said the younger generation's focus on lifestyle may conflict with older colleagues' values.

"Baby boomers define professionalism predominantly in terms of hours worked and complete dedication to the job," Dr. Smith wrote. "Dedicated to life balance, Generation Xers do not aspire to be like baby boomers."

Instead, Dr. Smith said, Gen Xers—who were often raised by absentee baby-boomer parents—are more focused on caring for themselves and their families, something he sees as a positive attribute. At the same time, he thinks older physicians can learn from their younger colleagues.

"It requires people speaking openly with each other," he said. "There ought to be creative practices that accommodate people who want to practice great medicine and also protect their personal time."

The unprecedented number of women entering medicine—many choosing to work part-time to raise families—is also having a big impact. "One of the unexpected benefits of having so many young women in medicine is that they are helping reshape the landscape of medicine in a positive way," Dr. Moskowitz said. "They are restoring the role and importance of being a parent and spouse—and I think it is all very positive."

So does Dr. Ralston. A newly hired female physician in his seven-partner practice recently went on maternity leave, a first for his group. "By that time, our new partner was part of our office family and we pitched in to make things work. She later returned the favor when others had personal or professional needs," said Dr. Ralston, who is age 51.

A balancing act

Throughout his 22 years in practice, Dr. Ralston said he has consistently worked to maintain the right balance between his career and his personal life.

By juggling his patient and ACP duties, he said, he makes time for himself and his family, bringing his wife and school-age children on business trips with him and then tacking on a few days for a family vacation.

"You take the amount of time you have," he said. "We find things that are close by so I can take a day off."

Dr. Ralston's balancing act has forced him to turn down some professional opportunities. "I had to choose between being an ACP Governor and president of the state medical society," he said, because doing both would have taken him away from home too much. "I think you are a better doctor," Dr. Ralston said, "when you are happy at home."

Kaiser's Dr. Jung would agree. The physical effort of woodworking—and Dr. Jung has crafted much of the furniture in his Oakland, Calif., home—provides a nice balance to the intellectual endeavors of medicine, he said. And lessons learned from woodworking serve him well as a physician.

"Woodworking is about focus and detail and precision," he said. "That aspect I bring back to work." In treating patients, he said, "it's not about grinding through 30 patients, but paying attention to details and getting satisfaction from doing something well."

Sandra E. Smith-Poling, ACP Member, age 58, has found equilibrium in her life through painting and music—which then inform her practice of medicine. "Art lends a balance to my life which extends to the way I interact with patients," said Dr. Smith-Poling, who practices in Port Townsend, Wash, and is a colonel in the Air Force Reserve. "Creativity makes me a far better diagnostician."

Edward D. Harris Jr., FACP, age 68, has likewise sought renewal through outside interests. He is an avid golfer and tennis player—and has played an upright bass with several jazz groups and orchestras over the years.

But he also seeks renewal through professional variety. "That is one of the joys of academic medicine," said Dr. Harris, a rheumatologist who is also academic secretary at Stanford University in Palo Alto, Calif., and editor of The Pharos, the journal for Alpha Omega Alpha, the National Honor Medical Society. "When I was working 12-to-14-hour days, I was still very happy because of that balance. Colleagues doing straight clinical work all day long were getting burned out. "

While professional diversity, outside interests and a devotion to athleticism all serve "as a release valve," Dr. Harris pointed out what patients gain when physicians safeguard their own personal time and interests.

"If you are feeling overstressed, over-worked and under-appreciated, that immediately is transferred to your practice when you have a patient come into your office," he said. "You just can't mask discontent or frustration."

Drawing closer to patients

For hockey player Dr. Cirigliano, who once played trumpet in a wedding band and is now an aviation buff, "my hobbies get my mind off the moment," he said. "I get so focused on how to design a wing spar for a model jet that I forget about the lady with lung cancer. In a way it's like seeing a psychiatrist."

It has also drawn Dr. Cirigliano closer to his patients, some of whom introduced him to his current hobbies. "My patients are my friends, not just someone I provide a service to," he said.

His advice for avoiding burnout? Schedule a week off every three months, build outside interests, and spend quality time with spouse and family. (See "Tips to help you avoid burnout.")

"I was told a long time ago that you don't want to be one dimensional," Dr. Cirigliano said. "I am multidimensional when it comes to my interests."

Robert Calandra is a freelance writer based in Wyndmoor, Pa.

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Tips to help you avoid burnout

By the time a physician treats his first patient, his tendency to burn out may already be at play.

"We are trained not ever to put ourselves first, but to sacrifice ourselves," said Linda Hawes Clever, MACP, a former Regent and president of Renew, a San Francisco-based organization dedicated to helping professionals regain purpose in their professional and personal lives.

Even more devastating, said Peter Moskowitz, MD, who is a career life coach for health care professionals, is the fact that physicians tend to not ask for personal help. "Physicians are trained to be tough and to handle their own problems," he said, "and not admit to vulnerability."

Such an ingrained mindset can be hard to change. Dr. Clever, a clinical professor of medicine at the University of California, San Francisco, said that any plan to avoid burnout needs to be tailored to each individual physician. But she and others outlined the following tips to help get you started:

  • Get exercise. The same advice you give to patients all day everyday in likewise applies to you: Exercise can help you reduce stress and improve your sleep habits and your health.

  • Learn to set boundaries. Leave the office at 6 p.m., not 8 p.m. During the day, Dr. Moskowitz tells physician-clients, block out five or 10 minutes for quiet reflection—and ink out chunks of time as soon as you get your new day planners.

  • Protect your personal time. That's the best advice he ever received from a professor in medical school, said Alan Jung, ACP Member, a senior partner in the Permanente Medical Group in San Francisco.

  • Develop interests outside of medicine. Focusing on non-medical activities can help relieve stress—and may suggest techniques to improve your medical practice.

  • Connect with other people, regardless of age or profession. "We may forget that we need mentors our whole life long," said Dr. Clever.

  • Say no. Sometimes, said Dr. Clever, we think that the more we do, the better we are, and that's not necessarily true. Tell those demanding some of your time that you can't fulfill their request right now, because you don't want to let yourself, or that person, down. It takes practice, she said.

  • Revisit your goals. These may change over time, Dr. Clever said. A physician may want to be department chair early on in her career—but those priorities may shift after children arrive. "That is not giving up the ship," Dr. Clever said. "That is paying attention."

"The goal is joy and meaning," she added, "and not just exhaustion. A physician taking care of himself is not selfish—it's self-preservation."

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