Burnout is described as a syndrome of “emotional exhaustion, depersonalization, and feelings of low personal accomplishment,” and is an increasingly problematic condition among physicians for a multitude of reasons. The job of a physician can be a physical and mental strain, particularly for those in oncology, where the demands of routine excellence and long hours are commonplace.

At The University of Texas MD Anderson Cancer Center in Houston, the burdens that physicians and other oncology specialists face receive special attention through the Faculty Health & Well-Being Program. Henry M. Kuerer, MD, PhD, a surgery professor at MD Anderson who helped launch the program, described the signs and treatment of physician burnout in an abstract as part of the MBCC mini-symposium Thursday.

Kuerer discussed the variables that go into achieving a proper work-life balance, such as attitudes and beliefs related to relationships, habits, skills, and personality traits.“We all know what burnout looks like in our colleagues, but it is often hard to identify it in ourselves,” Kuerer said in an e-mail interview. “Burnout is a real-life, everyday thing. As with most things in life, the recognition of a problem is the first step in prevention and recovery from the problem.”

Doctors who are more experienced may have greater difficulty in acknowledging burnout. “For those who trained before resident work-hour restrictions were instituted, there is an unwritten code of rules and expectations,” Kuerer said. “There is a mentality that the harder we work, the more patients we have, and that the more tired we are, the better physicians we are.”

MD Anderson launched its well-being program approximately 10 years ago as a result of a tragedy. “We initially had buy-in for a faculty health program at MD Anderson after the suicide of one of our beloved surgery professors. It took a devastating event for us to get momentum and resources to make this happen,” explained Kuerer.

Warren L. Holleman, PhD, a professor of Behavioral Science who serves as director of the Faculty Health & Well-Being Program, described in an e-mail how he went about structuring the program. “I visited with every individual and group that would see me, and asked them to tell me their needs and challenges in terms of maintaining personal health and job satisfaction,” he said. “Many said this was the first time anyone ever asked them their views on how to improve our work culture.”

Although some of the concerns reflected individual health needs, Holleman said “there was also a need to change institutional culture” so that faculty members spent less time on administrative tasks, had a greater impact on decisions affecting their daily work lives and career prospects, and had avenues for building stronger social support networks with colleagues.

Both Kuerer and Holleman noted that administration backing is vital. “One essential component is to have the appropriate support and buy-in from the leadership of an institution,” Kuerer said.

Although a medical institution’s leaders may want to provide wellness programs, financial pressures present challenges. “Executives have this bad habit of setting revenue targets that are unsustainable in the long run,” said Holleman. “So what gets sacrificed, of course, is the health and happiness of their employees. Health organizations need to stop judging success in terms of quarterly reports and set their eyes on sustainable, long-range targets. Health, happiness, and job satisfaction may be inversely proportional to short-term productivity, but they are directly proportional to long-term productivity.” Although physician burnout oftentimes flies under the radar, the fact is that this condition is prevalent among providers and must be addressed accordingly by both individuals and organizations. “There is extensive evidence that burnout is associated with medical error and therefore decreased quality of care, increased lawsuits, and ultimately costs,” Kuerer said. “At this pivotal time as the nation’s reforms its healthcare system, it is of paramount importance that physicians develop their own personal methods to prevent burnout and maintain resilience. Without this renewed effort and support, the public at large is also at risk.”

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Burnout is described as a syndrome of "emotional exhaustion, depersonalization, and feelings of low personal accomplishment," and is an increasingly problematic condition among physicians for a multitude of reasons.

Coping With Burnout? Tips on Handling This Occupational Hazard

A growing number of health care professionals are considering the use of medical tattoos as a permanent method of letting emergency workers know valuable information about certain medical conditions that require special management.

This area of interest was discussed by Saleh Aldasouqi, MD, an endocrinologist with the Michigan State University Health Team, on Thursday at the American Association of Clinical Endocrinologists 21st Annual Scientific and Clinical Congress.

Aldasouqi noted that many patients with chronic conditions opt to get a tattoo to denote their condition in case they require emergency treatment. These tattoos allow first responders to avoid possible complications by knowing how to properly manage patients given the conditions they may have. For example, many diabetic patients get a tattoo on their wrist or forearm. By knowing this, first responders can test the patient’s blood sugar and, if the levels are found to be low, treat the patient with glucose. Other medical tattoos denote conditions such as allergies, high blood pressure, and heart disease.

Prior to the advent of medical tattoos, patients have traditionally looked to forms of jewelry, such as necklaces or bracelets, to indicate a particular medical condition.  However, Aldasouqi said that there is a lack of data, standards, and regulations associated with them.

“The medical community, and particularly endocrinologists as diabetes experts, should establish guidelines regarding medical tattoos,” Aldasouqi said. “Specifically, patients who want a medical tattoo need guidance on how to get it safely, where it should be located on their body and what it should look like.”

In the cases of diabetic patients, their blood glucose and A1C levels should be in a normal range prior to getting a tattoo in order to reduce the risk of poor healing or developing infections.

Additionally, Aldasouqi said that certain medical tattoos should appear on certain visible locations of the body. This would enable emergency personnel to locate the information quickly when responding. Since no guidelines currently exist, patients opt for several different locations on their body to denote similar conditions.

“Each minute and each second will count, as far as survival is concerned, for a patient in a diabetic coma,” Aldasouqi said. “Accordingly, the medical community must take seriously the opportunity and responsibility to establish medical tattoo guidelines.”

Another presentation at the AACE meeting on Thursday featured Dr. Saleh Aldasouqi, FACE, ECNU, discussing a topic that is not heard about too often in the medical world: tattoos.

Why Medical Tattoos Shouldn't Be Taboo

Although the 21st Annual Congress of the American Association of Clinical Endocrinologists (AACE) is focused primarily on developments in diabetes, studies relevant to the oncology world were also presented. Two, in particular, were on display as poster presentations.

	“Insular Carcinoma: A New Face of Thyroid Cancer,” was conducted by Rattan et al of Geisinger and featured data on this histologically distinct subset of thyroid cancer, which falls between well-differentiated and anaplastic carcinomas.

	The presentation, a case study of a 79-year-old male, included a summary in which the researchers explained that insular carcinoma is a subtype of thyroid carcinoma “whose criteria for diagnosis is not uniform among pathologists.” They also noted that this subtype exhibits increased aggressiveness and a propensity for both local recurrence and distant metastases. Because of this, the authors concluded that “it is important to identify insular thyroid carcinoma, as it warrants aggressive management with total thyroidectomy followed by radioactive iodine ablation of any remaining thyroid tissue, which leads to better outcomes.”

	The second study on display, “Novel Gene Expression Classifier Raises Pre-Operative Suspicion of Medullary Thyroid Cancer,” was conducted by Kloos et al of Veracyte. Medullary thyroid carcinoma (MTC) is the most aggressive of the well-differentiated thyroid carcinomas.

	The study focused on the use of the Afirma Gene Expression Classifier (GEC), a test that “measures RNA transcript signals from 142 genes and applies an algorithm to classify nodules, with indeterminate fine needle aspiration (FNA) cytology, as either ‘benign’ or ‘suspicious.’”

	The study included more than 10,000 biopsied thyroid nodules and allowed for a combined prospective and retrospective analysis of pre-operative case series of cytologically indeterminate and malignant FNAs. No false positive cases occurred.

	The researchers concluded that “the GEC can raise suspicion for MTC in certain FNA samples,” and that “surgical management is altered to include a minimum of total thyroidectomy and central neck dissection.” The research team also mentioned that “pre-operative RET proto-oncogene status alters management of unintentionally devascularized parathyroid glands.”

A look at two poster presentations from the AACE meeting focusing on insular carcinoma and medullary thyroid cancer.

Oncology Posters Presented at Annual Endocrinology Meeting

Expert medical witnesses are in a tricky business. Many physicians are skeptical about getting involved in the practice, and rightfully so. 

 and other online physician communities are rife with posts and comments from physicians who know colleagues who have stretched the truth or even lied on the stand because of personal beliefs or compensation. Aside from not wanting to get mixed up in legal situations, physicians also have to consider the possibility of unpredictable court times conflicting with their practice hours. To better understand the pros and cons of becoming an expert medical witness, we spoke to three experts in the fi eld: Dr. Scott G. Seidman, Associate Medical Director at 

(AMFS); Steven Babitsky, Esq, coauthor of several texts on expert witnessing and president of SEAK, Inc, which “provides customized training, seminars, publications, and professional directories for expert witnesses, physicians, attorneys, independent medical examiners, and workers’ compensation professionals;” and Dr. Bruce Livingston, a physician who has also attended law school, and whose company, MedWitness.com, “locates medical experts to review and testify in any type of case involving medical malpractice, personal injury, and disability.”

The various professional medical societies and state licensing boards have developed (and religiously enforce) specialty-specific guidelines for expert witness testimony, and if a physician is suspected of providing false testimony, he or she may be disciplined, fined, or even stripped of their license. Seidman says that physicians should always act appropriately on the stand. “When a physician provides expert testimony, it should be with the understanding that this testimony not only may create a future standard of care, but also is, in reality, an extension of that physician’s professional practice of medicine. As such, the same attention to the integrity of the opinions and testimony should be applied as one would exercise in that medical practice.”

Know what to do if unfairly reprimanded by your medical society. 

In very rare circumstances, physicians may be unjustly reprimanded by their respective boards for their testimony. The threat of this, plus the close scrutiny on some specialties (especially neurosurgeons and Ob/Gyns, says Livingston), may make some physicians hesitant to testify as expert witnesses. If a physician is reprimanded or punished for his or her testimony, it can follow them around and possibly prevent them from being able to testify after the incident, as they must state this when asked if any prior off enses have been documented. To help prevent this, Livingston provides a service at MedWitness through which physicians can participate in a mock “hearing,” which includes a doctor from the accused physician’s field, a trial lawyer, and other professionals. Livingston explains: “Let’s say a neurosurgeon testifi ed somewhere and the academy found him guilty of improperly testifying—either for the plaintiff or the defendant; now, he has a bit of a black mark. Th e assembly is not a governmental agency, but if someone ever asked this doctor at trial ‘have you ever had anyone ever say you have done anything improper?’, he has to answer. What we off er is a counterbalance; we say ‘let us do it, too, and let us see if we agree with what they found, and we will put a trial on. If we disagree with what’s been found, we’ll issue our fi ndings.’ Th en, if questioned on the witness stand about being found guilty for improperly testifying, that physician can answer ‘yes, but this place also investigated the situation and they found that I didn’t do anything wrong.’” It’s a unique service, and Livingston admits that he has not had many takers yet. He notes that it’s a service people will use only when they are confi dent they have done nothing wrong; physicians who know they might have crossed the line would not be able to exonerate themselves by taking part in such a hearing.

Cross-examination will require that the physician answer to both the plaintiff ’s and the defendant’s lawyers; this will often result in a game of trying to trip the expert medical witness up by twisting words around. In addition, both sides are likely to present their own expert medical witness, who will sometimes disagree about the questions at hand. What happens when two supposed “experts” have dramatically diff erent opinions on the same legal case? Livingston puts it rather bluntly, “There are people who do not like the system that say ‘how do 12 non-medical jurors judge this expert from Harvard and one from Stanford.’ It’s tough, and you kind of get ‘rump justice’— you don’t really get the truth all the time. Just because someone won doesn’t mean they were right; it just means that the jury believed them. Maybe one doctor dressed nicer or spoke better.” Livingston claims that relying on jurors who are unlikely to have any medical knowledge to correctly choose between two seemingly reputable sources with distinctly diff erent stances makes it hard for many doctors to have faith in the system, leading to widespread physician disinterest in testifying.

Understand the difference between legal and medical standards. 

Another reason physicians may be reluctant to become expert medical witnesses, according to Babitsky, is because they are concerned with the less-stringent ways in which the law determines standards of care. “The law is concerned with the standard of ‘more probable than not’ (ie, over 50%). Medicine is concerned with much higher probabilities when rendering medical care. The problem for many physicians is that they are not used to the ‘more probable than not’ standard when rendering opinions and testifying in court.” Th is discrepancy between the two sets of standards concerns physicians who are skeptical about “correct medicine” prevailing.

At this point, we’re guessing you are absolutely enthralled about the possibility of becoming an expert medical witness. However, before you go thinking it’s more trouble than it’s worth, there are actually some benefi ts to consider before making up your mind.

Expert witnesses in general, not just expert medical witnesses, will always be needed. They have the knowledge and experience that are necessary to understand the nuts and bolts of complex legal cases. It’s just like anything else; in order to truly understand a subject, you turn to those who have dedicated their professional lives to it. When it comes to expert medical witnesses, Seidman concludes that, “Experts are commonly called to testify on several issues. These include standard of care, causation, damages, and prognosis. Several of these require the expert to apply his or her knowledge directly to the question, while others require the physician to incorporate knowledge of how others would act. In this way, the expert contributes not only judgment and expertise, but also the knowledge of how peers handle similar cases. Without the testimony of an expert witness, the evidence-based guidelines alone would be incapable of establishing the legal standard.”

Helping a patient in need can be extremely gratifying. 

Although we have all read accounts of physicians’ bad expert medical witness experiences, many also speak about how satisfying it is to help out one of their patients. Maybe you aren’t crazy about adjusting your regular schedule to possibly get caught up in a legal system that is far from perfect. However, many physicians decide to become an expert medical witness because they believe in the cause. By providing your honest testimony to support a cause, you might be able to help improve the quality of life of someone in need. You will be paid (sometimes handsomely) for your time. Many expert witnesses charge an up-front minimum payment, in addition to an hourly fee that is often more than they would be charging in the offi ce. Th is means that expert medical witnesses are, more often than not, being paid more for giving their medical opinion than they would be for actually practicing medicine in the typical sense.

First, if it’s offered, get boardcertified in your specialty. After that, it helps to find a business that will train you to become an effective expert medical witness and will then actively find appropriate cases dealing with issues in your specialty. Organizations like the 

 are excellent places to start; they can help you prepare for the experience and make sure that you understand exactly what you are getting into. Just remember to tell the truth, the whole truth, and nothing but the truth.

Many physicians are skeptical about getting involved in the practice, and rightfully so. Sermo and other online physician communities are rife with posts and comments from physicians who know colleagues who have stretched the truth or even lied on the stand because of personal beliefs or compensation. 

Sean Johnson

Articles

Coping With Burnout? Tips on Handling This Occupational Hazard

Why Medical Tattoos Shouldn't Be Taboo

Oncology Posters Presented at Annual Endocrinology Meeting

Expert Medical Witnesses: Should You Get Involved? We Plead the Fifth