While pursuing the second business and remaining active as a psychiatrist, the author believes she has improved her clinical skills as well as her leadership abilities.
ABSTRACT: The author uses her journey of setting up a second business as a backdrop to review key aspects of physician burnout. While pursuing the second business and remaining active as a psychiatrist, the author believes she has improved her clinical skills as a doctor as well as her leadership abilities. The issue of happiness deserves further attention if relatively established physicians opt for a career boost outside the medical realm.
If anyone had told me three years ago that I would become a beauty consultant, I would have been incredulous. This was not the expected path of an established physician with an academic bent. True, over the years, some of my colleagues had engaged in the “what else is out there” dialogue. For me, there was the allure of managing a bed-and-breakfast. Other colleagues fantasized about owning a plant store, becoming an antique dealer or delving into the media world. But we all reined in our excitement and eventually returned to the safety net of medicine.
So how did I come to launch a second business? While some of it was sheer timing, in looking back, the trail markers of physician burnout were there. For starters, there was the psychological exhaustion of seeing patient after patient in a high-volume practice. I also felt the increasing need to limit cumulative exposure to arcane psychoanalytic terminology, which started to feel vaguely oppressive. And draining as well was holding myself to the highest standard of comportment, part of the physician’s mandate. To top it off was a deeply ingrained challenge once offered by my residency director — a renaissance man, indeed — to “step out of the confines of your office into the community to make your mark.” Thus, my second business appears to have been a concerted antidote to professional fatigue as well as assertion of entrepreneurialism.
Burnout is generally defined as encompassing three major components: psychological exhaustion, feelings of workplace
detachment, and a sense of being underproductive.1,2,3 While it is difficult to measure precisely the subjective experience of being underproductive, I would imagine that it involves a perception that one’s professional contributions aren’t all that important in the greater scheme of things.
In a pertinent review article, Naomi Weinshenker, MD, points out that while overlapping with depression, burnout is its own entity, often entrained with one’s profession or specific situation. It is a syndrome of depletion rather than agitation that does not magically disappear without taking the necessary remedial steps.4 Anita Everett, MD, president of the American Psychiatric Association, emphasizes the importance of addressing burnout in terms of patient care and physician well-being. She explains that “the phenomenon of burnout exists across a continuum from routine fatigue to extreme depression … encompassing a spectrum of severity.”5
Few physicians like to admit they are burned out. Like me, they probably shudder at contemplating such a possibility, no less at the overused term “burnout” itself. For one thing, there is all that clinical training, the investment of time and money, and a higher calling to consider. While once attending a medical symposium, I recall the speaker asking for an audience show of hands “if you are feeling burned out.” Not surprisingly, almost no one responded, save for maybe a scattering of six brave hands around the hall, illustrating the shame factor among doctors along with the risk of underreporting when it comes to the prevalence of burnout.
The subject of physician burnout has begun to receive serious public health attention. A 2014 Mayo Clinic report found that more than half of U.S. physicians indicated having one or more burnout symptoms. That study noted an alarming 9 percent increase in burnout prevalence since 2011, a pat-tern observed across all medical specialties.6 An earlier poll conducted by the American College of Physician Executives (the former name of the American Association for Physician Leadership) had similar results: 60 percent of doctors contemplated leaving the medical profession, and up to 70 percent reported having a colleague who did leave.7
The incidence of burnout among American doctors is estimated at almost twice that of the general U.S. workforce, placing doctors at heightened risk.1 And contrary to popular thought, length of time in practice is nonlinear with respect to patterns of exhaustion and unhappiness. In one study, middle-career physicians were reported as most dissatisfied with their work, compared to earlier- and later-career colleagues.3
Strategies to Reduce Burnout
Not only is the internal recognition of burnout fraught with ambivalence among doctors, but, according to one research group, so is the seeking of help once burnout is self-acknowledged. “One reason that stress and burnout may be extraordinarily high among physicians is that doctors are not very good at looking after themselves or seeking help from others,” explains one research team, which adds that “… reports abound of physicians’ work interfering with their home and/or family life and the difficulties they experience in attempting to balance their professional and personal lives.”8
There is excellent documentation on risk factors and prevention of burnout. Most relevant articles mention three domains: self-care, manageable working conditions and supportive relationships.1,2,4,8,9,10
Prevention measures also can be grouped according to intrinsic and extrinsic interventions — intrinsic involving self-care modalities such as mindfulness, and extrinsic involving the optimization of working conditions. In a meta-analysis of 2,617 articles on burnout interventions, researchers found organizational interventions (i.e., extrinsic) to surpass those of individual stress management techniques (i.e., intrinsic) in efficacy.11
Generally omitted in these discussions, even as an outlier, is what some might label the audacious step of adding a second business while remaining active in medical practice.
Ever curious, I undertook an initial search to determine the prevalence of physicians with second businesses, but I came up short, regretfully. Ovid Medline and EBSCO searches, from 1996 to 2014, using keywords such as “physician job satisfaction,” “career mobility” and “expanded career choice,” produced a null result. Likewise, there was no definitive yield on the websites for the American Medical Association, the American Psychiatric Association, the U.S. Census Bureau nor the U.S. Office of Personnel Management. A further email exchange with a national expert on physician entrepreneurs did not lead to conclusive data.
Joining the 'Slash Generation'
Putting the lack of search results aside, it is compelling to read what a number of entrepreneurial physicians have done.
Some opted out of direct clinical care for allied medical opportunities, such as internet health care consulting, and medical leadership. Noteworthy were an ENT surgeon who gave up her practice to become an artist, a psychiatrist simultaneously pursuing his enthusiasm for composer Frederic Chopin, and an early career physician who became part of what the New York Times called “the slash generation” — psychiatrist by day/disc jockey by night.12,13,14,15,16,17
As for my entrepreneurial initiative, I traveled north on a two-year sabbatical from solo private practice to join a group practice as a psychiatrist. I arrived in the unadorned, tabula rasa manner of Delia Grinstead, the protagonist in Anne Tyler’s 1995 novel, Ladder of Years18 — with a new position, a suitcase, a mobile phone and a hotel room.
One evening, on returning from laps in the hotel pool, I chanced on a gathering of professionally attired women. Initially, I smiled and continued on. But something told me to return, to explore their visually appealing table displays of creams and fragrances. I discovered that many in the group were balancing their passion for glamour with an additional, unrelated day job. Perhaps you can guess what happened next. That evening, I accepted cosmetic samples and, three months later, against my better judgment and the utter astonishment of friends, family and peers, I launched a cosmetics business while still working as a psychiatrist. It was never my intention to give up being a psychiatrist, but rather to expand my horizons and balance the two careers, which has largely remained the case.
Lest I over-romanticize my tale, there were and continue to be challenges above and beyond the abundant energy needed to manage both careers. Unlike starting a medical practice, the cosmetics industry provides a level of infrastructure that relieves the new beauty consultant of typical startup costs, such as an office rental, expensive office equipment, multiple licensures and advertising. Plus, it has more flexibility in the consultant/customer relationship, as opposed to that of the doctor/patient, as it is not as highly regulated as medical practitioners find.
My main challenge has been some degree of affect dissonance, choosing the correct affect for the correct occasion, especially given the high value that physicians place on control. Psychiatrists are trained in affect prudence — to react to patient material as much or as little as necessary in the service of promoting client insight and personality growth. By contrast, beauty consultants are trained to exaggerate affect — to let out their inner yelp in the service of bonding and loyalty. Or, getting excited about your product and making your customer feel important.
There have been times when it was virtually impossible to linger in perky sales rep mode, especially on my long psychiatry days with an added cosmetic booking. I once was informed by a savvy customer that being soft spoken wouldn’t cut it as a beauty consultant. While I knew I was in the midst of new rules, that comment did not promote confidence in my selling abilities. I had always admired the casual, breeziness of department store sales reps who, from head to toe, from coif to boot, were utterly exotic to me. They didn’t analyze the emotional impact of their every utterance on the psyche of their customers. They slapped the moisturizer onto your face with finesse, and — voila! — closed the sale. I, however, would have to leverage the allure of being measured.
Obviously, the reasons for modifying one’s medical career are highly complex, and I must emphasize that starting a second business while remaining a practicing MD is not for everyone. For some doctors, however, documented reasons for career expansion include:
- Lack of fervent intellectual interest in the subject matter of clinical medicine.
- Lack of professional recognition.
- Rising malpractice costs and fears of lawsuits.
- Competing or greater love of entrepreneurial opportunities.
- Dread of stagnation.
- Lack of financial gain.
- Concurrent skill set or talent that must be nurtured.
- Psychological readiness for retirement from clinical medicine.
Regarding the latter, one psychiatrist wrote, “Came the day that I began to wonder whether I was still enjoying my work. Was I just filling up time, had the challenge gone? … I looked around for solutions [and] so I decided to take my own advice. I would have more time on my hands, time to lead a more complete life. … So I sent the letters and closed my practice. … Imagine leaving and never missing [anything].”19,20
The Public Health Relevance
Without question, society always will need dedicated doctors. From a public health perspective, the thought that more than half of middle-career physicians are unhappy in their work is frightening, especially given a projected shortage of physicians in the year 2025.21,22 Of equal concern is the federal government’s finding that an additional 2,800 psychiatrists are necessary to cover the current domestic mental health care need.23
Efforts toward the prevention of burnout in the service of preserving physician happiness, particularly early on in residency training, are of paramount importance and must be continued. Moreover, if relatively seasoned physicians like me feel the need for a boost in their skill set, then maybe this is worth a bit more scrutiny.
Studies stratified by years in practice consistently show middle-career physicians to be at the relatively highest risk for professional fatigue. One reason may be that expectations are so much higher than for those just out of training or on the verge of retirement.
My sojourn into a part-time entrepreneur while remaining a doctor has strengthened my clinical skills — how I listen to and care for patients, in part because of an enriched under-standing of human beings beyond the consulting office as well as a feeling of balance. Without trying to diminish either the stature of medical training or business coaching, I can’t help but to have recently noticed in my readings a degree of overlap between the skills for the successful psychiatrist in the growing field of collaborative care and those for a successful industry consultant.
It would be interesting to survey physicians about their out-side interests and inclinations to pursue those activities in more depth. The survey would aim to determine the likelihood of the doctor pursuing a new opportunity entirely, retiring and/or a maintaining a dual career. Regarding the latter, the nature of the second career, motivation, temperamental factors and perceived transferability of skill sets would be explored. Potential conflicts of interest between the two pursuits would also be explored, especially in the era of social media. Stay tuned.
Jane B. Sofair, MD, is a board-certified psychiatrist practicing in New Jersey. She is affiliated with Atlantic Health System and is a distinguished fellow of the American Psychiatric Association. She worked in a large, multispecialty psychiatric group in Connecticut when she began her second business.
- Alexander L. Burnout in physicians. New Jersey Physicians & Physician Assistants in NetCE Continuing Education. 142 (4):1-15, 2017.
- The Carlat Psychiatric Report. 14:(3);1-8, March 2016.
- Ayrbye L, Varkey P, Boone S, Satele D, Sloan J, Shanafelt T. Physician satisfaction and burnout at different stages. Mayo Clinic Proceedings. 88(12):1358-1367, December 2013.
- Weinshenker N. Banishing Burnout. Bergen Health and Life, June 2012.
- Moran M. Annual meeting town hall to address physician burnout. Psychiatric News. March 3, 2017.
- Shanafelt T, Hasan O, Dyrbye L, Sinsky C, Satele D, Sloan J, et al. Changes in burnout and satisfaction with work-life balance in physicians and the general US working populations between 2011 and 2014. Mayo Clinic Proceedings. 90(12):1600-1613, December 2015.
- Williams A. The falling-down professions. New York Times, Jan. 6, 2008.
- Wallace J, Lemaire J. On physician well-being: You’ll get by with a little help from your friends. Social Science & Medicine. 64: 2565-2577, 2007.
- Kumar S, Hatcher S, Dutu G, Fischer J, Etuini M. Stresses experienced by psychiatrists and their role in burnout: a national follow-up study. International Journal of Social Psychiatry. 57(2):166-179, January 2010.
- Chukwu I. Preventing burnout. Psychiatric News. Dec. 2, 2016.
- West C, Dyrbye L, Erwin P, Shanafelt T. Interventions to prevent and reduce physician burnout: a systematic review and meta-analysis. Lancet. 388:2272-81, November 2016.
- Wiebe C. Greener pastures. Modern Physician. 4(9): 60. September 2000.
- Kaplan A. Climbing the ladder to CEO, Part III: Following your own path. The Physician Executive. 16-19, May/June 2006.
- Anderson J. Practice makes perfect. Kiplinger’s Personal Finance. 61(1): 51, January 2007.
- Zagorski N. Richard Kogan, MD, to analyze Chopin’s mind and music. Psychiatric News. April 3, 2015.
- Marikar S. Defined by a slanting piece of punctuation. New York Times. Dec. 7, 2014.
- Weiss G. Taking your medical degree. Medical Economics, Aug. 19, 2005.
- Tyler A. Ladder of Years. House publishing group of Random House Inc., New York, New York, 1995.
- Greenwald J. How a first career enhanced a second. New York Times, Jan. 5, 2014.
- Kaplan R. Farewell to all that. Australian Psychiatry. 9(2): 167-170, June 2001.
- Kupfer JM. The graying of US physicians. Implications for quality and the future supply of physicians. JAMA. 315(4): 341-342, Jan. 26, 2016
- Grover A, Orlowski JM, Erikson CE. The nation’s physician workforce and future challenges. American Journal of the Medical Sciences. 351(1):11-19, January 2016.
- Levin A. Report details national shortage of psychiatrists and possible solutions. Psychiatric News, April 21, 2017.
Acknowledgements: With feedback and research support from Victoria R. Green, BA; Yi Zhou, MLIS; Naomi Weinshenker, MD; Danielle Green, MA; Nan Gallagher, Esq.; Nancy Block, MD; and Jon W. Green, Esq.