Ep 22 Doctors in Distress

Heather
Hi everyone, today I’m going to be talking about the lives of doctors, specifically what makes the majority of them feel dissatisfied with their work, at least at times. There’s ample evidence that doctors ARE feeling this way but I want to be clear that they’re not unhappy with anything related to their patients or patient care. They’re unhappy about the system that they’re largely stuck in. The same system that you, if you’re a patient, are stuck in also. And, that same evidence I mentioned shows that most doctors would choose to do it all over again if they had to start over. As my guest today points out: “if we could just sit in a room and talk to patients and help them all day, we would be so happy”. And I really believe this to be true. 

So why put out this episode, you ask? Because it’s my belief that the doctors and patients are, or at least are supposed to be, in a relationship together. And in that relationship it’s actually pretty simple. Someone needs help and care, and someone gives it. And if that’s all it could be, the whole thing should work. But the external forces around the doctor-patient relationship are destructive to it, and so to keep it together and stand strongly against those outside forces, we have to understand each other. Step one of that is learning about each other’s lives.

 Let’s dive in.

Today, I'm talking once again with Dr. Karen Leitner of Karen Leitner MD Coaching. Dr. Leitner was a practicing med peds physician. That's someone who's in primary care and can see both adults and kids in their practice. She left medical practice though, and is now a coach exclusively for women physicians. We talked in 2022 about why she left and how she arrived at coaching in episode seven, Dr. Burnout and Moral Injury.

It's definitely worth a listen and even a re-listen if you've already heard it. But today, we're gonna talk more broadly about why doctors are unhappy and what they're doing about it. Might this topic apply to other types of medical providers like nurses, assistants and others? Sure, but this is the topic that we know, so we're focusing solely on doctors today. Karen, nice to chat with you today. Welcome.

Karen 
Thank you so much. I'm happy to be here. 

Heather 
Hey, let's start off by talking about how many doctors feel dissatisfied or unhappy in their work today and how we know that. There are groups and organizations that regularly survey people in the health industry about all kinds of things, including whether they're not happy with their work. Back around 2018, 2017, about 40% of doctors in the US reported feeling symptoms of burnout and dissatisfaction and interestingly, that was across all races. In the more recent surveys, that number has jumped up into the 60 range. Just wow, what a huge increase. And as an interesting side note, there's a similar rate of dissatisfaction among residents, and it's even a little higher up in medical students, more like 70%. Karen, what's your take on this huge rise?

Karen 
It is a little overwhelming, isn't it? It's concerning and I think a lot of people aren't aware, like in the lay people population. So I'm so happy you're raising awareness and talking about it. I think it's multifactorial. So there's lots of different things and I'm not sure I'm gonna hit all of them. But one thing I noticed is that, you know, during the pandemic, people who are on the front line, like ER doctors, were for sure experiencing high levels of burnout. And in the subsequent years, they've sort of stayed the same or maybe decreased a little bit and then primary care specialties have had higher and higher rates because so much has changed in the practice of primary care as the system sort of struggles to meet the needs of the patients and it's insufficient. So there's not enough doctors, there's not enough staffing, there's been a huge resignation, there's not enough nursing, there's a lot of turnover. And I think like one of the biggest things that is foreign in the side of physicians is the administrative burden of practicing medicine.

 So if we could just sit in a room and talk to patients and help them all day, we would be so happy. But there's, we call it like death by a thousand clicks. So there's the electronic medical record, which really isn't designed. It was originally designed for sort of billing, but there's so many things it requires of us to document. And there's studies that show that in some specialties, like, you know, the amount of hours in a day that you would need to spend on your electronic medical record to meet the criteria for reimbursement is like, and to meet all the patient needs is like more hours in the day than exists. Like, so it's a huge, it's, it's a huge juggling act to get the administrative work done and not have it spill into your home life and your personal life and not to be expected to deliver care or be available 24 seven. So on some level, if you're creating boundaries in your life around the work that you could be doing, you, you're going to have to be letting someone down in order to prioritize yourself. It might be the nurses, it might be the patients, it might be the billers, it might be the charity people, and then sometimes it's your family who wants to spend time with you and there you are bringing all this work home with you in the evening time. So I think that that is a huge pain point for people. And then, you know, another big one is just the lack of autonomy.

Heather 
Wait, I just have to stop you there for just one second because I've been thinking about this for so many years now. I have never thought of it the way that you just said that at the end of the day, you have to let someone down every day. I never really thought of it that way, but that's totally accurate, I think. Like it is true that in a doctor's day, you cannot possibly fit everything you have to do into a day. So you're right. It's sort of like every day you have to show up there knowing that you're gonna have some sense, even if it's super tiny, even if you're trying to ignore it, you're gonna have some super sense of failure, super tiny sense of failure, right?

 Karen
Yeah, yeah, and we tend to be such high achievers that it's like, and it's not just failure, it's interpersonal, you know, it's, it's, it's sort of like letting people suffer and not doing anything about it is how it feels to us. We're just like, no, there's more patients, there's more need, I need to help more people. And in order for like self -preservation, you have to turn the tap off sometimes, you have to say no to the extra patient and then it feels bad. So that's moral injury that we talked about as part of contributing to.

Heather
Yeah, I'm glad you're saying that. Can you just remind everybody, because I think a lot of people probably did hear that other episode, but can you just remind everyone what burnout and moral injury are and what the difference is?

Karen 
Yeah, so moral injury is a term that was coined by a psychiatrist, but pertaining to Vietnam War when soldiers were coming back and some of them were having traumatic stress disorder and symptoms related to having experienced violence and seeing, you know, horrible things. But there was another kind of distress that some people experienced from having to behave in ways that went against their values. So maybe they didn't even believe in the war and here they are having  to show up and take these actions that went against their intrinsic belief system. And so Wendy Dean in 2020 wrote an article with Simon Talbot for the Stat News publication that was applying this lens to medicine and that physicians are being, quote unquote forced to provide care in ways that goes against our values and that the prolonged downstream effects of that contributes to burnout, which is a syndrome that by the WHO definitions has three components. One is emotional exhaustion. One is like loss of empathy. And then one is sort of a perception that you're, so loss of empathy meaning you're just not able to have as much care and concern and compassion for your patients as you see yourself as having. And then there's lots of judgments, self -judgements about that. And then the last piece is personal efficacy. Like, does what I'm doing even matter? Does it even make a difference? What's the point of it all?

Heather 
You know, last year, I don't know if you saw this, but there was a great article in the New York Times by Eyal Press in the summertime called The Moral Crisis of American Doctors. There was a great quote in there that I'm just going to read really quickly. He said, “In recent years, despite the esteem associated with their profession, many physicians have found themselves subjected to practices more commonly associated with manual laborers and auto plants and Amazon warehouses like having their productivity tracked on an hourly basis and being pressured by management to work faster”. That quote just stuck in my mind, like that's how I felt before I left medicine. Like I was just on a treadmill, you know, having to, yeah, like race ahead, fit as many people in, meet those goals. And then there's all this new terminology you have to learn, like RVUs and all the language related to how financial success is more the priority of your job. And yeah, it feels like morally wrong as a physician. You don't think you should be spending your time thinking about that.

Karen
Yeah! We used to say in my practice, it's like, we're not just sitting here building widgets. When you tell us how many patients we have to see in a given day and we're not seeing enough, it's like, these are people's lives we're trying to take care of. And how am I supposed to tell someone they have a terminal diagnosis or give support that their partner left them in a 15 minute interval where the clock is ticking? And so there's this conflict, like even doctors sort of, we..we hurt ourselves by falling into this belief that being more productive equals being a better doctor That's what I was saying about how the drivers of the system go against giving good care. Like on what planet does it mean you're a better doctor if you see 45 patients a day versus 20? 

 When I was in primary care, I do remember we get these productivity reports every month and you had these metrics you were supposed to meet. We're very like, we want external validation. We want to be told we're doing a good job. So if every month they're putting up on a screen, hey, here's how everyone is doing, Dr. Leitner, your productivity is falling down. We really need you to ramp it up. You're getting messages from the outside that you're not doing a good job. It's hard not to bite into that. And so sometimes in coaching, we'll slow down and people will even be like, I feel bad because it's tied into being a team player. And so if you're seeing fewer people, that means other people have to see more because there's a deluge. There's always like way more patients that need to be seen than we can meet up with. So I might be like, no, I'm fine. I just saw 17 today. I'm doing a great job. Meanwhile, people are waiting three months to get in to see me. So that also creates conflict. My brain is like, I need to see more and faster because people are suffering because I'm not seeing enough. And it gets very confusing in our brains. 

Heather 
That all makes sense. Was that, were your metric results put up publicly or just for you?

Karen
You know, I don't remember, but in a lot of places it's part of, you know, like certain specialties like radiology, for example, there's so much pressure to meet the volume to how many you're judged based on how many films you're going to see. And so I have to coach my clients who are radiologists who are like, I'm not, I'm not doing fast enough. I'm not seeing enough. And I'm just saying, just remember when you're the patient and it's your X-ray, you want the doc, you, you want someone to take their time and be methodical and careful. The fact that you're being pushed to see so many of these is because it's the volume of care delivered that generates the money. And that's why it's so broken. Like, fee for service medicine means your clinic gets paid by the insurers based on how many people walk in the door, not the quality necessarily, the care they give. So, I mean, this is a whole other conversation, but if money was tied to quality and the value of the care that was delivered instead of just the widgets and how many films you read and how many patients are coming through the door, it would create a lot more space for doctors to be able to have more time and be seeing the people who need it the most. Like I used to joke that it's like having a supermarket checkout line where, you know how we have like there's 10 items or less is one like aisle you can go in and then you might be in the like 50 items. And in medicine, everyone is in the same line. So you might see someone that needs five minutes of your time, and you might see someone that needs an hour of your time, and every patient gets the same amount of time. So it's just, you're constantly running behind, because you can't judge what someone's going to need from you on that given day, and then that makes us feel really rushed and bad.

Heather 
Well, I think that that's partly true and partly not true. I have long believed that if physicians answered the phone at a medical practice, like I think it would be so much more efficient. I mean, I can't even begin to tell you in my brain how this is working. It's like, it's awesome. Because part of the issue I think is when you call to make appointments, the people who are answering the phone to make the appointment do not have medical training. So they can't really like sit there and help figure out how much you need. But in my mind, and I am probably severely over-inflating my ability, but I thought like if I could be the receptionist at someone's practice, I'd be able to be like, okay, that's clearly gonna be a five minute thing, right? this person, this is gonna be 45. Like I know that just listening to their problem, like this is gonna be super complicated. You know what I mean?

Karen 
Yeah, totally.

 Heather 
But there's no, I mean, obviously that is a ridiculous system and you couldn't do that. But on the other hand, I mean, it's not working the way that we're doing it. Yeah.

 Karen 
I think it'd be an interesting application of AI, right? To just like the patient says all the things they want help with and then the AI generates like this is how long the appointment might take and it's something to think about. I had another thought, what was it? Oh, the thing that blows my mind is most patients don't even know how long their appointment is for. We don't do a good job of educating and I know you spend a lot of time and energy doing this and helping people realize it's not infinite time. So prioritize before you come to the doctor. Make sure you have all the information at your disposal so you ca be more efficient, like you and your doctor as a team want to be more efficient. What ends up happening is patients get mad that doctors don't have more time to spend with them and doctors feel defensive and end up wasting time justifying instead of both parties recognizing that they don't have control over how much time the appointments are. Neither of them does. And if we want the system to change, perhaps we should be fighting together to change that. But doctors spend a lot of time on the receiving end defending the system that they don't even, that they never, that they don't create and not realizing that's optional too. Cause that also feels bad. 

Heather
Yeah, yeah, I agree. I agree 100%. You sent me some really awesome tables ahead of time and I wanted to just talk about one of them entitled, What Contributes Most to Your Burnout? This was a survey given to physicians. I'm just gonna read what the top four were. So.

 Karen 
It's the Medscape annual, what is it called? Like depression, I don't read you exactly. Medscape's Physician Burnout and Depression Report in 2024, and they do this every year.

Heather 
Great, thank you. So on that report, 62% of respondents said that too many bureaucratic tasks contribute to burnout, like charting and paperwork and phone calls and stuff. 41% said they just spend too many hours at work. 40% said lack of respect from administrators, employers, colleagues, and staff. And 38% said insufficient compensation. 

Karen
Well, is it okay if we talk about prior authorizations for a minute because I think probably lay people don't even know what that is and that's been a huge

 Heather 
Yeah, yes, I'd love to.

 Karen
Wonderful. You're the only person.

Heather
No, because I agree, I know exactly what you're gonna say and yes, we have to talk about it, go.

Karen 
So a lot of people don't realize that every health insurer, like there's different medications and different tests and different treatments that it will and won't pay for. And so this is another sort of like a side. But they never teach us in medical school, you know, this is how much a knee replacement costs, or here's the 17 different health insurers and depending on which insurance brand you have, this is like the co-pay that the patient is going to get. So part of our moral injury is sometimes we're offering tests or we're prescribing things without knowing what the cost is, because we don't have the ability to know. And then patients are getting harmed, patients are getting big medical bills, and then they're coming back to the physicians and complaining. And we're like, my God, I harmed this person because I tried to order something that was appropriate for them. And I don't have control over it because I don't know about the costs or anything. So that's like just something that I think Wendy Dean does a nice job talking about that in the book that she wrote, which is called, If I Betray These Words, it talks a lot about corporatization of medicine in America and explains what a lot of these tensions are.  

Okay, but a prior authorization is you go to the doctor and let's say you're like I'm having the worst headache of my life and the doctor examines you and it's like my gosh I think you could have a bad problem and like let's order an MRI, whatever. And so they put in the check, the order into the computer and they send it to the radiology and then it gets denied by the insurance. you have to call, you have to clear. You know, you have to jump through eight hurdles for this to be paid for. They need this scan first, you need to document this, that, the other thing. And so the physician has to get on the phone or, you know, like, let's make it simpler. Let's just pretend it's like an asthma medication. It's like one kind of inhaler. We're like, you need this inhaler, you're having an asthma attack, let's get it for you. And then the insurance company is like, well, we don't cover that one, but we will cover this one. So then we, you know, change the orders and covers. Then it's like, well, you need to special approval. You need to call this phone number and talk to a peer reviewer and explain and justify why they meet the criteria for that one because this other one that's way cheaper for us would be better for us to give even if it's like not as powerful, not as strong, the patient's already taken it, it's not indicated, whatever. So we can't just prescribe the care without someone, you know, without all these barriers that take our time and energy and sometimes it's not, you know, life or death but sometimes patients really need something and we're being given the runaround. I remember I had a patient who had a kidney transplant who needed to take these medicines so she wouldn't reject her kidney. And one day all of a sudden, you know, something weird happened with her insurance and, you know, but she had three different insurances because she had Medicaid and Medicare and one other, you know, private insurance. And it was just such a, there's, there's not time in your day to fight these battles. You just can't, like can't justice just prevail? And when you, when you multiply that by several medications or several tests a day. It's just such a bad use of our time. And it costs the system as a whole a lot of money. And so like I live in Massachusetts, there was a lot of steps being taken to appeal to the legislature to regulate or restrict the requirements of prior authorizations because it's like money saving to the system, which is important, but then we have to look at where are these savings going? And a lot of times, right, it goes to like health insurers that are then making tons of money and taking money away from the patients. It's a very oversimplification of it, but it's very upsetting.

Heather 
Yeah, I when I hear about that, I can't begin to imagine when in a day physicians do that. I have to say honestly, like when I was in practice, I did not have to deal with it. Pretty much all my patients were on Medicaid, and they don't have as many prior authorization situations. So I didn't have to do that. But I can certainly tell you if I did have to, I wouldn't have had one minute to do it. I mean, I guess that's lunch. 

Karen
Lunch, I just hear physicians across the land laughing about lunch as if we get to take lunch. No, we don't get to take lunch. Most of us are eating like a sandwich at our computer covered with disgusting germs. You know? I had one. And so, you know, that's a lot of the work I do is like helping people be like, you deserve lunch. Even if someone has to wait, you have to take care of yourself too because we will always put patients first because it feels selfish to take care of ourselves because the system messages us that we shouldn't take care of ourselves and that's also a big part of the problem.

Heather 
Yes. Yeah, I agree with that. My father -in -law just went through something recently with prior auth where he needed a certain medication and he went through several different ones and they weren't working and he and his physician finally found one that was working great and it got denied. The doctor tried several times to do prior auths on it. They failed and got denied. They kept saying, you have to try this other medication first. The doctor or doctor's office, I mean, I don't know who actually was handling the paperwork, kept writing back. We've already done that as we've provided the paperwork to you to show. And I think it hasn't been resolved yet. I think now the physician himself has like written a one page letter explaining why this is a problem that they're not approving it. And then I come back to the same question, like, how did that doctor have time to do that letter? Did they even write it themselves? I don't know, but oh  my gosh, the hoops you have to go through.  I'm just gonna refer back to a couple episodes ago when I talked about drug costs in the US and just how that all works. I'm just saying it in case somebody hasn't listened to that episode. They really should because I went into detail on exactly why that situation occurs and how different insurance companies have different formularies and how those are made. And it's really just a wackadoodle system. And we're all kind of caught in the middle, the patients and the caregivers, we are caught in the middle of like the web. Yeah.  

All right, so we've sort of established the doctors are, the majority of doctors are feeling sort of dissatisfied and unhappy with their work. Let's talk about what are they doing about it? Like what are some examples of what you know from your clients and from what we've read, what are doctors doing about their unhappiness?

Karen 
Well, a lot of them are leaving, which is a really big problem for the system at whole.

 Heather 
Like you and I. We were both excellent doctors, by the way, and we both were like, no, we cannot do it. It's going to kill us if we stay. Yep.

Karen 
Yeah, yeah, it's interesting. I mean, it sounds so dire. I do just think it's important to make a plug that a lot of doctors still really love what they get to do. And the benefits of practicing medicine outweigh for a lot of people all this, you know, this is why we continue to do it because it is, I don't know if you want to include this in the podcast today, but like there's nothing like being able to help people in the way that we can. So I just don't want it to make it sound like every doctor hates their life and their job. Like there's plenty of people, right? There still are good opportunities out there and there are people who are, so you might start your own practice and then you have some autonomy back and then you get more control over your schedule, over how many patients you see, over who says what you can and can't do within your own practice. So I think that's, yeah.

Heather
Yeah, just to insert this from the JAMA open in August 2020, two thirds of the physicians across the country that they surveyed said they would choose to be a doctor again. I don't know what that would be for other occupations, but I mean, two thirds is a pretty high number, I think. If I think broadly about everyone that I know, I mean, a lot of people are okay with their job. Some love it, some are kind of unhappy, a lot are so -so. I think two thirds saying that they would do the exact same thing again is pretty high. So despite, I am glad you said it because despite everything we're talking about, the reality is that most doctors really just simply love taking care of patients and they just want to do it. And they're going to do it despite all this s-h-i-t that we're talking about. They're going to do it despite feeling unhappy, despite putting them their own personal lives on hold, despite all the hoop safe to go through, they're still going to do it again. So thank you for pointing that out, yes.

But so I know a lot of people are leaving and I want to come back to that more towards the end. And I also want to come back to, getting help like coaching, because I want you to talk a little bit about that, but some other things I'm thinking of, like, I know some doctors are leaving to do direct care practice models. That's kind of like concierge care and other things like it where doctors are more in control of how their practice works and they get to make more of the decisions. 

Residents and who are doctors and training are starting to unionize more and more. I mean, I kind of like that movement. I'm a little worried about what's going to happen when they leave residency and go out into the largely on unionized medical world, but good for them for now for doing that. I think it's Stanford that happened a couple of years ago and then they. Inspired a couple other places to do that. Yeah, I also notice I mean there's.

 Karen 
Yeah, that makes me think of, yeah, like the role of advocacy, the role of physician advocacy, which is not really something I was hearing or thinking a lot about when I was like in the throes of trying to survive practice. But, you know, people going to their government and like proposing initiatives through their state, you know, medical societies and trying to change some of these regulations and trying to speak on behalf of patients. I think that's something that some doctors are doing to try to take control back. 

There's this concept of learned helplessness which I see a lot in the people I coach which is you know who knows exactly where it comes from but I think a fair amount comes from our training where we're really not given any autonomy over like the lengths of our shifts you know what rotation we do when we go on vacation like do you remember having a golden weekend and that seemed like an amazing thing it was like that just meant you got two consecutive days off and you maybe you would get like, it wasn't every month, right? It was like a few times a year. So, then when you leave and you are in a role, we're just sort of like, what's the point? Learned helplessness was like one of those psychological experiments where they took rats and they like locked the cage and I'm gonna misrepresent it, but at some point they just stopped even trying because they're like, what's the point? Versus if they just got off and clicked the bar, the door would open and they would get food or whatever. So I think that plays a part in sometimes people are like well, what's the point? It's never gonna make a difference I'm just gonna say and complain but I'm not gonna walk down the hall and speak to the medical director because I did it one time and it didn't work so I give up, you know, and I'm not blaming doctors at all, but I'm I'm noticing like if we want change to happen, that's something we're gonna have to overcome because it's in the way we were indoctrinated.

Heather
So can we remind all the doctors out there right now that they can click the bar and get the food pellet? 

Karen
But like the way this shows up is like people won't even ask could I start my clinic 30 minutes later and then work 30 minutes later. Could I just shift? Even that? Well, they're not going to say yes. Well, how about you ask them find out and if they say no, then what? Like then what? In coaching we talked a lot about taking massive action. It's like, how many people do I have to ask? How many nos do I have to get before I finally get to a yes? It might be a bunch. But there's this, I'm not gonna ask.

Heather
Yeah, I understand that feeling of just, I actually understand learned helplessness. I do. I get it. Also combining that with the day that we've described. I mean, most physicians I know are just hanging on for dear life, like to get through day to day. You know, and I just don't think that they have the mental or physical time and energy to fight back, think about how to get changes made, improve the system. I just don't think they have the time.

Karen
I agree

 Heather 
which might be part of the point of the system to keep them so busy that they don't complain, you know.

Karen
Yeah, exactly. I mean, I think we'll get to this later when you're talking more about coaching, but there's also part of it that we, like no one's coming to save us, right? Like no one's coming to save this one. So if we don't,

Heather 
That sounds so awful. We are alone.

Karen
It's true though. We are, but we also, we can, we can save ourselves from ourselves. We can decide I'm not going to check my inbox when I'm on vacation and I'm going to be okay with whatever happens, even though the system says you should be checking an available 24 seven. Like at some point I have to be like, I'm not going to do that. Right. And it's because you're so tired and because your time is so limited that you have to do that instead of like, I can't, I just don't have the, you know, like it won't make a difference anyway. But well, how about you try and see because actually it can and it does. So.

Heather 
Yeah, but I also remember you talking a couple years ago, I remember this, that you said you were coming back from vacation and you were just dreading the inbox. Because you know, if you ignore it, it's like, it's kind of like, you know that you're going to come back to the pile. I don't know which is worse. I don't know.

Karen 
Yeah. Well, when I was in that place, I didn't know any of the tools of coaching. I didn't know how to manage my mind. And my identity was like, if my inbox has a lot of stuff in it and I haven't like gotten to all of it, I'm just bad. I'm a bad doctor. Like, so even just helping people separate, like, so that was part of the dread. What am I going to see in there that's going to tell me what a bad doctor I really am? It's not the inbox. It's like all the self-criticism, all the self -flagellation, all the comparing and despairing. That is something we have more control over. And then we have ways to like, my gosh, I don't want to take us off on a tangent, but there's one thing I posted on my Instagram right now that has 75 ,000 views. Do you know what it is? Which is like a crazy number of things. It's me saying if you are getting really, really long MyChart messages, part of it's your fault. And you need to stop trying to deliver care through the EMR and stop thinking that you're doing a good job by helping people because you're basically telling people it's okay to write me and expect me to diagnose and treat all my medical stuff in this technology that was not designed for this. It's just like, 

Heather 
Nice one. That clearly is resonating with everybody.

Karen
Well, not everybody. Some patients are really mad about it. But that's what I mean. We're just like, I can't help it. I get so many MyChart messages. It's like, but let's look at why. Yeah.

Heather 
All right, so let's dive in a little bit more into coaching then. I mean, how has coaching helped you and how is it helping some of the people that you're working with?

Karen 
So I found coaching at a time where I was in a job that I felt did not value me and did not compensate me properly and I was really resentful about it. And I wonder if there's, you know, when you read back what the top complaints physicians have about working in medicine, like this is up there, right? And so what I realized was I was choosing to stay in that role. Like I could leave. And coaching helped me really understand my value and what I had to offer and that if it wasn't being recognized somewhere, I could take my valuable self elsewhere. And so not that everyone who comes to coaching needs to change their job or leave medicine or that that's the heart of it, but it's starting to, you know, if 99 % of the problem is the system and like we've talked about before, all the things that make this, that make it so hard to be a physician about the system. Even if there's only 1 % that comes from the way we are indoctrinated in medicine that we can change how we think it can have huge, it can have a huge impact on our day to day. So I can give you some examples of that's helpful because I think it can be kind of abstract, but the things I tell that I tend to help my clients with, like the thing that helps people come with like a chart backlog of hundreds of charts and being on the delinquent list and then learning a new way to approach it and getting all their charts done by the end of the day they're seeing patients is usually looking at perfectionism and people pleasing. Perfectionism meaning you know my note has to be perfect and it's I don't have enough time to perfect it now so I'm going to do it later when I get home. Or people pleasing means like what are all the people going to think who read my note? What if there's… and I forgot perfectionism is also like what if I get sued it has to be perfect because somehow that's gonna prevent me from getting sued which is actually not true sort of magical thinking because it's bad outcomes that lead to lawsuits not like how good or bad your note is but I digress and then a huge part of it is people are worried about the next patient I'm gonna be late for the next patient so I'm gonna not finish the note now like finishing the note right after you saw the patient is always the most accurate, the highest level thinking and takes the least amount of time. So that's really what you need to be aiming for. But for so many of us, we make ourselves wrong. We're like, I don't want to be late to see that next person. And so helping people realize you're not wrong if you're late. And of course you don't want to be late, but sometimes you have to trade maybe disappointing someone else. And again, like a lot of times they're not even late. They're just making it up. It's just a story they're telling, but you have to disappoint someone else to avoid disappointing yourself. 

And then there's like, what about all my colleagues who are reading my note? I can't have a typo. What if they think terrible things about me? And it's being like, make your note accurate. Tell the facts, like write the minimum of what you need to convey. What's important for care and for billing and like move on with your life. So just these small things can make, and people interrupt you all the time, right? You're trying to do a note. Someone comes in. So learning how to sit with the discomfort of holding that boundary and saying, I need a minute, like, can you wait while I finish this? It's really important to me. And how to do that in a way that feels good to you instead of being like, oh my God, they're gonna hate me. You know, we just pride ourselves on like being a helper and being universally liked. And you cannot be universally liked if you're going to not lose your mind in medicine. And that's the harsh reality. I don't mean to laugh about it, but it's like, you have to like yourself and recognize even if you work 24 hours a day, seven days a week,you can't meet the demand and you can't make everyone happy. And it shouldn't even be the goal. So prioritize yourself and take care of yourself. That's what we do in coaching.

 Heather 
This comes right back full circle to where we started saying that you have to start your day assuming that you're going to let someone down.

 Karen
Well, I think saying it that way, that's one way to look at it. And the way I think about it is I'm going to show up and do the absolute best job I can. And I'm going to know that it's not possible to make everyone happy. And that shouldn't be my goal. But I can still do a lot of good and have a lot of incredible impact on the world. And that's what I'm going to focus on. You see how it has a different feeling versus like, I'm going to piss people off today. It feels pretty lousy. But I'm a valuable resource and I cannot, like I cannot allow a patient to derail those 20 valuable minutes we have together from my medical expertise to help them, to complain about my office staff or, you know, the scheduling or the parking lot. I just won't. So, because a lot of times we sit there and we just take it. That doesn't feel good either.

Heather 
Yeah, great. I asked the question hoping you would answer that way. Because I want to point out the difference in how people think about it. You know, it is, I mean, attitude is probably everything, I think, in today's medical care. Like how you show up those first 10 minutes of the day probably make a big difference, no?

Karen 
It makes a huge difference even how you show up to your patients. If you show up being like, sorry, I'm late versus I am so happy to see you. Thank you for waiting. What can we talk about today? Like how can we make this visit? How can we slam it out of the park for you? Energetically for you, the doctor that feels so much better. And a lot of what drives us down is just that fatigue of like apologizing, like in this rivalry energy, like we're doing something wrong when we're not. We're just never going to be on time. It doesn't even matter if we are. Just do your best, you know?

Heather
It's one of the reasons why I'm also so interested in what's going to happen with the next generation of doctors coming up. I mean, like when I mentioned the unionizing earlier, it's going to be fascinating when those unionized Stanford residents graduate. I'm going to be so interested to see how they choose to practice and how they tackle the systematic problems. Although I also feel like we're kind of in a different phase lately with awareness about physician satisfaction and burnout. Like, I know there's now there's like chief wellness officers and burnout languages become more mainstream and there's more partnering with administrative levels and seems like a lot of the focus is going off individuals but more onto like systems and processes and teams and I think it'll just be really fascinating to see how these guys come up. And interestingly, all this is in the news, I think quite a bit now, whereas before it wasn't, but it doesn't sound like medical student applications are falling at all. Like they are not daunted by what they're hearing, or they're not hearing it, who knows? If it's not on TikTok, I don't know. But I don't think numbers have gone down at all for medical students in recent years.

 Karen 
Do you remember when you were applying to med school, like all this energy around you telling you not to do it? Medicine's changing, don't do it, it's, you don't remember that? I definitely got that, it was like, you know, because my dad's a doctor too and there was some kind of Medicare reform and like billing was changing, like there was some big, you know, and the administrative burden was growing. So I just remember hearing a lot of like, it's not gonna be good like it used to be, you won't be able to make as much money. And that just made me wanna do it more. I was like, I'll show you, I'm so altruistic, you tell me I can't do it, I'm gonna do it, right? So I don't know if that, you know, but I do think sometimes there's just, you have to be toned up, you follow your passion, and then you get into it and then you're like, I didn't realize this was all happening. I just pulled up on this statistic, because you were just talking about it, from that Medscape survey. It said, does your employer seem to recognize burnout problems? And 48 % of people said no. Which I'm actually like, that means half think their employer does. So I don't know if that's, we don't have like the before, right? What was it five years ago, 10 years ago? But I would agree it does seem to be more discussed, but a lot of times it's like superficial. It's like we have a wellness officer that just like buys people around the drinks or like a Starbucks gift card. Isn't really changing, isn't really looking at the workflows or that, you know, making a big impact.

Heather 
Yeah, yeah, those are changes that I'm reading about. But yeah, I don't know if they're impactful or not impactful. I don't know. It shows movement, though. It shows awareness. But placating awareness isn't helpful. I'm not sure what kind of awareness it's showing. But do you ever talk to young people that are considering going to medical school? Like my kids' friends are at that stage now where they're starting to think about it. And one in particular regularly says that they want to become a physician. I'm always in my head, I'm like, what do I say? Don't do it. I don't say that because I just think it's somebody's choice. I'm trying to just say, well, this is why I left. You know, I do know people that are happy in their jobs. So, but I'm basically just trying to make them aware of what some of the challenges are that they'll be up against without telling them not to become a doctor because we need them.

Karen
I know. I mean, I also sort of think like I can't know what's best for someone else. So it's like, why do you want to and what do you think it's going to be like? And if they're making an informed decision, I was thinking about like, I'm more likely to see, you know, med students here and there. And I was at this like award ceremony for my medical society and there were two medical students there winning awards. And I went over to them and I was like, Hey, you know, so nice to meet you. I'm a coach. This is what I help people with. If I can ever help you along the way and things get hard, you know, because I just remember how hard it was for me. And if there had been someone I could really talk to, could normalize the experience for me, I did see a therapist, but it wasn't someone who dealt with physicians. And I didn't really feel like my institution was particularly supportive. So here I was meeting these med students thinking like, here I am on a plate, you know, and I could just see in their faces, they were like, they couldn't understand why they would need that kind of help. Like they were very happy, you know, they were just like in, they're like, yeah. And some people don't, some people just don't experience things the way you and I did. And you know, some people don't.

Heather 
Well, although 70 % of them will be understanding you by four years.

Karen
my gosh, my gosh, I know. The other thing I was just looking at in those slides, which I think is really interesting, which is off topic, but they asked people who had depression, is confiding in other doctors about depression a practical idea? And 57% of people said no. And 40% of people said, having depression makes a negative statement about me personally. 37 % were worried people would think less of me. So just to kind of highlight also the lack of space in medicine for, you know, tending to mental health and just normalizing how many of us experience anxiety, depression or other mental health things. I think it's a really important piece of a conversation to have. I don't know how exactly it fits to what we're talking about, but it's like so many people are suffering with this in silence, thinking it means something about them as a human, not realizing that you know, they've done studies looking at mental health before you go into medicine and then mental health in medicine. There's something about medicine that is good for your mental health. And it's not a huge mystery. It's like, you know, sleep deprivation, over self -sacrifice, being so self -critical. 

Heather
That’s all for today. I hope this was informative for you, whether you’re a doctor or a patient, because we really do have to all come together to make these relationships stronger to withstand all the external forces trying to influence them. You can find Dr. Leitner at karenleitnermd.com that’s (spell), or on various social channels at karenleitnermd. Also, I put links to all these sites in the show notes. 

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