Starting With Curious

It was the third of September

That day I’ll always remember, yes I will

Cause that was the day that my daddy died…

Papa was a rolling stone

Wherever he laid his hat was his home

And when he died all he left us was alone

Few issues define the cultural divide as sharply as one’s stance on family structure.  Senator Ron Johnson, for example, in a presentation I heard at Children’s Hospital of Wisconsin, placed the blame for America’s fiscal and other woes on single parent families.   (This didn’t go over so well at a workplace that is overwhelmingly female and with more than a few highly successful single parents.)  A fascinating recent article in Pediatrics may shed some light on this debate, or may simply generate more heat.

Researchers from Michigan and Princeton looked at the association between loss of a father and telomere length, a chromosomal marker of stress that is itself associated with a variety of adverse health outcomes.  (Telomeres shorten with age, and when they become sufficiently short cells die.  Thus telomere length has been called a “biological clock.”)  In this study, children who lost a father for any reason had significantly shorter telomeres than those who had not.  This effect was strongest for the death of a father, somewhat less for incarceration, and least for separation or divorce.  And it was stronger for boys than for girls.

Traditionalists might use this as evidence for the superiority of raising children in a two parent (specifically, mother and father) home.  But not so fast.  This study only examined those children who started out in a home with a mother and father, and then lost the father.  Loss and absence are not necessarily the same thing.  Also, at least for loss due to separation or divorce, nearly all of the effect (95%) is explained by lost income.  So one could as easily say this is evidence for the superiority of a living wage, and equal pay for men and women.

These findings also support the need for a change in the mass incarceration policy in this country.  The millions of men in prison – many of them men of color – are leaving behind millions of children who we now know suffer not only emotional but biological damage as a result.  This public policy crisis is creating a public health crisis.

One other tidbit in this study was intriguing.  The effect of loss of a father on telomere length was strongest among those children with a genetic variant in molecules involved in processing certain neurotransmitters.  How one copes with adverse events, like the loss of a parent, isn’t simply a matter of one’s character, or the strength of one’s support system.  Biology may not be destiny, but it sure tilts the playing field.

A rolling stone may gather no moss, but it can sure leave a lot of havoc in its wake.

This song about burnout on the job was quite popular in 1977 (original version by Johnny Paycheck; subsequently also recorded by Dead Kennedys). While many of you are not old enough to have been assaulted by the recording on AM radio, the sentiment probably isn’t at all foreign.  The phenomenon of burnout among medical professionals has been the subject of both serious research and discussion in the lay press.  A 2012 study in JAMA Internal Medicine revealed high levels of self-reported burnout among physicians, especially in “front-line” specialties such as family practice and emergency medicine, where over half of physicians reported some form of burnout.  (Fortunately, both primary care pediatrics and pediatric subspecialties had below average rates, although a recent study among pediatric emergency physicians was concerning.)  Also, physicians had higher rates of burnout than the general population.  (There are studies showing similar statistics for nurses, but I haven’t been able to find any studies specifically dealing with burnout among advanced practice providers.  I think we can assume it’s fairly similar.)

Burnout is defined as “a syndrome characterized by a loss of enthusiasm for work (emotional exhaustion), feelings of cynicism (depersonalization), and a low sense of personal accomplishment.”  Effects of burnout include symptoms of depression and/or anxiety, loss of empathy and objectivization of patients and co-workers, unprofessional behavior, high rates of error, and turnover or leaving the profession entirely.  It can also lead people to leave the profession.  Thus, burnout is a problem for the providers, for their patients, and ultimately for the system.

While a good bit has been written about the prevalence of burnout, there seems to be little data on what can be done to prevent it.  Burnout doesn’t appear to correlate strongly with hours worked, income, or satisfaction with work-life balance, but data are limited.  Consistent with what has been described, an internal survey of physicians at Children’s Minnesota revealed two overarching themes.  The first is dissatisfaction with the conditions of work themselves – things that make it difficult to do a job, everything from lack of staff to cumbersome electronic health records to dealing with insurance companies.  But the more important is dissatisfaction with the one’s ability to influence the conditions of work.  This includes lack of input into decisions, as well as the feeling that external forces – changes in the nature of healthcare – are inexorable.

For example, a commonly cited factor contributing to burnout is the electronic health record.  We physicians have been complaining about paperwork and charting since well before Epic and Cerner were a glimmer in anyone’s eye.  And honestly, even a digital non-native like me, with a bit of advance prep, is able to complete an EHR record in no more time than I could a written one, certainly when adjusted for quality and completeness.  So is the computer really the problem?  It seems to me what is different is that I have less control over the EHR.  With a written chart, I could decide how thorough to be, and what format to use.  But now a bunch of bureaucrats, administrators, and Millennial programmers determine what we need to document, and how, without seeming to care when it doesn’t make sense.

There’s good news and bad news here.  The good is that both of these themes can be addressed.  The conditions of work can be ameliorated – the EHR can be modified, scribes hired, staffing needs addressed.  And those doing the work, including physicians and other clinical staff, can be empowered to participate in decision-making.  At the same time we have to recognize that health care has changed and will continue to, in fundamental ways.  As the cost of health care now consumes almost one-fifth of the entire US economy, resources will be more limited, forcing us to make hard choices about those conditions of work.  Scribe, or clinic nurse, or staff to screen for social determinants of health?  Unlike in the past, we can no longer afford all three.  And no matter how much providers participate in making those choices, the locus of control has moved away from physicians.  Many of us came up in the era when the doctor had the final word.  When no one would ever question his (and it was usually his) productivity.  Accepting that decisions are made at least multilaterally, and increasingly by patients and families as consumers, is in my opinion a key underlying factor driving dissatisfaction and burnout.  Whether this will be as true for the newer generation, which doesn’t have the same inherent expectations of command and control, remains to be seen.

Burnout is real. There are many proximate causes, and we should try to address those to the extent possible.  But the root causes are related to the fact that being a health professional doesn’t mean what it used to.  At least not in the way we deliver health care.  Doctors have neither the status nor the authority nor the autonomy they once did.  Yet the mission of improving the health of those we serve hasn’t changed.  It’s still health care, and we do.  Anecdotally, keeping that front and center has kept me and many of my colleagues this side of shouting Johnny Paycheck’s lyrics at the top of their lungs in the clinic.  Perspective matters.  So if you need a little pick-me-up, watch this