Most people are familiar with that certain person at work who really gets under your skin. It can be the boss, or a co-worker at your same level, or someone at a lower ranking position. It is a big list, so I will break it into parts. Today, I will be discussing the same level co-worker. In my situation, as a physician, it involves individuals at my same level of duties and education. In particular, they were partners in my practice. One was a narcissist of the highest order. The other was hugely passive-aggressive.

I will start with the narcissist. It this case, it is a he. He was not American and came from a society that was heavily patriarchal. As I was researching dealing with the narcissistic personality, I discovered that there are two broad types. The first is the “grandiose narcissist.” This person always has to get the credit for any good that happens in the life around him. He is very willing to take someone else’s work and make it his to advance his cause and prestige. He may not necessarily be toxic. If you can get inside his circle, you can rise right along with him. But, you have to realize that you will likely not get much credit for the rise. That passive rise is enough for some people to keep their candle burning. Just remember that to cross a narcissist invites a certain amount of their wrath.

The other type of narcissist is the “vulnerable narcissist.” This is, by far, the most toxic type of narcissist. He wants to be seen in the best light possible and will not hesitate to trash to people around him to get there. This is my former partner. This type of person operates from some form of low self esteem. His need for acclaim is so strong that it is all consuming. This particular person is also quite lazy. So, he would cut corners, and avoid work as fas as he could get away with it. But, when something inevitably went south, it was never his fault. He would throw his colleagues and the nursing staff under the bus at a moments notice to deflect the investigation away from him. If you confronted him directly, he’d get angry, then interrogate you in the most derogatory manner until you caved on the subject. But, to the hospital administration, he was “just the nicest guy.” Those of us who were in the trenches with him wanted to smother him with a pillow.

I was the head of the department and I was powerless to stop this guy. He ultimately had to almost kill a patient before anyone would listen to us. Even then, it took 10 months to get him fired. It about killed me. The stress was so great on top of the real work that needed to be done that I think I almost had a stroke. This one year in my life truly burned all of my fuel.

To be honest, I have not yet figured out how to deal with people such as this. You have to be fairly strong in yourself and hold the line to keep them from attacking you. I had to document in great detail all that he said and did or didn’t do. It was tedious to say the least. In the end, it worked. For those of you that might have a vulnerability narcissist as a superior, life at work can be hell and you have no way to defend yourself. Most people in this situation get burned out quickly and move to other job environments. Life is too short to deal with people like this. Ultimately, the Karma Wheel does catch them. Save yourself.

The lack of sleep that becomes inherent in most health professional’s jobs is the largest drain of fuel for me. In my last post, I mentioned that one needs fuel to keep their fire burning. ”Rest,” ”sleep,” “recharging the battery“ are ways of saying that we need this down time to replenish our fuel supply. The fatigue fact air has been the elephant in the room for physicians and other healthcare providers. For a long time, centuries maybe, it’s been kind of a merit badge to say how long you’ve been working. I used to think that it was a great accomplishment to stay up all night doing my jobs. As I’ve aged, I discovered that this is crap talk. You just don’t think as well the next day. You forget stuff that is important to doing the job. You drive and don’t know how you get where you’re going. You fall asleep at the sop light. It sounds funny, but all of these things have happened to me.

A year or so ago, I was reading a journal article about the fatigued physician, as part of my annual OB/GYN Board re-certification. I was alarmed by a few things that were mentioned. Did you know that staying awake for 24 consecutive hours puts your brain in a state of disruption that is equal to being legally drunk? So a physician that worked in the office all day, then spent all night after that on the labor and delivery floor delivering babies or in the ED taking care of miscarriages or tubal pregnancies, then goes to the operating room for his/her regularly scheduled hysterectomies is actually doing those hysterectomies as if drunk. This sounds like a tragedy waiting to happen. The article also said that is takes three eight-hour sleeps to get back too normal. Did you realize that the vast majority of doctors never get eight hours of sleep a night, for years on end? As a doctor, this information scares the hell out of me.

Another article stated that some where between 50,000 and 100,000 deaths a year are due to the healthcare provider being tired. My mouth dropped open at that bit of data. It went on to state that the usual work shift of a resident physician in the first year of their residency is 36 hours. A physician at Harvard decided to decrease the work shift to two sixteen-hour work shifts and found that medically related errors decreased by 36%. That is amazing. This study lead to the Residency accreditation governing body to mandate that resident work hours be changed. I remember when these changes took effect, about fifteen years ago. Suddenly, these residents were not around for the surgeries that they needed to learn or the deliveries that they needed to do. For the attending staff, this meant more work for them. We all thought that the residencies would need to be lengthened in order for the training doctors to get their experience. In the ensuing years, the residencies stayed the same length. But now the residents were more rested and could remember their studies better. They were more engaged with their patients. The big problem was that when they graduated from their residency, they went to smaller practices and had to work more hours. They were unprepared for the “real” world day to day practice of medicine. The bottom line is that physicians need rest and needs to be supported by administrations in all hospitals across the nation.

The same problem of poor job performance in relation to fatigue is seen in other professions. Most notably, we’ve seen it in the transportation industry. The statistics say that it is safer to fly than drive a car. One reason for this is that airline pilots and crews are mandated to only work a certain number of hours in a row, twelve. After that, they are required to rest for twenty-four hours. On long flights, they actually have more than one set of crew on the plane. While one set is working, the other is resting is a special compartment is the tail of the plane. Why would this be a happening? The rested crew makes far fewer mistakes. If you make a mistake in a jumbo jet, hundred of people die. Research has also shown that this data is transferable across all of the transportation industry (trains, ships, buses). But for some reason, it has’t made it to mainstream medicine.

Beyond job performance, there are numerous detriments to ones health as one is deprived of sleep. Sleep loss leads to increased blood pressure and heart disease. It leads to increased irritability and social maladjustment. It leads to increased appetite and decreased metabolism, which subsequently leads to weight gain and obesity. If you are tired and irritable and hungry, you do not want to interact with other people and really don’t want to do your job. So, it stands to reason that work place productivity would decline as worker fatigue increased. Employers may not see this problem until something bad happens. It’s a shame in this modern world that someone has to breakdown in order for some positive change to occur in the culture of administration to be more proactive when it comes to worker health. A plane has to crash. A patient has to die. A doctor has to commit suicide. All are preventable if awareness is increased. I hope that this blog sheds some light on this subject. We’ll be looking more at the work environment in future posts.

Everyone can relate to this. It’s Monday morning and the alarm rings. You hit the snooze. I usually have to hit it 2 times or set several alarms. It’s time to get ready for work. Most of us dread it, I think. There are thousands of memes on social media exploiting this theme. But for some of us, the idea of going to “that job” again is loathsome. That is how it became for me. I’m an OB/GYN physician. For those of you that don’t know, I spent my days and nights delivering babies and taking care of all things that ail women. I particularly dealt with the aftermath of childbirth in the form of urinary incontinence and something called pelvic prolapse. After a baby is born, and as a woman ages, things tend to drop out of the hole, so to speak. I spent 65% of my time repairing that problem.  I really liked my job. It was important to me to help these women regain a certain quality of life. My problem was that I did not have enough time in the day to do it the way I thought that it needed to be done. I also did not have enough partners in my practice to cover all the bases, especially if someone was on vacation or something. You can only be in one place at a time.

 

They say I got burned out. What does that mean?  A fire burns out when it runs out of wood or air. A candle burns out for the same reason. How does a person burn out. This is becoming a hot topic in medicine. We physicians are supposed to be invulnerable.  We can take it. That’s how we’re made. I used to think that staying up all night was something to be worn like a medal. As I’ve aged, I’ve come to realize how bad it is for the body and mind to be deprived of regular sleep.  For a long time, burn out was considered a psychological problem of the doctor. There must be some flaw in that person or he/she could take it. For centuries, women were thought to not be tough enough to do the job. We now know that this is not true. 

 

So what can make a highly intelligent and motivated individual “burn out?”  Well, let us look at the fire, or fuel. In humans, this fire is often called passion. What fuels passion?  The things that fuel passion are different for each of us. Some are driven by the need to do good and help people. For some, it is the lure of the money.  And others, it is the need to be somebody that other people can respect. For me, it was a mixture. I initially went into medicine for the prestige it would bring me. I then discovered that I really did want to take care of people. Then I saw my first baby being born and was awestruck. Boom, I will do OB/GYN. The money just came along with the work. What we are not taught in school is how to manage a medical practice and take care of ourselves at the same time. 

 

After twenty-four years of caring for women and delivering babies, I was exhausted. Along the way, my health began to suffer. I ruptured a few discs in my back and had back surgery.  My body got slower. The night call got more burdensome. The pain in my back never left, and in fact got worse every time I delivered a baby. Then, I got to the point were I thought, on several occasions, that I could not get the baby delivered. I just could not get my body into the right position to do it, due to my back. It scared the crap out of me. 

 

Suddenly I found myself not sleeping well. If I screwed up a delivery, or a surgery, and hurt someone, how could I live with myself?  The easy answer, I would not be able to live with myself. I became so tired that I started to miss things. Try as I might, I just could not keep enough fuel in my tank to do my job. I confided in my partner that I feared that I might be a danger to my patients. Well, when you say that in certain circles, you get asked to take time off and go get your head evaluated. I felt like I’d been hit with a baseball bat. 

 

Now it’s been 7 months, I’ve had the second back surgery and a whole lot of counseling. I’ve come to realize that “burn out” is not a problem with an individual in isolation.  It is quite often a response that an individual makes in the face of overwhelming stress. In fact, the World Health Organization (WHO) has redefined their interpretation of burn out as an employment related syndrome. The bottom line is that the individual is the candle wick and the was is the fuel that keeps the wick lit, 

The wax is whatever you need to do your job to the best that you can do it. It’s the right equipment for your job, or the right people with whom you work, or the amount of rest and time away from the job. If your work environment does not supply the fuel well, you will lose energy. Eventually, you will lose all fuel and become ineffective.  At this point, you can literally die. The trick is to discover that you are in trouble before that happens. 

 

In my situation, I was in a partnership with one other physician and a midwife.  We were a rural practice owned by the hospital. We originally had four doctors and two midwives. We suddenly found ourselves two doctors and one midwife down. Each of the remaining doctors, my partner and me, was on call twelve to fifteen days per month. We each performed gynecologic surgery at least one full day a week. We could easily have to add surgery or deliveries at any given time. And we saw fifteen to twenty-five patients in the office per day. We needed another doctor, at least, to help the load. We worked this way for over a year and our business grew 67%.  

 

Then I started to run out of fuel. I found that I could not keep up with the work demand. I talked to the CEO of the hospital about getting us help.  What I really needed was less time on call so I could rest. He did not want to spend excessive money on a doctor to give us a break. We interviewed several doctors to fill the spot, but they never seemed to take the job, for some reason. I finally broke. My needed fuel was sleep and I could not get enough.  Thankfully, I figured it out before I really hurt someone. Many of my colleagues don’t figure it out and they inadvertently commit malpractice. Some turn to drugs or alcohol. Some commit suicide. I’d like to help this problem somehow. This blog will be my musings on the business and practice of medicine, and specifically OB/GYN.  I hope to encourage discussion on the many crossover issues related to work fatigue in other industries. The transportation industry has addressed these types of stressors. It’s time for medicine to do so as well.