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Dr. Jennifer Caudle:
The Journal of Academic Medicine recently reported that medical students compared to age-matched fellow college graduates reported significantly higher rates of burnout. What is happening to our 80 thousand US medical students? I'm your host, Family Practitioner Dr. Jennifer Caudle, and to discuss the issue of burnout in our young doctors is Dr. Richard Gunderman. Dr. Gunderman is a Professor of Radiology, Pediatrics and Medical Education, Philosophy, Liberal Arts, and Philanthropy, and he is also Vice Chair of the Radiology Department at Indiana University. Dr. Gunderman, welcome to Reach MD.

Dr. Richard Gunderman:
Thank you, it's nice to be here.

Dr. Jennifer Caudle:
Thanks for being with us. I read your article with great interest about physician burnout. Can you first start off and just tell us a little bit about your background and your career as a physician?

Dr. Richard Gunderman:
Well, I trained at the University of Chicago. I was in the medical scientist training program there, the MD PhD program, but did something somewhat unusual by earning the PhD in the Committee on Social Thought. And after completing residency training I came to Indiana University where I've been on faculty in the different areas you mentioned for the past 17 years.

Dr. Jennifer Caudle:
You wrote this article about burnout, and this is a subject that we often hear about all the time, often hear about in the medical community. What led you to write this article?

Dr. Richard Gunderman:
I have the opportunity to work with literally hundreds of medical students a year. Most of them sail through pretty well. We all face psychological challenges with our family and just the professional challenges of becoming a physician, but I was concerned that a significant percentage of students experience even greater difficulty, and I think that partly has to do with the nature of medical training and practice.

And I wanted to reach out in particular to young physicians and hopefully give them some nourishing food for thought about the etiology, the causes of burnout, and also the steps that each of us might take to try to prevent it or if we feel it developing to try to counteract it.

Dr. Jennifer Caudle:
Right. Right. And I think this is so important. Just so that we can define what you mean by burnout, if you can tell me now how you define it, and also a second part to this is, do you have any statistics regarding say even the number of physicians or young doctors that are experiencing this burnout?

Dr. Richard Gunderman:
Yes. I am not an empirical researcher who's generated data on this question, but there are a lot of thoughtful physicians and social scientists who've looked at the problem. And some of the most important work on the subject I think has come out of the Mayo Clinic.

Several physicians there are interested in the phenomenon of burnout, and they've estimated that something on the order of 46 percent of respondents to surveys indicate at least one symptom of burnout, which would mean that they're not finding as much satisfaction or joy in the work they do, sometimes that they're developing problems like depression or conceivably even suicidal ideation that are thought to be at least partly related to their work or the difficulties they're experiencing in balancing their work with other parts of their lives.

Dr. Jennifer Caudle:
That's interesting. Do we see this being an issue in the medical profession, do we see it more in the medical student realm, or is it more in the residency phase, or younger physicians, or older physicians? What phases do we see these symptoms more often?

Dr. Richard Gunderman:
As you would surmise they are present at all levels, from the day students come to medical school basically till people reach the end of their careers, and even in retirement, which I think is actually an important concern. But the causes and I think appropriate responses to the phenomenon of burnout are going to vary depending on a physician's state of preparation.

For example I find in medical students in the first year or two at many schools around the country, that portion of the curriculum often called pre-clinical provides students with relatively little opportunity to interact with patients let alone feel like they're making a meaningful difference for their patients, and students may burn out because of that. I went to medical school because I wanted to relieve suffering and help cure disease, and here I am in a lecture hall many hours each week, and basically just studying for exams.

So for students like that one effective response to burnout I think can be to try to help them perhaps get more patient contact, find opportunities to help patients even if it's only an hour or a few hours a week, and then also to step back a little bit and think about how what they're learning week to week is preparing them to make a difference in the lives of patients.

Now on the other hand, there are physicians at the other end of the career spectrum who are burning out I think for very different reasons. For example, they're disenchanted because of what they see as increasing red tape, bureaucracy.

They're spending more and more hours every day talking with insurance companies, health care payers, hospital officials about the care of their patients and devoting less and less of their time each day to actually doing what they went to medical school for, namely to care for their patients. So I think burnout is pervasive in medicine. You can find it at every stage. But again, the causes and appropriate responses are going to differ depending on where a physician is in their career.

Dr. Jennifer Caudle:
Referencing the article that you wrote, you've written a sentence here that I thought was really quite interesting and I wanted to bring up as you're talking about burnout at the different levels. And you say that burnout at its deepest level is not the result of a train wreck of examinations and call shifts, et cetera. You say, "It's the sum total of hundreds and thousands of tiny betrayals of purpose," which I thought was really quite interesting. And how do you think that fits in with sort of the things that you're describing at the different phases of medical practice and training?

Dr. Richard Gunderman:
I've talked to a physician in the greater Philadelphia area just in the past week on this matter and matters related to it, and he expressed to me how discouraging it is to him to be under day-to-day and even hour-to-hour practice to increase his productivity, to increase his throughput. In other words, to see not a patient every 15 minutes but a patient every 12 minutes, and then every 10 minutes, and then perhaps now down to every eight minutes.

But he also needs to spend at least a few minutes of each of those encounters collecting data, which he finds rather unfulfilling. So this is an example of a physician whose job didn't change overnight. It's been a fairly gradual evolution over the course of years, but he now feels himself at a point where he doesn't feel like he can really take care of his patients the way they deserve. And in his case it makes him long for days gone by, the style of practice he had 20 years ago.

I don't think for a moment any of us can turn back the clock and just return to the way we practiced decades ago. But on the other hand if we know what's really important to us about the practice of medicine, what being a good doctor really means to each of us, I think there are steps we can take to move our daily practices in that direction so that we do feel like we're making a bigger difference for our patients and find more fulfillment in our work as doctors.

Dr. Jennifer Caudle:
Wonderful. These are really great insights. If you're just tuning in, you're listening to Reach MD. I'm your host Dr. Jennifer Caudle, and joining me is Dr. Richard Gunderman from Indiana University. I really want to take this conversation maybe to the next step. You're bringing up some really interesting points about physician burnout, which is what we're talking about and the article that you wrote for the Atlantic. I'd like to now shift focus to talking about what we do about this physician burnout. One thing that you wrote in your article, you say "Nothing is more needed than nourishment for the imagination." Okay, that was one sentence that you wrote, and I thought that was quite interesting. Can you talk a little bit about what you mean by that, and other suggestions you might have for how we can deal with physician burnout?

Dr. Richard Gunderman:
Well, I think many of us become accustomed to our routines and come to take for granted almost that there's really only one way in this day and age and this particular work environment where each of us is posted, there's only one way we can practice medicine. We need to do it the way everybody else in our group is doing it or the way that the hospital or the insurers or the government would have us practice.

And I don't think for a minute we could ignore those forces, but I think one of the biggest constraints each of us faces at work isn't external controls, regulations, or requirements that are being placed on us from outside agencies. I really feel like the biggest constraint most of us face is our own imaginations. I think one thing we need to do is engage in some serious creative reflection and conversation around what medicine at its best looks like to each of us.

If I could be the kind of doctor in my heart of hearts that I most aspire to be, provide the kind of care to patients at my best that I would want a colleague to provide for my spouse or my parents or my children, what would that look like? I think most of us don't step back very often and ask ourselves that kind of question, but if we do I think we can gain some deep insights.

I'm not saying we can create heaven on earth, so to speak, in the practice of medicine, but if we see our target more clearly, if we understand better the kind of practice that ideally we'd be engaged in we can at least move things in that direction. And in my experience those movements, even incremental ones, can sometimes add up to making a big difference.

Dr. Jennifer Caudle:
Sure. You're advocating for physician insight and reflection. Having gone through medical school myself and done the same, sometimes that's really hard to keep in mind when you're in the process. What's your recommendation for students and residents? Should this type of reflection and insightful thinking be taught in medical schools? Is there a place in the curriculum for this type of education or thought process for not only medical students and residents? How do we address this with younger physicians?

Dr. Richard Gunderman:
Well, I can tell you what I do. I have occasion, as I said, to interact with many medical students every year, in large part by teaching very conventional subjects in the curriculum. I happen to be a radiologist, a pediatric radiologist, and get to teach medical students about the imaging of the cardiovascular system, the respiratory system, gastrointestinal system, and so forth.

I'm always on the lookout for opportunities in the course of trying to help them learn about how to handle the imaging workup of their patients and interpret the results, on the lookout for opportunities to encourage them to think more broadly about the practice of medicine and to engage their imaginations, and then basically to issue invitations to likeminded students to meet outside of class to talk about these matters.

And I think that sends an important message to the students. This is a part of medicine that we need to attend to on a regular basis, but it's not really part of our formal jobs in the sense that it's what the medical school or our employers require us to do. Rather it's something we choose to do voluntarily, of our own volition, because we recognize that how we use our leisure time, our time outside of work, has a huge impact on what our time at work really amounts to.

So I've found conducting these discussion groups, one of which is just called Literature and Medicine, that's a fairly common title. Another one happens to be called The Spirit of Medicine. But that participating in these discussion groups makes a big difference for the students and residents who are involved, and frankly make a big difference in my life, because getting to work on the kind of texts we read and discuss them is like an opportunity to recharge your batteries, not only as a physician but as a human being.

Dr. Jennifer Caudle:
You brought up some really interesting ideas, I think points and even suggestions for those of us who are in academia, those of us who deal with students and residents, but even for maybe how to approach this from our own lives and our own standpoints as physicians. Is there sort of any policy change, maybe thinking larger, outside of the medical school residency realm, are there any policy changes or policy shifts that need to occur that could help deal with physician burnout?

Dr. Richard Gunderman:
Well, I think one thing is that physicians themselves, there are something on the order or 800 thousand of us in the United States, need to begin to take more responsibility for the way the practice of medicine is structured. So another thing we've done at Indiana University is develop a course, this is a part of the formal curriculum, called Leadership in Medicine. And the purpose of that course is to help develop these young physicians as future leaders.

Because in my own experience many of the most important external causes of burnout can be traced ultimately to the fact that physicians feel that we're losing control of the practice of medicine, that we're doing the bidding, being told what to do, being evaluated on how well we do it, by very well-trained intelligent well-intentioned people, but people who perhaps never went to medical school, haven't practiced medicine, and haven't cared for patients in the same way we do.

I think if we can better prepare physicians to serve as leaders in terms of how health care is organized and financed, how the daily rhythm of let's say primary care is structured, we can achieve huge gains in terms of not only reducing burnout but also helping physicians find deeper fulfillment in the practice of medicine.

Dr. Jennifer Caudle:
That's very interesting. Yeah, this is a very important topic, the topic about physicians and burnout, and how it's dealt with at all different levels. I do have a quick question that goes back to some of the numbers that we discussed a little bit before. In some of your research that you have reviewed, is there a difference between female and male medical students or residents in terms of burnout? I'm just curious if there's a gender difference when it comes to this feeling.

Dr. Richard Gunderman:
Yeah, I think the answer is yes. And in general, this is a very broad generalization and I apologize for that, but in general I think the risk of burnout is somewhat greater for female physicians, and I can't claim to understand that in great depth. But certainly one factor is what's perceived to be a greater challenge in balancing personal and professional life for female physicians.

Dr. Jennifer Caudle:
And that is definitely a big topic for women and men as medical students and residents and physicians are trying to manage their careers and families, as you mentioned. This has been very interesting. Can you tell me any final thoughts that you have or any other hopes that you have for the future in terms of helping young doctors, physicians, and students with burnout?

Dr. Richard Gunderman:
Well, I feel like to some degree many of us have been asleep on watch for the past few decades as the level of engagement of physicians in the leadership of health care has tended to decline and as the medical school and residency curricula have become more and more jam-packed with molecular biology or the latest diagnostic and therapeutic techniques, and somewhere along the way the physician as human being has gotten pushed more and more peripherally in the conversation.

And I think we need to restore the physician as human being and the physician as one who cares for human beings back to the center of the conversation. And I think one way every physician can do that, even those of us who say aren't at academic medical centers, don't have the opportunity to work with medical students and residents on a daily basis, one way we can all do that is to read more wisely.

If our only reading consists of the conventional medical journals and maybe national newspaper and who knows, The Wall Street Journal or the Financial Times, we're basically subsisting on the kind of diet that's going to produce a state of psychological and spiritual malnourishment. If we can read better, reading novels, watching good films or dramas on the stage, poetry, music conceivably, art, sculpture, and painting, but I'm going to call all that reading well.

If we can read well I think we can lead better lives. And in fact I've come to think increasingly over the years that in the final analysis each of us can really be only as good as the books we're reading. And one service every single one of us can perform is to engage at least one colleague in meeting regularly to read and talk about good books.

Dr. Jennifer Caudle:
That's very interesting. I really like your suggestions. I think these are very tangible suggestions that a lot of people will be able to take ideas away from. And I also like your phrase, I actually wrote it down, you said, "It's important to restore the physician as a human being," and I think that's something that we can really all take to heart. Many thanks to our guest Dr. Richard Gunderman for being with us today. Thank you so much for coming onto our program.

Dr. Richard Gunderman:
It's been a pleasure. Thanks very much.

Dr. Jennifer Caudle:
I'm your host, Dr. Jennifer Caudle, and you've been listening to Reach MD. To download this podcast and many others in this series please visit us at ReachMD.com. Thank you for listening.