He was supposed to be the first patient of the day — not the last. He started as a “no-show” on an already overbooked afternoon office schedule. A gift of sorts, I thought, making clinic a little bit easier and a tiny bit quicker. But Jim showed up hours later in my waiting room. The front office staff asked if I was willing to squeeze him in, presenting me a choice: say no and reschedule for another day or add him on and extend my pain. It was my tenth consecutive day at the hospital, including a brutal weekend of call covering the ICU. My once-a-week afternoon office was the one chance I had to finish work during daylight hours. It was supposed to be a respite from the chaos inside the hospital. My beaten down brain and fatigued body just wanted to say no to Jim. I didn’t realize it fully at the time, but it was more than just ten days straight of work affecting me. I was suffering from burnout. Half of my brain tried to deal with the complexities of managing critically ill patients, new pulmonary consults, and outpatient phone calls. The other half was somewhere else; dreaming of sleep, alternate jobs, and searching for relief from the burden of a never-ending workload. That was the first time I almost killed Jim. When I almost said no. I did not hide my frustration well as I begrudgingly said I’d fit him in at the end of the day. I remembered Jim’s story. He was involved with the cleanup at the Twin Towers after 9/11 and suffered from lung complications. I saw Jim as the sun faded on the other side of the window. He was always a bit edgy and anxious, and today was no different. I half-listened to his answers from my rote list of questions. One eye on the words I typed out on the screen, the other on the clock and a disappearing sun. “Still smoking?” “Yes.” “Using your inhaler?” “Not really.” I admonished him and wrote scripts for refills as I went through the multiple clicks to try and close out his electronic chart and cross that threshold from “at work” to “on the way home.” It was just Jim and his open chart standing between me and the last few minutes of daylight. He didn’t jump up to leave as I would have expected. Over the years, you learn how to move patients along. Getting up out of the chair and shaking a patient’s hand is a strong nudge that the visit is over, and I was just about to do just that. This was the second time I almost killed him. Instead of initiating my move, I stopped and looked at him — really looked at him. He didn’t see me. He was somewhere else at the moment, just as I had been a few moments ago. “Jim, you OK?” I took a couple of slow breaths, waiting. With each exhale, my brain shifted from being in the car on my way home to back in the here and now of the exam room. And slowly, with both of us actually being present, his gaze met mine. And now I saw. His eyes were a web of lacy thin red vessels. I felt his fatigue overwhelm my own. His face looked gaunt. I had not appreciated his weight loss. His hands alternated, gripping his own fingers, squeezing them, as if afraid what they might do unchecked. I focused on my breathing and waited, giving Jim time. “I can’t sleep anymore …” The floodgates opened. His troubled marriage. The sleepless nights. Images stuck in his head of remains, the bones at Ground Zero. He wanted to shut his eyes and have it all go away. He was suicidal. He wanted to die. “Do you have a plan?” “Yes.” “Do you have a gun?” “Yes.” “Do you have bullets?” “Yes.” Things moved pretty quickly from there. He refused to go to the ER but agreed to meet me in the office during lunch the next day. He took my cell phone number and agreed to call me if he felt he was going to hurt himself. I wrote a prescription for an antidepressant and told him I would find a therapist for him by tomorrow. I called him the next morning to check-in, and he confirmed he was coming to our appointment. By then, I had recruited a psychiatrist to do the initial visit until I could get through the bureaucracy of the 9/11 Health and Compensation Program to get him approved for psychiatric services. We met daily for the rest of the week, and by the end, he was more hopeful, no longer wanting to hurt himself. Twice, I almost closed the door on a man desperate for help and hope. But as a physician suffering burnout, I was challenged to navigate what is basically a routine event: a patient late for their appointment. It was more due to random chance, as opposed to an experienced physician practicing at the top of their level, that I asked an extra question instead of pushing him out the door. Had Jim died, it would have been a horrific error and a preventable death. But that error would never have shown up on any quality metric or incident report. The impact of physician burnout on patient safety is very real and quite challenging to quantify with any sort of accuracy. Recent studies suggest that burned out physicians are more than twice as likely to report medical errors. When you have fatigued and emotionally spent physicians trying to preserve their own sanity, how many “Jims” do we fail to see? I have made quite a few changes since then. I cut back from full to part-time and ultimately landed on doing shift work. My time on and off work is much more routine and dependable. I look my patients in the eye, take more histories myself. Trust, but verify, the information in the electronic record. I no longer roll my eyes at technology and apps and the friction they sometimes added to my day. I have more patience to work through initial learning curves and take advantage of the potential improvements they bring to my daily workflows. All this to say, physician burnout is a patient safety issue. When we advocate to improve patient safety, it is imperative that we also advocate to reduce and prevent burnout. Nearly half of physicians, a third of nurses, and up to 50 percent of advanced practice providers report experiencing burnout. There’s no doubt that the epidemic is impacting provider well-being and, in turn, affecting quality of care and patient safety. I saw Jim a handful of times over the next few years. He would often still be late, but that didn’t matter. No longer in crisis, we would spend a few minutes each time catching up on things other than his lungs. I don’t hesitate to see late patients anymore. Jeremy Topin is a critical care physician who blogs at Balance. He is a member of the medical advisory board, Lightning Bolt Solutions. Source
