The Invisible Burnout

I'm feeling a little overwhelmed. And I think it's just all because of me and not knowing how to adjust the expectations I lay on myself. 

Being a family medicine resident definitely has a much better work schedule. The calls are less intense and most of the nights I sleep in my own room instead of at the hospital's. The days are more routine, and I like to say, the "experiences with patients feel more normal"... From a time-stress continuum there should be comparably less burnout, but family medicine residents faces a different invisible monster - the probably insurmountable scope of knowledge that we feel we must master, and the weight of every specialist under the sun telling us that "you HAVE to know this".... and us often believing them...

Ever since the first day of medical school we've been told, "don't worry, you can never learn everything". I just never brought it. 

I never brought it because in any other field of work, knowing everything about your topic is what your clients expects of you. It's why we are a "professional". Whether you're a doctor, a lawyer, a pilot, or a real estate agent. Clients what people who are the best at what they do. Otherwise they might as well go to someone else.  

Of course I'm being naive. But I'm intentionally being silly about it. For fair reasons. 

Being a family doctor in today's world is harder than ever before. It used to be that "everyone who graduates medical school can be a family doctor". Many would dawdle in the field for a while  before going back into a specialty residency. There was this notion that family doctors were "the ones who didn't go for any additional training". Oh it's easy work, everyone can do it. 

Perhaps they can. But can they do it well? Do they know if they could have done it better?

Medical advances have taken on such a staggering pace that essentially every facet of medicine has so much scientific insight that there is no topic that you can rightfully just "blow over". Every madness in the field of medicine has its reasons. And those reasons can go so deep. Titrating anti-depressants is an art that takes psychiatrists five years to master. Managing complex diseases using the most complete latest evidence takes Internists hours of reading per day or week to ensure they are up to date. Even something as simple as managing gastroenteritis to avoid hospitalization in kids has more scientific insight than ever before. In every single topic, you can find piles and piles on literature telling you "how you can do it better". In the bookstore, there are books on every topic you can think of with more information than one can ever remember. No stone is being left unturned. 

That's great for the patient. But what does it do to the doctor trying to keep ahead of all this? How do we keep up with this? And when does "too much information" stops being useful?

In family medicine, the two biggest challenges are the wide scope of practice, and, in a way more unsettling, the much more limited time to assess each problem. A doctor who specializes in women's health may have a clinic that takes 30 minutes to do a FOCUSED assessment. A sports medicine specialist takes up to an hour to assess all the mechanics surrounding the problematic joint to reach a management plan. Most specialists book 30-60 minutes to assess ONE focused problem on their initial consult with a new patient. On the contrary, family doctors are often expected to manage multiple problems (average is 3) on a much smaller time frame (average is 11 minutes per patient).  On any given single patient, you might be trying to diagnose his latest knee injury, adjust his cardiac medications, attend to his skin complaints, then spent time counseling on his latest psychiatric concerns. Are we expected to do a poorer job in each of these complaints because we have less time? That would be unacceptable to us and to the patient. There is no mediocre medical care. You are either "the best doctor" or you shouldn't be one. How does one balance each task then, and not get the feeling that we are forever "short-changing" our patients? "Oh, I could have done a such better job on that one if I only have more time and don't have to attend to the 5 other problems he has got". A very familiar sentiment in many family physicians' minds, I'm sure. 

And because of that daily struggle, I am often left with the unsatisfying and bitter taste in my mouth - am I often driven to provide sub-optimal care because of the circumstances surrounding how I practice? As hard as I try, I feel like I can ever only become an almost-perfect practitioner providing almost-perfect care. To the patient, to society, to ourselves, what is the acceptable limit of slight incompetencies?

In reality, there are many things that a family doctor is better at, even if it's on somebody else's turf. Often we actually have much more realistic and practical solutions to our patient's problems. Even when it comes to the "bread and butter" of each field, we probably see more if it than anybody. We manage upper-respiratory problems much more rationally than probably what most ENTs would. We are much better in offering useful and practical management to most diabetics or geriatric patient that most Internists could. We often even have a much better handle of the interplay of most patients' psychiatric issues and their life situations than most psychiatrists would. And nobody would be able to match our abilities to assimilate all the relevant areas of a patient's health care and managing them in the most efficient and practical manner. It's like being a top executive of a company trying to balance all the facets of the company's mechanics. The type of global executive planning skills required is impressive. On top of that it all has to be carried out with much compassion, much sensitivity, and much patience as what all good doctors should do. Finally, it all has to be done in 11 minutes. 

So how do we cope? Or how should I cope?

By being better managers. By being more resourceful in assessing and using today's overwhelming amount of medical knowledge. The future direction of education for family physicians must be to give them skills on data and resource management as well as patient and society management. Family doctors are executive managers above all else (it is rightfully listed as one of the competencies in the CanMED criteria in physician training). 

They must also redefine their traditional approach to learning. The traditional way of "see one, do one, teach one" approach to medical education would not work. You just would not see enough to be competent in a 2-year residency. On top of learning all that they need to function as safe and competent physicians, it is more importantly that they know where and how to learn new information quickly. The notion of not being able to "learn everything" should not be tossed around in defeat, but with the secured sense that they do not need to because the content is actually quite accessible in front of them. Being a good family doctor shouldn't feel like a losing battle, and there should be continued support and improvement in this scope of practice that is so central and vital to our medical system. Starting at the level of the family medicine resident, we must learn how to start rethinking family practice, to make it sustainable, to keep it healthy, and to keep us all sane.