Subscribe to The Podcast by KevinMD. Watch on YouTube. Catch up on old episodes!

We sit down with Scott Abramson, a retired neurologist with over 40 years of experience, to discuss the pervasive issue of physician burnout and moral injury. Scott shares his insights on the external pressures from EMR guidelines, hospital administration, and big pharma, as well as the internal myths that contribute to these challenges. He delves into the self-imposed beliefs of “I should do things right” and “I should do it with compassion,” exploring how these internal forces impact physicians’ well-being.

Scott Abramson practiced neurology with Kaiser Permanente Northern California for over 40 years, from 1979 to 2020.

He discusses the KevinMD article, “Repaving your path: How clinicians can prevent burnout by embracing core values.”

Our presenting sponsor is Nuance, a Microsoft company.

Together, Microsoft and Nuance are leveraging their rich digital technology and advanced AI capabilities to tackle some of health care’s biggest challenges. AI-driven technology promises to revolutionize patient and provider experiences with clinical documentation that writes itself.

The Nuance Dragon Ambient eXperience, or DAX for short, is a voice-enabled solution that automatically captures patient encounters securely and accurately at the point of care. DAX Copilot combines proven conversational and ambient AI with the most advanced generative AI in a mobile application that integrates directly with your existing workflows.

Physicians who use DAX have reported a 50 percent decrease in documentation time and a 70 percent reduction in feelings of burnout, and 85 percent of patients say their physician is more personable and conversational.

Discover AI-powered clinical documentation that writes itself. Visit https://nuance.com/daxinaction to see a 12-minute DAX Copilot demo.

VISIT SPONSOR → https://nuance.com/daxinaction

SUBSCRIBE TO THE PODCAST → https://kevinmd.com/podcast

RECOMMENDED BY KEVINMD → https://kevinmd.com/recommended

GET CME FOR THIS EPISODE → https://kevinmd.com/cme

I’m partnering with Learner+ to offer clinicians access to an AI-powered reflective portfolio that rewards CME/CE credits from meaningful reflections. Find out more: https://kevinmd.com/learnerplus

Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast, and get CME for this episode by clicking on the CME link in the show notes. Today we welcome back Scott Abramson. He’s a retired neurologist, and today’s KevinMD article is “Repaving your path: How clinicians can prevent burnout by embracing core values.” Scott, welcome back to the show.

Scott Abramson: Thank you, Kevin. I appreciate you having me.

Kevin Pho: So Scott’s been on multiple times. Go to KevinMD.com/podcast to search for his name and hear his story and prior episodes. But today let’s jump right into your most recent KevinMD article, “Repaving your path: How clinicians can prevent burnout by embracing core values.” What’s it about?

Scott Abramson: Kevin, the article is about burnout, the so-called burnout, what we can do about it. And if you remember, the byline of the article said, don’t blame others on the path you’re on, it’s your own asphalt. And that’s asphalt, a-s-p-h-a-l-t.

I know that’s kind of a harsh thing to say, and I know docs and all clinicians are burdened by the EMR, by hospital administration rules, by the medical industrial complex. But the reason I wrote this is because I’ve read so many of your articles about burnout and so forth on KevinMD, and they’re good articles and they’re certainly legitimate, about the external forces that cause us this consternation and this feeling of burnout. But I wanted to address the internal factors, the things that we can address within ourselves. And that’s why the title, it’s don’t blame others, it’s your own asphalt. It’s kind of harsh, but there’s a truth to it, I believe.

Kevin Pho: So you’re right that a lot of the articles focus on these external systemic factors that may precipitate physician burnout, but you take a different approach in terms of trying to address some internal core factors. So tell us more about that.

Scott Abramson: Like I say, those external, if you can change your EMR thing, if you can talk to hospital administrators and get more flexible schedules, that’s great. I mean, that’s a wonderful thing, I certainly encourage that. But what I’m talking about are the internal things.

So when people say burnout, and then they say burnout is moral injury, that’s the mantra. But then the next question is, what is moral injury? What do we mean when we say moral injury? And I would submit to you that when we say moral injury, and this is the best definition that I’ve heard, moral injury occurs when our actions or our feelings don’t match our values. When our actions and our feelings don’t match our values.

And let me just give you a quick example of that, Kevin. So Kevin, I don’t know if in your practice, do you have like what we call a homepage? Like if a patient wants to see you for the first time, they can look you up and see what your philosophy of medicine is and your background. At Kaiser we call that a homepage. And I would bet you 90 percent of the people that have a homepage like that, it will say something like this: my philosophy of medicine is to treat all my patients like family. My philosophy is to treat all my patients like family.

Now that’s a great value to have, and we all, I think, come out of our medical school, we go into medical school with that kind of ideology and idealism. But what is it like when you go to work and day after day you find that you’re not treating everybody like family? And you know, it’s like one little hit after another. Gosh, you know, if that person was family I would have treated them different. You know, I had to cut corners. I couldn’t answer that email for 24 hours and I know they were worried about it.

And just to give you sort of a glimpse of what my professional life was like, and this is a typical thing, it’s not anything special, but let’s say I got a call, let’s say it’s a Friday, I get a call from a family, a patient of mine with Parkinson’s disease. The guy’s going downhill and there’s just absolutely no way that I can see this guy. The family’s worried, the guy’s not doing well, but I’ve got, you know, I’m running late, I’ve got three work-ins, I’ve got an in-basket full of stuff. And I tell my nurse, you know, well, try this, call them, tell them this, try this, try that. But if I really was true to my values, if I really treated people like family, I would have seen this guy. But I didn’t. And I took a hit. My moral compass took a hit. And it happens again and again.

Kevin Pho: So from your experience, you’ve practiced for decades and talked to many, many other of your colleagues, and even reading things on KevinMD, what are some of the reasons why physicians may not be able to treat all their patients like proverbial family?

Scott Abramson: Certainly a lot of this has to do with systemic issues and so forth, but what I wanted to focus on is, what is the damage when we can’t do that? And the damage is because that’s what moral injury is about, is that we can’t live up to our values. And those are, and most doctors, those are their values. And I think those values come deep-seated within us, and that’s what I think we can address.

I mean, if you can address the EMR, if you can address hospital administration, great. But the things we can address, the things that are our own asphalt, these are the things internal with us. And so here’s what I think the internal drivers are. We work under these two myths, two myths.

The first is that we have a banner at Kaiser and it says, excellence every patient, every visit. Excellence. And that’s our values. All our lives we’ve been trained to be excellent, to achieve. I mean, if we got a B in middle school it was a family crisis. And I have a colleague of mine who says she was trained to be an Asian perfection machine. But the fact is, you don’t have to be Asian to be an Asian perfection machine. We all were trained that way, that’s in our DNA. And when we can’t do excellence with every patient, like I say, that’s what leads to our moral injury. And that’s why that visit with the Parkinson’s patient was so, you know, little bit, little bit of pain there, little bit. And it just accumulates.

So that’s the first myth, that’s the first thing that we have, that I do things right. I do things right, that’s me. And when I don’t, it takes its toll.

And the other value that we have besides I do it right is, I do it with compassion. I’m a compassionate guy, compassionate gal, that’s why I went into this. And when we find we can’t do it with compassion, and there’s another banner we have, it says, compassion every patient, every visit, form a bond. But when we can’t do that, and that’s not just a banner, that’s our internal banner, and when we can’t do that it takes its toll.

And for instance, that Parkinson’s patient that called in, I wasn’t compassionate. I was feeling angry. I was feeling angry at this patient, I was feeling angry at this family for calling on a Friday afternoon asking to be seen. And then I was angry at myself because I was angry at all this stuff. And it just snowballs.

So those are the two things that drive this feeling of burnout, that I do it, you know, this is me, I do it right and I do it with compassion.

And I’ll tell you this, Kevin. I have a colleague who’s a GI guy, and basically he spends 95 percent of his time doing procedures, looking through scopes and stuff. And he loves it. He loves it. He says it’s like being in a pinball machine, you know, you put the scope in and you snip this one, you scope that one, you biopsy this. And he looks at it as like a shooting gallery. But he doesn’t feel any burnout, because he feels his value is being in a shooting gallery and having fun. And so it doesn’t bother him that he doesn’t feel compassion for these patients. I mean, he wouldn’t say it like that, but that’s how it is.

Kevin Pho: So tell us some of the strategies that you found effective in terms of dealing with those conflicts that you mentioned.

Scott Abramson: Yeah. And Kevin, thank you, that is really the key question. Is given the fact that we have this in our DNA, that I must do it right, I must do it with compassion, and we can’t do it, and it takes its toll, that’s what happens, that our values are not matched by our feelings.

So let me try to explain this, what we can do, by telling you an epiphany that I had when I saw one of my patients, and this gave me the clue about what we could do.

So Kevin, I’m seeing this patient, her name is Joanne. She’s 38 years old, she’s got two twin daughters, they’re about ten years old. And when Joanne was about that age, her own mother died of a brain aneurysm. So Joanne went in to have herself checked, and she went in for an MRI, and the MRI didn’t show an aneurysm or anything, so she was fine. But it did show some, you know, like MRIs do, some minor little abnormalities. So that’s why she was sent to me.

So she comes in and I show her the MRI and explain everything, everything’s fine, there’s nothing to worry about, the MRI just showed this, what we call an incidental, just a benign coincidence, just a nothing. That’s what we call it in the business, it showed a nothing.

So I’m telling Joanne all this, and I’m just about to leave the room, and she grabbed my hand and she wouldn’t let me leave. She says, oh doctor, doctor, thank you so much, doctor, doctor, I was so, so worried, doctor, God bless you, doctor. And frankly this was all very embarrassing to me, because all I did was just look at this silly MRI and tell her it was OK. And I said, Joanne, don’t worry about it, Joanne, it was nothing. And I left.

But later on I thought about this, and I thought, you know what, to Joanne this was not nothing. This was something. This was a big something. And to me it should have been just as much a something. It was a blessing to Joanne, it should have been a blessing to me.

And around this time I happened to see a bumper sticker, and I think there’s great wisdom in bumper stickers, by the way. And so the bumper sticker says, it’s amazing the impact you can have on people’s lives and never even appreciate it. It’s amazing the impact you can have on people’s lives and never even appreciate it.

And I can tell you, Kevin, for the first 20, 25 years of my career, I was 40 years at Kaiser, I was in the never appreciated category. I was in the category that would walk out of the room, it’s nothing, next patient please. But when I realized how much this was a blessing to Joanne, and how this should have been a blessing to me, I should have reveled in that blessing. It should have made my day, what happened in that encounter.

And that’s the thing. And I think so many of my fellow clinicians, fellow doctors, are in the never appreciated category. And if you learn to appreciate those encounters, those honors, I think that goes a long way for bringing joy and meaning into your practice.

Kevin Pho: Well, that’s pretty profound, right? So I think that I read a lot of message boards and social media, I’m sure like you do, about how a lot of physicians, they actually don’t feel appreciated. And sometimes they need to be reminded, a simple thank you to a physician, a physician needs to remember that blessing, like you said, the blessing of the nothing, about the impact that they have on patients. Even though they don’t feel like they’re making an impact, that makes a profound difference in terms of physicians’ purpose.

Scott Abramson: Yeah, it really does. And that’s what I tried to do. It’s a struggle, because you know, you’re behind, you’ve got patients, you’ve got all these pressures. But if you can stop for just a moment and think about what you did for that patient, even though you thought it was a nothing, it can have a profound impact on the way you view yourself and what you do every day.

Kevin Pho: Now, do you have a story of one of your colleagues, or something that you’ve heard of, a physician having that epiphany? You mentioned that you had this epiphany perhaps later on in your career, but have you heard a story of a physician having this epiphany perhaps earlier in their career, and making that difference in that physician’s life, and perhaps alleviating some of that moral injury by reminding them of the impact they make?

Scott Abramson: Well Kevin, let me tell you a story about one of my colleagues who should have had the epiphany but didn’t.

So this happened many, many years ago, and I woke up one Sunday night, I was getting ready for the next day and I was shaving at night, and I noticed this like mole-like thing on my cheek. And I had this instant revelation that this was a malignant melanoma. And that Sunday night I didn’t sleep at all. We lived in Alameda, California, and I walked up and down the shoreline of Alameda all night long, thinking about how I was going to spend the next six months of my life.

So the next Monday I make an appointment to see the dermatologist on call. Sitting in his chair, he comes over, it’s a busy day for him, you know, and he comes over, he takes out this lancet, he goes to this mole-like thing, and he says, that’s just a blood blister. Pats me on the back, says take care buddy, and he’s off to the next patient.

Now at that moment, it so changed my life, I was ready to fall to my knees and kiss the hem of his Kaiser-issue lab coat. But here’s what I wonder. At that time, the doctor’s name was Dr. Gary Dick, and I said, Doc. And I wonder if Dr. Gary Dick had felt any satisfaction from that visit. Did he feel like he did something special? Did he feel like a hero?

But see, I don’t think he did. For him it was just, you know, popping some pimple on a neurotic colleague and you’re off to the next patient. But you see, he should have felt like a hero. He should have felt like a hero, because he was one to me.

And what I would ask all of your listeners out there, and my colleagues and your colleagues, is, listen, we are heroes to so, so many people. And we’re heroes just for all the ordinary, mundane, routine scut, blister-popping stuff that we do. And I wish, I hope, I pray that we start honoring ourselves as heroes, because we deserve it.

Kevin Pho: We’re talking to Scott Abramson. He’s a retired neurologist. Today’s KevinMD article is “Repaving your path: How clinicians can prevent burnout by embracing core values.” Scott, as always, we’ll end with some of your take-home messages that you want to leave with the KevinMD audience.

Scott Abramson: Well Kevin, are you familiar with the song by Kenny Rogers called “The Gambler”?

Kevin Pho: I am familiar with that song.

Scott Abramson: OK, so in that song he says that the gambler’s secret to surviving is knowing which cards to let go of and which ones to hold on to. And then he says that any hand you are dealt can turn out to be a winning one or a losing one.

And that’s the same thing with our patients. When they come in to see us, we can look at it as just a nothing, just a losing hand, just a pimple pop. Or we can look at this as, wow, I did something very special for this guy, I feel like a hero. It’s our choice. And like I said, you know, don’t blame others for the road we’re on, it’s our own asphalt. We can change things. We can practice mindfulness, gratitude. Mindfulness, gratitude.

Kevin Pho: Scott, thank you again for coming on the show and sharing your wisdom. Thanks again for the perspective.

Scott Abramson: Thank you so much, Kevin. I appreciate it.