Fresno Clinic May Help Prevent Physician Burnout

FRESNO — The most obviously ebullient person at the Tzu Chi free health care clinic was four-year-old Philip Esparza, who was getting a pre-kindergarten check-up.

“I’m 44-inches tall. Forty-four!” he announced after being measured.

But not far behind him in the beaming department was Le Ha, an oncologist volunteering for the first time at the weekly clinic.

“This is a blast,” he said. “I’d had a real rough work week. And now I don’t even remember why it was so bad.”

Clues as to how to address two of the thorniest problems in health care reform — providing care for the uninsured and protecting the sanity and humanity of physicians and other health care workers under ever-increasing pressures — might be found here, in this peaceful, well-organized clinic set up at the Cesar Chavez Adult Education Center in Fresno every Tuesday and some Saturdays.

Tzu Chi, the Taiwan-based Buddhist organization running the clinic, is more known for providing relief in far-flung disaster areas such as Indonesia, Haiti, Kosovo, Rwanda, Cambodia and North Korea. Founded by a 72-year-old Buddhist nun, it is the largest non-governmental organization in the Chinese culture.

Partner Kaiser Permanente has been mentioned during national health reform discussions as an example of a system that delivers cost-effective care. At the same time, “closed” systems such as Kaiser Permanente shoulder little responsibility for anyone outside their system.  Within the system, doctors are often expected to see a different patient every 15 minutes.

These unlikely allies, over eight years, have built a steady, dependable free clinic in Fresno. Kaiser provides Tzu Chi with grant money and equipment. Tzu Chi gives Kaiser staff a place to practice medicine in a slower-paced, revitalizing environment.

There were other reasons Fresno Kaiser chose Tzu Chi as a grant recipient. For instance, during a previous program, volunteers from Kaiser treated 600 to 800 patients at a one-time, one-day health clinic hosted by their own hospital. For less money, the effort run by Tzu Chi sees 500 to 600 patients every month.

Still, providing an ongoing opportunity for Kaiser staff to volunteer was an important boon. Tzu Chi welcomes all volunteers, but is largely staffed with Kaiser personnel who are familiar with the clinic and its schedule.

“Our people were volunteering in droves. They needed it. They wanted more opportunity to help,” said Ivonne Der Terosian, Kaiser’s Fresno community benefits manager. “We can all get into our little silos, our individual units and get disconnected from the community. When you face the bigger need outside your own walls you come back to work refreshed, tired sometimes, but refreshed.”

The Cost of Burnout

The concept might be soft and fuzzy, but the need to restore the flagging spirits of doctors is hard and real.

A 2009 study in the Journal of the American Medical Association found that internal medicine residents suffering from high levels of stress and fatigue were more likely to report making medical errors.

A recent survey conducted by the American College of Physicians and the American Board of Internal Medicine found that at a time when there is a shortage of doctors, high numbers are burning out and leaving the field — 17% of general internists are no longer working in their field of practice about a decade after their original certification.

In 2008, Sen. Mike Enzi (R-Wyo.), introduced legislation to provide government insurance for doctors who volunteered.

While the main purpose of the law was to provide doctors to the poor, Enzi noted the benefit it would give doctors.

“My mother always told me that service to others is the rent we pay for the space we take up,” Enzi said.

The bill was based on a similar Florida program, which paid the malpractice insurance for doctors volunteering to treat those with annual incomes below 200% of the poverty level. The program cost the state $600 to $900 a year and volunteers provided more than $1 billion in care a year. More than 20,000 doctors volunteered their services.

The national bill died in committee.

In California, one of seven states with no regulations protecting volunteer health care providers, the California Medical Association and the Medical Board of California are stumping for new state regulations that would expand malpractice insurance coverage for volunteers.

Both organizations support SB 1031, by Sen. Ellen Corbett (D-San Leandro), which would change state law to offer medical malpractice insurance to physicians and surgeons who provide volunteer services.

‘Did You See That Smile?’

Jennifer Yang, a Kaiser pediatrician, is a fan of the hospital she works for, preferring it to the pressures of private practice.

Still, at her “real” job, with four scheduled patients an hour, she doesn’t have time for chatting. She is exhausted by the end of her week. Working at the clinic on her day off may seem counter-intuitive. But on a recent Saturday, Yang said she felt energized.

“It’s been such a luxury to sit across from people today and find out a little more about them. Did you see the smile on that little boy?” she asked about Philip.

“He was telling me all about how excited he is for the first day of school.  I had another long conversation with a 12-year-old about why he is so afraid of the dentist.  I’m remembering why I got into medicine.”

Behind her at another table, oncologist Ha, Yang’s husband, was treating a young man brought in by his sister. As they were leaving, the sister held out her hand to Ha and said, “Thank you. I just want to tell you that I admire you very much.”

Ha said the encounter counteracted a week of stress.

“Sometimes, even though you’re a doctor you feel like you’re taking orders. People think of themselves as paying customers, more than as patients — which is fair, they are paying — but they’ll say, ‘I want you to do this. I want you to do that.'”

“But that woman who brought in her brother — I got a chance to talk to her. She had her own struggles. Still, she cared enough to take a day and make him see a doctor. Meeting someone with that strength of character and having them express appreciation — it really is a blessing,” Ha said.

A Humanistic Culture

It’s hardly a new thought that the one giving sometimes receives the greater gift.

But Steven June Keong Voon, Tzu Chi’s medical program director in the Central Valley, said that in this case, the greatest benefactor is the health care system as a whole.

“The doctors are restored. They have more compassion for all their patients.  And the people they treated are funneled into health care. We direct them to social agencies. Maybe they don’t go to the emergency room. Maybe they are in better health and less of a risk by the time they can afford health insurance,” he said. “We’re the missing piece between the system and the very poor. I don’t think that need will change.”

In other parts of the world, Tzu Chi is known for delivering services with a bow to show respect for who they serve.

Fresno is a largely conservative Christian area, and Voon is judicious about bowing.

“It offends some people and that is not our intention,” he said. “I’ve even had some doctors say they could no longer volunteer because they were pressured by people at their church for spending their time with a non Christian-based organization. But none of the people we treat are Buddhist.  This isn’t about religion.”

It is, however, about principles.

Voon said it is not just a happy byproduct that caregivers leave the day uplifted.

“It is one of our four core goals. We are here for charity, medicine, education and to promote a humanistic culture.”

Voon said physicians are given the equipment they need to provide the same standard of treatment they would to paying patients. They are given time to talk and listen to every patient they see.

“We call it ‘treat the poor, teach the rich,’ he said.

Voon bristles with shy pride as he shows the various stations and treatment rooms. There is a calm pace, even when there is a line of patients.

In every room, conversations, punctuated by smiles and even laughter, are taking place between patients and doctors and administrators and lab technicians.

“I just got back from Haiti. That is a different kind of need,” Voon said. “But what happens here on an ongoing basis is very important.”The need for care and the need to serve, come together and each are fulfilled in an ongoing way,” he said.

“It is something worth observing carefully.”

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