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Medicine and Its Discontents

  • Glen O. Gabbard
    Correspondence
    Correspondence: Address to Glen O. Gabbard, MD, The Gabbard Center, 6750 West Loop South, Ste 460, Bellaire, TX 77401.
    Affiliations
    Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX
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      There can be little doubt that work satisfaction for physicians has declined in recent years. Few physicians today are observed whistling down the hospital corridors. Although many of us still view medicine as a noble profession, 2 contributions in this issue of Mayo Clinic Proceedings
      • Dyrbye L.N.
      • Varkey P.
      • Boone S.L.
      • et al.
      Physician satisfaction and burnout at different career stages.
      • Spinelli W.M.
      The phantom limb of the triple aim.
      add to the chorus of voices in recent years describing the suffering of legions of physician colleagues. Some are “drowning” in overwork and disenchantment to the point that perhaps 30% to 40% of physicians are experiencing professional burnout. In addition, for every physician who is drowning, there are many others struggling to stay afloat.
      Although the causes of this discontent are speculative to some extent, an elegant survey conducted by Dyrbye et al
      • Dyrbye L.N.
      • Varkey P.
      • Boone S.L.
      • et al.
      Physician satisfaction and burnout at different career stages.
      reported in this issue of the Proceedings sheds further light on the interface of work satisfaction and career trajectory for physicians. The authors selected a diverse sample of 89,831 physicians from all specialties in the American Medical Association Physician Masterfile, which lists 814,022 physicians. These individuals were sent an e-mail inviting them to participate in an anonymous voluntary study. The 27,276 physicians who opened at least one invitation e-mail were considered to have received an invitation to participate in the study. Of this group, 7288, 26.3% of the total, completed surveys. These participants, who were demographically similar to those composing the total American Medical Association Physician Masterfile, were distributed throughout the country and covered all specialties. They were grouped into early career, middle career, and late career physicians. Burnout was measured using the Maslach Burnout Inventory,
      • Maslach C.
      • Jackson S.E.
      • Leiter M.P.
      Maslach Burnout Inventory Manual.
      a standard instrument in the field. There are 3 domains of burnout: emotional exhaustion, depersonalization, and low sense of personal accomplishment. The survey revealed significant differences among the 3 groups in the first 2 domains. Most striking was that middle career physicians were more likely to be exhausted or burned out than either of the other 2 groups. Depersonalization was more common among early career physicians. The authors also found evidence that those who were retired or no longer in practice may have chosen to leave practice at least in part because of burnout.
      It comes as no surprise that middle career physicians may have higher rates of overall burnout given that early career physicians may be highly focused on getting their careers started and late career physicians may be planning for retirement. However, there are a number of surprising findings in the data. Early career physicians were more likely to struggle with recent conflicts between work and home despite working fewer hours than middle career physicians. Moreover, this early career subgroup had the lowest level of satisfaction with their overall career choice. It was also surprising to discover that a substantial number of middle career physicians felt that they had “had enough” and were planning exit strategies over the next 24 months.
      Dyrbye et al highlight the distinct challenges that middle career physicians are encountering. In profile, this demographic group has always been the mainstay of the medical system. These are seasoned professionals who tend to have mastered their specialties. They know what they are doing and serve as mentors for trainees and younger colleagues. They have large practices and take on important administrative positions. They are generally regarded as having the energy to withstand the stresses inherent in these responsibilities. The results of the survey by Dyrbye et al, however, suggest that a disconcertingly large percentage of these stalwarts are disillusioned, burned out, and looking for a way out. As we stand on the brink of a new wave of health care reform that may result in patients who were previously uninsured lining up at physicians' offices for diagnosis and treatment, we should take seriously these aforementioned findings regarding all physicians, but particularly middle career physicians.
      Dyrbye et al
      • Dyrbye L.N.
      • Varkey P.
      • Boone S.L.
      • et al.
      Physician satisfaction and burnout at different career stages.
      acknowledge that the design of their study cannot definitively identify causes or conclusions. However, in the second article considered in this editorial, Spinelli
      • Spinelli W.M.
      The phantom limb of the triple aim.
      writes of a glaring omission in our health care planning. He notes that the efforts to improve contemporary health care focus on a triad of improving patient care quality, decreasing costs, and enhancing access. In this context, he asks a reasonable question: Why hasn't the well-being of those destined to deliver this care in a cost-effective manner been taken into account in the planning? Indeed, physicians are sometimes regarded as mere automatons who will smoothly fit into the system, and little attention has been given to the fact that these same physicians are indispensable to the success of any innovation in health care planning and delivery. Without physicians who feel engaged, valued, and treated fairly, any new health care delivery system will not function at maximum quality or capacity.
      The business models that have been widely applied to health care delivery do not translate well from other venues. To state the obvious, the work that physicians perform is different than the daily activities of the average businessperson. Those who wrestle with life-and-death issues and experience the pain, grief, and terror of patients and families take home an emotional burden at the end of the day that makes physicians different from most other workers. As evidence, the prevalence of burnout among physicians is higher than that in any other comparable professional group and twice the rate of the general population of the United States.
      • Shanafelt T.D.
      • Boone S.
      • Tan L.
      • et al.
      Burnout and satisfaction with work-life balance among US physicians relative to the general US population.
      So what do we do about this situation? The answer to that question is straightforward—nobody knows. Mandatory work hour restrictions are one approach, but most remain unconvinced that such measures are the key to improving job satisfaction. After the Accreditation Council for Graduate Medical Education implemented the 80-hour workweek restriction in 2003, some data suggested that burnout rates did not decrease in concert with the work hours.
      • Thomas N.K.
      Resident burnout.
      The feeling of being overwhelmed and emotionally exhausted at work is complex, likely involving a variety of factors and varying from one person to the next. Indeed, the findings of physician dissatisfaction reported in this issue of the Proceedings occur in the context of data showing that work hours of physicians have steadily decreased in the past decade.
      • Gabbard G.O.
      The role of compulsiveness in the normal physician.
      Spending too many hours at work is the time-honored excuse used by physicians who are having difficulty with intimate relationships at home. It is noteworthy in this regard that Dyrbye et al
      • Dyrbye L.N.
      • Varkey P.
      • Boone S.L.
      • et al.
      Physician satisfaction and burnout at different career stages.
      found that early career physicians were most likely to experience a recent work-home conflict despite working fewer hours and were least likely to resolve the conflict. Being “busy” in the office or hospital is the great scapegoat. The number of hours one spends at work away from one's home has many determinants. There are personality traits in those who seek out medical careers that lead them to be thorough and competent physicians but may lead them away from placing a high priority on the value of emotional intimacy.
      • Gabbard G.O.
      The role of compulsiveness in the normal physician.
      • Gabbard G.O.
      • Menninger R.W.
      • Coyne L.
      Sources of conflict in the medical marriage.
      • Myers M.F.
      • Gabbard G.O.
      The Physician as Patient: A Clinical Handbook for Mental Health Professionals.
      The compulsive perfectionism that drives physicians to be thorough and leave no stone unturned may cause them to stay at work a little longer, see one more patient, and write longer notes. Many physicians persistently feel that they are not “doing enough.” Overwork associated with little time at home may simply reflect the physician's characterological preference for work over intimacy rather than the true cause of disturbances of home relationships. The influx of large numbers of women into medicine may have had a positive influence because of their traditional emphasis on family and relationships, but problems persist.
      Physicians also tend to value autonomy and independence from external control, and the vast changes in the roles played by third-party payers, governmental regulatory bodies, and hospital/health care systems may have influenced physician discontent as well. Physicians frequently complain about being trapped in systems in which they have no say in what is being done to them by forces beyond their control, and loss of the traditional autonomy and control appears to be a factor that contributes to burnout.
      • Dyrbye L.N.
      • Shanafelt T.D.
      Physician burnout: a potential threat to successful health care reform.
      If physicians cannot influence how their work is distributed, they begin to experience their work environment as a series of obligatory tasks. Feeling like a cog in a machine, they experience less of a feeling of accomplishment at the end of a hard workday.
      Middle age is typically a difficult passage for many professionals. It is a developmental phase involving the mourning of lost opportunities and the acceptance of one's limits. One also reflects on his or her identity, takes note of regrets, and reevaluates how one will apportion time in the future. There is no doubt that today's middle career physician faces a sense of disillusionment. The promise of an emotionally gratifying and well-compensated career that initially attracted young men and women to the field may seem increasingly out of reach as one enters the middle phase of one's career and instead feels overregulated, underappreciated, and buried under a pile of administrative tasks that take away from patient care.
      The suggestion of Spinelli
      • Spinelli W.M.
      The phantom limb of the triple aim.
      to pay greater attention to physician health is unimpeachable. However, physicians themselves are often their own worst enemies. Physicians may not wish to admit their vulnerabilities and place themselves in the patient role.
      • Myers M.F.
      • Gabbard G.O.
      The Physician as Patient: A Clinical Handbook for Mental Health Professionals.
      Even if a system attempts to accommodate physician well-being as part of their quality improvement effort, physicians may be “too busy” to participate in the program designed for them. They might even view it as wasting their time or yet another example of employer-dictated activities encroaching on regenerative downtime.
      We must acknowledge that we lack definitive data about the problems that cause work dissatisfaction among physicians and solutions to the burnout problem. Those who respond to questionnaire surveys may be preferentially upset and want to register a complaint. Thus, response bias cannot be entirely eliminated as a possible contributor to the physician profiles reported in the study by Dyrbye et al.
      • Dyrbye L.N.
      • Varkey P.
      • Boone S.L.
      • et al.
      Physician satisfaction and burnout at different career stages.
      However, those of us who have spent much of our careers evaluating and treating physicians know that they do not easily deal with change and loss of autonomy. They also don't necessarily do what is in their own best interest from a wellness perspective.
      As a society, we do not like complexity. When we address systemic problems, we like to identify the cause and approach it with the solution. Unfortunately, the work dissatisfaction and burnout of physicians does not lend itself to that approach. We need to examine ways to streamline administrative work for physicians, decrease their paperwork, restore a sense of participation in decision making, and encourage attention to wellness. However, we physicians must also look inward at our own psychological propensities and our own need to be needed.

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