A recent headline in the Magic Valley Times-News declares "Idaho's doctors are the most overworked in the United States." What? OK, OK, we all know that Idaho has been at the bottom of the stack for a long time if you measure physicians per capita. And in fact, this is the data that the headline is based on. It cites a MedicareHealthPlans.com article reporting just 1.7 physicians per 1000 Idahoans. But does that necessarily mean that they are the "most overworked?"
Earlier this year, I poured over a copy of the 2016 Physicians Foundation "Practice Patterns and Perspectives" report for Idaho, conducted by the physician search and consulting firm Merritt Hawkins with 17,236 survey respondents nationwide. When it comes to the self-reported number of hours worked per week, 69% of Idaho physicians work 60 hours or less which is right on point with the national average. When asked if they were "overworked or overextended," Idaho docs are within two-tenths of a percentage point of the national average as well, at 28.4%. In fact, 25% said they had time to see more patients and assume more duties. One concern I have with this study, though, is that only 70 Idaho physicians are represented in the sample; depending on who they were, the realities of the 50% who practice in Ada County versus the rest of the state are vastly different.
If you look at WalletHub's ranking of "Best and Worst States for Docs," Idaho scores within the top three this year and has moved up from #5 in 2016. Woot woot!! The nice thing about their survey is that they openly explain their methodology and sources, detailing how they weight various items like wages, quality of hospital systems, and malpractice award payouts. This ranking is corroborated by Medscape's state rankings in 2016 where Idaho placed fourth (and sixth in 2015).
For 2017, Medscape chose to report on the best and worst places to avoid burnout, a topic near and dear to my heart. I'm probably biased, but I think Boise got shafted for placing 19th. Their factors include cities with a "calmer and happier life, fewer lawsuits, least punitive medical boards, teamwork with advanced practitioners, cultural attractions, golf amenities, bike, pet and walk friendly settings." Come on! Boise has all that in spades! (Well, maybe not cultural attractions so much, hence the dig by Ryan Gosling's jazz piano playing character in 'La La Land.')
Speaking of movie references to Idaho: did you see the trailer for the soon to be released thriller/drama "The Mountain Between Us." Kate Winslett is a woman engaged to be married and along with a busy surgeon (Idris Elba) is forced to take a charter plane home from Idaho after their flight is delayed because of weather. As the prop job takes off from some rural airport, Winslett's character asks 'Dr. Ben Bess' why he came to Idaho. His response: "A medical conference." I'm pretty confident they must have heard about our very own Winter Clinics CME conference in February in McCall!
Idaho portrayed by Hollywood as hosting a medical conference attracting out of state doctors? Dang! Our medical community really must have something going for it!
So, in spite of the abysmal physician rate per capita, lower compensation, and less than amazing Medicaid coverage and Medicare reimbursements, I would hazard a guess that it is as much about perspective as anything. Here's the thing: physicians don't end up in Boise or Idaho by accident; they come here on purpose. So, whether it is falling in love with Idaho's natural beauty and fantastic people on at a medical conference, choosing to attend our great medical residencies and then staying, or returning home to be near families and old haunts, lifestyle and community trump deficiencies by a landslide.
Twelve years ago, in the aftermath of Hurricane Katrina, I sat fixated on helicopter images of people in New Orleans escaping rising flood waters, scrambling on rooftops, and fighting for shelter in the Louisiana Superdome. At night, I couldn't get the images out of my mind. "This can't be happening in the US of A!" I thought, "We're a civilized nation, not a third-world county. How can this be?" Frankly, looking back, I was probably experiencing a little bit of shock.
So, when news about Hurricane Harvey started flooding in last week, I honestly did not want to experience the same thing all over and purposefully avoided the news stream and images. I hardened my heart to the pain and misery of an event that by all measures will eclipse Katrina. I even got mad while playing a game with my daughter and listening to the radio when after every single song the announcer would say, "If you haven't heard the news about Houston"…"tragic stories coming out of Texas"…"people are calling and asking for us to pray for them in the flood".... From the safety of my Boise home in 100 degree weather I just didn't want to be bothered.
It is the heart-numbing effect produced by repeated exposure to pain, trauma, loss and grief and for you as a care provider, an occupational hazard. I think of it as an emotional defense mechanism that when overwhelmed with stimulus screams, "ENOUGH! I can't take anymore." On the healthy side, it is probably like how your brain starts ignoring certain sounds after a while and pushes them to the background or the pressure sensations on your bottom while sitting that you stop feeling after a while. On the unhealthy side, you all know what happens when patients lie in a hospital bed without movement or sensation for too long. At some point, we must turn our hearts back on if we intend to remain human.
Years ago, I read Dr. Paul Brand's "The Gift of Pain" about his work with leprosy patients in India and diabetics in the U.S. This renowned surgeon made the point that pain has a value that becomes clearest in its absence. He taught his leper patients to examine their own and each other's digits and limbs and eyes everyday to look for unintentional and unfelt wounds that their body had stopped delivering pain messages to their brains about.
I've spoken with some physicians over the past couple years who have honored me by opening up about the difficulty of losing patients. Many of them assume the blame for not being able to provide the right treatment or for care in time to save their lives. One particular conversation left me thinking, "Doctors eat grief for a living, but how do they digest it?"
Some learned to cope with it by turning their hearts off entirely, avoiding the uncomfortable feelings and processes of the heart. Others wander through life shell shocked by the trauma, eyes glazed over in perpetual distress. Many have learned a place within and with friends how to properly process and "eliminate" the meal their occupation serves up to them.
As I do the same, can I encourage you to examine yourself – and others around you if they will – to look at places in your own life and work where the effect of grief, loss, and trauma has been eating away at you unseen. Find a safe place to bear each other's burdens and expose your own. This is hard work and requires a vulnerability many physicians avoid. But, I would suggest that what makes you a great doctor is not just your brain and years of medical education, but also your heart and the ongoing emotional education and healing needed as you grow through your career.
The unwieldy name of the resolution was "Lessening the Stigma and Potential for Negative Professional Consequences to Physicians Seeking Mental Health Care Services." It sailed through the Idaho Medical Association House of Delegates without comment on Friday July 21 during the first session. But when it came time to vote on Sunday morning, the reference committee requested more input from delegates. Suddenly what sounded like a no-brainer to most physicians became the most contested resolution at the IMA's Annual Meeting, hosted this year in Sun Valley.
The resolution sought to promote an atmosphere where physicians are able to freely seek mental health care without being afraid of losing their job, their license or their professional standing when they admit it. (See recent University of Michigan study on this issue.)
Take this example, shared on a national residency faculty listserv:
"Talk about shame and stigma - one of our residents is currently applying for his full license in another state (moving there for a new job after graduation). Apparently, the application asked about mental health disorders and he checked 'yes' for his hx of MDD (stable, no relapses x years, on same dose of meds x years and wouldn't know it unless he told you about it). He now has to pay for a forensic psych eval (about $1800 at least, out of pocket), arrange for his PCP to speak to the BOM-contracted psychologist, do drug-testing and then wait to hear if he will be able to move forward, have to enter a monitoring program, or be denied his license (unlikely I think)."
I have to trust the doctors I know personally who have served on Idaho's Board of Medicine. To their credit, they claim that IBOM always treated physicians in situations like these reasonably quickly and fairly. Unfortunately, I've heard one too many blood-curdling instances in-state where peer-review processes by employers and groups meant to improve patient care have been weaponized against physicians.
Unquestionably, public and patient safety has to be maintained and that is the primary goal of application and review processes. But I contend when those processes are not fair or transparent and doctors are forced to run blind-folded through an administrative gauntlet, this burdens them with an additional layer of avoidable trauma and fear that is too much for some. Whether the above examples were warranted and repeated or not, word travels fast among physicians that can have a chilling effect on healthy disclosure and that is not in the best interest of patient safety.
Doctors forced to run blind-folded through an administrative gauntlet burdens them with an additional layer of avoidable trauma and fear.
The direction I hope all Idaho employers, licensors and credentialing boards start moving in is to provide the positive message that "if you are a medical provider, we encourage you, we want you, maybe even expect you to seek mental health care preventively. It's good for you and it's good for your patients. And unless there is a real impairment, we're not going to be punitive when you tell us about it. In fact, to encourage you to do so we're going to be very open about our review process."
I believe that the employers, hospitals, practices and states which are the most transparent, whose medical cultures allow for doctors to remain human, are the ones where doctors will gravitate to as the burnout epidemic takes its toll.
Eventually, the House of Delegates resolution was referred to the IMA Board of Directors for further study. Clearly, this was no simple matter to be debated in short order while trying to finish up HOD business. As ACMS continues to advocate for physicians, I invite you to share stories that would help various institutions understand what it feels like to sit on the other side of the desk.