Physicians suffer one of the highest burnout rates among professionals. Dr. Kimberly Becher, one of two family practitioners in Clay County, West Virginia, learned the hard way.
For most of her life, Dr. Kimberly Becher has moved fast. She was married at 21, started medical school with a 3-month-old and has trained for two marathons. In the halls of her clinic, between a bank and a Baptist church in Clay — the county seat of Clay County with a population of 396 — she walks fast, often looking down at her phone as she speeds around corners. She talks fast, too, organising her staff and speaking crisply with a mountain accent.
But her aspect changes when she enters an exam room where a patient is waiting. She slows perceptibly, and the otherwise intense beam of her attention softens.
Recently, Becher, in bright pink scrubs, sat with Zane Wilkinson, 15, who had come in for a monthly checkup in the company of his mother, Julia. He wore a newsboy cap and a blue surgical mask; he has Behcet's disease, a rare autoimmune disorder that, as Julia Wilkinson described it, "is like having multiple sclerosis, Crohn's, lupus and arthritis in one bundle." Zane had been on chemotherapy for five years with mixed results and had not attended school in person since before the pandemic. But the recent combination of drugs was working well, his mother told the doctor: "He's almost back to being a normal boy."
Becher made the diagnosis in 2017, after the family had spent years bouncing among doctors in confusion. ("They call her Dr. House, because she can figure out things nobody else can," Wilkinson said of Becher.) The question in July was whether Zane could safely return to the classroom despite the risk of Covid-19.
"So, what do you think about school?" Wilkinson asked Becher.
The doctor tilted her head. "Well, I think you might be at a point where you have to consider the social benefits in addition to the health risks," she said. "Like, I don't want you to feel like you can't have quality of life just because you might get Covid. You've got to live your life." Zane and his mother nodded.
"Hoover over Clay?" Becher asked Zane, referring to two nearby high schools that he could attend, Clay County High School and Herbert Hoover High School. Wilkinson, who teaches at Hoover, laughed. "Would you like to talk about that?" she asked Zane.
"No, not really," he said.
It was the first thing he had said during the visit, and all three of them laughed.
Becher has spent eight years as a family physician in Clay, working for Community Care of West Virginia, a federally qualified health centre. West Virginia tops most national lists of poverty and poor health outcomes: the highest prevalence of obesity, coronary disease and diabetes; the fourth-highest poverty rate; the second-highest prevalence of depression; the shortest life expectancy. In Clay County, there is no public transportation, no stoplight, no hospital. Most residents live in a food desert. And as one of only two family doctors in the county, Becher has an all-encompassing job. She visits children in their living rooms to vaccinate them, organises food drives and administers Suboxone to treat opioid addiction.
But as the political climate around Covid-19 grew heated, and as some of Becher's patients and neighbours began to dismiss the science, she became frustrated, then angry. She began to run more, sometimes twice a day, for hours at a time, "raging down the road." She was mad about the widespread distrust of vaccines; mad about teachers who went to school even after testing positive for the virus; mad about the endemic food insecurity, the county's lack of affordable transportation, the high rate of fatty liver disease.
The indignities layered one atop the next, forming a suffocating stack. More than anything, Becher was mad at how she couldn't seem to do anything about any of it. Some days she went home from work, chugged a beer and ran for miles. Then, on April 17, 2021, her heart broke.
Anger, exhaustion, despair
In 1981, two psychologists at the University of California, Berkeley, published a paper in the Journal of Occupational Behavior on "the burnout syndrome." The authors, Christina Maslach and Susan E. Jackson, set out to measure the degree of stress and emotional exhaustion experienced by professionals like doctors, social workers, therapists and teachers who, they noted, must constantly navigate complicated interactions "charged with feelings of anger, embarrassment, fear or despair."
Their questionnaire — the Maslach Burnout Inventory, or MBI — is now a scientific standard. Among physicians, a high score on the MBI has been linked to increased errors, decreased patient satisfaction and quick turnover. Burned-out doctors show higher rates of cardiovascular disease, substance abuse and divorce. A 2017 study of about 5,000 physicians published in Mayo Clinic Proceedings found that some 44 per cent exhibited at least one sign of burnout. A 2019 report by the National Academy of Medicine pointed to studies showing that 54 per cent of physicians and nurses were burned out.
"Your patients kind of embrace you as a part of their community; they almost become a part of your family," said Dr. Tate Hinkle, a family doctor in Lanett, Alabama. Many physicians cite these interpersonal connections as the primary reason they go into family medicine. But the sense of dependency can place a significant emotional burden on doctors, Hinkle said, especially in isolated rural areas, where chronic illnesses and social disadvantages superimpose: "It just adds that sense of pressure on yourself to make sure you take care of people."
On that April day in 2021, Becher was at a chess tournament with her teenage son when she suddenly felt as if she were having a heart attack. She left for the emergency room, barely able to see, her blood pressure dangerously high.
Tests soon revealed that she had a rare disease called takotsubo cardiomyopathy, which forces the tip of the heart's left ventricle to stretch. Most cases occur in older women who have recently experienced some type of intense physical or emotional distress, like the loss of a loved one or a serious accident. It has gained a catchy moniker — broken heart syndrome — but its causes remain unknown.
In the hospital, Becher argued with the doctors as they tried to treat her. Her clinic's answering service called her three times while she was being diagnosed; her husband, Mike Becher, had to take away her phone. She protested until she saw the medical imagery: a portion of her heart had been paralysed, and her left ventricle had ballooned.
"The first emotion I felt was actually anger — the very thing that brought me to this cold, hard table," Becher wrote in a blog post months later. "Quickly the anger faded, and I felt utterly mortified. I wasn't tough enough to follow the path I'd set myself on."
She added: "No one put me in this position. I applied to medical school, I sought a job in rural primary care and I poured my identity into it. Takotsubo's is typically caused by severe acute stress, something traumatic and abrupt. Mine was just from going to work every day and seemed super lame to me in the moment."
An hour to the nearest grocery
Becher grew up in Sissonville, a small community an hour west of Clay. Her aim was to leave West Virginia and never return. She graduated as valedictorian of her high school class and went to Denison University, in Ohio, where, in one of her first courses, she met her future husband. After college the couple moved to Cincinnati, where he studied environmental law and she worked at an Olive Garden, then in a medical lab.
Three years later she was back in West Virginia, with a newborn, studying medicine at Marshall University. "I realised that I liked living here better than I liked living in places with everything I wanted," she said. In 2014, immediately after finishing her residency, she and her husband and son moved into a house atop a hill in Clendenin, about 30 minutes away from the clinic in Clay. She had US$180,000 in debt from student loans.
"Mike had two requirements when we were choosing where to live," Becher said recently, looking out at the trees and pond at the bottom of her hill. "We couldn't be able to see any neighbours, and he had to be able to shoot things from the porch." She liked it. "I need to feel tortured and alone, for some reason," she said.
Becher spent her first years in Clay building up what she called "patient equity." She slowed down in her characteristic way when talking to her patients and learning about their lives and health issues, which could stem from causes as varied as diabetes, opioid addiction, anxiety, loss of electricity or an old car that had recently broken down. But outside of these interpersonal relationships, she continued apace. She began blogging for the American Academy of Family Physicians, took on advisory roles in local government, increased the number of patients she saw and made more home visits to people unable to drive to the clinic.
"Every couple days Kimberly would come back ranting about insurance companies," Becher said. "But she's been pretty much the same since we first met: intense."
In 2016 a flood destroyed houses along the banks of the Elk River and closed the only grocery store in the county. Becher visited the local dollar store and came up with a list of inexpensive, minimally processed foods to recommend to her patients. By 2020, with the pandemic in high gear, she was lobbying town officials to bring in a new grocery store and helping to organise monthly food distributions.
I was living in eastern Kentucky at the time, reporting on how the pandemic was affecting food access in Appalachian communities, and on a sunny day that autumn I drove out to talk with her. We met behind her clinic, near a parking lot crowded with cars where a half-dozen nurses were busy administering Covid tests through rolled-down windows. Over the next several days, nearly 200 families would benefit from a food giveaway that Becher had helped coordinate at the high school.
"When we have meetings with people involved in the town or the county, there's this level of, 'Well, if you keep giving out enough food for two weeks every month, we're never going to get a store,'" she told me. "But there's not a store. So I'm going to give out food until there's a store."
The primary health issues that her patients faced, Becher said, were hunger and a poor diet. Most of them had the means to buy healthy food, she added, but many drank multiple cans of soda a day. Some could not afford to fix their car and so were unable to drive to the nearest grocery store, an hour away; others had to choose between paying for internet service or fresh produce. With grants from nonprofits, Becher began paying some people's bills, but blood-sugar levels and blood-pressure readings kept rising.
"You have no way to make that impact," she said, "and you're just looking at them like: 'I know your heart rate is going up. I'm sorry you can't get food. That really sucks.'"
Late nights, long weeks
Several months later, early in February 2021, I drove to Clay again. The morning air was crisp, the ground frosty, and I met Becher in the doorway of her clinic as she was talking to one of her nurses, Cristine Dean. The first Covid vaccine had been released just weeks earlier, and West Virginia had one of the highest vaccination rates in the country; Becher had been helping lead the region's efforts. That day she was quarterbacking an operation to bring vaccines to homebound patients. At her disposal were two nurses, 10 vaccine doses, six hours and a four-wheel drive.
"I'm excited for you guys," Becher told Dean, who was also her marathon training partner. "I want to do it."
"Yeah, but you got a full schedule," Dean replied.
Becher had been working in the clinic seven days a week most weeks, and often stayed up late at her kitchen counter, writing notes on patients' charts and grant applications for food vouchers. She had begun encountering resistance to Covid science, which added to the strain on her, she said; patients she had seen for years were suddenly questioning her judgment.
Friends and colleagues described similar experiences. Hinkle, in Alabama, whom Becher had known since residency, described a longtime patient who came in with symptoms of Covid. When the doctor recommended testing, the patient responded, "We're not going to talk about that; it's all made up," Hinkle said. "And he stormed out of the office and fired me as a doctor."
Several studies have found that the pandemic significantly increased levels of burnout among physicians and health care workers. More than 20 per cent of respondents in one study reported being bullied, threatened or harassed by their patients at work. "What Covid has done is taken many people who had no margins left and it pushed them over the edge," said Mark Greenawald, a family doctor in Roanoke, Virginia, who studies burnout among doctors.
Later that day in February, Dean visited the mountaintop home of Bonnie White, one of Becher's patients, to administer a second dose of the Covid vaccine. "Do I really need to get the second dose?" White asked. Dean replied: "Well, let me put it this way — Dr. Becher thinks you should get it, and Dr. Becher herself got hers. So I think if she wants you to get it, then you can trust her to get it."
White said: "I do what she tells me to do. She's the best doctor I've ever had."
In practice, most of Becher's patients took her advice and got the vaccine. But even as the pandemic introduced an element of distrust to her work, older patients begun coming to her depressed, unable see their children or grandchildren. Becher and Dr. Joanna Bailey, a family doctor in Wyoming County, West Virginia, talked almost every day in a group chat about vaccine distribution, their mounting paperwork and the need to make long-term plans for their communities.
"I've felt myself getting angry with a patient over this Covid vaccine," Bailey told me. "That's where I decided, I cannot argue about this anymore. I'm going to tell them it's recommended; I'm going to have my little three lines to say, and that's it. It's too big for me."
But Becher couldn't let it go. She joined more boards, saw more patients, considered running for a government seat, tried to channel her frustration. Her husband knew that the pace she was keeping was not sustainable, but when they talked about it late at night, they realised there was no stopping, he said: "It was like, she was helping people, and if she didn't do it, then no one would."
'I'm completely broken'
That April, when her heart broke, Becher stopped seeing patients. She quit every board she was on. For a couple of weeks, on bed rest, she tried to figure out what had gone wrong. "Why had I said yes to doing so many home visits?" she later wrote on the blog. "Why did I work so hard to make food accessible in this town that I don't even live in?" And: "Why did I keep saying yes to everything anyone asked me to do?"
How could she return to her previous life, knowing it had almost killed her?
The roots of the challenge ran deep, Becher came to realize. Many new physicians, often carrying hundreds of thousands of dollars in student loans, face a dichotomy once they start practising.
"Rarely is there a health care organization that is able to say that we value your well-being as health care providers above our productivity," Becher said recently. Her student debt has gone down but remains above US$60,000. "But it's not just a financial thing," she said. "It's that people need care, and when you're in more rural areas like this, you might be the only source."
In early 2022, Becher moved to a more administrative role at Community Care of West Virginia and reduced her time in the clinic to one day a week. "I am shifting my focus toward helping other physicians learn from my mistakes, which means I have to actually tell my story," she wrote in her blog in February. "I am definitely a work in progress, and I am always on the edge of a cliff, at risk of jumping back into being angry and putting myself in a position to be hurt again. But at least now I know there is a cliff."
Dr. Lisa Lavadie-Gomez, a family doctor in Iowa City, Iowa, who had recently experienced a health scare of her own, reached out after reading the post. The two physicians talked about their experiences and later recounted the exchange.
"The empathy and altruism wears you out to the point where you're depleted, and I was depleted," Lavadie-Gomez said. "I'm taking care of people with my whole heart, yet I'm completely broken. How do you keep going amid the moral overwhelm?"
Becher responded: "There have been moments, since last April, where it'll hit me, like, my life is so different from before. Because I had a couple runs of heart rhythms that are not good, there's also this fear I have, like, what if I literally just die?"
Recently. Lavadie-Gomez confided that she had decided to leave medicine. "I will always be a doctor; that will never change," she said. "I will always have the same skills and empathy, care and ability to solve problems. I'm just choosing to use that energy somewhere else. And I probably just haven't admitted that I'm leaving my job until right now — today — and my conversation with Kimberly."
Creating a new path
On a Friday in late July, Becher invited Dr. Anne Jarrell, a third-year medical resident from Eastern Tennessee State University, to tag along as she worked her day in the clinic. The region had been without a regular family doctor since April 2021, and Becher was hoping that Jarrell, who grew up in West Virginia, could fill that hole.
"Like, this is why you do medicine," Jarrell said, as the two physicians squeezed into the nurses' office at midday. Jarrell, cheerful and energetic with a bandanna holding back her long hair, peppered Becher with logistical questions. The closest hospital? About 45 minutes from the clinic on the interstate — but it depended on where you were coming from. Becher's threshold for prescribing opiates? Very high. The patient population? All over the county. Did she prescribe Plan B, the morning-after contraception pill? "Yes," Becher said. Jarrell voiced her support with a small fist pump.
The next appointment was with a young transgender woman, Dany Frye, whom Becher had been seeing for a couple of years, and who was now weighing the options for surgery.
"Do you have her on hormone therapy?" Jarrell asked.
"Yeah," Becher said.
"Awesome," Jarrell said. "So you do that here?"
"I do that here," said Becher, who has more than a dozen transgender patients. "I would love it if you came here and did it."
Afterward, Frye reflected on the appointment. "I didn't know how life-changing it would be," she said. "Having that resource in such a small county is so shocking. It's crazy how we just have her here."
Although Becher's most recent echocardiogram was normal and her cardiologist cleared her to exercise regularly again, she had not run since April 2021. Mentally she was working up to a turkey trot in November with her husband and son, but her marathon dreams were over. "I just can't do distance running ever again," she said. "I mean, that was what I did. That was my hobby. That was all I did."
In her new role at Community Care, Becher has been developing a support group for rural physicians through the Robert C. Byrd Center for Rural Health at Marshall University. "She kept all this close to her vest for a long time," said Jennifer Plymale, the director of the center, who has known Becher since she was in medical school. "But I believe she's creating a new path for her that's not all about patient care."
Later that day in the clinic, Becher and Jarrell squeezed into a room with Larry O'Dell, a longtime patient whose wife of more than 60 years had recently died. O'Dell was healthy and cognitively sharp, working in his garden most days, although he had lost most of his hearing. His daughter Sheila accompanied him for the visit, often repeating into his ear, loudly, things that the doctors said.
Becher ran a physical exam, prescribed some medication, then sat and chatted with O'Dell about his garden and his daughters.
"You know what," he said, suddenly shifting the topic. "You look better than you did the last time I saw you."
"Thank you," said Becher, slightly taken aback.
"Are you better?" he asked.
"I am better," she said. "I'm a lot better." There was a pause, then she added, "I was wondering why you were staring at me so weird." And everyone in the room laughed.
This article originally appeared in The New York Times.
Written by: Oliver Whang
Photographs by: Maddie McGarvey
© 2022 THE NEW YORK TIMES
