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Palliative care physician and author Alen Voskanian discusses his article, “Discover the secrets to regaining joy in medicine,” based on an excerpt from his book. Drawing from his personal experience with burnout where he felt isolated and like a failure within the demanding medical industry, Alen strongly emphasizes that burnout is a common result of a broken health care system, not an individual failing. He offers key advice points for physicians and health care workers: recognize burnout isn’t your fault, engage in fixing the system, always prioritize patients ethically, let go of harmful comparison and competition, seek help without shame, make time for loved ones and important life events, prioritize personal health and wellbeing through nutrition, sleep, exercise, and mindfulness, practice gratitude, curb perfectionism, and continually reconnect with your core purpose for entering the field. Alen urges colleagues to understand that joy is their right and to actively reclaim it for themselves, their families, and their patients.
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Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today we welcome back Alen Voskanian. He’s a palliative care physician and author. Today’s KevinMD article is an excerpt from his book. It’s titled, “Discover the secrets to regaining joy in medicine.” And his book is titled Reclaiming the Joy in Medicine: Finding Purpose, Fulfillment, and Happiness in Today’s Medical Industry. Alen, welcome back to the show.
Alen Voskanian: Thank you so much for having me back.
Kevin Pho: All right. So let’s jump straight into the excerpt that you shared on KevinMD. For those that get a chance to read it, tell us what this one’s about.
Alen Voskanian: A couple of years ago, I wrote a book about my experience with burnout and how I found my way back to loving health care and medicine. The excerpt is from the last chapter, which has some high-level advice to other clinicians who experience burnout.
Kevin Pho: All right. Tell us about some context. Tell us about what in medicine led you to be burned out in the first place, and then we’ll, of course, talk about some of the tips that you share in your excerpt for getting physicians out of burnout.
Alen Voskanian: For me personally, this happened even before the period when we were using the term burnout. It happened almost 20 years ago when I had just finished my fellowship in HIV and AIDS, and I was seeing a large volume of patients in a very short time. My patients had a lot of other issues in addition to having toxoplasmosis and multiple opportunistic infections, but they were often living on the street or had substance abuse issues, and I realized that I wasn’t doing a good job taking care of them because I was always rushing. Doing that for a couple of years led me to this sense of not doing a good job and losing the joy in health care.
I took a pause; I did a career pivot. I started working in hospice and palliative care. Then I got board certified in palliative care. I realized once again that I loved spending time with my patients, addressing their concerns, and being there for them when they were feeling vulnerable and also abandoned by our health care system. Often, hospice and palliative care patients feel this sense that the health care system washes its hands and says, “OK, there’s nothing we can do.” I wanted patients to know that they still deserve to be taken care of by a health care professional, by a physician. I found that period of time extremely fulfilling, to be involved in someone’s life in the last part of their life and helping them live their life without pain and focusing on the quality of life.
That gave me this renewed sense of purpose, which is one of the tips I share in the book when people feel burned out. I’ve talked to so many of my colleagues and medical school friends who feel that sometimes they lose that sense of purpose and why they went into medical school in the first place. For me, finding my why was really important.
Then I realized, wow, I wasn’t alone. There were so many other doctors who were feeling the same way. It was more of a mid-career mindset shift. I looked around and I thought, oh my God, this health care system is so broken. There are so many things we need to fix. But often, the doctors are not in the room when solutions are being offered.
I wanted to be more involved in fixing the problems. I realized I lacked skill sets such as business acumen and things that they teach you in business school. I actively sought opportunities to improve my leadership skills and decided to get an MBA. Meanwhile, like most other physician leaders, I was being tapped to lead my group and larger branches of where I was working, which, when I talk to a lot of physician leaders, that’s not uncommon. I call it incidental leaders. We get tapped on the shoulder if we do a good job at what we’re doing. They say, “OK, can you lead this division or department or be a medical director?” But I wanted to do that job well. I became a medical director, but I also got my MBA, which gave me a more global understanding of health care economics. I got involved with the Center for Medicare and Medicaid Innovation as an innovation advisor. All of that gave me better skills to help other doctors who were struggling with burnout.
Kevin Pho: One of the things that you talk about in the excerpt was a transition where burnout is focused on the individual physician. And transition that into more systemic causes of burnout. Talk about that transition, because a lot of times when physicians are burned out, it’s framed as a matter of a lack of resilience when it’s really more systemic. Talk about that evolution.
Alen Voskanian: That drives me crazy when people say, “Oh, let’s have the doctors sign up for this mindfulness app.” Or, “Let’s bring yoga,” or, “Let’s throw a pizza party.” Even though people who recommend those possibly have good intentions, it’s really misguided. It’s the worst thing you can do when someone is feeling burned out to tell them, “OK, now, come to this evening meditation session” or something similar. It just doesn’t help.
I’m not saying those interventions are not helpful. Mindfulness and all of those interventions are helpful, but they need to be driven from people’s individual beliefs and their own intention to do those things for themselves. But we miss the opportunity to fix the system, the root cause of it. It’s almost like putting a bandage on a deep, bleeding wound and wanting to fix it. We need to stop the bleeding.
To me, stopping the bleeding is fixing the operational challenges that we all face. I still see patients, and there are days in the clinic where I might not have the right nurse helping me, and I know on those days I’m going to be miserable trying to juggle many things. How do we fix those operational challenges that we all face? That tsunami of in-basket messages? Every doctor sits in front of their computer when they get home, when they should be spending time with their kids. Now they’re sitting, maybe eating while they’re responding to email. That’s what motivated me to go into leadership and administration.
For me, I truly believe in trying to fix all of those operational challenges by creating a system that reduces chaos. I always say, “Less chaos, more care.” The way I’ve done it in various health care systems has been based on relying on principles that other companies with intricacies outside health care systems have used to reduce waste and reduce unnecessary things that need to happen. Make sure that you consistently support the clinic. There are engineering principles that people use. We can learn so much from the airline industry; they make sure their error rates are low and a pilot is ready to fly the airplane. Using checklists, using different things to ensure operations are running smoothly.
Now, no one… I’ve traveled the world studying health care systems. No one has figured this out. I haven’t figured this out, but we are constantly trying to improve it. It requires constant performance improvement. I’m very optimistic that things are improving; actually, AI is bringing a little bit of hope in reducing some of these redundant tasks that physicians are doing. I think there’s so much opportunity in ambient listening for scribing to avoid time doctors spend typing. I’m very hopeful, but that’s the reason why I went into administration.
Kevin Pho: That is a common piece of advice for physicians who want to change a system: Go into leadership and get some of those business skills. Give us some examples of the operational challenges that you’ve helped improve by learning these business skills, going into administration, and becoming more of a leader in your organization.
Alen Voskanian: I think one of them is really being a translator between physicians and non-physicians. I always find myself saying the same thing in two different ways. When I’m talking to a group of physicians, I focus on language and things that resonate and make sense. When I’m talking to a chief financial officer, I say it in a different way, in a language that makes sense if it’s focused on the bottom line or EBITDA. But if I go and talk to a physician about EBITDA, that doesn’t resonate. It’s, “What about the care of my patient? What about the patient that is struggling, that I need to help?”
I think physician leaders, by improving their business acumen and figuring out where they are lacking leadership skills, can be that translator between physicians and non-physician leaders by addressing those gaps.
A more specific example would be… one thing you often hear is that physicians don’t have a voice, that we don’t have a voice in what’s happening. We really focused on creating an operational system which we call dyad leadership, which pairs up a physician with an operational leader. This reduces that head-butting that exists in so many health care systems between physicians and administration. When people feel they’re truly a united team, they can address their operational challenges from the front line instead of those solutions coming from the top down.
Kevin Pho: For those physicians listening, EBITDA is earnings before interest, taxes, depreciation, and amortization. Had to look that up while you were talking. Just so we’re all talking the same language.
One of the things that you mentioned earlier was finding your why as the first step to climbing out of burnout. Give specific instructions. How can physicians reconnect with their why?
Alen Voskanian: For me, obviously, if you haven’t watched Simon Sinek’s TED Talk or YouTube video on finding the why, I highly encourage you to watch it. It’s a quick watch. He’s very inspirational. But he says we often focus on what it is that we do, but not why we do that. For example, we might say, “Hey, I’m a brain surgeon, and I focus on addressing a specific type of cancer.” But why do you do that work? The work is to help maybe keep someone’s child alive. It’s much deeper. It gives you the sense of purpose. I know some people who are listening might say, “Well, that’s touchy-feely.” But I think we all have a little bit of touchy-feely inside us, and it motivates us during those hard times.
For me, initially, I wanted to serve patients struggling with HIV. I was passionate about that, and it gave me a sense of purpose. I got burned out. Then it was, “I want to really help patients who are close to dying, palliative care patients, and I want to make sure I’m making a difference in their life.” That was my compass. When tough things were happening, when I wasn’t sure, a family would say, “I really want my mom to take this one last round of chemo.” I knew the chemo might not be as effective, but I knew it was going to be helpful for their daughter, who had to live the rest of her life feeling that they never gave that chemo to their mom. Having an open, frank discussion, knowing, OK, what is the right thing here for this family? Maybe it’s having that chemo. It gives you a sense of purpose and direction.
I did that. Then more recently, my why changed from “I can help one patient, one of my palliative care patients, or one of my HIV patients,” to “I really want to fix the system, the health care system.” I want to help make it better for doctors because if it’s better for our doctors, it’s going to be better for our patients.
Some of this came from my mom’s experience. My mom passed away unexpectedly during the pandemic. It was really devastating to me, and that’s when I started writing as a coping mechanism. But I remember I rushed to this community hospital. She lived 30 minutes away from me, and I’m Armenian. We are very family-oriented; cousins, brothers. Everybody was rushing to the hospital. A day prior, she was healthy, doing well. It was a shock. It’s the pandemic, early in the pandemic. We had all been isolated, and we were stopped in the parking lot and told that we couldn’t visit; just one person could visit per 24 hours. Meanwhile, they were going to extubate or remove the breathing tube from my mom. I knew she was going to die that night.
That was an example where the health care system, the way it’s set up, fails us. It’s about care, it’s about compassion, but sometimes it’s also about policies and things that are put in place that prevent people from doing the right thing. I remember, and I’m forever grateful to this hospitalist doctor who… we were told no. The nursing director came, the security guard. My family is all six feet apart in this parking lot. I was able to talk to the ICU doctor, who was just so kind. She was so fatigued and tired, but she came down and she said, “I’ll let your family members come and say goodbye.” She let me and my two brothers be in the room as we removed the breathing tube. If you were asking me what is my why? My why is to fix the system. So a doctor like that doctor who helped me could do the right thing.
Kevin Pho: We’re talking to Alen Voskanian. He’s a palliative care physician, and we’re talking about an excerpt from his book, Reclaiming the Joy in Medicine: Finding Purpose, Fulfillment, and Happiness in Today’s Medical Industry. Alen, let’s end with some of the key messages that you want readers to come away with from your book.
Alen Voskanian: I think one is, I encourage everybody to get involved in fixing the root causes of operational challenges. Focus on the why; understand why you are in health care. Is it still the same thing as when you applied to medical school? Has it changed? It’s OK if it has changed, but just make sure it’s very clear to you what it is.
Then I do talk about how we stay well and healthy. This is something I’ve had to think a lot about as I’ve gotten older: really focusing on things that keep me healthy. Those are very basic: making sure I exercise every day, making sure I’m eating healthy, making sure I’m getting enough sleep. Making sure—for me, mindfulness is a big part of my life, and I do that in small increments. When I’m in clinic seeing patients, every time I put my hand on the doorknob, I just take a deep breath and let go of everything that’s on my mind: the last patient, just everything. I tell myself, “Just focus on this next patient behind this door. Be the best doctor you can be.”
I think “don’t forget the basics” is the message. Are you going to exercise today? Are you going to walk? Are you going to eat? We often ignore our food, don’t eat well, or grab something while we’re in between patients. I guess focusing on the basics. Because we can’t do it all, and we need to take care of ourselves. That’s the big takeaway.
Kevin Pho: Alen, thank you so much for sharing your perspective and insight, and thanks again for coming back on the show.
Alen Voskanian: Thank you so much for having me, Kevin.