Steve Adelman

Where Have All the Smiles Gone?

Posted in Caring for the Caregivers, Physician Health, Steve Adelman on August 26th, 2013 by MMS – Comments Off

By Steve Adelman, MD

What happened to turn the bright-eyed and bushy-tailed young house officer (right) into the late career physician (below) whose withering glance strikes fear in the hearts of patients, colleagues and office staff?

The answer, of course, is stress and burnout. The practice of medicine these days is inherently stressful.  The so-called health care system is more complex than ever, and the practice lives of most physicians are replete with all manner of acute and chronic stress.

We are victims of our own success. As life expectancy increases in the face of more and more administrative overload, reimbursements are decreasing. The art and craft of medical practice are gradually giving way to an industrial model of care that runs against the grain of many of our best and brightest. Our profession is in the midst of a painful transition, and legions of physicians feel as though they are wandering in the desert, with no view of the Promised Land in sight.

A Medscape survey earlier this year demonstrated burnout rates ranging from 30 percent to over 50 percent, depending on medical specialty. The hardest hit specialties include internal medicine, family medicine, and ObGyn, along with emergency medicine and critical care.

Medscape defined burnout as “loss of enthusiasm for work, feelings of cynicism, and a low sense of personal accomplishment.”  It also involves the trifecta of physical, emotional and cognitive exhaustion.  Little wonder that our late career physician isn’t smiling.

So what can we do to reduce physician stress and burnout?

Come learn about a variety of actionable countermeasures at our upcoming day-long Caring for the Caregivers CME program. Domain experts will share their wisdom on utilizing peer support, resiliency, mindfulness and compassionate care to combat the stresses of everyday medical practice.

Participants will have an opportunity to work in small groups to develop a roadmap for integrating these self-care methods into their daily practice lives. The program will conclude with a spirited feedback session that will involve discussing the matter at hand with a panel of senior health care leaders – an opportunity for dialogue to promote meaningful change on the front lines of medical practice.

Dr. Adelman is director of Physician Health Services, Inc., a corporation of the Massachusetts Medical Society. For more information, visit www.physicianhealth.org. Opinions expressed here are his own, and do not necessarily reflect those of the Massachusetts Medical Society or Physician Health Services.

Smitten by TED

Posted in Steve Adelman on July 18th, 2013 by MMS – Comments Off

By Steve Adelman, MD

I’ve been smitten by TED.

Not the movie, and not one of those stuffed animals emulating a roughriding former president.

I’m referring to TED talks, aptly described on the TED.com website as, “riveting talks by remarkable people, free to the world.” Some TED talks are under 5 minutes. Others may last 20 minutes. More than 1400 TED talks are currently available for viewing, and new talks are being created and posted every single day.

TED talks are free and they are easy to access. Think: Website, YouTube, SmartPhone, Tablet, Netflix. On the way to work yesterday, I listened to a marvelous TED talk by a surgeon who decided to give up the scalpel and devote his career to basic research aimed at discovering the underlying cause of Type II diabetes and metabolic syndrome. His career change was prompted by an emergency room encounter that forced him to take a critical look at himself and his tendency to “blame the patient.” See for yourself as Dr. Peter Attia answers the question, “Is the obesity crisis hiding a bigger problem?”

More than 20% of TED talks focus on a broad and eclectic variety of topics in medicine and health care. A recurrent theme in many of the other talks is the indomitability of the human spirit. I don’t know how they do it, but the people who deliver TED talks are all gifted speakers with amazing stories to recount. They truly inspire.

Early on, the talks focused on “Technology, Entertainment, Design” – hence, TED. These days, the scope is much broader – any great idea will do for a TED talk, provided that the talker knows how to mesmerize the audience.
Anybody interested in pedagogy should pay close attention to TED’s master teachers. I’m already scheming about how to make Grand Rounds feel more like a TED talk.

You can learn things about medicine and healthcare from TED talks that you won’t learn anywhere else. And any physician who delves into TED’s bounty of moving accounts of other walks of life is in for a real left-brain/right-brain treat: your analytical faculties and your emotions may be equally stimulated. As the practice of medicine becomes more and more of a left-brain enterprise, I suggest making use of this wonderful resource that speaks to the totality of our beings.

Dr. Adelman is director of Physician Health Services, Inc., a corporation of the Massachusetts Medical Society. For more information, visit www.physicianhealth.org. Opinions expressed here are his own, and do not necessarily reflect those of the Massachusetts Medical Society or Physician Health Services.

Each Physician Counts

Posted in Physician Health, Steve Adelman on June 6th, 2013 by MMS – 1 Comment

By Steve Adelman, MD

Last month I wrote about the MMWR’s report of an alarming increase in overall suicide rates when comparing 1999 with 2010. The demographic breakdown of the data did not include an analysis of employment or professional status.

It is well-known that physicians have an especially high suicide rate. Over the years, various studies suggest that physicians kill themselves at a rate that is about double that of the general population. Approximately one U.S. physician per day commits suicide. This represents an annual physician suicide rate that is the equivalent of 3 graduating medical school classes. If these high suicide rates are sustained, more than 2% of all medical school graduates will take their own lives.

The suicide rate of female physicians is particularly high. Women account for almost one half of all physician suicides, and they kill themselves almost four times as often as female non-physicians.

Time will tell whether or not the overall increase in completed suicides reported in 2010 continues to be sustained. It may be related to the economic downturn that led to high unemployment and the glut of home foreclosures.

We also do not know if the already high rate of physician suicides is increasing. The information on physicians cited above is based on data collected intermittently over the past 40 years. However, in 2013 the medical profession is rife with reports of physician stress and burnout. Few of us would be surprised to learn that suicide remains a significant occupational hazard in our profession.

There has been much speculation as to the causes of the heightened physician suicide rate. There are many reasons to believe that the current environment may be increasingly hazardous to the health of physicians. To wit:

  • We are victims of our own success. The explosion of medical knowledge and therapeutics has increased longevity, and as people live longer, their medical care becomes more complex and demanding. Concurrently, there is growing pressure on the health care dollar. In this environment, many doctors are called upon to do more with less.
  • Technology and regulatory requirements add new layers of complexity to the practice of medicine, and the pressures to be a productive physician have never been greater. There is less time available for the sustaining human connection that is at the heart of the doctor-patient encounter, and this frustrates every physician I know.
  • The demanding health care world we live in makes it more difficult than ever to balance the demands of work with the pleasures of family and community, and many of us find it increasingly difficult to take good care of ourselves.

It is incumbent upon us, as a profession, as members of health care teams and organizations, and as individuals, to meet these challenges effectively in order to improve the quality of physician life in our society. I am hopeful that we in the physician community will use our wits, our energy, and a spirit of self-help to establish successful strategies to counter the occupational stresses and pressures that may contribute to our unusually and unacceptably high suicide rate.

On October 3, 2013, the Massachusetts Medical Society and Physician Health Services are jointly sponsoring a one-day “Caring for the Caregivers” CME event that will focus on peer support, mindfulness, compassionate care and resiliency training as strategies that can be utilized to improve the work life of practicing physicians. Stay tuned.

Dr. Adelman is director of Physician Health Services, Inc., a corporation of the Massachusetts Medical Society. For more information, visit www.physicianhealth.org. Opinions expressed here are his own, and do not necessarily reflect those of the Massachusetts Medical Society or Physician Health Services.

Physicians Take Notice: Suicide Rates are Increasing Dramatically

Posted in behavioral health, Medicine, mental health, Steve Adelman on May 23rd, 2013 by MMS – Comments Off

By Steve Adelman, MD

Earlier this month, the CDC’s Morbidity and Mortality Weekly Report (MMWR) presented alarming data comparing age-adjusted suicide rates between 1999 and 2010.

Historically, the two major causes of death of younger people have been motor vehicle accidents and suicide. As motor vehicle accident deaths have gone down, suicides have gone up: 2009 was the first year in which the number of people who put an end to their lives themselves was greater than the number who lost their lives in car accidents.

Overall, the suicide rate jumped by 28.4% among persons aged 35-64. The rate of increase was even greater for whites, American Indian/Alaska Natives, older women (60-64), and people living in the West. As usual, in most successful suicides the cause of death is firearms.

To put the numbers in perspective, let’s think about a busy, multispecialty ambulatory adult primary care practice that employs a group of 4 internists, 2 nurse practitioners and a physician assistant. In the course of a year, perhaps 12,000 unique patients are seen in the office. A practice of this sort in Massachusetts, New York or New Jersey is likely to see one patient die by suicide per year. In Midwestern practices of this size, a second patient suicide would be predicted.

Suicide, not murder, is the most prevalent form of firearm death in this country. What is the role of primary care physicians in addressing this worrisome, growing public health problem?

Provide an opening: Give patients in the office enough time and space to talk about the things that worry them and weigh on them. A question like, “Is there anything else going on that you’d like to share with me? “ may give permission for a suicidal person to open up. A comment like, “Sometimes the most important stuff is the hardest to talk about….I’m all ears,” followed by enough time for the patient to think and open up, can make a difference.

Know your patient’s psychiatric history: Many elements in a patient’s history elevate the risk of suicide: a history of previous suicide attempts, a known mood disorder, a history of a substance use disorder, recent losses, and family history of suicide. Take the time to know your patients, and get help from mental professionals, as appropriate.

Clarify access to firearms: As firearms are the commonest proximate cause of violent deaths, physicians should understand whether or not their patients have access to firearms. It is appropriate to be worrying about high-risk patients with access to firearms, and to address this risk factor with the help of the patient’s family, mental health professionals, and, in some cases, the police.

Let patients know that the channels of communication are always open: People who know that they can always call and reach a health care professional have a place to turn when all else fails. Make sure that your practice has accessible 24/7 coverage, and that those covering know what to do when somebody suicidal calls for help.

In my next  post, I plan to discuss an important related topic: physician suicide. We have always been a high risk group, and this is especially worrisome in view of the recent overall increase in suicide.

Dr. Adelman is director of Physician Health Services, Inc., a corporation of the Massachusetts Medical Society. For more information, visit www.physicianhealth.org. Opinions expressed here are his own, and do not necessarily reflect those of the Massachusetts Medical Society or Physician Health Services.

 

20:20 Hindsight

Posted in Steve Adelman on May 17th, 2013 by MMS – Comments Off

By Steve Adelman, MD

Nobody has asked me to write these words; they are mine, and mine alone.

I should have realized, before the fact, that my speculative blog post on a possible marijuana-marathon connection had the potential to offend many good people. In retrospect, I regret the fact that I linked a painful and horrific public tragedy to the alleged perpetrator’s reported use of marijuana. I didn’t intend to upset, provoke and irritate, but that is exactly what my blog posting has done. I feel bad that my words and ideas were offensive to others, and I have asked that the post be removed.

I see little point in attempting to explain what I was trying to accomplish with my speculative posting. Going forward, I plan to focus on topics concerning the health of physicians. With stress and burnout growing in the medical profession, there is much work to be done in this area. Physicians who take really good care of themselves are best able to help their patients. I plan to do my best to promote the health of caregivers and the public.

Dr. Adelman is director of Physician Health Services, Inc., a corporation of the Massachusetts Medical Society. For more information, visit www.physicianhealth.org. Opinions expressed here are his own, and do not necessarily reflect those of the Massachusetts Medical Society or Physician Health Services.

 

Listening First Aid

Posted in Boston Marathon, mental health, Physician Health, Steve Adelman, violence on April 23rd, 2013 by MMS – 1 Comment

By Steve Adelman, MD

In the past two days, I have had the privilege of participating in two large support sessions for volunteers who witnessed the horrors at the Boston Marathon finish line. The sessions were organized by the Boston Athletic Association, in conjunction with the Massachusetts Department of Public Health.

The purpose of these events was to give stressed and  traumatized volunteers an opportunity to come together, share their experiences, and to commence the process of regaining a sense of emotional well-being after having served a sudden and unexpected tour of duty in an urban war zone.

Sunday’s session took place at the Boston Sheraton on Boylston Street, not far from the finish line. Monday’s session took place at the offices of the Massachusetts Medical Society and Physician Health Services, in Waltham.

Many affected volunteers at each session expressed feelings that they wish they had done more. Virtually everybody at the scene was thrust into a chaotic and unpredictable situation, one that nobody anticipated. In the minutes after the blasts, most everyone at the scene of carnage experienced serious challenges to their sense of being competent and effective.

Although the results speak for themselves – many, many lives and limbs were saved by a superlative team effort – the members of the team are all feeling pretty bad. It’s as if they were saying, “I have no idea how our team won on Monday, because I certainly could have played better.”

Many of the survivors described awkward conversations in the community and the workplace:  “People call me a hero, but I don’t feel like a hero.” It’s very difficult to feel incompetent and to be told that you are a hero.

Several survivors have learned that people out there “just don’t know what to say.” After the manhunt ended on Friday, a common comment they heard was, “You must feel better now.” But they didn’t feel better – many of them felt worse.

Question: How do we talk to people who have recently endured extreme trauma?

Answer: Very little – better to listen than to talk.

Listen very carefully, and try to put yourself in their shoes. Ask open-ended questions and respect their answers and wishes. Follow the lead of the person you are listening to. Here are a few questions and comments to consider utilizing if you undertake a conversation with a traumatized person:

  • Do you feel like talking?
  • What would you like to talk about?
  • Tell me more.
  • What was that like?

Don’t assume that you know how the other person feels, and don’t assume that their experience of the trauma is what you imagine it to be. By asking gentle, empathic questions, you can help the trauma survivor to unburden himself or herself, but only if he or she wants to.

As an empathic listener, your job is to follow the other person’s lead, never to take the lead. If the survivor you are with prefers to remain silent, that’s okay. Just let them know that you’re ready to listen if they ever feel like talking.

Gregorio Billikopf Encina of the University of California Berkeley has referred to this form of “empathic listening” as “listening first aid.”

Now that the acute trauma of the Marathon explosions is beginning to subside, let’s approach our conversations with the survivors – in our communities and throughout the health care system – in a low-key, respectful, and empathic way. By applying “Listening First Aid,” we can promote healing by helping them to feel understood, by trying, as best we can, to see the fractured world through their eyes.

Dr. Adelman is director of Physician Health Services, Inc., a corporation of the Massachusetts Medical Society. For more information, visit www.physicianhealth.org.

“This Too Shall Pass”

Posted in Boston Marathon, Physician Health, Steve Adelman, violence on April 19th, 2013 by MMS – Comments Off

By Steve Adelman, MD

The surreal situation unfolding today in Greater Boston will surely pass. In the meantime, a tsunami of images, directives, theories and fears is flooding the hearts and brains of our entire community. In this kind of atmosphere, those who are emotionally vulnerable are being whipped into a frenzy of stress, anxiety, and, in some cases, panic.

As physicians, we are uniquely qualified to help our community maintain a sense of proportion. We know how to stay calm in times of stress and strain; we know that the “tincture of time” is sure to heal in aberrant situations like this one.

The public looks up to us.  Let’s do our best to communicate a sense of calm and reassurance to all. Let’s use our knowledge, experience and professional perspective to help people maintain, or regain, their composure.

Dr. Adelman is director of Physician Health Services, Inc., a corporation of the Massachusetts Medical Society. For more information, visit www.physicianhealth.org.

We are All Patients, We are All Healers

Posted in Boston Marathon, Physician Health, Steve Adelman, violence on April 16th, 2013 by MMS – Comments Off

By Steve Adelman, MD

Terrorism is a vile disease, and when this disease strikes civilized society as it has in Boston, we are all afflicted. A sudden explosion turns all of us, immediately, into patients.

In times of crisis like this, we are all in pain. We suffer together. Each and every one of us has been violated. Innocents have been slaughtered and wounded; lives have been permanently damaged; a day of joy and celebration has been transformed into a day of mourning.

The disease of terror is not a fatal one. We New Englanders are fighters and we are helpers, and within seconds of the Marathon explosions we went into “healing mode.” A photographer at the finish line used one hand to shoot pictures while, with the other hand, he tore down barricades to get to the wounded . Momentarily stunned medical personnel immediately transformed the first aid tent into a field hospital. Friends and family rallied to assist and reassure one another, taking advantage of technology to reconnect and begin bouncing back.

Some bounce back faster than others. Here are some readily available resources that may be of assistance:

Coping with Disaster
FEMA – Ready.gov

Managing traumatic stress: Tips for recovering from disaster and other traumatic events
American Psychological Association

Recovering Emotionally
American Red Cross

Disaster Distress Helpline (24/7 phone and text)
Substance Abuse Mental Health Services Administration

Kevin Kennedy, Ph.D., is a Chief of Behavioral Health at Harvard Vanguard Medical Associates and a highly-regarded expert in parenting. I asked Dr. Kennedy to provide some practical parenting tips to guide us in talking to our children about the disaster in Copley Square. Here’s his advice:

“Events like the tragedy at the Boston Marathon cause children to feel vulnerable and unsafe. This is unavoidable. It is important that parents be realistic about the fact that some people do bad things but that most people are nice.

“Children are reassured by order and structure, so it helps to maintain the usual schedule of routines and activities in the family. In an environment of 24-hour news, parents can help children by limiting their exposure to excessive television coverage. Repetition of troubling videos can convey a disproportionate degree of danger.

“For much the same reason, parents should limit the amount of conversation about the tragedy in the presence of their children. Be sure to ask if the children have any questions and be alert to their concerns. Don’t be surprised if they want to remain close to home and need more than the usual attention or reassurance.

Above all, parents can assure children of their love and affection and their intention to take good care of them.”

Dr. Adelman is director of Physician Health Services, Inc., a corporation of the Massachusetts Medical Society. For more information, visit www.physicianhealth.org.