HJAR Sep/Oct 2023

HEALTHCARE JOURNAL OF ARKANSAS I  SEP / OCT 2023 19 about my first call night. I told him that it wasn’t too bad, “I only admitted 4 people total with 2 after midnight,” to which he gasped and ex- claimed “Oh my gosh, you got killed!” Since my prior frame of reference for a typical night of call was double digit admissions, 4 had seemed easy, and I had even managed to get a few hours of sleep. I remember smiling to myself and thinking, “wow, if that’s getting killed, then this private practice thing won’t be so bad at all.” Physicians don’t mind working hard, in fact we expect it. Burnout is not due to weakness or lack of emotional resilience. Burnout occurs when we find ourselves severed from the deep sense of purpose as to why we chose to go into healthcare. When we fail to deliver the type of care and the quality of outcomes that we be- lieve we could, we experience moral injury, and the result is burnout. And so, as we turn our attention to improving care outcomes for our patients, we are not only healing them, we are also healing ourselves in the process. And while confronting our country’s epidemic of diabetes and obesity — which are tightly interrelated — we also need to address the epidemic of provider burnout that is gripping our nation. Traditional management of diabetes For this article, we will only be discussing type 2 diabetes mellitus, a condition where the pathogenesis is related to insulin resistance, which in turn is strongly linked with obesity. Type 1 diabetes mellitus is a state of insulin deficiency where the organ that typically pro- duces insulin fails to do so. Type 1 diabetics typically do not suffer from obesity and require exogenous insulin just to stay alive. But patients family, and I think of him with the same level of respect I would have for a second father. For those of you who have been reading this series of articles and noted my prior references to a view of healthcare from the moon, it is partly because he often accuses me of being from outer space in how I think about the transfor- mation of healthcare. He does so affection- ately, always chiding me for good measure, something I enjoy immensely. I recall one oc- casion, a few years after having left practice, I ran into him in a local grocery store, where after the usual exchange of pleasantries — which for him would typically go something like, “Cole, they let you shop in this place? I think I need to find me another grocery store …” — he al- luded to something that I had never contem- plated before. At some point in our conversa- tion, I said, “You know … I didn’t burn out,” to which he replied firmly, “Yes, you did.” I denied it a few more times, to which he kept reaffirming, “Yes, you did.” And after reflecting upon the conversation, I came to the inescap- able conclusion that, as usual, he was right. I suppose I was in denial because the term burnout implied some type of weakness. My own work ethic was inspired by my actual father, and I never minded working hard, especially if the work was meaningful and purpose driven. In residency training, we routinely worked 36- hour shifts with little to no sleep, often admit- ting more than 10 patients over a 24-hour pe- riod. I will always remember my first weeknight of call after residency in private practice where I “only” admitted 4 people, with 2 of them after midnight. The following morning, as I was up- dating one of my partners about a patient that I had admitted the night before, he inquired By the year 1950, the volume of medical knowledge contained in the published lit- erature was doubling approximately every 50 years. By the year 2020, the volume of medical knowledge was doubling every 73 days. The number of indexed citations added to Medline in 1995 was just under 400,000. By 2021, it was over 1.2 million. Staying current in the field of medicine is now beyond the limits of the hu- man brain. It has literally become impossible for any one person to stay completely up to date with all advances of modern medicine. Given this impossibility, it becomes more im- portant than ever to embrace technology, sys- tems, and processes that ensure high quality, reliable care whenever possible. It will also be essential to reduce “burnout” in all disciplines, but especially in primary care. Under the pre- vailing volume-driven, transaction-based eco- nomic models, providers feel like hamsters on a treadmill, running faster and faster just to stay in place. There are never enough hours in the day to address all the questions and concerns of patients, and then to add insult to injury, they may find themselves delivering substan- dard quality of care because of their failure to remember everything. There is evidence that this injury — also known as “moral injury” — is one of the biggest drivers of burnout caus- ing providers to want to leave the practice of medicine (something I never thought I would ever do, but actually did in the year 2014). The road to burnout One of my dearest mentors is the longtime CEO of a large multispecialty clinic where I practiced medicine as a primary care physician for over a decade. I still consider that group as “The core structure of medicine—howhealth care is organized and practiced—emerged in an era when doctors could hold all the key information patients needed in their heads and manage everything required themselves. …We were craftsmen. We could set the fracture, spin the blood, plate the cultures, administer the antiserum. The nature of the knowledge lent itself to prizing autonomy, independence, and self-sufficiency among our highest values, and to designing medicine accordingly. But you can’t hold all the information in your head any longer, and you can’t master all the skills.” — Atul Gawande , in his commencement address to the 2011 class of the Harvard Medical School