A new Hebrew book examines the causes of physician burnout and suggests ways of returning genuine caring to medical practice.
By JUDY SIEGEL-ITZKOVICHdoctor book 311(photo credit: Courtesy)
It’s truly getting back to basics, as if modern man were to switch from iPad computers and microwave ovens to striking flints to make fire.While this just-published Hebrew book – by a clinical psychologist and two psychiatrists at Soroka University Medical Center in Beersheba and a family physician at the Rabin Medical Center-Beilinson Campus in Petah Tikva – has nothing to do with making actual sparks, it is aimed at reviving, rejuvenating, inspiring and reheating “burned out” Israeli doctors and other medical practitioners, and even students who haven’t yet received their diploma.It is titled Mashiv Haruah: Yetziratiut, Hitlahavut U’Meniat Shehika Bemiktzo’ot Harefuah (Rekindling the Spirit: Creativity, Passion and the Prevention of Burnout in the Medical Profession) and published by Tel Aviv University’s Ramot Press. The first two words of the title come from the start of the daily Jewish prayer for rain during the winter that refers to bringing back the wind followed by rain; the title, though, is a hint that the medical profession – worn down by low government priority, privatization of public services, abandonment by physicians to better-paying positions in the private sector and even emigration to “greener pastures” – needs help.During the earlier decades of the state, yearning to be a physician in an Israeli hospital – before they were all called medical centers – was the height of their desires and dreams. The stethoscope, the white coat and being addressed as “Doctor!” were glamorous and empowering.But today, in a global economy and a world where qualified and knowledgeable physicians are at a premium, things have changed. Once one earns the prestigious medical diploma and gets some experience, it is easier than ever to benefit financially from being a doctor. One can add a law degree to become an expert on medical negligence lawsuits, set up a company for insurance or state compensation for illness or damage, run for the Knesset (as numerous physicians have done), accept consultations and perform surgery in shiny, comfortable private medical centers – or go part way by giving private medical services in public hospitals where Sharap is legal.SOROKA PSYCHOLOGIST Dr. Stanley Rabin, former psychiatric department chairman Prof. Benjamin Maoz, senior psychiatrist Dr. Yuval Shorer and family medicine specialist Dr. Andre Matalon write: “We all need the feeling that we have the ability to help others.Giving to one’s fellow man provides ‘sustenance’ for the soul. The satisfaction the doctor feels when he knows his activity has improved the lives of his patients is the strongest possible antibody to the erosion” of his wellbeing.They dedicated the 174-page volume to Dr. Erika Landau of Tel Aviv, who at the age of 23 had been the youngest medical doctor in Israel – a psychotherapist and educational expert who founded and directs the non-profit Young Persons’ Institute for the Promotion of Creativity and Excellence, and has devoted herself to spreading creative thinking in a variety of professions.“Creativity,” wrote the late British-Jewish essayist, novelist, political activist and autobiographer Arthur Koestler, “is a type of learning process where the teacher and pupil are located in the same individual.”This message is presented as a theme by the authors at the beginning of the soft-cover volume. BGU president Prof. Rivka Carmi prefaces it by asking “why are so many doctors are not happy?” She describes too many of those who had initially been enthusiastic from their medical work but who had later declined into disappointment, anger at the system and burnout. At the same time, too many physicians are shocked by the verbal and physical violence in the healthcare system. Ironically, these developments occurred at the same time that significant breakthroughs occurred in medical technology, diagnosis and treatment. But physicians complain that their dissatisfaction has grown; they are regarded with suspicion along with lack of trust and appreciation.
What is to blame? writes Carmi, a pediatrician and geneticist and former dean of BGU’s Health Sciences Faculty before she became the university’s muchadmired president. Is the reason for the heavy burden on physicians shrinking manpower and many additional tasks that are not really medical? Is it due to the constant need up update oneself about medical developments via the Internet, where reports get as much or more credibility than physicians? Is it the demands of bureaucracy and administration that sometimes conflict with the good of the patient and accepted medical practice? Or maybe, suggests Carmi, it’s the defensive medicine and threats of lawsuits, or patients who are sometimes so ungrateful that they rage and rant at their doctors.CARMI NOTES it’s not surprising that three of the four authors of this book come from BGU, which from the start insisted on thinking deeply about its medical studies and practice and ongoing links with the community, its health and cultural variation. The medical profession, she concludes, “seems to have lost its way somewhat” and expresses her hope that books and thinkers like these will restore the ability to achieve genuine fulfillment and contentedness.The authors map out the erosion of doctors’ enthusiasm for their work, which begins with idealism, too much personal identification with patients and the doctors’ subsequent wasting of mental/emotional energies, a resulting frustration and avoiding of personal encounters with patients that turns into a general emotional disconnection.Finally, they invest only a minimal amount of time in their work, come in late, are absent with excuses, extend their breaks and end up by concentrating on dry medical research while giving up on patient care. Compassion is nearly dried up. A sad state indeed.THE BOOK is a variation of the “Balint group” – a group method of training physicians – both general practitioners and specialists – that was developed over six decades ago by Michael and Enid Balint at the Tavistock Clinic in London. Balint, born a Jew named Mihály Maurice Bergmann in Budapest, eventually changed his name to Balint Mihaly, escaped the Nazis and became a Unitarian Christian, studied psychoanalysis and established Balint groups to discuss psychodynamic factors in doctors’ problematic relationships with their patients.Even after the couple’s deaths, Balint groups continued, with an international federation, periodic world conferences and national non-governmental societies from Britain to Begium, Italy, Russian and beyond.The book often refers to Balint groups when discussing the need to diagnose, treat and heal while considering the patient’s emotional and personal needs. Shorer himself leads Balint groups for family physicians, and is a member of the Israeli Balint Society’s board.Such bodies, write the authors, make it possible to boost a doctor’s ability to listen to his patients rather than just look at their medical files. The Balint group is a place where doctors can present people needing help not as “cases” but as people with feelings and associations that have much influence on whether they get better or not.While Balint groups are not widely attended by Israeli doctors in their free time, the authors advocate not only this but a wholely different and more comprehensive attitude that improves not only patient health but also makes doctors more creative. They explain in detail that a physician regards doctoring as a kind of “sandbox” such as the framework in which a young child tries out a variety of tools and skills freely without being boxed in by convention and habit. Doctors are encouraged to look at patients’ psyches, feelings of guilt, even going back to their childhood relationships with their parents or their relationships with their own children. Introspection into the doctor’s life, his or her motives and and appreciation of pluses and minuses are a key part of this process.HUMOR IS also described as an important part in giving medical practice new life, improving relationships with patients and medical colleagues and viewing processes from a different angle; they are careful to point out that none of this comes at the expense of the patient’s humanity. One can even play the role of the painful back of a patient named Motti, his wife and the medical authorization he uses to get off work.One can describe comic situations that make ordinary routines more livable.Improved ways of working with medical students and of introducing psychotherapy in the teaching and practice of medicine are discussed.Actual – and even imaginary – home visits to see patients are encouraged by the authors according to this technique to understand his or her way of life and other ways of introducing a more personal and intimate understanding of what makes him hurt.Each of the authors brings his own personal history to the book. Matalon, the only family physician, notes that he has been personally familiar with the “fear of death” since the age of six. He suffered from serious asthma attacks, and was often rushed outside to breathe fresh air and undergo inhalation while taking adrenalin pills; often, these had side effects, causing uncontrollable shaking. He felt as if hours passed before a physician came to see about his lung problems. “He would speak to me and with my father calmly, in a relaxed conversation. He usually left only after I felt at ease. It may be that these experiences influenced my decision to study medicine.Without doubt it caused me to control anxiety.Today, just like that old doctor who came to visit me and calm down the whole family, I visit and calm people down as well.”The authors are well aware that their book seems to have been written for an ideal world – one in which physicians have the time to look their patients in the eye, understand their motivations, feel real compassion in their hearts, and are no longer forced by bureaucrats to “treat” 60 patients listed each day.One hopes that such better days will come.
