From the Stage to the Clinic and Back: Medicine and Burnout - Stuart H. Bloom
January 23, 2022
Stuart Bloom, MD, MSc, Medical Oncologist, Associate Professor of Medicine, Division of Hematology, Oncology and Transplantation, University of Minnesota
Charles J. Ryan, MD, the President and Chief Executive Officer of The Prostate Cancer Foundation (PCF), the world’s leading philanthropic organization dedicated to funding life-saving prostate cancer research. Charles J. Ryan is an internationally recognized genitourinary (GU) oncologist with expertise in the biology and treatment of advanced prostate cancer. Dr. Ryan joined the PCF from the University of Minnesota, Minneapolis, where he served as Director of the Hematology, Oncology, and Transplantation Division in the Department of Medicine. He also served as Associate Director for Clinical Research in the Masonic Cancer Center and held the B.J. Kennedy Chair in Clinical Medical Oncology.
Charles Ryan: Hi and welcome. I am delighted to be joined today by a friend and colleague, Stuart Bloom. Stuart is an associate professor of medicine at the University of Minnesota, where I work. And he's a medical oncologist with a very interesting background and an ongoing program looking at physician burnout. So we're going to talk today about the ongoing problem, the epidemic one might call it of physician burnout, healthcare provider burnout, really, and what we can think and do about it in the context of the COVID pandemic, but hopefully after the COVID pandemic.
Stuart, thank you so much for joining me today. You have been practicing medicine for many years in the community here in Minneapolis with a focus on breast and GU cancers. And most recently joined us at the University of Minnesota and were charged with an opportunity to address the issue of physician burnout and what we might do about it. Now, most people who take on an academic project, whether it's research or whether it's education or something, they may go get a grant. They may write some papers, but you chose to do a one man musical number to introduce, or to bring us up to speed on your area of passion. So tell us a little bit about it.
Stuart Bloom: Yeah. I grew up in the Twin Cities and I had this storied amazing high school acting career. I was the lead role in every show in high school. And then I thought I just really wanted to be an actor. And so I went to college, started doing some acting there, and then I moved to New York City and pretty quickly I wrote an Off-Broadway ... Off-Off-Broadway musical that got a good review in the New York Times. My picture was in the paper. It was like, "Oh my gosh, this is it". And so I spent 10 years in New York City as an actor and a comedian and a bookstore clerk. And I knew enough about what it felt like to be a successful actor in New York, in terms of, if you line up all my jobs end-to-end, but enough not to realize I didn't want to do that the rest of my life.
I had always written songs and I wrote funny songs. I was a regular at the Improv for a while. And then I turned 30 and I wasn't rich and famous. Then my own father got sick with cancer. So we flew back to Minneapolis to see him. And it was just life altering to see somebody you love so much be so ill. And my wife was reading a book by a cancer doctor called Love, Medicine and Miracles by Bernie Siegel. And she read the book, she closed the book, she gave it to me, I read it and I closed it. And I said, "Gosh, maybe I should be an oncologist". But I had no pre-med classes. I hadn't had a pre-med class for ... I hadn't done a science class since I was 17, where there was test tube with boiling chips or something, I don't know.
I'm probably dating myself. I went down to the University of Minnesota and the admissions part, I said, "Do you even accept guys in their thirties? How do even get into medical school?" And they said, "Well, you just need five classes, a year of biology, a year of chemistry, a year of organic chemistry, a year of physics and a year of calculus. It's easy." And I'm like, "Eh." So there are these things called post baccalaureate programs where you can get your pre-med stuff. So we went back to New York. I had graduated from NYU at that point. And I started doing the pre-med classes. It took me two years. We moved back to Minneapolis. I started medical school at 33, finished at 37, did my internal medicine residency from 37 to 40. And did my heme-onc training at University of Minnesota, finished at 43 and I've been doing it for 20 years.
But what I've always been doing though, too, is still writing songs. I have been writing songs about the whole process, did shows at medical school. I wrote an operetta in residency about what it was like to be an intern called Miserable Wretches Are We. I had been still writing songs about what it was like to be an oncologist, just for me to process stuff. And as things continued, about five, six years ago, I started looking at the songs and I realized, "Oh my God, there's an arc here". As things get more difficult to do ... when things happen in an incremental fashion, change, you don't really notice it, but I had these songs and they gave me an understanding of what was happening to me personally, and certainly was happening to everybody professionally.
So I realized I had a show. I wrote this show and it's called How to Avoid Burnout in 73 Minutes: A Minimally Invasive Musical Procedure. And the action of the show is me and my inner voice go through a burnout questionnaire with thoughts. It starts in an oncology clinic and all the barrage of patient stuff. And I end up on the floor with drooling and my inner voice comes out and we start doing this. And so, www.burnoutmusical.com in an act of shameless self promotion.
Charles Ryan: Not shameless at all. I saw it myself, really enjoyed it.
Stuart Bloom: Thank you.
Charles Ryan: And I'm struck, Stuart, by the triad of what you're doing with this musical. You're highlighting a problem. So you're educating people about a problem. You are, at the same time, developing a coping mechanism for the problem. And then at the other same time, you are modeling a behavior of how others can deal with a problem of burnout. In your case, it's writing songs, in other cases, it might be playing tennis or going fishing or whatever.
Stuart Bloom: Right.
Charles Ryan: But you are showing the world what you do to cope with your burnout problem and at the same time addressing the burnout problem and educating others about it.
Stuart Bloom: Yeah.
Charles Ryan: So-
Stuart Bloom: I didn't realize that at first if you're doing show business it's always like "Me, me, me, me". Even though the show is about what I've gone through, it's not really about me. And the only reason why it's resonated so much with so many people is that it's through what I experience, it's what they experience. It's what all of us experience who are trying to hang in there with being ethical, beneficent, altruistic physicians in this increasingly difficult environment.
Charles Ryan: So let's talk a little bit about the scope of burnout. You, in your new capacity, have had an opportunity to think through this on a ... let's for lack of a better term, perhaps a more academic or statistical kind of perspective. As we record this it's the depths of the COVID pandemic. We're in the omicron phase, it's January of 2022, where are we? What's the snapshot right now of physicians and burnout and maybe healthcare in general?
Stuart Bloom: The more I think about this I think I've landed on what the big, deep, fundamental emotional heart of the issue is. I think that all of us get involved with medicine for a certain reason, right? We want to help somebody else. And as a matter of fact, if you really think about the history of humanity, of homo sapiens, right, there's always been people who have been getting hurt, and there's always people who are trying to help those who get hurt. When people talk about it and write about it, Hippocrates or Maimonides or there's in Indian culture in India there's similar people writing about it. It's always about how we need to be altruistic and we're doing this because we care about another human being.
We don't do it for somebody else, for financial reasons. It's all such a privilege to be involved. And in fact, that's why we go to medical school. In fact, in our medical school interviews we don't say this, we don't get in. And so that's how we are. We're altruistic, we're not burned out. We're excited, we're idealistic. We're not nihilistic. But over the course of training, that kind of goes down. And now where over half of physicians who are working are employees, well, it turns out the employers don't have the same altruistic beneficent goals that we do. So we think one thing and then suddenly we're employed by people who don't think that. It's like, you can think it if you want to, that's fine, but you better do what I tell you to do because we are so ... doctors, we're just hard hardwired to be caring.
We're just caring people. But we're in these environments now where people ... caring is a plus, but it's not as much as important as it is to keep seeing patient after patient after patient. It's really a case of cognitive dissonance, right? You have a deeply held belief and you want the world to be that way and then you see that the world is not that way. And so people, we crave consistency. We don't like dissonance. So we either decide to abandon our deeply held beliefs and go with what we're supposed to be doing as employed physicians, or we maybe leave. But if we can't do either, what do you do? Your heart breaks and that's burnout.
Charles Ryan: Yeah. Well said. And I think you put your finger right on potentially what you may think to be the issue, which is that we are no longer masters of our own destiny as physicians. We're cogs in the wheel, we're employees of a big system. And that's because medicine, healthcare has gotten so big, so Byzantine in terms of how we conduct medicine, but it's also really complicated biologically and technologically and all these other factors. So what do you think is the way out and what do you, or what are we proposing to do about it in Minneapolis?
Stuart Bloom: Right. I don't know, but I do know that there is a way out. I mean, there is a way out and I don't quite know yet what that is. I'm still in very much in a data gathering mode, talking to the various people in our division, interviewing them. Everybody's experiencing some things of burnout. Everybody feels underappreciated and there's just been huge resignation. Did you see how many people left work just in November?
I mean, it's people need meaning and we have to find a way to allow physicians to continue. And for physicians that means other healthcare providers, PAs, nurse practitioners, other people too. But we have to find a way to realign our deeply held beliefs with what we do every day in clinic. There has to be some kind of giving. And if employers don't see that, what do employees do when the employers don't listen? Well, you can strike or, I mean, do you unionize, I don't know the answer to that, but I do know that we spend the most ... the US, this is well known, spends the most on healthcare and has the poorest outcomes.
Charles Ryan: Right. We also probably have the most healthcare administrators of any healthcare system in the world-
Stuart Bloom: We do. We do.
Charles Ryan:... by far. And you've probably seen that graph where the number of doctors has stayed flat to slightly increased over the last generation and the number of people working with healthcare-
Stuart Bloom: Administrators. Yeah. It's insane. And so in terms of estimates of how much money is spent on those people, depending on what you understand, the total healthcare expense, the most recent total healthcare expense, I think in 2019 was $4 trillion and about a quarter of that is in administrative cost. That's a trillion dollars. Now clearly we need to have a scheduler and somebody needs to bill, but there's ... I think there a lot of people who are writing about this and thinking about it, understand that there's so much waste.
Charles Ryan: Yeah. Yeah. But [crosstalk 00:12:10]-
Stuart Bloom: I don't the answer.
Charles Ryan: I think it would be really interesting for all of us to pull out the essays we wrote to get into medical school every year and read them out loud to one another. And I think a lot of us would be, you would be surprised at what we said then.
Stuart Bloom: Right.
Charles Ryan: And how maybe we've lost a little bit of that, but I think some of us would look at those essays and they would be heartened. We would be heartened. We would be inspired by our own selves from 20, 30 years ago, trying to get into medical school. And I say this as a second generation physician, and I say this as a parent of somebody who is working to get into medical school, which is, that that idealism is there in the beginning and it goes away.
And I think that's another key point. How do we preserve that energy in our young ... you were in your thirties when you started medical school, but a lot of people in their twenties, they start out for ... they're starting out for all the right reasons. They're not saying, "I want to go to school to generate X number of RVUs per week and maximize profit for my network."
So there's a preservation, a burnout prevention issue to address. And then there's the preventing people from leaving the field in their prime. And I think about this a lot because it doesn't ... it takes you about 15 to 20 years to get your skills, whatever you do, to get your skills maximally refined. So that you're at the peak of your technical game, whether it's practicing oncology, you're removing a prostate, or identifying lesions on the skin. It takes a while to get that. And if people are leaving at that time of maximum productivity and maximum efficiency, then we're losing our best people and that's what's happening.
Stuart Bloom: I've been at the university for about 12 minutes now. And what I have noticed is that when I tell ... people say, "Well, why'd you come here?" And I'm like, "Well, I believe in the mission, I need this." I need to be rebooted because I've always ... I've been told I was going to burn out my whole career because I'm so passionate and energetic and care a lot. And what happens is, over time there's incremental ... you take incremental hits and you don't even notice it.
One of my last patients I saw in the community before I joined here, had a hemoglobin at 2.4, and I thought, "Hemoglobin, 2., that's not even consistent with life". And I run to see her in the hospital and she goes, "Oh, hi. Yeah, I'm feeling a little tired." And I'm like, "What?" It turns out she's got chronic hemolytic anemia and she never follows up to get prednisone. And so her hemoglobin is slowly, slowly gone down so that she can tolerate a hemoglobin of 2.4.
The same token, I've taken so many hits that when I realized I was so burnt out and I sent some feelers to the University of Minnesota to see if there was any interest in a broken down, old oncologist and was delighted to hear, "Why, yes, they do have a spot". Looking back now on how I was feeling there, not being at the U. I didn't realize how unhappy I was. I knew I was unhappy, but I didn't know how unhappy. And it's because you take these hits over and over and over again, but they're incremental. And then you look up and you can't recognize where you are.
Charles Ryan: Well, we're delighted you joined. And I think the-
Stuart Bloom: You say that now.
Charles Ryan: Yeah, I say that now, now that I've left but-
Stuart Bloom: Yeah, that was just a bait and switch, wasn't it? You wanted me to get there. And then as soon as I get there, I get an email that Chuck Ryan's leaving. What? I thought I felt like I was on Candid Camera or something [inaudible 00:16:02].
Charles Ryan: Well, I consider it a great success that we were able to bring you to the university. I think the community needs your message. I think the world needs your message. And hopefully people watching this video will see that in you as well. Tell us a little bit about, in closing, the feedback you're getting on the musical. And if you're seeing that it's getting the ... reaching the people you want it to reach and where you want it to go next.
Stuart Bloom: Yeah. At first, we didn't really know what we had. I had these songs and in both the show and it seemed to be ... I lived in my head so long these last 20 years of writing these songs, of playing them for my wife and myself and, "Really good, honey." "Thank you." I mean, I didn't really know what we had. And then I got some commercial theater people involved with it and they were like, "Yes, this is a commercial theater thing." But the truth is I felt it was more for people like us, people in healthcare, but I didn't really know what we had until I did it. And the response was overwhelming.
It really was overwhelming that people said, "Gosh, this is, you're saying what I need to ... what I want my spouse to see. This means so much everybody should see this." And we just did it again. And you know, it sold out three weeks, three weeks of shows sold out quickly and over and over again, it's just the same. The people who emailed me, I put some of what they said on the website. It's just that we have to keep doing what we do.
Nobody wants our job to be easy. We did not go into medicine because we wanted an easy job. You can't make a difficult job easy and you don't want a difficult job to be easy, but you want it to be less onerous. You want it to be less painful, I guess. And there's so many things that are in place right now that just increase pain without increasing the heart stuff that we need. That was not articulate at all. But you know what I mean?
Charles Ryan: Yeah, I know. I mean-
Stuart Bloom: And so that's what I've been getting from everybody.
Charles Ryan: Yeah. I mean, there's the personal, the emotional. There's the reasons why we do this. And there's the system that is working against us. I think that that highlights the fact that the change probably needs to come through systems and systemic change. The subtext of what I'm hearing from you also is that we have let non-physicians get us into this position and the physicians need to lead us ... we need to be the part of the solution as the healthcare providers, right?
And a first step of addressing a problem is identifying it, I think identifying it and communicating it. And this is why I'm such a big fan, Stuart, which is you're identifying and communicating this in an entertaining way, which is everybody in communications will tell you, that's the way to reach a greater audience and get a greater appreciation of what you're trying to communicate. So I applaud you for that. I love the show. I hope you get to perform it more broadly. And I hope I can, through my connections and network can help you to do that. And we're going to work on doing that. So I want to thank you for your time today. And the website again is?
Stuart Bloom: Www.burnoutmusical.com.
Charles Ryan: And it's Dr. Stuart Bloom from the University of Minnesota. Thank you so much, Stuart, for joining us.
Stuart Bloom: Thank you.