Commentary

Embracing Change: Is It Possible?

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Changes in health care have led to an epidemic of physician burnout. Although it is relatively low in dermatologists, consequences of burnout are major and can include decreased quality of care, increased clinical errors, frequent job changes, migration to other occupations, early retirement, and even suicide. Dr. Suzanne M. Olbricht discusses strategies for coping with change and increasing job satisfaction among dermatologists.


 

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My life is not the same as it was 15 years ago; my children are grown, my parents are elderly, and what I do in my leisure time reflects both new friends and maturing old friends. Some of these changes I embrace; others I simply accept. Some changes I intensely dislike but still know I have to accept them. Family changes can be difficult for all of us to manage. But changes in our profession? Now that gets to our core. These changes are unwanted and we do not have the time or energy for them. We have patients waiting! We have worked hard to develop a practice style that fits our patients’ needs and that feels authentic to our personal experiences and skill set. I completed 7 years of postgraduate training and still spend a lot of time pursuing continuing medical education opportunities, but now my prescription pad has become a suggestion pad and my overhead has swollen. Sure, I am happy to have new bench-to-bedside approaches to understanding diseases and cutting-edge treatments, but role changes? Employer expectation changes? Changes in insurance benefits for my patients? Regulatory invasion? Alternative payment models? The tsunami of changes we heard about several years ago is now crashing up on the shore.

Take a minute and write down 3 changes in your practice over the last few years that you dislike the most and then turn over the paper. We will come back to them in a minute.

In the midst of all these changes or perhaps as a consequence, there has been an epidemic of physician burnout characterized by emotional fatigue; depersonalization as evidenced by a negative, callous, and cynical attitude toward patients and their concerns; and a decreased sense of personal accomplishment. Burnout symptoms are more common in physicians than in the general population and penetrate as high as 46% of physicians in general practice, but it is relatively low in dermatology, affecting approximately 24% of our colleagues.1 Just working in a practice with high expectations surrounding the use of an electronic medical record creates burnout and the intent to leave the practice.2 Consequences of burnout are major and can include3 decreased quality of care, increased clinical errors, frequent job changes, migration to other occupations,4 early retirement, and even suicide.5 Change can sometimes feel like too much to endure.

People manage change with a number of strategies. One group of strategies is labeled disengagement: wishful thinking, problem avoidance, self-criticism, and social avoidance.6 Some of us just do not implement any meaningful use measures; we wish they would just go away and, after all, the penalties are not pinching us yet. More alarmingly, rates of physician substance abuse are rising,7,8 a response to stress that allows for at least temporary problem avoidance and creates social isolation. Disengagement strategies do not promote coping, our ability to reduce or control stress.

Another group of choices include engagement strategies: problem solving, social support, expression of emotion, and cognitive restructuring.6 These strategies develop resilience, which is the capacity to respond to stress in a healthy way so that goals are achieved at minimal psychological and physical costs. Resilience creates positive resource spirals, and resilient individuals bounce back with increased strength.9

Let’s do some cognitive restructuring: First, we accept that change happens. Even facts change. Psoriasis was once said to be a disease of the keratinocytes, but now we consider it a disease of the immune system gone awry. It was dogma 30 years ago that excision of melanoma required 5-cm margins of normal skin, but the standard of care today includes much narrower margins. Once we accept that change happens, we learn to expect it as the natural course of events, and then we can look for the parts of change that we can enjoy. Learning something new about psoriasis and melanoma can be stimulating. Learning something new about the science of population health, patient management rubrics, quality measure development, and practice business models can be energizing too. Spend time and effort working on embracing changes that both interest you and are relevant to your practice. Do you hate the idea of having to incorporate quality measures in your practice? The fact that regulatory policy requires quality measures is not going to change, but we can gain some control by reading quality measure literature, working within our practice settings to develop quality improvement projects that are relevant and effective, and contributing to the discussion of quality measures in dermatology either in print or through committee work. Accepting change as well as working with our colleagues to promote relevant and positive change are examples of engagement strategies that help develop resilience.

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