Meet the psychiatrist who never burned out

Dr. David Heath, retired Waterloo region psychiatrist helped me write this. He never burned out after 60 years as a psychiatrist. He attributes this to having a passion in home-based psychiatry and also changing jobs whenever he felt he was becoming stale. “Psychiatrists represent a high-risk group among doctors for experiencing burnout, alcohol and drug use, posing suicide risk and other forms of work-related stress.”1Psychiatry has undergone significant and rapid change in a relatively short period of time, which may mean constant adaptation to new ways of working for many psychiatrists. Psychiatry has also changed from being a custodial to a therapeutic discipline. Simultaneously, the expectations of society have also increased dramatically: people seek psychiatric help not only for relief from disorder but also for manifold problems of everyday life—whereas many psychiatrists may not feel equipped or comfortable in taking on such roles, psychologists can help but are often not covered by insurance.There has been a change from a caring, paternalistic attitude towards the mentally ill to a therapeutic partnership. Relatives of mental-health patients on the other hand widely harbour unrealistic expectations of therapy outcomes. Psychiatrists in many developed countries report excessive workload which they try to deliver within grossly inadequate and underfunded mental health systems. There is an increasing expectation from the society that psychiatrists ought to be precise in predicting risk of violence and suicide among their patients even though the task of predicting is well recognized to be often impossible.Almost in parallel with these changes, psychiatrists report being distressed by a higher frequency of face-to-face and often aggressive interactions with patients.Dr. David Heath avoided burnout by always changingHis first job was as an academic psychiatrist for 5 years from 1973 to 1978:. He was director of a mental health clinic plus an inpatient ward. Then when that didn’t work out he became a psychiatric consultant for probation and parole and local jails plus inpatients. He decided academic psychiatry was not for him, and became medical director of the psychiatric ward at Grand River Hospital in Kitchener/Waterloo in 1978. During a severe bed crunch, in 1982, Dr. Heath read about Canadian research showing some patients destined for hospitalization can be treated at home instead. This led to the founding of Canada’s first Intensive Home Treatment (IHT) service called the Hazelglen in 1989. He started a second IHT service in Cambridge in 1998. In 1991, he added variety to his work by working in a rural mental health clinic in the small town of Listowel every two weeks for five years. Throughout all this time, he always had a private office practice every afternoon. When the Bob Rae NDP clawbacks started in 1996, he said enough of OHIP, and moved to a salaried half time position at Homewood Health Centre in geriatric psychiatry. This allowed him to take up a position in community geriatric psychiatry in Seniors Mental Health Cambridge Memorial Hospital in 1998.In 2004, a new opportunity arose at Homewood—psychiatrist in a rural Assertive Community Treatment (ACT) team in small town of Fergus, Ont. In 2007, he started the gradual process of retirement at age 64. He quit the ACT team and Hazelglen and started as a consultant at Sun Life Financial insurance company in the group disability section, continued Seniors mental health and added a position as assistant clinical professor at the McMaster Department of Family Medicine teaching residents psychiatry once a week. In 2011, he added another weekly position doing collaborative care at New Vision Family Health team for 3 years. He finally retired in June 2023 at age 80.He also had hobbies. He started learning the cello in his early 30s and joined an orchestra in 1980. He enjoyed the challenge, plus met lots of friends in the orchestra—not to mention enjoying the music. In his 40s he learned the bagpipes and joined a pipe band.(My bagpipe joke. Why do bagpipers walk when they play? To get away from the music.)What is unique to psychiatry? Psychiatry has all the other causes of burnout that all doctors face, plus they deal more frequently with suicide, which is difficult to predict and causes lots of grief and guilt in survivors—including the psychiatrist. In the bad old days, patients were locked away in chronic psych hospitals which have since been put out of business. Now, many these people have ended up in the homeless population.David recommends debriefing of the whole team after any critical incident. Before any critical incident family meetings can also help. Good note taking which outlines advising all patients who are at risk to call a suicide hotline and or go to the nearest ER if suicidal can help avoid problems. Families may sue or complain to the college, so your only defense is good note taking.Another unique aspect of psychiatry is the patient often doesn't think they are illDavid says that seriously ill patients with schizophrenia and severe bipolar disorder are said to have anosognosia or a lack of awareness that they are ill due disordered brain function. With manic patients one can sometimes “hook them” by indicating some advantage in being treated: "This will keep your mother off your back, "or "this will help you stay out of trouble with the cops.” Psychologist Xavier Amador, whose brother had schizophrenia, wrote a wonderful book I am not sick. I don’t need help, explaining how you can engage such patients by listening empathically to their delusional talk and gradually finding some common ground to get them to take and keep taking meds. Family members can be very helpful in persuading patients to cooperate and take treatment.David told me that psychiatrists use themselves as a tool like a surgeon uses a scalpel. Warmth, sincerity and genuineness help with success in using cognitive behavioural therapy.Psychiatric problems often affect the family, friends and employers, tooDavid once naively offered to see patients from the hospital crisis clinic at short notice for a consultation even when not on call because his office was in the hospital. He discovered that you often can’t just do a single consultation like most specialists. You see the patient. And then the calls start coming in from the the employer, school, and family, wanting advice or relaying concern about whether the patient is dangerous. He stopped offering that service quickly! Being realistic helped him avoid burnout.Dr. Heath made a practice of seeing the families of most of his patients and most patients appreciate that and gave consent. In some cases he would need to point out that he could receive useful information from them but not tell them anything. Engaging families is often neglected he found. But there are sometimes patients who refuse care and have to be be admitted against their will.Passion is one of many antidotes to burnoutDavid's passion was home care for psychiatric patients. In 1982, David noted a severe bed crunch. Government was not going to provide more beds. What to do? He read a small monograph about a study at Montreal General Hospital in 1978 in which patients needing admission were randomized to home treatment or admission. Results were the same. It was an epiphany that really sick people could be treated at home. He got funding for a team and in 1989. It was thrilling.They knew they were pioneers, treating patients with schizophrenia, severe bipolar disorder, etc., at home. The patients were so thankful to avoid hospital. Realizing this was one of the few areas of psychiatry no one had written a book about, he decided to write one. All the staff came to his house once a week to eat pizza and to help him write it. The team had a lot to teach David about how they dealt with these challenging situations in the patients' homes. The book was called Home Treatment for Acute Mental Disorders: An Alternative to Hospitalization and was published in 2005 by Routledge, New York, to good reviews. In later life, David transitioned into seniors mental health care. This is where I worked with him as medical director of two nursing homes. He was a great asset because he had a team consisting of a social worker and nurse who did house calls with hime at the nursing homes. They did a great job helping me and my nurses look after patients with dementia. Families often feel guilty and they need a lot of input to treat their loved ones. For example, the nurses often complained about aggressive patients due to dementia. Medications often made the patient sleepy, so David and his team helped get the right balance which was tricky. Medication titration and behavioural support need lot of time and skill and communication with the families and staff.Don't forget exercise For most of his life, he has gone to a gym about four times a week to work out with weights and exercise machines. He likes it because he can see his progress; an extra rep here; a few extra pounds lost there. What do you think about psychiatrists avoiding burnout even if you are not one.Email me at drjohncrosby@rogers.com or comment below. Check out my website on time, stress and risk management for all doctors.And check out Dr. David Heath's website here. References: Dr. S Kumar Burnout and psychiatrists: what do we know and where to from here? Epidemiology and Psychiatric Sciences , Volume 20 , Issue 4 , December 2011 , pp. 295 - 301DOI: https://doi.org/10.1017/S204579601100059X

Meet the psychiatrist who never burned out

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