Mary Remón: Welcome to Burnout by Specialty. This is our internal medicine episode hosted by Doctors on Social Media. My name is Mary Remón. I’m a licensed counselor and coach for physicians. And I am so grateful to have three internal medicine physicians here today.

We have Dr. Dami Bambaniji, Dr. Robert Duhaney, and Dr. Diane W. Shannon. Welcome. Let’s start with brief introductions.

Dr. Bambaniji.

Dami Bambaniji: Yes, I’m so glad to be here. Thank you all for having me. My name is Dami Bambaniji. I am a hospitalist in Dallas, Texas, and I also work as the Medical Director for Clinician Wellbeing for a medical group. So glad to be here.

Mary Remón: Welcome, welcome. Dr. Duhaney.

Robert Duhaney: Yes, I’m glad to be here as well. My name is Robert Duhaney. I’m an internal medicine physician. I practice primary care in Austin, Texas with One Medical. It’s a national primary care group. I also do some consulting for hospice and other agencies.

Mary Remón: Thank you for being here. Dr. Shannon, welcome.

Diane W. Shannon: Thank you. Great to be here. I’ve had three careers so far in my 30 years in healthcare. The first was internal medicine primary care, where I burned out. My second career was 20 years as a healthcare writer writing about our healthcare system to try to understand why I burned out. And most recently, for the past seven years, I’ve been a full-time coach for physicians, helping them create sustainable careers so they can stay. I’m located in Boston.

Mary Remón: Thank you very much. Well, let’s get started. Dr. Bambaniji, this one is for you. What does burnout look like in internal medicine compared to other specialties?

Dami Bambaniji: Well, that’s a great question. Because I haven’t worked in other specialties, I’m not going to be able to speak on their behalf. But for us in internal medicine, which can be outpatient or inpatient, I’m going to speak from the inpatient side.

I’m a hospitalist, an academic hospitalist, and I get the pleasure of teaching medical students as well as residents. Sometimes I’m also on the private service as well. On the private service, you do have the risk of running into burnout more because you carry more of the load by yourself.

It’s an onslaught of admissions, rounding, paperwork, consults. I feel like burnout from an inpatient standpoint is being pulled in so many directions that you don’t have a center anymore sometimes. You get frazzled because your attention is demanded in so many ways.

So there’s this misalignment between what you want to do and what you’re actually doing. That definitely creates a recipe for burnout.

And then if we want to add administrative responsibilities too—paperwork, meetings, committee assignments—all the things that keep adding on. Yes.

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Mary Remón: That’s a lot. Dr. Duhaney, what would you say is the part of the job that is most draining?

Robert Duhaney: I’m coming at it from an outpatient perspective in the clinic. When you go into primary care, typically you have a strong desire to build relationships with patients, and you love that aspect of it.

But there are so many different things that can be draining. One particular thing, and I know a lot of physicians agree with this, is the prior authorization process.

When you know you want to implement a treatment plan, prescribe a medication, or get imaging done, there can be a roadblock from the patient’s insurance saying they need to go through certain steps first.

Even when we know they’ll eventually need the thing we’ve prescribed, we still have to go through those steps.

I think it started with the intention of controlling costs and making sure things were evidence-based, but it’s gotten way out of hand. It’s become a giant block on patient care.

It really drags us down.

At One Medical we have a remote administrative team that helps with prior authorizations, but you can imagine when GLP-1 medications came out for weight loss. They’re great medications, but you can imagine all the prior authorizations we’ve had to deal with. Some get covered, most don’t.

But it’s the burden of it. It slows down patient care. And patients sometimes think we’re the ones preventing them from getting the medication, when really it’s the insurance company.

So it even interferes with the physician-patient relationship.

Mary Remón: Thank you. Dr. Shannon, from your perspective, what do people outside of internal medicine not see?

Diane W. Shannon: I’m not sure they don’t see it, because many stressors are common across specialties.

What I found in the physician groups I run is that physicians hear about another person’s challenge and think, “I didn’t realize you were spending three hours every night finishing charts too.”

Obviously this is less common for procedure-based specialties where notes can be completed immediately.

But internal medicine physicians often have ongoing communication with patients through portals and long-term relationships.

So the burden of charting, prior authorizations, and patient communication is huge.

When you can’t do what you know is right for the patient because there aren’t enough resources, staffing is inadequate, or insurance companies deny coverage, it really strains that physician-patient relationship.

Mary Remón: Thank you. Some people say that leads to moral injury.

Dr. Bambaniji, let’s think about system pressures. Where do system pressures hit hardest in internal medicine?

Dami Bambaniji: That’s a great question. Speaking from an inpatient standpoint, the hospital itself has to function effectively.

I’m in a Level 1 trauma center, so it’s very busy. We’re also a safety-net hospital, so we receive many referrals and emergency room admissions.

Bed availability is always a challenge.

We have a mix of very sick patients and we’re also a transplant center. You’re constantly trying to manage bed flow.

There’s pressure to discharge patients so new patients can be admitted. But if a patient isn’t ready to be discharged, or you haven’t even had enough time to evaluate them fully because your census is so large, that becomes stressful.

You’re trying to deliver excellent care while also trying to move patients through the system.

Sometimes there’s pressure to discharge before a certain time. That adds pressure because you’re trying to think clinically while also meeting operational goals.

That’s how system pressures can add to physician stress.

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Mary Remón: Thank you. I love your three unique backgrounds, because even within internal medicine the pressures are different.

Dr. Duhaney, what feels most unsustainable?

Robert Duhaney: Diane touched on something earlier about patient portals. In outpatient primary care, patients now have full access to the clinical team through portals.

Day and night we receive messages.

Patients are often engaged and well-meaning. Many of my patients in Austin are young tech workers who listen to longevity podcasts and want to try various interventions.

But the volume of portal messages can be very high.

There are also response-time metrics requiring us to respond within a couple of days.

So you’re trying to manage portal messages while seeing patients all day in clinic.

And not every clinic has the same level of support staff. If you don’t have nurse practitioners, physician assistants, or adequate support personnel, more of that burden falls on the physician.

That can definitely drive burnout.

Mary Remón: Thank you. Dr. Shannon, you practiced internal medicine and now have a big-picture perspective. What do you wish leadership understood?

Diane W. Shannon: I love this question because leadership has a huge impact on burnout.

There’s strong data linking leadership behavior to physician burnout.

One key factor is communication and physicians feeling valued.

Leadership that encourages two-way communication rather than top-down mandates reduces burnout.

Physicians need to be involved in planning, decision-making, and providing feedback about clinical implications.

There’s a term called administrative harm. It refers to decisions made by administrators that negatively affect patient care or the physician-patient relationship.

These decisions are often made far away from the clinical environment.

Leadership needs to shift toward a servant leadership model—supporting the clinicians who care for patients.

And the data shows this type of leadership is more effective.

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Mary Remón: Thank you for that perspective.

Dr. Bambaniji, what keeps people practicing?

Dami Bambaniji: That’s a great question. I’ve spoken with colleagues who are burned out or recovering from burnout.

One thing that keeps people going is the joy of using their skills to help people heal.

Most physicians didn’t enter medicine for money. They entered because they want to care for people.

For example, during the COVID pandemic when I experienced burnout, I still wanted to care for my community.

But I also had to be present for my family.

So you’re caught between wanting to care for patients at the lowest point of their lives and needing to care for yourself.

But the desire to help people heal is what keeps many physicians going.

Mary Remón: Thank you for your service. No one should have to choose between their family and their patients like that.

Dr. Duhaney, if one thing changed, what do you think would reduce burnout the most?

Robert Duhaney: I liked what Diane said about leadership and feeling valued.

If clinicians feel valued and their feedback matters, that can make a big difference.

Often decisions are made that affect patient care without input from clinicians.

If clinicians were part of those decisions, it would help.

There are many contributors to burnout—prior authorization, patient portals, quality metrics—but feeling valued by leadership would go a long way.

Mary Remón: Well said. Dr. Shannon, any advice for doctors going into internal medicine?

Diane W. Shannon: Yes. What I wish I’d known is that you’re human.

That sounds simple, but during training many of us shed parts of ourselves just to survive.

I trained before work-hour limits, and to keep up I gave up hobbies, relationships, sleep, and exercise.

I wish I’d known how important it was to keep those parts of myself.

We deserve to be human.

Yes, medicine requires sacrifice, but not to the point of self-erasure.

Also, be thoughtful about the career path you pursue. Don’t climb ladders simply because they seem expected.

Choose the career that aligns with what you want.

And protect the things that sustain you—sleep, exercise, relationships.

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Mary Remón: Such great advice. Thank you.

I have one final question for each of you. How can we make internal medicine more sustainable?

Dr. Bambaniji?

Dami Bambaniji: To make internal medicine more sustainable, we need to make it more humane.

Physicians must be allowed to be human.

We’re not immune to the conditions we diagnose in our patients.

We can’t keep pouring from empty cups.

Taking care of ourselves allows us to care for others.

Mary Remón: Thank you.

Dr. Duhaney?

Robert Duhaney: There’s a lot of unlearning required.

Medical training teaches us to be superhuman and sacrifice everything.

But we need boundaries.

We need time with family, hobbies, and rest.

We can still be excellent physicians while living full lives.

Mary Remón: Dr. Shannon?

Diane W. Shannon: I agree with everything that’s been said.

But I would also add that we need to rethink how healthcare is financed.

When systems focus heavily on profit and margins, fewer resources go toward supporting clinicians.

For example, when physicians go on vacation, why not have a float pool of physicians who can cover?

Instead, colleagues often have to absorb extra work.

We need to invest more in the people doing the work.

Mary Remón: Each of you brings such important perspectives to this conversation. Thank you, Dr. Bambaniji, Dr. Duhaney, and Dr. Shannon for joining this internal medicine episode of Burnout by Specialty.