Title:Physician Wellness

Beyond the Burnout

Above: Medical assistant Ja’Mia Anthony works with physician Emily Zucker to review patient scheduling at a community health clinic in Northeast D.C.

It was a bitter cold January morning when family medicine physician Emily Zucker (M’15) arrived at the community health center clinic for work. She thought some of her patients might be deterred by the deep freeze, but despite the frigid 9 degree temperature, the waiting room was full, and Zucker was busy.

On her schedule that day was a new patient, a 13-year-old boy brought in by his grandma, his main caregiver. She was worried because her grandson was struggling in school and increasingly depressed. He had been on medications for attention deficit hyperactivity disorder in the past, and so she brought him in to Zucker for a refill.

In the short confines of a 15-minute visit, without any of his medical records, Zucker didn’t feel like it was safe to restart the medications. She examined him, made sure he was up-to-date on his vaccines, and listened to their concerns. But when she explained that she’d need more information—like a formal ADHD assessment from his teacher—before she could consider a new prescription, the grandmother became frustrated.

They left that day, Zucker says, upset with her and with the health care system in which she works: one with impossibly short appointments for complicated problems, and an electronic medical record that can’t access what his doctor at another clinic wrote. Visits like that, she says, always make her wish she could do more.

“What did I really do for him today?” she asks. “It wasn’t sufficient.”

But when she can’t do more—limited by the structure of primary care or by problems beyond the scope of medicine— she tries to take it all in stride.

I caught up with her after her clinic session ended that evening to learn more about her philosophy as a clinician. As a fellow in Georgetown’s Department of Family Medicine, I also see patients at the same community health center. Since we began working together last year, I’ve been impressed with her positive attitude and sense of calm in the midst of our often chaotic clinic days.

As we talked in our windowless workroom on that chilly January day, I started to understand more about how Zucker approaches the challenges of being a primary care doctor in the 21st century. She is a 2015 graduate from Georgetown University School of Medicine, and a 2018 graduate of the Georgetown Family Medicine Residency Program.

Like her fellow Georgetown medical school graduates—from recent alumni like herself to experienced physicians who have practiced for decades—her choices exemplify the balancing game that modern clinicians must play. We must consider many competing demands: our patients, our bosses, electronic medical records, insurance companies, and our own lives outside of work.

Lurking in the background of our busy days is the specter of burnout, stories of physicians so fed up with the grind that they leave medicine altogether.

Zucker reads the headlines about physician burnout, and she understands why it’s in the news. She sees about 22 patients a day, and she estimates she spends about an hour and a half finishing up her patient notes on the electronic medical record every day. She sees mostly Medicaid and Medicare patients, and insurance-related red tape abounds: prescription coverage denials, prior authorizations. But she’s made deliberate choices about her career that she hopes will be protective.

To stay inspired, Zucker turns to the memory of her grandfather, a family doctor in her hometown of Pittsburgh. He was the kind of doctor who exemplified the “good old days” of medicine, doing home visits and serving as a fixture at his patients’ birthday parties, weddings, and funerals.

“I think he would be proud that I’m a family doc,” Zucker says. “I feel like my work is very valuable and my patients need me.”

She also takes intentional steps to make her working life easier: she lives a 10-minute drive away from her clinic, she doesn’t multi-task when she’s finishing her notes, and she strives to maintain a good working relationship with the clinic staff, which eases the hand-off of non-physician tasks. She has a group text with her friends from residency where they compare notes, ask questions, and occasionally vent about their new roles as attendings.

And when it comes to patient care, knowing her limitations is key.

“I think I have a pretty good outlook, making sure that I don’t feel responsible for everything. Almost all problems can be taken on incrementally,” she says. “And I try not to take on someone else’s problems as my own.”

But Zucker is a new attending, and by her own admission, she worries that her low-stress approach to work and home might change when she has kids or more responsibilities outside of work. She loves her job, but she does sometimes wonder: In the current system, is physician burnout inevitable?

Daniel Marchalik, MD (G’16), doesn’t think so. He’s an assistant professor at the medical school and a urologist, and he’s charged with preventing burnout amongst MedStar Health’s 2,500 employed physicians and 1,150 trainees. His title, medical director of physician well-being, didn’t exist until he took the job in 2017. But the work he’s doing, he says, has been a long time coming.

“Our profession is transforming,” Marchalik says. “We’re not keeping up.”

MedStar is unique in appointing a faculty member to examine physician burnout, Marchalik says. It’s one of the few organizations in the country to devote real resources and time to the issue.

The Maslach Burnout Inventory is usually how academics measure burnout, which is defined as a self-reported job-related syndrome. The MBI is a psychological questionnaire that asks respondents to rate their answers to statements like “I feel used up at the end of the workday,” or “I have accomplished many worthwhile things in this job.”

Although a recent JAMA systematic review found that many researchers fail to use a standard definition of burnout, Marchalik cites a 2012 JAMA Internal Medicine paper in which he says the evidence is clear on one essential point: “We know that physician burnout rates are higher than any other profession.”

Experts tend to group burnout symptoms into three major categories. The first is moral distress, a kind of psychological trauma clinicians experience after witnessing the suffering of many patients over time. The second is fatigue and frustration from administrative tasks related to insurance companies or the electronic medical record.

The third is simply working too much: when the scales of work-life balance tip too far towards late nights at the office and away from time with family, friends, and even time spent alone. Since each problem is so different, each requires unique solutions.

Marchalik got interested in the issue of physician well-being—which he defines broadly as keeping doctors happy, healthy, and engaged in their work—while he was a urology resident at MedStar Georgetown University Hospital.

As a lifelong lover of literature, Marchalik decided to take advantage of the courses that the university had to offer, and he got a master’s degree in literature during the final years of his residency. A literature and medicine track for Georgetown medical students is now Marchalik’s passion project. He devotes an evening every month to discussing a contemporary novel with the students, a practice which he finds personally protective against burnout. Research shows, he says, that reading books is one of the best ways to help doctors stay happy.

“If you can’t keep your docs happy, the hospital can’t thrive,” Marchalik says.

While he can’t guarantee that doctors will always get to leave work on time, he is committed to exploring how the institution can do a better job supporting them. To Marchalik, that doesn’t mean lunchtime yoga classes or mandatory meditation sessions.

“Putting people in the line of fire and asking them to take deeper breaths doesn’t make any sense,” Marchalik says. “Physicians are really late to the ballgame in terms of advocating for themselves.”

Instead, Marchalik wants to focus on making concrete policy changes that make it easier to be a doctor at MedStar.

He recently introduced a program for house staff that gives them access to free emergency child care, for example. He’s also working on a long-term project to “optimize” the electronic health record, digging down into the nitty-gritty of how clinicians use it and how changing it might save them time. Although he’s optimistic about the work, he also knows he and his colleagues have a long way to go—and need to do a better job studying whether or not their interventions are effective.

“We’re all learning all the time,” he says.

Across the country, other Georgetown medical alumni are also grappling with questions of how to thrive at work.

Take Luella Toni Lewis (C’93, M’04), a family physician and geriatrician in Brooklyn, New York. For Lewis, health equity and social justice activism allows her to stay connected to a larger community and mission. Having a thoughtful wellness strategy has been key to her resilience—in medical school, residency, fellowship, and in her life now as a physician and consultant.

She first became involved as the president of the residents’ union and as a community activist during her residency and fellowship training at St. Vincent’s Catholic Medical Center in Queens, New York. After residency, it was a natural transition to a role as the chair for health care at the Service Employees International Union (SEIU), where she advocated for the rights of doctors, nurses, and other health professionals.

There, she worked on both political and policy strategy, and was often asked to share her tools for wellness with union members and staff. These grew into formal workshops for health care workers, and when she left SEIU in 2017, she started Liberation Health Strategies. She now spends her time as an advocate for health equity, both as a practicing physician and as an activist.

Her work is about “shifting culture and centering wellness as a strategy for both day-to-day protection from burnout, and creating a space to imagine an equitable health present and future,” she says.

For Lewis, her advocacy work for the rights of health care workers and marginalized communities goes hand-in-hand with teaching self-care to her workshop attendees. Her workshops teach both wellness routines and strategies for institutional change. Tools like yoga, exercise, and aromatherapy, she says, complement the work of fighting for improved working conditions.

“Sometimes it’s just providing the space to think about what’s going on,” she says.

When Jacksonville, Florida, cardiologist Thomas Hilton (M’81), started to feel burned out, he took a different approach: he cut his working time in half and devoted his energy to CardioStart International, a nonprofit organization that provides free cardiac care in developing countries.

He took his first trip to rural Peru about 10 years ago, where he saw patients with advanced cardiac disease. Nobody on his team seemed to be worried about money, status, or litigation—concerns that had plagued him back in Florida. It was a refreshing change.

“There’s almost a kind of reverse burnout,” he says. “Those cases are extremely rewarding.”

Deciding to work part-time in Florida took courage, Hilton says, and a step back from the lifestyle to which he was accustomed. But the global health work made him feel so invigorated, he says, it was well worth it. Now, he goes on several trips a year, and trains echocardiography technicians in Nepal.

One reason the work is rewarding, Hilton says, is because the CardioStart teams are so collegial and friendly. Having breakfast with his colleagues and discussing the cases for the day makes the work more purposeful. Back in Florida, he says, the doctors in his office are so busy that they work through lunch and often seem too stressed to talk to each other about their patients or making the practice better. All-staff meetings, he says, are sparsely attended affairs.

“This isn’t lonely,” he says of his global health work. “This is meaningful. And I feel like I’m good at it. This was one of the most important decisions I ever made in my life.”

As he nears the end of his career, Hilton is focusing on increasing his global reach. And at the beginning of hers, Terrika Jones (M’17)—now a Georgetown obstetrics and gynecology resident—is thinking about how staying close to home might be the right move for her.

The demands of residency have forced Jones to take a serious look at what she values.

“We often forget about ourselves,” she says. “You miss out on a lot of things: big events in family members’ and friends’ lives because you’re trying to uphold the obligation that you’ve made to so many other people who are dependent on you.”

As she thinks about her post-residency plans, a return to family—most of whom are in the Columbus, Mississippi area—is Jones’ planned strategy for staying happy and healthy.

“I want to be able to be prepared for whatever may come my way, but I also want to be able to share that with my family, and to have a family,” Jones says. “I want to still have a life despite being in this stressful field.”

Her time at Georgetown taught her to devote her energy to the positive aspects of caring for patients. She hopes to focus on high-risk obstetrics and reproductive health for teens.

“Georgetown prides itself on cura personalis—care of the whole person—and has taught me a sense of community,” Jones says. “It is so rewarding to bring joy into others’ lives.”

On Valentine’s Day at the community health center where Emily Zucker and I practice, our physician workroom was a smorgasbord of treats. Medical assistants, nurses, and front desk staff all breezed through to chat and sample the desserts. It was one of those days where we really felt like a team.

Zucker’s contribution was homemade brownies from a family recipe, and the batch was almost completely devoured by mid-morning. As we continued our conversation about the big questions facing our profession—about how to take care of ourselves as we take care of our patients—I was reminded that sometimes, good food is one of the simplest ways to bring colleagues together.

As she looks to what she hopes will be a long career in primary care, Zucker often thinks of her training at Georgetown. Her formative experiences as a student and resident helped ground her in the type of medicine she wants to practice for years to come.

“Georgetown has a very strong family medicine department, and they emphasize the value of primary care,” she says. “The cura personalis motto reminds you why you are going into the practice of medicine in the first place.” 

Mara Gordon is a family physician in Washington, D.C., and a health and media fellow at the School of Medicine and NPR.