How to create a positive practice environment (AAFP scientific assembly)

Before seeing a patient, family physician James W. Ferguson, MD, reviews the individual’s medical chart and quickly runs through a few jokes. He’s not trying to perform a stand-up routine for patients. He just wants to make them laugh a little.

“We need some humor in medicine,” said Dr. Ferguson, who has run a solo practice in East Islip, N.Y., for 30 years. “We need to lighten up and show that we’re more than doctors. We’re humans.”

Using humor with patients strengthens the physician-patient relationship, health professionals say. It makes physicians more approachable. And it can relieve patients’ anxiety about the medical visit.

Just as important, incorporating humor can rejuvenate physicians who experience burnout due to the challenges of their job, said Mark Greenawald, MD, associate dean for student affairs at Virginia Tech Carilion School of Medicine in Roanoke.

“Humor relieves some of the pressure [on physicians]. Their work is hard, and the stakes are high,” said Dr. Greenawald, president of the Virginia Academy of Family Physicians.

At a time when demands on primary care physicians are rising and many doctors report experiencing burnout, it’s critical that physicians use humor and other tools to create a positive environment in their practice. That was the message delivered by medical experts at the American Academy of Family Physicians’ annual scientific meeting in Philadelphia Oct. 16-20.

During the meeting, physicians and mental health experts offered doctors guidance on how to weave humor into their day and how to maintain a positive attitude. Several sessions focused on effective ways to manage work-related stress and highlighted steps physicians should take to ensure their own well-being.

“We know there’s a crisis in health care, but there’s also a crisis in our practices,” Dr. Greenawald told colleagues during a session on bringing energy and passion to work. “Many family physicians are experiencing a crisis of burnout, compassion-fatigue and moral distress. Many are thinking of getting out of practice.

“We believe it’s part of our responsibility as leaders in family medicine to do what we can do to help rejuvenate our colleagues. We want to help doctors rekindle their passion for medicine.”

Burnout widespread among doctors

Forty-six percent of physicians experience at least one symptom of serious burnout, such as emotional exhaustion, depersonalization and a low sense of personal accomplishment, according to a June 2011 survey of 7,288 doctors nationwide. The findings were published in the Oct. 8 Archives of Internal Medicine.

Researchers found significant differences in burnout by specialty. Some of the highest rates were among physicians in emergency medicine, general internal medicine and family medicine.

Contributing to the high rate of burnout among doctors are increasing administrative demands, long work hours and concerns about medical liability lawsuits. That discontent can negatively impact the environment in physicians’ practices and hinder patient care, said Stephen P. Bogdewic, PhD, who led a session with Dr. Greenawald on bringing energy and passion to work.

“Doctors are the leaders of their team,” said Bogdewic, professor of family medicine and executive associate dean for faculty affairs and professional development at Indiana University School of Medicine. “In a leadership role, everything that goes on with them influences the health of their practice. If they’re experiencing burnout or feeling depressed, there’s no way they can disguise that completely.”

Such dissatisfaction can make it difficult for doctors to pick up on patients’ subtle cues, such as body language and tone, he said. Those cues can offer insight into medical problems or health concerns the patient might not feel comfortable bringing up during the visit.

Patients also can sense when a doctor is in a bad mood, and that can make them reluctant to share important health information, Dr. Greenawald said.

In those situations, patients “feel like they’re being treated more like problems than people. There’s nothing healing about that at all,” he said.

The key to achieving a positive attitude, even during the most stressful times, is starting the day by thinking about someone or something you are grateful for, said comedian and motivational speaker Steve Rizzo, who spoke at the AAFP meeting.

“You have a choice at that moment to steer your thoughts and emotions in the direction you want them to go,” he said. “You can choose to seize the day or you can let the day seize you.”

People who reflect on things they are grateful for feel better about their lives, are more optimistic about the upcoming week and report fewer physical complaints than those who focus on hassles or events that poorly affected them, said a study of 192 college students. The findings were published in the February 2003 issue of the Journal of Personality and Social Psychology.

Dr. Greenawald refers to this reflective behavior as “choosing your attitude.” He recommends that physicians take a few moments throughout the day to think about the good things in their lives. Doing so can help them put the challenges they face in perspective.

For instance, Dr. Greenawald often reminds himself, “My worst day as a physician is better than the best day of some of my patients.”

He incorporates humor in interactions with patients and colleagues to help lighten the mood and build stronger relationships. Humor does not have to involve telling jokes or being silly. He often makes a funny comment based on an observation.

When an older patient brought his wife to a recent medical visit, Dr. Greenawald asked the man, “Does your wife know you brought your girlfriend to the office today?” The patient smiled, and his wife laughed.

That type of humor “lightens the mood, and then we can dive in and start talking about things that matter,” Dr. Greenawald said. “Patients are more willing to talk openly [when they have] that human connection.”

Laughter enhances a person’s intake of air, which stimulates the heart, lungs and muscles, and increases endorphins released by the brain, according to Mayo Clinic. The result often is reduced feelings of stress.

More research is needed before broad claims can be made about humor’s impact on health outcomes, some medical experts caution.

Doctors can neglect their health

A common mistake physicians make is becoming so consumed with caring for patients and staff that they neglect their own physical, mental and emotional wellness, said U.S. Navy Capt. Mark B. Stephens, MD. Self-neglect impacts not just the individual doctor, but also his or her patients and the office environment, said Dr. Stephens, professor and chair of the Dept. of Family Medicine at the Uniformed Services University of the Health Sciences in Bethesda, Md.

For example, burnout in physicians has been linked to poorer quality of care, increased medical errors and decreased ability to express empathy, health professionals say. Personal consequences of burnout include stress-related health conditions, substance abuse and marital problems.

“If you don’t take care of yourself, you will have a hard time taking care of people in the long run,” Dr. Stephens said.

One component to boosting wellness is pausing during natural lulls in the day and thinking about what is going well and what isn’t, he said. Those moments improve self-awareness, which could help physicians identify, for example, when their negative mood needs to be made more positive, Dr. Stephens said. Stepping back to examine the day also can help doctors think of constructive ways to handle conflict.

Dr. Stephens encourages physicians to slow down when they eat, consume more nutrient-rich foods and be more physically active. Each of those simple behaviors not only improves physical health but also can boost happiness, he said.

“The natural elevation in mood and health that is associated with physical activity has been known for a long time and it’s the cheapest, best medicine,” Dr. Stephens said.

He recommends that physicians consider standing while doing administrative work to increase their energy. And he challenges doctors to view their office duties as another important aspect of their job rather than begrudge them.

The mindset of “just getting the work done is a survivalist mode of thinking,” he said. “By embracing the work, it mentally becomes easier to get through some of the chores and mundane aspects of practice that don’t deal with the doctor-patient relationship.”

Dr. Ferguson, the family physician in New York, admits that he has, in some ways, felt dissatisfied. He often has to debate the necessity of a medical test with insurance companies and frequently is pressed for time when caring for older patients who have multiple ailments and medications.

Yet he remains upbeat and tries to ensure that patients and staff have a positive environment at his practice.

“You live in your office,” he said. “You have to make it comfortable.”