It happened again.  I was talking to a particularly sick patient recently who related another bad experience with a specialist.

"He came in and started spouting that he was busy saving someone's life in the ER, and then he didn't listen to what I had to say," she told me.  "I know that he's a good doctor and all, but he was a real jerk!"
This was a specialist that I hold in particular high esteem for his medical skill, so I was a little surprised and told her so.
"I think he holds himself in pretty high esteem, if you ask me," she replied, still angry.
"Yes," I agreed, "he probably does.  It's kind of hard to find a doctor who doesn't."
She laughed and we went on to figure out her plan.   
This encounter made me wonder: was this behavior typical of this physician (something I've never heard about from him), or was there something else going on?  I thought about the recent study which showed doctors are significantly more likely than people of other professions to suffer from burn-out. 
Compared with a probability-based sample of 3442 working US adults, physicians were more likely to have symptoms of burnout (37.9% vs 27.8%) and to be dissatisfied with work-life balance (40.2% vs 23.2%) (P < .001 for both).
 This is consistent with other data I've seen indicating higher rates of depression, alcoholism, and suicide for physicians compared to the general public.  On first glance it would seem that physicians would have lower rates of problems associated with self-esteem, as the medical profession is still held in high esteem by the public, is full of opportunities to "do good" for others, and (in my experience) is one in which people are quick to express their appreciation for simply doing the job as it should be done.  Yet this study not only showed burn-out, but a feeling of self-doubt few would associate with my profession.

Analyzing questionnaires sent to more than 7,000 doctors, researchers found that almost half complained of being emotionally exhausted, feeling detached from their patients and work or suffering from a low sense of accomplishment. (From NY Times Health Blog)

Yet my own experience with my own emotions in medicine, as well as my experience with other physicians, suggests that half of the physicians in the survey are probably lying.  Being a doctor is certainly a great privilege, but it is also an enormous tax on the emotions.  Since I haven't done other jobs I can't compare, but there are many days I find myself wishing I had a job I could just do and then just leave at the office.  The changes in health care over the 18 years I've practiced have increased that frustration and fatigue, causing me to catch myself pining for the "good old days."  Ugh.

It is interesting that the study showed the highest rates of burn-out in the "front line" professions, such as family medicine, internal medicine, and emergency medicine.  So what is it in my job that makes me feel symptoms of burn out?  Here's my top ten list:
1.  The pressure to see a high volume of patients - because I am paid by volume, I am constantly pressured to spend less time with my patients.  This makes me feel like I'm not doing a good job on anyone.
2.  The fact that good work is penalized - When I do explain things, call people, or just act friendly toward my patients I am rewarded with a lower salary.  I constantly have to choose between doing good and getting paid, and that's really lousy.
3.  The piles of paperwork - This has grown steadily over time, and is barely reimbursed at all.  The time I spend doing paperwork either takes away from my productive time with patients, time with my family, or my own personal time to take care of Rob.
4.  The ridiculous rules - Complying with coding requirements for documentation, with "meaningful use rules," and with increasingly invasive rules around prescribing controlled drugs makes me nauseated.  Not only are these rules complicated and confusing, but noncompliance (intentional or not) to them could make me lose my license or worse.
5.  Dr. Oz and his cronies - I single out Oz only because of his overall influence (and to get back at Oprah for her vendetta against me), but the increasing invasion of medical information with self-serving balderdash is both annoying and destructive.  I don't want to explain why all fatigue is not thyroid, or why gluten is not a toxin, yet I must do so to be able to care for my patients.
6.  The Evening News - The love affair the networks (CNN and company included) have with the "latest study" is enough to make me consider experimentation in television/baseball bat mating.  Every day there is a study showing that what was helpful last month will now kill you.  It's all headling grabbing for money, and I spend an increasing amount of my time dealing with it.
7.  Drug seekers - Fueled by codependent doctors who can't say no to requests for controlled substances, far too much of my day is spent explaining why Percocet is not a good choice for chronic pain, and daily Xanax will just make things worse.  A huge percentage of my phone messages are about these medications and I would gladly stop prescribing them altogether if they didn't help some of my patients as much as they do.
8.  Politics and medicine - I've already said enough on this issue.  Unfortunately, the politicians are supposed to fix this mess, and that's a pretty depressing reality.
9.  The constant weight of responsibility - Over the past 18 years I have never had time away from the reality of this.  It isn't gone when I go home, and it doesn't disappear when I go on vacation.  I can do 18 years of good work, but I can never coast.  The next exam room may be that child with subtle meningitis, or the person seriously considering suicide.  It's in the fine print of the job, and I accept that, but it gets pretty heavy over time.
10.  Knowing that it can all crash any moment - If I miss one case of meningitis, don't address the depression properly, or simply have a bad day, I can see my reputation ruined.  Any day could be "that day" when my life can become 100 times harder.  Despite a career of doing good, one bad day can put me in the spotlight as a "bad doctor."

So do I want you to feel sorry for me?  Please no.  But I do want people, especially those who regularly put doctors in their crosshairs, to remember that this is a really, really tough job.  Yes, it's a privilege, but sometimes the pressures can turn the nicest doc into a jerk, the most careful clinician into a quack, and the most caring person cold.

Some of the things on my list are just part of the job, regardless of the system, while others are caused by the ills of society and our ridiculous system.  We need to fix what we can for both doctors and patients.  We also need to understand that we are all humans (despite repeated evidence to the contrary).

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