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Diane Newman: Welcome to UroToday's Bladder Health Center of Excellence. I'm Diane Newman. I'm a nurse practitioner at the University of Pennsylvania, and I'm the Center's editor.

I'm really pleased to introduce to you a friend of mine, Dr. Scott MacDiarmid. He's a urologist in North Carolina. Scott and I have practiced and been colleagues now for many, many years. He's been in urology practice now for over 30 years. He originally was trained in Canada and we're lucky to have him down here in the United States because he's really considered an expert in lower urinary tract dysfunction. And why I have him here today is because Scott and I have been talking now for the past few years about burnout, what's happening in the medical and nursing field, and Scott has written a really impactful and insightful book called Fist Pumps. It's a neat title, Scott. And I asked him here today because I thought that he could talk a little bit about his book and I really think our audience would be very interested in this because I think a lot of us are going to resonate with what you're saying, Scott. So talk to us a little bit about your book, Fist Pumps.

Scott MacDiarmid: Yeah, well thanks, Diane. I'm going to start with a few little introductory slides and it's easy for me to say this, but it's an honor to be here with you because as you said, I remember the first time I met you at dinner and we've been colleagues in our leaky bladder society forever and I know we're great friends and I want to thank you, Diane, and UroToday especially, because it's a serious topic.

Burnout and physician joy is so important and we really do need loud voices and it's not just going to be mine or yours, Diane, but all these little things we do, we need together to make a significant impact for this issue that's affecting all our healthcare providers. And maybe this little visit today could help someone struggling with burnout or more importantly... I want to love what I do. I want healthcare providers to love what they do when they go to work every day and serve our nation.

When I talk about healthcare, or write about it, I start off by saying, "We have a healthcare crisis and the crisis is now."

And you think about it, costs are just soaring out of control. They really threaten the financial health of individuals by the entire system in our country. Quality is deteriorating in spite of all those World-Class Care signs seemingly on every corner. I think quality's going down and unfortunately, the healthcare providers, the nurses, the doctors and APPs are checking out and burning out at record number. And I do think it's one of the great societal issues of our times, actually.

I think what we've actually done, we've just overcorporatized the American healthcare system. We made medicine a commodity. It just is, and the Main Street of medicine is doing great. The makers of drugs and equipment, the hospitals, the attorneys, the third party payers, the Wall Street of medicine is doing really well; but the Main Street, our functional healthcare: the doctor, the nurse, the patient. We're actually the commodity. I think we're getting hammered. I really think it's really been something for all of us.

I think you can make a case that the doctor and nurse and patient now sort of exist for a whole bunch of people to make a whole bunch of money. And I don't mean to be cute at that and I don't want to demonize corporatized healthcare. I'm a capitalist, and they've brought us this world-class system. I just think it's gone too far and I think what the death blow, or the final straw, for the healthcare system, I've predicted for a long time now, is the devaluation and the commoditization and really the gutting of the profession of medicine. And I really mean that, because when the profession of medicine dies, there's so many downstream negative effects on society. I really believe that. And look what's now happened to nursing and it's really sad for our country.

We're going to talk just quickly about, I'm going to remind you... You folks know the causes, but I'll summarize some of my favorites. Every day I go to work, it seems like death by a thousand cuts. It's another preauthorization, another rule or regulation. I got another one today from Medicare, and EMR, and it wears you down. It wears down resilient people over time.

I do like saying that we're like restaurant owners herding cats, and what I mean by that, we're trying to drive excellence as a healthcare provider with this type A personality, often with a team that is fragmented and having less ability or want to drive excellence with us. It's very frustrating.

I think many of us, we're employed by a healthcare system or we work in one that we don't necessarily believe in what they believe or trust or respect them. I think it's the truth for some of us, and if that's the case, emotionally, that's a hard one to bear actually. I think that wears you down and causes burnout. Doctors do well, we do well, but I think it is reality and at least our perception that the harder we work, we keep getting paid less. And that's hard on someone's psychology. That's hard on your psyche. It does wear you down.

Probably as a Canadian, I should be more PC, but I'm not. I think this, for me, is my biggest cross to bear, because I think the patients are killing us in a sense. I think the loss of civility of the country, I love, America, and myself, I'm part of the community and I'm a citizen in this country, it brings me despair, quite frankly. But that same loss of civility, if I'm right, is in my waiting room and speaking to my patients every day. And as a reconstructive urologist, the pressure we're under for perfection in delivery of care is palpable; in some of us, I think it's the cause of our burnout, and I underlined the loss of control. I realized as I was writing the book, when you feel you've lost control, which we have, it makes all these things a lot worse.

Burnout for me is living in a valley and I think there are stages and the stages worsen as you go down further into the valley and you're more adversely affected, as are others around you. Early in the descent, many of us are irritated, we're frustrated.

I used to jokingly say, "You're just chronically annoyed."

I mean, you can almost joke about it. What normal person wouldn't be annoyed every day doing this?

And that's where I thought I lived for decades and then I realized in retrospect that I'd slipped further in the valley, really losing a lot of good Scott and gaining more bad, and I really didn't nip it at the bud and I slipped further down into the valley. I think that many people deeper in the valley are bitter, they're angry, they're resentful. I've learned by reading and my own experience, that resentment is common in medicine. It's very destructive to you and those around you. You know that easy anger, that short temperament, that cynical, cutting, sarcasm, the way you speak to administrators, maybe to other people. We start commoditizing our patients. We're caring less, we're listening less. We're trading excellence for apathy. I think this is really endemic now in our healthcare system. I think the deepest in the valley of burnout, fortunately, I've never ventured there, but I think many physicians are discouraged, they're lonely, they've lost hope, they're fearful.

I think some have lost... They just don't believe in their purpose anymore. They gave their life to be a healthcare provider and they don't believe in it anymore. That would be very sad, and some would even call it Hell, and some have committed suicide.

The reason I have talked about these causes and the valley of burnout, Diane, was really for two reasons. I would urge, first of all, if you're, the valley of burnout and how it affects you emotionally doesn't just stay at work. It doesn't stay within the four walls of work. That same biting sarcasm, or those anger spells, or being judgmental. When I learned that was affecting my relationship with my wife, Andrea, and my great kid, Lindsey, that was really my turning point a number of years ago, and I want to remind my colleagues that when you're not joyful at work, this is a life mission you're all in, and if you're burning out and you're not joyful and you're discouraged, that doesn't live in isolation, that those around you, it affects so many. Your family, your friends, your community, and your patients.

Don't do what I did. You want to nip that at the bud. The job is not worth that. What I also say is we talked about the causes and I really did that just to give this message as there are so many causes of burnout and look in our own mirror, you see many, but waiting for the system to change is not a good strategy. I would not recommend that.

What you want to do and what I decided to do is you make the decision that, "I'm going to climb to my mountaintop. I am going to live differently and take that journey to the mountaintop of joy and fulfillment."

The book actually, Fist Pumps, provides you solutions and survival tactics to help you on that journey. It's not perfect, but hopefully it really helps you. It was really written, when I thought about it, to encourage and inspire you to begin your journey to the mountaintop of joy and fulfillment, but also equip you to say no to the valley of burnout. And we have a website and an app and a whole bunch of fun things, but I hope you enjoy the book.

Diane Newman: Scott, that was wonderful. And I had to tell you, reading the book, it resonated with me because you're right, you included nurses, nurse practitioners, physicians, of course. And you're right on the dime here. A lot of people are saying this. A lot of people are burned out. What I'm seeing is an excess of really high quality physicians, nurses who've been in the field for many years who just don't want to deal with it anymore. So I really commend you for writing this book and you really bring out the different components of why people are burned up.

Scott, tell me, why did you write the book?

Scott MacDiarmid: What happened, Diane, it's a little bit of a story, but in the early '90s, I was doing my fellowship at Duke, in incontinence, but it really hit me in the face as a Canadian, I said, "Huh, they've made medicine a commodity in this country, like they did the school system, and I'm not sure that's going to work out well."

And I always had this interest in healthcare and when I give... Let's say I was giving a review course and Peter [inaudible 00:10:53], my friend, would say, "Scott, could you give five or six talks on incontinence?"

But I said, "If I can give one on healthcare."

And so I used to talk and soapbox about healthcare and the theme of my talk at the time was, When I Die, You Die. The Fall of American Healthcare. What happens to a society when physicians check out? What that could do, much like if that happened to teachers or others who serve.

And I give that talk and people say, "Well, Scott, talk more about the burnout part. You seem to have a bit of a gift or insight on that."

And it really was an aha moment. It really simplified the book, I was trying to save the world on healthcare, turned into... I don't have to do any research, really. I think I could share a lot of things that I've learned that maybe I could share with others. And I must say, Diane, writing makes you think. It's unbelievable. It's been the coolest experience for me. And I realize, first of all, I wrote the book because I had something to say, but it said, "What was your lofty goal?" And it is today, it's what I get up for now, is to help create a world that lifts up physicians and healthcare providers who serve. That's why I'm existing right now. It's really to create a world that inspires healthcare providers and encourages them to use their gifts and talents to help others. And the book's just one way hopefully that would help achieve that.

Diane Newman: How did you come up with the book title, Fist Pumps?

Scott MacDiarmid: Yeah, what happened with Fist Pumps, was that when you think about it... I've shown videos of Tiger Woods and people doing the fist pump, there's something about it that is very encouraging, not just tapping yourself on the head or a thumbs up. It really is a very uplifting emotional gesture, actually. I'm sure it's been around to the Olympians way back. But what happened is it's a bit of a long answer.

We've talked about valleys in the book. We talk about mountaintop and mountaintop decisions. In contrast to the valley, the mountaintop is that place where you're living where you find virtue, you find contentment. You're joyful. Life's giving you meaning. It's really timeless. You just know that what you're doing, all the difficulties of medicine, in this case, are worth it. You're living your purpose.

I'm over 60 now, and when I say or think this, it's that place where you stand and you look out over those valleys and back over your life and you say, "Job well done."

Those are good words of finishing strong. That's the mountaintop.

Then I said, "Well, Scott, how do I get there?"

Or other people say, "How do you get the mountaintop?"

For me, it became a decision and a choice. The decision was to accept healthcare. I was not accepting it. I was fighting it. I'm going to accept it.

"Yes, Scott, you're devalued. Yes, you're commoditized. Yes, EMR is killing you, but the good old days of medicine are over and you're going to accept that if you want to reach your mountaintop."

I want people to listen to this. I think it's important. We all know this, but this is how I'll phrase it. I find many times a day I come to a crossroad and the crossroad is, which choice am I going to make? Am I going to continue to walk down the the easy path, often, to the valley of self-pity, anger, frustration, criticism, or to send or choose the harder, often upward ascent to the mountaintop and make those right choices.

I just encourage you to make the mountaintop decision, to go the upward ascent. Some can be driven, make that decision, given the strength maybe from a transcendent force or an inner strength. Others will be pushed up to the mountaintop by their fear of leaving the valley. That is actually a great motivator.

But a mountaintop decision, in summary, is when you think, feel, say and do something that affirms the upward mountaintop ascent much more calmly when you don't think, feel, say, or do something that pulls yourself down. It's self-destructive. And when I did that, I was giving myself...

You should reward yourself. You give yourself a congratulatory fist pump. Well, I found myself fist pumping all the time, and I found this behavioral therapy exercise. You start anticipating the stressors. I'd be walking down the hall and I'm a great soapboxer and say, "Nope." The hand just went up like this.

"What did that guy just fist pump himself far?"

Well, I'm going in the doctor's room and I'm not going to soapbox. I'm going to have a sandwich and leave. And hence, if you think about every mountaintop decision you make and you give yourself a fist pump, you have self-prescribed the treatment for your burnout.

Diane Newman: Well, it's interesting because you're right, you talk about burnout, which of course is a negative, but I love your title because it's a positive. Give yourself that little pump. Like you're saying, try to achieve. Now you also talk in the book about the greed virus and the seven systems of healthcare. Explain that a little bit.

Scott MacDiarmid: Yeah. The greed virus is... The healthcare system's like the human body. You have multiple organs that are co-dependent on each other. The health of one depends on the other. The body of healthcare has seven organs. The healthcare systems, the providers, the makers of drugs and equipment, the regulators, attorneys, the government, the patients and the makers of drugs and equipment.

The book used to be called at one time The Greed Virus. And what's happened is all seven systems, us included, providers and doctors are infected with the greed virus and entitlement virus. We have been taking as much as we can, as fast as we can, for decades. And the system has exploded, quite frankly, and the system is dying. And the reason I put them into the middle aspect of the book was not to throw each one of us under the bus. I'm hard on doctors, but you have to identify what we're doing to each other, or hospital greed virus, as an example. But it was put there not to throw the hospitals under the bus. It was to then say, recognizing that currently exists, how could you find joy and fulfillment in that? And I give recommendations for that to the best I can.

Diane Newman: You also talk about the fact that you're putting on your suit of armor, and the purpose of the white lab coat. And I thought that was interesting because you're right, we wear these lab coats almost like an armor or maybe even a barrier to the patient, right?

"Look who I am, so then you have to treat me a certain way or I'm apart from you," type of thing. I don't know. In some ways, I think the white lab coat is the worst thing that we've done in medicine.

Scott MacDiarmid: I sort of have a canned answer that you've got me thinking about that. I'm going to give that a lot of thought, the latter part of what you said, it may be a barrier, but what happened is for myself, putting on your suit of armor is having the personal qualities, the inner strength, the fortitude to take on the battle. Gratefulness, et cetera. But I thought the most important way is to know your purpose, is to know your why. It's to understand why you're here on this earth to accomplish. And I believe that healthcare providers were given gifts and talents to help others and to serve. I don't think it's coincidence. I think we were called to serve. And what I realized is when you think of it, Diane, most people who serve in their job in our country wear uniforms.

Well, I learned in the early 1900s, the doctors went to the lab and got that three-quarter length white lab coat. They're actually trying to give themselves some scientific credibility because otherwise, they were being looked upon as a bunch of quacks, giving out these potions and pills. And even to this day, it's looked upon as a symbol of a scientific healer.

So I use it when I speak. I often will hold it up. And I try not to get too emotional by saying, this is your suit of armor. This is why you're different. When you put it on each and every day, you straighten your shoulders, you be proud of yourself. You've been called to serve, you've been called to sacrifice. You've been called to reach beyond yourself for others. And I think many of the finest are asked and given that responsibility,

Diane Newman: Well, I think it's an interesting take on the lab coat because like I said, I think more and more in healthcare we're not using it because sometimes I think it can turn off patients. But you're right, it is an honor and it also gives us a certain level of respect, I think, and also of what we're all about.

The other thing that you talk about that I thought was really interesting in the book was about fortifying the homeland. Explain what you mean. You mean the homeland of the health system, or...

Scott MacDiarmid: Fortifying the homeland is really having a healthy work environment. So one that would inspire you to go to work in the morning. You feel safe when you're there. You feel fulfilled when you go home. I mean, we know that, but that's true. And I mean doctors, we're pretty dysfunctional in our offices. We might blame the healthcare system, but ours was whether you're privately owned or in a hospital base, we're low-hanging fruit. There's a lot of things we just we're just read the book. But the nice thing about it though is that whether it's better communication, keeping people accountable, empowering people, margin builders, there's so many things you can do that are really fist pump opportunities. And don't underestimate. These little things add up that all of a sudden you're actually feeling better. This includes your staff and as a team, your nurses, your extenders and patients will notice.

Diane Newman: I have another question for you, Scott. What do you mean when you say "Begin your journey?

Scott MacDiarmid: Well, the journey, as I've mentioned, is really going from your valley or wherever you are to your mountaintop of joy and fulfillment. And for myself, what I think the book does, it really symbolizes the decision. So when I'm going to read this book, I'm really deciding that I'm going to begin my journey to my mountaintop of joy and fulfillment. I'm really going to decide to say, I'm going to start living and practicing differently. And I really want, whether it was a book, this video, a song, advice someone gave you, don't minimize the importance of that one decision, that I'm going to change. And again, the book was just a way of trying to support that. Now, when you read the book, I also say near the end when you've read it, you've now officially joined the Fist Pumps revolution. Really, basically it's my movement in a sense.

But you've joined the fist pump revolution. And what I mean by that is when you're climbing to the summit, it's difficult. It's a steep climb. It's my biggest challenge. Some days it seems impossible, but if we do it together, the revolution is we do this together, then we're going to help one another in the journey. And then we take thousands of like-minded people that want to create that world that lifts up physicians and healthcare providers who serve. We're really going to be much more successful. And then as one voice, we really could make a difference.

I'm hoping the website is going to be popular. I call it FistPumpsRx.com. So it's FistPumpsRx.com. It exists. We're just getting it started. But it's really in the movement for each of us to share our solutions and survival tactics, whether you got that from the book or you learned it from another expert or the resources you want to share. But please share that with one another. Share even the frustrations you have and the things you're going through.

But again, don't underestimate what you can do. Just helping the littlest thing can make a difference. So I really hope we can all join the revolution together as one.

Diane Newman: And the other thing you brought up, Scott, that's important, is after at the end of each chapter you have what we can do. You have some suggestions there. "Write down what are the top three things that you have issues with." I like that in the book.

Scott MacDiarmid: I called it Journey Moments. It was just a minute, "Hey, sit and think about this," or maybe tee up the next thought that may lead to the next chapter. I realized, if I could write faster and better, you could have almost a whole workbook on that. But I thought that was useful. Thank you.

Diane Newman: And you provide suggestions, "Okay, what about this and that?"

I really actually found those really helpful. I think that's a neat way to not just go onto the next chapter, but stop and think, "Hey, yeah, what are some points I can do? What else should I be thinking about with this?"

Well, I want to thank you a lot. I did tell you, I think it's a great book. And also, Scott, there's not a lot out there on this. And I think that it's so timely because, like you say, the nurses who we can't find, the strikes that we're having, the number of individuals leaving the medical profession is really alarming. And I think burnout is such an integral part of what's happening. And I think that you succinctly really have hit on a lot of really important points. But what I got from your book was that we have to persevere and we have to concentrate on things that are going to give us joy, and that's really going to uplift us, especially if we're going to stay in the profession, right?

Scott MacDiarmid: Yeah.

First of all, Diane, I want to finish up by saying to all the providers, nurses, APPs, docs, I'm really proud of them, proud of every one of you. Thank you for sacrificing for your country, I mean, for your patients. It's a heavy cross to bear, serving this nation. It really is. But I think picking up that cross and carrying it is very rewarding, but I want you to nourish yourself and nurture yourself, and you've got to be strong and healthy to serve.

And then Diane, I really wanted to finish with a little exercise. You're going to join the revolution by doing this. I want you to hold up that fist pump, and I want you to start fist pump and repeat after me.

You want to say, "I've got this!"

Diane Newman: I've got this! I've got this!

Scott MacDiarmid: "I can do it!"

Diane Newman: I can do it!

Scott MacDiarmid: "I was called to serve!"

Diane Newman: I was called to serve!

Scott MacDiarmid: "And I'm on my journey to my mountaintop!"

Diane Newman: And I'm on my journey to my mountaintop!

Scott MacDiarmid: Thanks, Diane.

Diane Newman: Let's go!

Thanks so much. Bye, Scott.

Scott MacDiarmid: Thank you. Bye-bye.