June 26, 2017

Functional Medicine – Could It Be For You?



I didn’t set out looking for a Functional Medicine doctor. I wasn’t sure what such doctors do. But that’s where I ended up. I was suffering from “nonspecific, slowly progressive gym funk.” You might be thinking, JUST WASH YOUR GYM CLOTHES! I wish it had been that simple. Rather, my issue was not having enough energy to work out at the gym. Some days I would put in a respectable effort and break a sweat. But on other days, I’d spend more time sitting on the machines than actually using them. Was I just lazy? Not getting enough sleep? Eating too many chips? I wasn’t sure.  After routine blood work failed to show a reason for my gym funk, I by chance found a Functional Medicine doctor.

Before I go on, let me share a definition of Functional Medicine from the Institute for Functional Medicine (IFM) Website:

“Functional Medicine addresses the underlying causes of disease, using a systems oriented approach and engaging both patient and practitioner in a therapeutic partnership…By shifting the traditional disease-centered focus of medical practice to a more patient-centered approach, Functional Medicine practitioners spend time with their patients, listening to their histories and looking at the interactions among genetic, environmental, and lifestyle factors that can influence long-term health and complex, chronic disease. In this way, Functional Medicine supports the unique expression of health and vitality for each individual.”

Back to my story….

The Functional Medicine doctor took a detailed history, did a lot of blood testing, and found out I had a methylation defect. This was news to me. There were some other issues that showed up which made sense from my history – i.e., a low vitamin D which may have contributed to a prior unexplained stress fracture, and a few other findings. She prescribed methylfolate, vitamin D, multivitamins, and some other supplements. After about 6 – 8 weeks, I noticed more energy and was able to work out much more consistently.

I can’t say for certain if the methylation defect was the culprit (it’s apparently pretty common), but if I stop the methylfolate, doing so adversely impacts my energy. Whatever the truth is, I was able to see a physician who could spend as much time as need with me, addressed my problem, and provided effective treatment.  And she didn’t have to deal with insurance. Sound good?

Hoping this career direction might be an option for some of my war-weary physician clients, I decided to attend the Institute for Functional Medicine’s foundational course – Applying Functional Medicine in Clinical Practice. Even though I was only able to attend the first of five days, I felt I had a good toe-dip into the program.

The first day was packed with presentations, round-table case studies, and time for networking and super delicious, healthy snacks (I’d go back for the food alone). The aim of this course was to provide an in-depth experience of the IFM’s model of assessing and treating patients. Additional training can be taken, leading to a certification in Functional Medicine.

Here is a partial list of topics addressed during the conference:

  • Root Causes and Treatment of GI Dysfunction
  • Immune Dysfunction and Inflammation
  • Food Allergies, Sensitivities, and Intolerances
  • Prescribing an Elimination Diet
  • ABCD’s of Nutritional Evaluation
  • Assessment and Treatment of Adrenal and Thyroid Dysfunction
  • Understanding Sex Hormones
  • Managing a Woman’s Hormones
  • Mitochondria and Energy Dynamics
  • Insight, Intuition, and the Therapeutic Partnership

While at the conference, I ran into a friend of mine, Dr. Julie Reardon. Julie is a Family Practice physician who completed a fellowship in Integrative Medicine and has a busy private practice in Austin. We did a post-conference debriefing. She said she has already been using some of the Functional Medicine approaches with her patients, but that the conference was a fantastic learning experience.

“It was like being back in medical school, and drinking from a fire hydrant, but in a good way,” she said. “We delved into a lot of the science and biochemistry (remember the Krebs cycle?). They have excellent tools and resources for us to use in our practice, such as the Functional Medicine Timeline to capture the patient’s medical history in a way that makes it much easier to see connections, correlations and inciting events.”

She was clearly very energized by her experience, summing it up by adding, “My greatest surprise and pleasure out of all it was that the Institute for Functional Medicine embraces uncertainty in practice. They give us the science and tools to work with, but they keep the art of medicine alive by not being so rigid in the approach. They are willing to think outside the box.”

In addition to running into Julie, I had another stroke of luck getting to meet with one of my clients, Dr. Lara Salyer, a family physician from Wisconsin.

We had a chat a few weeks later and she shared some impressions of her experience,

“Initially I thought my career fatigue was due to medicine in general. But in reality, it’s the way our current primary care office visit is structured. As a traditional Family Practice doctor, we aren’t allowed the time or supportive resources to make any substantial impact in mind-body-spirit health as a whole. Learning about Functional Medicine inspired me to reconsider staying in medicine. I am excited to dig deeper into the biochemistry and physiology to help patients live a healthier life, hopefully with less reliance on prescriptions. My favorite part was connecting with other physicians who had already transitioned into their Functional Medicine practices. I understand it takes time and there are challenges, but I am willing to give it a try.”

I asked Lara if she had any advice for other doctors experiencing burnout? She offered these words, “Before you abandon medicine, take a look at this. If you went into medicine because you care about motivating the individual and making real changes socially and humanitarianly, don’t jump ship just yet. Check out Functional Medicine.”

Let’s say you check out Functional Medicine and do the training. What kinds of opportunities exist?

This is where I got a big surprise.

Before I did my research for this blog, I was only familiar with doctors who hung up their own shingle and started a practice from scratch or incorporated Functional Medicine into an existing practice.

Then I stumbled upon this website, Integrated and Functional Connections, where there are actual jobs (I mean real, live, jobs!) for Functional Medicine physicians! Currently, there are postings by the Cleveland Clinic, Baylor Scott and White, and the Sutter Medical Group, to mention a few. Before I could even finish reviewing the jobs, I reached out to Lisa McDonald, founder of Integrated Connections, to learn more. Lisa is truly passionate about her role in connecting her clients with healthcare providers. She is very excited about the significant increase in job opportunities since she started her company 7 years ago. When asked about compensation, Lisa responded, “The salaries have also been increasing, and are now competitive to those a Family Practice or Internal Medicine physician makes in the more traditional positions.”

It was very encouraging to hear that both smaller practices and large healthcare systems are recruiting for Functional Medicine physicians.

Although the specialties Lisa recruits from are predominantly Family Practice and Internal Medicine, physicians from a wide range of specialties have become certified in Functional Medicine.

The most common specialties I noticed on the IFM FIND A PRACTITIONER page are:

Family Medicine, Internal Medicine and (IM subspecialties), Emergency Medicine, Anesthesiology, Neurology, Physical Medicine and Rehab, OB/GYN, and Pediatrics. However, I also saw doctors from these areas as well: Psychiatry, Surgery, Radiology, Dermatology, Radiation Oncology, and Ophthalmology. Some physicians devote their entire practice to Functional Medicine, while others offer the model as a complement to their established practice.

If you are interested in learning more:

IFM offers 2 free online eLearning courses, which provide an overview of Functional Medicine and Functional Nutrition.

You can read here about the IFM certification program. And see a listing of upcoming conferences and courses here.

Functional Medicine uses both traditional and novel approaches to help patients. It may be something you want to consider, or not. The good news is that there are options to explore if you are frustrated by the current practice environment. You get to decide if something could work better for you. At the very least, being able to connect with doctors who are finding their passion again may provide some hope and inspiration for your own journey

ER Physician Career Transition: Dr. Dale Ray

Dale Ray, MD

Before his career transition, you were likely to find Dr. Dale Ray intubating a patient, running a meeting, or mentoring a resident. Now, in his new role working for the ACGME (American College of Graduate Medical Education), odds are you will find him on an airplane. Dr. Ray worked for many years as an emergency medicine attending, oversaw graduate medical education, and had several different roles in hospital administration. Now he travels all over the country on a weekly basis to offer feedback to the hospitals and medical centers that train the nation’s residents and fellows.

In this interview, Dr. Ray talks about his non-clinical career as Field Representative for the ACGME. He has been in this position for almost 3 years, and in spite of the heavy travel, is very happy with his choice. He would like to let other physicians know that for the right individual with a background in graduate medical education, there are opportunities in this area.

HF: What kind of work are you doing for the ACGME? (Accreditation Council for Graduate Medical Education)
Dr. Ray: I work as a field representative for the Clinical Learning Environment Review (CLER) program. Our team visits teaching hospitals and provides formative observational feedback on the learning environment. We provide the assessment through six focus areas, including patient safety. Through a series of group and individual meetings, including with members of the C-suite, we seek answers regarding the infrastructure of the clinical learning environment, the integration of Graduate Medical Education (GME) within the hospital and its activities, and the engagement of residents and fellows. With these efforts we hope to assist the individual sites to improve patient care and GME, as well as help move forward patient care and GME on a national level.

HF: Can you describe a typical week for you?
Dr. Ray: Monday is a travel and prep day. We visit a hospital or medical center Tuesday and Wednesday (and sometimes Thursday), then return home either Wednesday evening or Thursday late afternoon. Thursday and Friday we are writing up our visit report and preparing for any upcoming visits, as well as participating with any team meetings.

HF: How do you do your site assessments?
Dr. Ray: We initially have separate group interviews with the GME leadership, the senior leadership team, and the patient safety and quality improvement teams. We have a series of group interviews with residents and fellows, faculty members, and program directors. We also make walking rounds where we talk to nurses and residents on the floors and units about the clinical learning environment and patient care.

Depending on the size of the institution, we may have a second series of interviews with the physician groups. We provide a report to senior leadership based on what we have learned in six focus areas: patient safety, quality improvement, transitions of care, supervision, fatigue management, and professionalism. Our approach is unique in that our feedback is not tied to standards or citations. Rather it is observational and formative, allowing the site to process and adopt the information provided. It is our desire that the site find components of the report valuable to help them on their patient care and graduate medical education endeavors. Although some may interpret what we do as consultants, we are different in that we are not there to give advice or recommendations. In many ways, reflective feedback to an organization may be seen as more powerful. I think it is safe to say that my teammates and I look at this as a collaborative effort between the CLER program and the sites we visit.

The reports we put together are confidential, as they deal with the institution’s priorities and patient safety issues. They are generally about 17-20 pages, and most sites acknowledge the thoroughness of our work. Many say that the reports provide value for their own work and internal assessment. Receiving this type of feedback is a significant component to my job satisfaction.

Lastly, as I mentioned, our work serves to help inform on a national level, both with data collection and by affecting patient care and physician training

HF: How much do you work in a week?
Dr. Ray
: I have never sat down and counted, and some of the work hours are travel related. I would estimate 50 plus hours per week. One of the positives is that I do not have unending piles of work. The work is pretty well defined. I do not have 80 emails to answer every day nor never-ending projects to complete. I know when my work is done. There is some work on the weekend, but generally not a lot. I will probably work an hour today (it was Sunday).

HF: What were you doing before you transitioned?
Dr. Ray: I was practicing emergency medicine. I was 20% clinical before I transitioned to this position, as I had increasing administrative responsibility inside the health system where I was employed. I was Medical Director and Operations Director for a transfer center, Medical Director over our healthcare disparities unit, and had GME responsibilities. I had some other roles working with the Chief Strategy Officer.

HF: Did you have prior experience in Graduate Medical Education (GME) before your current position?
Dr. Ray
: I was a core faculty member, followed by being the Associate Program Director, and then was Program Director. I was then recruited and assumed other roles outside of the residency program. Soon after I left GME (Graduate Medical Education), I realized how much I liked GME and the people, both at the local as well as national level. As educators, we want to work together and have helper personality traits. I liked the atmosphere in GME. I like the teaching aspects and helping residents evolve. I would have stayed in the Program Director role longer, but I was recruited to other roles, which I accepted as I thought it was a career step.

HF: What other areas did you consider before you took this job with the ACGME?
Dr. Ray
. When I considered what I wanted to do next in my career, I was open to a wide variety of opportunities. To be honest, I was quite uncertain as to my path. My search started organically, looking into different roles in hospital systems, both in my institution and elsewhere where I had conversations about leadership and physician executive roles. However, I did not identify the right fit. For me, that included considering the management component of the job, and the individuals I may be managing. The wrong mix can be very challenging. I was also looking for something unique, as well as meaningful, where I can have an impact on healthcare. Ultimately, I was uncertain and was not finding the right fit in this leadership direction. There was no reason for me to foolishly rush into a position, so I kept looking.

HF: Were you burned out when you started looking?
Dr. Ray
: I wound not say that I was burned out, but circumstances left me open for a change. I could have stayed where I was for the near to mid-range future, but life circumstances made me think that if I was ever going to make a change, this was the right time period. I could have returned to practicing clinically full time, but balancing clinical with other activities had always been important to me.

The topic of burnout is very important to the ACGME, the CLER program and our individual team members. It is prevalent amongst physicians. It is an issue the CLER program is investigating, and hopefully we can provide information to help address burnout. It is one thing if one pursues non-clinical options because of personal interests; it is another if individuals, who are good clinicians, leave clinical medicine because of being burned out. We need to do what we can to preserve their careers.

HF: What do you enjoy about your work for the ACGME?
Dr. Ray
: I think we are making a difference in patient care. I also hope I am helping to improve physician training. I enjoy the people within GME; they are collaborative and want to do the right thing. In nearly all circumstances, we receive feedback from the site that they think our activities will positively influence the work they perform. In addition, I have frequent moments to do some teaching with the residents and fellows, and it is especially gratifying when you see a light bulb go off with regard to patient safety and concepts and ways they can improve their care. Perhaps we have inspired a few to consider work in patient safety and quality improvement as their professional focus. I meet many great people, and it has been reinvigorating.

It is also a learning adventure for me. Even though I was fairly well versed in medicine, I have made tremendous knowledge gains in areas of medicine I knew nothing about. This has been intellectually satisfying. Lastly, I enjoy my team members and our staff at the ACGME; they all have levels of expertise, competence, reliability, and emotional intelligence.

HF: What is challenging about your job?
Dr. Ray
: One challenging consideration for people is the travel. You have to be at a point in your life where those in your life understand and accept that you will be gone two to four days most weeks. You have to be practical and thoughtful (before considering this position) that you can do the travel. You can live anywhere you want, as long as you can get to an airport. Between site visits and other activities, I travel about forty-five times a year.

Beyond the travel, one needs to be flexible and adaptable to potential changes in circumstances. On nearly every visit, some unpredictable event occurs, and one needs to roll with it.

HF: What makes you especially suited for this kind of work?
Dr. Ray
: I am comfortable speaking with CEO’s and other senior leadership. I have worked enough in the C-suite that I understand their perspectives. I am also pretty curious and inquisitive, and this job is a new learning experience each week. I think this improves my performance and keeps the job interesting.

HF: Is there anything you wish you’d known ahead of time?
Dr. Ray
: There was a fair amount of disclosure from the ACGME about the position and by myself about what my professional needs and goals were. It was a big professional leap for me, so they wanted me to know if I could make this commitment. I joined the team early on, so there were a few “if I had known that” type of considerations that had to be worked on as the program matured. For anyone who is considering a big transition to a different role, I would recommend they ask detailed questions about a wide variety of scenarios and the day-to-day work. I would also recommend a contingency plan – no one takes a position that they think will not work out, but it is good to have a plan B just in case.

HF: Do you still do any clinical practice?
Dr. Ray: I gave it up in July. Part of my plan B was continuing clinical practice. I practiced two years after joining the ACGME. I was the last holdout of the full-time CLER field staff to maintain clinical activity. I gave it up because my wife and I were moving to a different state, but even if we had stayed, it was not fair for me to be traveling during the week, and then to work clinically on the weekend. Primarily it was not fair for home life, but sometimes it was a long week for me personally. In addition, with the limited amount I was working clinically, it was getting increasingly difficult to keep up with the new processes, technology, EMR demands, documentation requirements, and compliance work. At the time I left I was working clinically about 16 – 24 hours a month. It seemed I was spending at least half that amount of time with all the non-clinical activities related to work. I do miss some parts of the work, especially the “great cases” and working with residents. The job I currently have fulfills a number of those needs. I required a slow wean.

HF: How has the job change impacted your personal and family life?
Dr. Ray
: Even though I have a heavy travel schedule, much of the work I do at home I can accommodate on a flexible schedule. Therefore, I can make time for my wife, my home activities, and myself. Since I can travel from most any airport, it has allowed us to relocate and try a new life adventure. If this does not work out here, we can try somewhere else.

HF: How long did your career transition take?
Dr. Ray
: Once I decided I would be willing to leave my current position and organization, it took me about two years to find the right fit.

HF: Who would be a good candidate for this kind of job – both experience and specialty wise? Are there any openings?
Dr. Ray
: GME experience is necessary, as is a knowledge of patient safety, as well as having a broad range of knowledge and experience across our six focus areas. Some visits you are in charge and some you support the lead, so you need to be able to switch back and forth from being a leader to a follower. Although gratifying, the visits are demanding and you must have a level of emotional and physical stamina. You have to have some resilience to deal with both travel challenges and if an issue were to arise at a site. In addition, understanding the challenges to and the pressures on health care systems will help you do the job effectively. With regard to clinical experience, we have a wide range of generalists and specialists. In fact, having a diversity of specialties adds to the richness of the teams.

Currently, we do have an opening and we have periodic full-time and part-time openings as the program grows. These will be posted on the ACGME website.

HF: What are the different ways one can obtain GME experience?
Dr. Ray
: It’s essential, and core to the job. Current team members have been head of GME at their institution, a program director, or Chief Medical Officer. We have not had any team members who served as only either Chief Quality or Safety Officers without a formal GME role, but I suppose there may be circumstances where that may be considered. Conversely, someone with GME experience without knowledge of patient safety or quality would probably not be a competitive candidate. It is not a job for a 31-year-old, as you need to have a breadth of experience. Most people are in their late 40’s through early 60’s.

HF: Any advice for other doctors considering a career change?
Dr. Ray
: First, magical thinking will not work. It takes time, effort, and commitment. Under any circumstances, it is important to be prepared, proactive, and patient, yet ready for an opportunity. I was in a position where I was valued and liked the people I worked with, so perhaps I had some advantages in that I wasn’t jumping out of a frying pan. Coaching helps. It helped me both with clarity and to help sort out opportunities, what the marketplace of opportunities looks like, and to provide objectivity. It also may help you from simply jumping to next thing that is offered, without taking the long view. Coaching also played an important role in quickly eliminating a myriad of possibilities for which I was ultimately not fit. Regarding the objectivity, a coach should have a client’s interests as their sole interest. Potentially free advice is worth exactly what it costs, and even though it may be given out in a well-meaning manner, I would be cautious. I would also not underestimate the need for financial preparation. If the right position for your happiness is one that requires a pay cut, golden handcuffs will make that transition challenging.

Thank for this great interview Dale!












Burning Out? Recommendations For Your Personality Type

I really, really wish I could change the healthcare system so it would stop burning out so many hardworking doctors. I would gladly be out of a job if it meant this soul-crushing medical system cared half as much about doctor satisfaction as it did about patient scores.

But sadly, I know I alone will not change the system. So every day I ask, “How can I help my doctor clients avoid burnout?”

It’s not a magic wand, but what I offer here is a tool to help you better understand your risk factors for burnout based on personality type, and provide recommendations for healthy coping strategies.

My approach is based on the Enneagram Personality System, which has 9 basic personality types (ennea means nine). If you don’t already know your type, you can take the most accurate $12 Full RHETI test – by clicking here. Alternatively, you can read through the descriptions and see which ones best fit you. Even though you will only have one primary personality type, aspects of the other types are present in you to a lesser or greater degree. This is a long blog, so it is fine to just read the section for your type!

enneagram type 1 mThe Reformer/Perfectionist: High standards, wants to do the right thing, disciplined, focused on improvements. Wants to avoid mistakes, can be self-critical, judgmental of others.

Risk Factors

  • Working in an environment where integrity & respect are lacking
  • Being obsessive/compulsive regarding charting and tasks
  • Feeling guilty when relaxing and not being “productive”
  • Having difficulty delegating and trusting others to do a good job
  • Having a harsh inner critic

Recommendations:  Since you have a very high degree of integrity and care deeply that things are done correctly, you can suffer greatly in a work environment that is not aligned with your values. You may be spending extra time and energy trying to change a system that does not see things as you do. If this is the case and conflict is arising, you may need to find a different approach or a better job fit. You have high standards for your work, including documentation, but if charting is taking an inordinate amount of time, do a trial period of more succinct notes for two weeks. You can always go back to the longer notes, but perhaps shorter notes (with even a few typos) may be acceptable. The Type One has a very strong inner critic, which can be very hard on itself (and others). See how it feels to take on a kinder, more forgiving tone with yourself. There is often a subconscious fear in Ones that if they give themselves a little slack, they will turn into slackers, but this is not a risk! Allow yourself more freedom for guilt-free indulgence, and simple, pure fun.

enneagram type 2 mThe Helper: Enjoys doing for others and being needed. Warm, compassionate, connecting. Can over-do and get caught in people- pleasing.

Risk Factors for Burnout

  • Becoming overcommitted
  • Having difficulty saying “No” and setting boundaries
  • Allowing others to take advantage of the desire to please
  • Losing focus on your own needs and wants
  • Being overly empathic and suffering compassion fatigue

Recommendations: You truly enjoy helping others, connecting and seeing how you can meet the needs of others. As a physician, this can put you at high risk for compassion fatigue and burnout from giving too much. Examine your current personal and professional commitments. Where are you being stretched too thin? What can you let go of? Before saying “yes” to additional commitments, press the pause button and consider whether this obligation serves you. Is it something YOU want to do? Take stock of your self-care and personal time. Is all your time going towards work and family, with little left over for you? Try putting yourself first for a few weeks and see how that changes things. To do this, you will likely need to ask for more from others and redefine some boundaries. If others’ needs are so important, why would yours not be just as important?

Enneagram type 3 picThe Achiever: Focused on accomplishments and getting things done. Motivating, efficient, adaptable. Likes to check off boxes and climb the ladder. Image conscious, competitive.

Risk Factors for Burnout

  • Looking to achievement for self-worth
  • Being a workaholic
  • Losing self in the pursuit of goals/status
  • Letting relationships suffer from neglect
  • Having difficulty slowing down and just “being”

Recommendations: You excel at setting goals and achieving. You thrive from performing well and having the high regard of others. Doing so can result in career success and a great CV, but it can also leave you feeling empty and disconnected from your heart. Ask yourself what is important about your goals, why do they matter to you? What have you had to sacrifice to achieve your goals? Are there other things more important to you now? As an achiever type, you may have put your feelings aside to reach your goals. Slow down in order to find out what is driving the achievement. Ask yourself if there is something else your heart desires. Even in spite of significant achievement, Threes can have self-esteem issues. A good counter to this is fully accepting who you are, and letting go of comparisons with others. Finding your own authenticity and being comfortable with all aspects of yourself, including your appearance, will create more inner peace than any outer achievement.

Enneagram type 4 fThe Individualist/Romantic: Values self-expression, creativity, and finding meaning. Well-developed aesthetic sense, stylish. May be moody and overly sensitive.

Risk Factors for Burnout

  • Working in an environment that is a mismatch for your True Self
  • Being hypersensitive to criticism, feeling shame from mistakes
  • Being prone to moodiness, melancholy, depression
  • Becoming quickly dissatisfied with accomplishments, circumstances or people
  • Allowing emotions to get in the way of staying on task, not being disciplined

Recommendations: You are highly creative, intuitive, and seek meaning and connection in your work. As you like to express your ideas and unique approach, a work environment that is too confining and does not value your individuality will not be a good fit. Having a job primarily for income will not be sustainable. Look for ways to custom tailor your work to match you. Allow yourself time for creative pursuits in your personal life: writing, music, interior design, acting, cooking, etc. If your emotions are getting in the way of finishing more mundane jobs such as charting and completing projects, habitually schedule specific times for these tasks on your calendar. Melancholy is pretty common for this type; but if you find yourself slipping into depression, seek help. See where you can acknowledge the goodness in yourself and what you have created in your life and find satisfaction there, without anything having to be different.

Enneagram type 5 fThe Investigator/Observer: Tireless learner and experimenter. Perceptive, innovative. More comfortable acquiring knowledge and working with ideas than interacting with others. May feel socially awkward. Likes time alone for thinking.

 Risk Factors for Burnout

  • Excessive patient and staff interactions (strong introversion)
  • Having to be in a noisy, busy clinic or hospital setting
  • Feeling intellectually stagnant in routine practice
  • Avoiding dealing with issues because of emotional content
  • Being preoccupied with “what if’s” – worries, scary thoughts

Recommendations: You are an innovator and deep thinker. Your ideal work setting is one where you can focus deeply without interruptions and work independently in your area(s) of interest. A clinic setting with high patient volume, interruptions, and too many routine cases is going to burn you out quickly. Diversifying patient care with research, teaching, and projects can be helpful. Try to find a quiet place to do your work and ask others to minimize their interruptions. Wealth and prestige are not huge motivators for you, but internal success is. You do what you do because it fascinates and intrigues you. If your work is not feeding this need, it may be valuable to reexamine your job/career.

Enn type 6The Loyalist/Questioner: Dependable, hardworking, reliable. Wants to know the rules, do what’s expected. Engaging, loyal. Concerned with security and preparing for the future. Prone to “what if” thinking and anxiety. ***At least half of my clients are Type 6’s. Very common for doctors.

Risk Factors for Burnout

  • Over-working and preparing in order to exceed expectations
  • Worrying about patients and catastrophizing
  • Focusing on problems instead of possibilities
  • Staying in a bad situation out of loyalty
  • Being uncomfortable with uncertainty – (change is hard)
  • Experiencing self –doubt (second guessing decisions)

Recommendations:  You excel in organizations due to your hard work, problem-solving abilities, people skills, and desire to exceed expectations. Able to make sense of large amounts of complex information, you can readily explain things to others in simple terms. You easily over-work yourself, so set healthy limits on your own expectations and set boundaries in your work environment. Because anxiety and self-doubt can be an issue, make a realistic assessment of your abilities and have more confidence in your own decision-making capacity. Try to avoid spending unnecessary time second-guessing yourself and asking other’s opinions. Pay attention to how often you are worrying about the future. See what you can take care of in the moment to relieve your anxiety, and counter the habit of perseverating. Trust that you have the resources, both internal and external, to meet what the future holds. This trust can help you move forward if you need to face uncertainty in order to make positive changes.

enneagram type 7 mThe Enthusiast/Adventurer: Optimistic, social, multiple interests and activities. Resists limits. Can become easily bored, scattered.

Risk Factors for Burnout

  • Becoming bored from limitations of routine practice
  • Being impatient and seeking adventure can lead to impulsive decisions, risk taking
  • Getting scattered from too many spinning plates
  • Becoming dissatisfied with present, focusing on future
  • Avoiding underlying issues/anxiety by keeping busy

Recommendations: You are a glass is half full kind of person and bring energy, high spirits, and a sense of adventure and fun to those around you. You will do best in a work environment with a lot of variety, stimulation, and interaction with others. Jobs where you can take on new projects and then move on, such as consulting, or jobs with excitement and the fast pace of the ER are good options. If you’re feeling bored in your career, take time to understand yourself and your needs before leaping into something else. Be careful not to overload yourself with so many activities that you get scattered, impatient and drained. The desire for adventure and excitement, and avoidance of anxiety and pain, can make it hard to be present and enjoy the now.

Enneagram Type 8 pic maleThe Challenger/Asserter: Assertive, big energy, likes to be in control, lead others. Entrepreneurial, may be a risk taker. Will suffer in order to protect others. Not overly concerned with others’ opinions. Avoids vulnerability.

 Risk Factors for Burnout

  • Pushing beyond healthy limits, overworking
  • Getting into conflict/power struggles
  • Not wanting to show vulnerability, not seeking help
  • Taking risks that jeopardize financial stability

Recommendations: As a Type 8, you like challenges, autonomy, truth, and being able to be your own boss. You may be in a surgical subspecialty and or have a leadership role. You are no stranger to hard work, and may put in longer hours than your colleagues. However, know that you’re human too, and need rest and healthy limits. Take a look at your weekly schedule. Are you overdoing it? Is there any downtime? Try to understand what is driving you to push yourself so hard. What do you want to achieve from your efforts? If you tend to be overly self-sufficient, see where you might allow others to meet some of your needs and provide support for you. There may be times when you are feeling passionate about something, but others may interpret this as anger. A rousing discussion to you could feel like an argument to someone else. If you are experiencing conflict with others, it could be helpful to hear their perspective and solicit feedback.

Enneagram Type 9 PicThe Peacemaker: Grounded, calm, agreeable. Goes-with-the-flow and keeps peace at any cost. Able to see all sides of a situation. Patient. Non-confrontational.

 Risk Factors for Burnout

  • Putting others needs, wants, and preferences first
  • Failing to advocate for self by being conflict avoidant
  • Having difficulty knowing what you really want
  • Procrastinating, escaping reality (reading/TV, etc)
  • Discounting your value, selling yourself short


Recommendations: You bring a calm, accepting energy to your workplace and like to be in a comfortable environment where you feel connected to others and valued. You listen deeply and have a gift for seeing things from someone else’s perspective without judgment. These are great things, however your adaptability and sensitivity to others can cause you to lose sight of your own needs and wants. Often there is something you need to express or ask of someone else, but you discount its importance or do not want to stir up conflict. Try writing out exactly what you want to say or ask for, whether it is to your boss, spouse, colleague or friend. Find a diplomatic way to then address the issue. It is important for you to know that you can have a voice and express yourself. As a type 9, you may be staying way too long in a job that you don’t like. Inertia can take over and days can turn into years. Procrastination is rarely due to laziness. There is usually some underlying fear, concern, or false belief that is maintaining the status quo. Give yourself a pinch, set a deadline for action, and know that when you align with your own inner driver, you are unstoppable.

Final Note. One reason I like the Enneagram system is because it is a tool for personal transformation. For each of the nine types, the Enneagram system describes nine levels of psychological health, offering a roadmap for moving up the levels, thus enabling us to live from our highest, truest self. The things that challenge us about our type, often become our greatest gifts, as we learn who we really are, beyond the structure of the personality

Want to learn more?

Enneagram Institute Website


The Wisdom of the Enneagram by Riso and Hudson

Bringing Out the Best in Yourself at Work: How to Use the Enneagram System for Success by Lapid-Bogda

The Career Within You: How to Find the Perfect Job for Your Personality Type, by Wagele and Stabb

The resources above were used to help create the content of this blog. The focus on physician burnout is my own and does not necessarily represent the views or opinions of the authors.

I Was A Sick Superman!


We’ve all heard about doctors with a Type A personality, and how these individuals can be workaholics, driving themselves to burnout. While it’s true this type can definitely suffer from burnout, all personality types have risk factors.  In two weeks in the blog, I’m going to detail the different risk factors for the most common personality types I work with, giving recommendations for avoiding burnout. But today, I have a special interview to share with you; Dr. Arcadio (not his real name) is one of my great clients who shows how his personality type led to burnout and how he recovered to enjoy his practice again.

HF: Can you tell me what factors led to your burnout?

Dr. Arcadio: I have a type A personality. No, probably triple A. Growing up in an immigrant family, and being the first to go to college, I was driven to make something of my life. Getting my degree was a huge accomplishment, and it made me believe I could do anything. I started my own practice and kept telling myself I could work harder and see more patients. I kept doing this until I became a “Sick Superman.”

HF: What did your life look like when you realized you were a “Sick Superman?”

Dr. Arcadio: I was working 6 days a week, 12 -18 hrs a day, and seeing over 70 patients in a day. I was in an underserved area and the patients needed me. I’d been doing this for a number of years, and then one day I started to feel strange. A once very cheerful and kind physician became someone who started to hate being around patients. When I had a difficult patient my head would get really hot and my scalp would start to itch like I was going to blow my top. It was hard to control my temper. My family life was suffering and I was miserable.

HF: Besides working so many hours, what else contributed to your burnout?

Dr. Arcadio: It was not one thing, but I felt attacked on many fronts. Today’s healthcare is “managed” now from the very top of government to the insurance companies, and even pharmacies. And as I mentioned, the physician personality is partly to blame. We like to be perfect, and are expected to be perfect. This includes never calling in sick, being available late at night and for weekend emergencies, and even while on vacation. I felt like I needed to take ALL insurance plans and squeeze patients in even when I was very booked out. I had to see referrals promptly and keep the referring physicians happy. Then there were all of the business decisions and office management to keep the practice going. I felt like I had created a monster that I needed to feed.

HF: How bad did the burnout get?

Dr. Arcadio: Twice I had suicidal thoughts. It was right before I called you. I didn’t have a plan but I just didn’t want to be here and couldn’t see a way out. I have never ever been depressed, so this was very strange for me.

HF: What else was going on in your life during this time?

Dr. Arcadio: I was involved in a bunch of charities and did medical missions in the US and elsewhere. Before I knew it, the frequent, “Sure, I’ll help you with that,” turned into being heavily involved in 8 non-profit organizations… As part of my “burnout treatment” I now must say “No.” Not because I don’t love helping, but it is part of my treatment plan. I’m afraid I have disappointed most of the organizations I used to help, but I have to get better. I will help again, but I’ve had to realize it’s OK to have limits.

HF: Did you know that burnout was common for physicians?

Dr. Arcadio: I had no idea! I got a shock when I called a local doctor whom I’d always admired and respected. When I asked him if he had ever experienced burnout and he said, ”Yes, many times,” it was such a surprise to me. Something I never would have expected. I felt better knowing it was not just me.

HF: What other steps have you taken to counter the burnout?

Dr. Arcadio: Lots. I have cut my hours back significantly. I often leave the office by 3 pm. I have another doctor who alternates Saturdays with me and I am recruiting for an associate so I can scale back even more. I take more days off to spend with my wife and kids. One of my loves is investing and managing rental properties. Now I can devote more time to this as I’m pretty hands on and like to do the work myself. I have to constantly be on guard, and remember that I’ve been a “burnout patient” and make sure I don’t go crazy with over-doing. You don’t just simply get “treated” and go back to normal. To me, physician burnout is like being an addict. You must have a treatment but you will struggle daily with this condition to keep your sanity. I now feel a lot of joy, which was something lost to the “old me.”

Dr. Arcadio’s personality type in the Enneagram System showed him to be very high in the Type 8, which is referred to as “The Challenger,” or “The Leader.”  This type is especially driven, energetic, confident and likes to be in charge. In medicine they are often surgeons. Famous type 8’s include Franklin D. Roosevelt, Barbara Walters, Martin Luther King, Jr. and “Dr. Phil” McGraw.

In the Enneagram Personality System, there are 9 types, and the test results give you a quantitative distribution among the types. Your highest scoring type is usually your primary type. If you don’t already know your type, but would like to find out before next week’s blog on burnout and personality type, visit the Enneagram site and take a free RHETI test, or the  more accurate Full RHETI test ($12) and discover your type!


Books on Amazon for Physician Burnout

The Wisdom of the Enneagram by Don Riso and Russ Hudson


Working for Health Insurance – Is This Really the Dark Side?

doctor with brief case pixaby

“Work for a health insurance company? You mean go to the dark side? No thanks!”

This is what I hear a lot from my clients who are considering a non-clinical career. However, with the way things are going in medicine, some are reconsidering. They are willing to temporarily suspend judgment to at least learn about this area. What they are finding out is the dark side is not necessarily so dark after all.

To get the inside scoop, I interviewed one of my awesome clients who generously agreed to share her experience working for a major health insurer. For the purpose of this interview, I will refer to her as Dr. Crawford (not her real name).

Background: Dr. Crawford is board certified in internal medicine and practiced for over 10 years before transitioning into the health insurance industry.

HF: What is a typical workday like for you?
Dr. Crawford: I work from home, usually 8 am – 5 pm. I take an hour off for lunch. My work focuses on Medicare inpatient claims. I participate in case management rounds. These are generally for chronically ill patients that are in the hospital a lot. Nurses prep the information for me and we do rounds on the phone. A lot of times there are crazy social issues. There was a patient who had some medical and psych issues. The hospital tried to place him in 40 skilled nursing facilities to no avail, as no one would accept him due to behavioral issues. We had to push the case managers at the hospital to get him a guardian since his family was not caring for him. Finally they were able to place him in a nursing home. I also do some appeals for cases that have been denied and a few pre-certifications.

HF: Are you required to go into an office at all?
Dr. Crawford: No. I don’t go into an office. Instead, there are occasional meetings in surrounding cities where I learn about new Medicare policies and anything that affects my workflow. This is when I see my other team members. I work with 2 family practitioners and one oncologist.

HF: How do you deal with doctors who are angry because you are questioning their treatment plan or denying something?
 Dr. Crawford: I tell them I understand your frustrations and how with discharge plans social issues can get in the way. I don’t always nitpick down to the minute criteria. I let them know I understand that these things can come up with older folks, that I used to take care of them. It is only rarely that I have to speak to doctors who are upset. I’ve probably had 2 in the past 10 months. Of my cases, only about 10% require a peer-to-peer where I need to speak to the physician. One guy threatened to sue me personally for my decision. I said OK I am going to end this call because you are repeatedly threatening me and let him know of his right to appeal the decision.

HF: What do you like about your job?
Dr. Crawford: I love working at home. I like my team. I like my superiors and the management structure of the company. They take your concerns into consideration and try to make it work for you. The benefits and pay are really good. I enjoy getting to use my medical knowledge. It’s not a simple job, but there is so much less stress than when I was in clinical practice.

HF: What don’t you like about your job?
Dr. Crawford: There is a lot of typing and mousing. I was having trouble with my wrists before and I still do…I get up and take some breaks and move around.

HF: How are you treated?
Dr. Crawford: Really well. In my last job I was a corporate employee. This is vastly different experience. I was warmly welcomed. I have one-on-one meetings with my boss. When I was in practice as a corporate physician, they always forgot Doctor’s Day. This year I received 42 Happy Doctor’s Day emails. It’s a much better feeling.

HF: What kind of compensation could a doctor anticipate for an entry-level position?
Dr. Crawford: $200 – $220K. There are lots of good benefits. We have a nice 401K match, annual raises, a generous yearly bonus. Health insurance, dental, disability, some employee discounts. EAP. Financial counseling. 23 days PTO, 5 days CME, CME stipend and malpractice coverage

HF: What advice would you give other doctors who are interested in working for a health insurance company?
Dr. Crawford: I would not discount it based on any preconceived notions about insurance companies. I have always felt that the criteria they have is based on sound medical evidence. It made sense to me. I found it to be clinically sound and sensible. I never thought, “I can’t believe they are doing this.” My boss is always telling me, if there is any question in your mind, always err on the side of the patient.

HF: What are the opportunities for advancement?
Dr. Crawford: I could move up and become a senior medical director and then a regional medical director. I don’t think I want my boss’s job. There is a lot of HR you have to do in addition to regular job. They are big on career development. You have two reviews a year and you need to write down your goals and how you will accomplish them. They suggest you find a mentor in the company for support and guidance. One other area that medical directors can be involved in is the medical policy department.

HF: Do you see yourself doing this job long term?
Dr. Crawford: Yes I hope I can do this until I retire.

HF: What kind of doctor would make a good fit for this kind of work?
Dr. Crawford: Anyone who would appreciate the lifestyle improvement and doesn’t need to continue clinical care. There are all specialties. As long as they maintain board certification. We have a lot of primary care physicians, including pediatricians, as well as OB/Gyns, an anesthesiologist, a spine surgeon, one neurosurgeon, a dentist, and a pharm D.

HF: What kind of doctor would not be a good fit for this kind of work?
Dr. Crawford: One who wants to be clinical or who is not a team player.

HF: How is this job different than you expected?
Dr. Crawford: Much better than expected. Great company. They take their employees’ concerns into consideration. They have their HR stuff straight. There are less issues than at my last company. I have not found anything wrong in their policies.

HF: How much do you enjoy the work you are doing?
Dr. Crawford: It is not always the most intellectually stimulating, but I am reading medical cases, and applying the criteria. I get to use my medical brain. I won’t say I am passionate about it. But it is doable and easy.

HF: Do you miss anything from your previous work as an internal medicine physician?
Dr. Crawford: No!!!!!!!!!!

Dr. Crawford’s job focuses on Medicare patients in the hospital setting. A physician working for the commercial side of insurance, and with outpatients, will have different duties. For those interested in applying for a health insurance position, the general requirements are 3 – 5 years clinical experience, active licensure, and board certification. It is helpful to have some type of utilization review or management experience, but this may not be necessary.