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Commentary| Volume 90, ISSUE 9, P1176-1179, September 01, 2015

Turning Physicians Into “Heartwood”

Published:July 22, 2015DOI:https://doi.org/10.1016/j.mayocp.2015.06.003
Turning Physicians Into “Heartwood”
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      As trees age, the older cells at the core of the trunk lose some of their ability to conduct water. The tree allows these innermost cells to retire…. This stiffened heartwood core…continues to help structurally support the tree…. Here a tree honors its elderly cells by letting them rest but still giving them something meaningful to do. We non-trees could take a lesson from that.Spike Carlsen
      • Carlsen S.
      A Splintered History of Wood: Belt-Sander Races, Blind Woodworkers and Baseball Bats.
      HarperCollins Publishers, New York, NY2008
      Can the medical profession take a lesson from trees? Can we give elder physicians something meaningful to do while they offer us structural support? Could this structural support provide something meaningful to organizations? Could a series of organizational investments in these elders that go beyond financial remuneration or workplace process changes enhance the well-being of both organizations and physicians? These investments would leverage the wisdom and experience of senior physicians as well as honor their lifetime contributions and could include phased retirement, reduced productivity requirements in exchange for career extension,
      • Pit S.W.
      • Hansen V.
      Factors influencing early retirement intentions in Australian rural general practitioners.
      Occup Med (Lond). 2014; 64: 297-304
      an opportunity for career reflection and sharing of accumulated wisdom, mentoring new physicians, and community engagement via volunteering or leadership in civic activities.

       Why Is “Heartwood” Important?

      The conflicting forces of an increasing demand for primary care, an aging and retiring primary care workforce, and an aging population create a need to develop new strategies in employment, human resources administration, and practice management for primary care physicians. Although this demand may be shared by all specialties, the current national debate on health care reform focusing on primary care as entry points and navigators for patients suggests an impending shortage of available practitioners and will be the focus of this article. These primary care workforce projections are predicated on many factors including a decline in the number of young primary care physicians and the aging and imminent retirement of aging baby boomer physicians.
      • Dall T.
      • West T.
      • Chakrabarti R.
      • Iacobucci W.
      HIS Inc, Association of American Medical Colleges
      The Complexities of Physician Supply and Demand: Projections From 2013 to 2025; Final Report.
      Association of American Medical Colleges, Washington, DC2015
      , 
      • Colwill J.M.
      • Cultice J.M.
      • Kruse R.L.
      Will generalist physician supply meet demands of an increasing and aging population?.
      Health Aff (Millwood). 2008; 27: w232-w241
      Starting in 1999, senior medical student applications to family medicine residencies
      • Kutob R.M.
      • Senf J.H.
      • Campos-Outcalt D.
      Declining interest in family medicine: perspectives of department heads and faculty.
      Fam Med. 2003; 35: 504-509
      and the total number of available family medicine residency positions steadily decreased. Similar patterns occurred in general internal medicine training.
      • Pugno P.A.
      • McGaha A.L.
      • Schmittling G.T.
      • DeVilbiss A.D.
      • Ostergaard D.J.
      Results of the 2009 National Resident Matching Program: family medicine.
      Fam Med. 2009; 41: 567-577
      Although recent data show a trend reversal, the nature of medical education creates a substantial lag time for entry of these new practitioners into the workforce. At the same time, aging and loss of currently practicing physicians threatens workforce and reform goals.
      • Dall T.
      • West T.
      • Chakrabarti R.
      • Iacobucci W.
      HIS Inc, Association of American Medical Colleges
      The Complexities of Physician Supply and Demand: Projections From 2013 to 2025; Final Report.
      Association of American Medical Colleges, Washington, DC2015
      The intensity and pace of contemporary medical practice are both physically and emotionally challenging. Many senior physicians express joy in caring for patients but are concerned about maintaining the pace of full-time practice. Attracting these senior physicians to a flexible, phased retirement program that extends careers by offering a decreased clinical workload in return for increased structural support (heartwood), such as mentoring or teaching students and young physicians and creating enhanced community engagement opportunities, may assist in slowing the attrition rate of senior primary care physicians and bridge the workforce gap while awaiting the arrival of young physicians into the workforce.

       Career Choice

      Dating from the early days as the town general practitioner to the current era of specialization, primary care physicians have long been at the root of American health care. In the 1970s, family medicine was a specialty defined by social need,
      • Kutob R.M.
      • Senf J.H.
      • Campos-Outcalt D.
      Declining interest in family medicine: perspectives of department heads and faculty.
      Fam Med. 2003; 35: 504-509
      and medical students were frequently selecting it for residency. By 2006, the number of US senior students entering family medicine (1132) had declined by 48% from the peak year of 1997 (2340). A trend reversal in the past 5 years has resulted in a net increase in the total number of family medicine residents, which now approaches 1996 levels.
      • Porter S.
      Family medicine match rate increases for 5th consecutive year.
      Ann Fam Med. 2014; 12: 279-280
      Primary care internal medicine has seen similar declines. In the past decade, the percentage of internal medicine residents choosing general internal medicine as opposed to hospitalist or specialty medicine has declined by 50%. However, unlike family medicine, internal medicine is showing less encouraging signs of returning to previous levels.
      • Okie S.
      Innovation in primary care—staying one step ahead of burnout.
      N Engl J Med. 2008; 359: 2305-2309
      An improved work environment, increasing compensation, and an enhanced role for primary care in the new models of health care delivery promise to increase the attractiveness of primary care to medical students, but while awaiting that transition, attending to the well-being of senior (elder) physicians and providing phased retirement alternatives may be an attractive strategy for extending their careers and maintaining an adequate workforce.

       Physician Burnout

      Baby boomer physicians are entering the twilight of their careers, and many are overwhelmed by the pace and demands of their work, become cynical,
      • Leiter M.P.
      • Frank E.
      • Matheson T.J.
      Demands, values, and burnout: relevance for physicians.
      Can Fam Physician. 2009; 55 (1225.e1-e6): 1224-1225
      and experience high levels of burnout.
      • Dyrbye L.N.
      • Varkey P.
      • Boone S.L.
      • Satele D.V.
      • Sloan J.A.
      • Shanafelt T.D.
      Physician satisfaction and burnout at different career stages.
      Mayo Clin Proc. 2013; 88: 1358-1367
      Many physicians express frustration over long work hours, productivity demands, and professional fatigue. For some, the only relief is early retirement. Organizations and researchers have begun to address the problem of burnout by identifying its causative factors and developing individual intervention models
      • Awa W.L.
      • Plaumann M.
      • Walter U.
      Burnout prevention: a review of intervention programs.
      Patient Educ Couns. 2010; 78: 184-190
      such as mindfulness training,
      • Krasner M.S.
      • Epstein R.M.
      • Beckman H.
      • et al.
      Association of an educational program in mindful communication with burnout, empathy, and attitudes among primary care physicians.
      JAMA. 2009; 302: 1284-1293
      resiliency training,
      • Epstein R.M.
      • Krasner M.S.
      Physician resilience: what it means, why it matters, and how to promote it.
      Acad Med. 2013; 88: 301-303
      , 
      • Adams S.
      • Camarillo C.
      • Lewis S.
      • McNish N.
      Resiliency training for medical professionals.
      US Army Med Dep J. 2010 Apr-Jun; : 48-55
      and enhancing meaning in work.
      • Remen R.N.
      Recapturing the soul of medicine: physicians need to reclaim meaning in their working lives.
      West J Med. 2001; 174 ([op-ed]): 4-5
      Efforts to increase the sustainability of these interventions by changing workflow processes and other system changes are emerging.
      • Bodenheimer T.
      • Sinsky C.
      From triple to quadruple aim: care of the patient requires care of the provider.
      Ann Fam Med. 2014; 12: 573-576
      , 
      • Sinsky C.A.
      • Willard-Grace R.
      • Schutzbank A.M.
      • Sinsky T.A.
      • Margolius D.
      • Bodenheimer T.
      In search of joy in practice: a report of 23 high-functioning primary care practices.
      Ann Fam Med. 2013; 11: 272-278
      , 
      • Ruotsalainen J.H.
      • Verbeek J.H.
      • Mariné A.
      • Serra C.
      Preventing occupational stress in healthcare workers.
      Cochrane Database Syst Rev. 2014; 11: CD002892
      , 
      • West C.P.
      • Dyrbye L.N.
      • Rabatin J.T.
      • et al.
      Intervention to promote physician well-being, job satisfaction, and professionalism: a randomized clinical trial.
      JAMA Intern Med. 2014; 174: 527-533
      Human resource policies aimed at retaining senior physicians with innovative workplace arrangements can augment the individual and system initiatives.

       Retirement

      As the stress of medical practice and productivity demands escalate, retirement becomes an attractive option for many physicians.

      American Medical Group Association. Physician turnover remains high as more physicians retire. ScienceDaily website. http://www.sciencedaily.com/releases/2014/08/140821115632.htm. Published August 21, 2014. Accessed April 21, 2015.

      A 2014 study by the Physicians Foundation reported that 44% of physicians want to reduce their access to patients, 39% will accelerate their retirement planning, and 50% would not recommend medicine as a career.

      The Physicians Foundation. 2014 Biennial Physician Survey Report: Practice patterns & perspectives. 2014_Physicians_Foundation_Biennial_Physician_Survey_Report.pdf. Accessed November 25, 2014.

      Although these numbers have slightly improved from preceding surveys, the alarming number of dissatisfied experienced physicians and the resultant loss or distancing from practice will diminish the ability to meet patient access demands.

       Creating Heartwood

      Traditional methods of enticing senior physicians to maintain their practice include decreased clinic hours,
      • Merline A.C.
      • Cull W.L.
      • Mulvey H.J.
      • Katcher A.L.
      Patterns of work and retirement among pediatricians aged ≥50 years.
      Pediatrics. 2010; 125: 158-164
      limitation of call responsibilities, and for those who have retired, contract work. Although these methods will entice some to stay, most senior physicians are less inclined to be motivated by financial considerations and are more inclined to search for other forms of reward and satisfaction.
      • Odom Walker K.
      • Ryan G.
      • Ramey R.
      • et al.
      Recruiting and retaining primary care physicians in urban underserved communities: the importance of having a mission to serve.
      Am J Public Health. 2010; 100: 2168-2175
      , 
      • Bahrami B.
      • Elder J.
      • Jacobson S.
      Change in the U.S. health care system: effects on physician retirement and implications for health care managers.
      J Health Hum Serv Adm. 2002; 25: 342-370
      Tenure and age requirements for participation may vary by organization, but creating alternative late career pathways for senior physicians may help them rediscover meaning and purpose in medicine and potentially prolong careers by increasing “joy in practice.”
      • Sinsky C.A.
      • Willard-Grace R.
      • Schutzbank A.M.
      • Sinsky T.A.
      • Margolius D.
      • Bodenheimer T.
      In search of joy in practice: a report of 23 high-functioning primary care practices.
      Ann Fam Med. 2013; 11: 272-278
      In addition to part-time clinical care, these pathways could include professional mentoring, teaching, and/or meaningful community involvement such as volunteering or citizen professional
      • Doherty W.J.
      • Mendenhall T.J.
      Citizen health care: a model for engaging patients, families, and communities as coproducers of health.
      Fam Syst Health. 2006; 24: 251-263
      engagement with service agencies and communities that are important to their organizations. In return for this engagement, organizations would reap the benefit of the accumulated institutional wisdom and increased community engagement from senior clinicians as they continue medical practice and bridge the interval before the arrival of new primary care practitioners.

       Decreased Patient Contact

      Physicians frequently state that the primary focus of their careers is caring for patients; however, the pace and volume of that care frequently is challenging
      • Tucker P.
      • Bejerot E.
      • Kecklund G.
      • Aronsson G.
      Ǻkerstedt T. The impact of work time control on physicians' sleep and well-being.
      Appl Ergon. 2015; 47: 109-116
      and can be exacerbated as practitioners age. Providing the prospect for continued practice at a less hurried pace may entice more senior physicians to delay retirement.
      Already, many physicians are choosing to decrease their work to less than full-time,

      The Physicians Foundation. 2014 Biennial Physician Survey Report: Practice patterns & perspectives. 2014_Physicians_Foundation_Biennial_Physician_Survey_Report.pdf. Accessed November 25, 2014.

      with resultant decreased patient encounters and decreased institutional revenue. Prorating compensation to match full-time equivalent worked will aid in financial balance, but the continued cost of benefits will remain. However, when that benefit expense is compared with the expense of recruiting a new physician (estimated by some to approach $250,000 per physician
      • Buchbinder S.B.
      • Wilson M.
      • Melick C.F.
      • Powe N.R.
      Estimates of costs of primary care physician turnover.
      Am J Manag Care. 1999; 5: 1431-1438
      ), the cost of supporting part-time practicing physicians becomes more attractive.
      • Buchbinder S.B.
      • Wilson M.
      • Melick C.F.
      • Powe N.R.
      Estimates of costs of primary care physician turnover.
      Am J Manag Care. 1999; 5: 1431-1438

       Career Reflection

      In his work entitled Drive,
      • Pink D.H.
      Drive: The Surprising Truth About What Motivates Us.
      Riverhead Books, New York, NY2009
      Daniel Pink identifies autonomy, mastery, and purpose as the main motivators of personal and professional success. Physicians often have the luxury of autonomous work and have ideally mastered their profession; unfortunately, many have either lost focus on their purpose or need a new sense of meaning in their work.
      • Odom Walker K.
      • Ryan G.
      • Ramey R.
      • et al.
      Recruiting and retaining primary care physicians in urban underserved communities: the importance of having a mission to serve.
      Am J Public Health. 2010; 100: 2168-2175
      Palmer and Rudnicki
      • Palmer P.J.
      • Rudnicki S.
      Let Your Life Speak: Listening for the Voice of Vocation.
      Jossey-Bass, San Francisco, CA2000
      teach that by reconnecting “our soul with our role,” it is possible to increase our personal resources and more clearly identify our passion and our purpose. Physicians can explore their commitment and passion for medicine and their communities by asking:
      • •
        How did I get to this stage of my career?
      • •
        What do I want the next stage of my career to look like?
      • •
        What are the skills needed and the possibilities available for this next stage?
      • •
        How can I learn from and share these journeys with colleagues?
        • Remen R.N.
        Recapturing the soul of medicine: physicians need to reclaim meaning in their working lives.
        West J Med. 2001; 174 ([op-ed]): 4-5
      Organizational facilitation of this reflective practice for senior physicians will encourage many to consider the heartwood model and provide role models for other physicians as they evaluate career trajectories and adjust retirement expectations.

       Mentoring and Teaching

      The traditional medical education model is often described as “see one, do one, teach one.” Although this model may have value for technical training, it offers no advice on how to adequately transfer the accumulated knowledge and wisdom senior physicians have gained to younger physicians. Leider and Shapiro
      • Leider R.
      • Shapiro D.A.
      Claiming Your Place at the Fire: Living the Second Half of Your Life on Purpose.
      Berrett-Kohler Publishers, San Francisco, CA2004
      stated that there is “no guarantee we will get wiser just by getting older…but there is a correlation between age and wisdom.” Capturing that wisdom and sharing it through mentoring and role modeling is a function that can be filled by senior physicians.
      • Harrison R.
      • Anderson J.
      • Laloë P.A.
      • Santillo M.
      • Lawton R.
      • Wright J.
      Mentorship for newly appointed consultants: what makes it work?.
      Postgrad Med J. 2014; 90: 439-445
      , 
      • Unterman A.
      • Achiron A.
      • Gat I.
      • Tavor O.
      • Ziv A.
      A novel simulation-based training program to improve clinical teaching and mentoring skills.
      Isr Med Assoc J. 2014; 16: 184-190
      It will require a conscious effort on behalf of elders to understand their own passion and stories and then to reach out in a manner that reflects the needs and the interests of medical students and young physicians.

       Community Engagement

      Taking advantage of the institutional memory of the senior cohort of physicians by mentoring in the workplace is just part of their value; equally important is role modeling behaviors within the larger community. Although some physicians seek volunteer opportunities, as a profession physicians volunteer at a lesser rate than most other professionals.
      • Grande D.
      • Armstrong K.
      Community volunteerism of US physicians.
      J Gen Intern Med. 2008; 23: 1987-1991
      Facilitating connections to nonprofit organizations, community organizations, and public institutions in search of increased citizen participation may increase participation. Filling those volunteer needs will require new strategies for engagement that allow physicians to make meaningful contributions based on their skills and interests. For example, the citizen professional model pioneered by Doherty and Mendenhall
      • Doherty W.J.
      • Mendenhall T.J.
      Citizen health care: a model for engaging patients, families, and communities as coproducers of health.
      Fam Syst Health. 2006; 24: 251-263
      at the University of Minnesota (Minneapolis-St Paul) may have particular interest for physicians. Citizen professionals are defined as being “on tap, not on top”
      • Boyte H.
      The Citizen Solution: How You Can Make a Difference.
      Minnesota Historical Society Press, St Paul, MN2008
      and have been effective in mobilizing citizen action with the assistance of volunteering professionals who are not direct leaders. This level of service, with conditional leadership, may fit into the busy professional lives of physicians and also assist health care organizations that have an institutional or regulatory commitment to community service to fulfill their mission.

       Conclusion

      Innovation is more than simply technical, rational process improvement; innovation is also investing in people. Investing in the retention of experienced practitioners by reinforcing their sense of purpose, fostering community engagement, learning from their accumulated wisdom, and reconnecting them to the “meaning in medicine”
      • Remen R.N.
      Recapturing the soul of medicine: physicians need to reclaim meaning in their working lives.
      West J Med. 2001; 174 ([op-ed]): 4-5
      will allow senior physicians to offer structural support to their peers and organizations as they become health care heartwood.

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      References

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        A Splintered History of Wood: Belt-Sander Races, Blind Woodworkers and Baseball Bats.
        HarperCollins Publishers, New York, NY2008
        View in Article
        • Pit S.W.
        • Hansen V.
        Factors influencing early retirement intentions in Australian rural general practitioners.
        Occup Med (Lond). 2014; 64: 297-304
        View in Article
        • Dall T.
        • West T.
        • Chakrabarti R.
        • Iacobucci W.
        • HIS Inc, Association of American Medical Colleges
        The Complexities of Physician Supply and Demand: Projections From 2013 to 2025; Final Report.
        Association of American Medical Colleges, Washington, DC2015
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        • Cultice J.M.
        • Kruse R.L.
        Will generalist physician supply meet demands of an increasing and aging population?.
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        View in Article
        • Kutob R.M.
        • Senf J.H.
        • Campos-Outcalt D.
        Declining interest in family medicine: perspectives of department heads and faculty.
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        • Pugno P.A.
        • McGaha A.L.
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        Innovation in primary care—staying one step ahead of burnout.
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        Demands, values, and burnout: relevance for physicians.
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        Physician satisfaction and burnout at different career stages.
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        Association of an educational program in mindful communication with burnout, empathy, and attitudes among primary care physicians.
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        • Epstein R.M.
        • Krasner M.S.
        Physician resilience: what it means, why it matters, and how to promote it.
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        • Adams S.
        • Camarillo C.
        • Lewis S.
        • McNish N.
        Resiliency training for medical professionals.
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        Recapturing the soul of medicine: physicians need to reclaim meaning in their working lives.
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        • Rabatin J.T.
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        JAMA Intern Med. 2014; 174: 527-533
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        View in Article

      21. The Physicians Foundation. 2014 Biennial Physician Survey Report: Practice patterns & perspectives. 2014_Physicians_Foundation_Biennial_Physician_Survey_Report.pdf. Accessed November 25, 2014.

        View in Article
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        • Cull W.L.
        • Mulvey H.J.
        • Katcher A.L.
        Patterns of work and retirement among pediatricians aged ≥50 years.
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        View in Article
        • Odom Walker K.
        • Ryan G.
        • Ramey R.
        • et al.
        Recruiting and retaining primary care physicians in urban underserved communities: the importance of having a mission to serve.
        Am J Public Health. 2010; 100: 2168-2175
        View in Article
        • Bahrami B.
        • Elder J.
        • Jacobson S.
        Change in the U.S. health care system: effects on physician retirement and implications for health care managers.
        J Health Hum Serv Adm. 2002; 25: 342-370
        View in Article
        • Doherty W.J.
        • Mendenhall T.J.
        Citizen health care: a model for engaging patients, families, and communities as coproducers of health.
        Fam Syst Health. 2006; 24: 251-263
        View in Article
        • Tucker P.
        • Bejerot E.
        • Kecklund G.
        • Aronsson G.
        Ǻkerstedt T. The impact of work time control on physicians' sleep and well-being.
        Appl Ergon. 2015; 47: 109-116
        View in Article
        • Buchbinder S.B.
        • Wilson M.
        • Melick C.F.
        • Powe N.R.
        Estimates of costs of primary care physician turnover.
        Am J Manag Care. 1999; 5: 1431-1438
        View in Article
        • Pink D.H.
        Drive: The Surprising Truth About What Motivates Us.
        Riverhead Books, New York, NY2009
        View in Article
        • Palmer P.J.
        • Rudnicki S.
        Let Your Life Speak: Listening for the Voice of Vocation.
        Jossey-Bass, San Francisco, CA2000
        View in Article
        • Leider R.
        • Shapiro D.A.
        Claiming Your Place at the Fire: Living the Second Half of Your Life on Purpose.
        Berrett-Kohler Publishers, San Francisco, CA2004
        View in Article
        • Harrison R.
        • Anderson J.
        • Laloë P.A.
        • Santillo M.
        • Lawton R.
        • Wright J.
        Mentorship for newly appointed consultants: what makes it work?.
        Postgrad Med J. 2014; 90: 439-445
        View in Article
        • Unterman A.
        • Achiron A.
        • Gat I.
        • Tavor O.
        • Ziv A.
        A novel simulation-based training program to improve clinical teaching and mentoring skills.
        Isr Med Assoc J. 2014; 16: 184-190
        View in Article
        • Grande D.
        • Armstrong K.
        Community volunteerism of US physicians.
        J Gen Intern Med. 2008; 23: 1987-1991
        View in Article
        • Boyte H.
        The Citizen Solution: How You Can Make a Difference.
        Minnesota Historical Society Press, St Paul, MN2008
        View in Article

      Article Info

      Publication History

      Published online: July 22, 2015

      Identification

      DOI: https://doi.org/10.1016/j.mayocp.2015.06.003

      Copyright

      © 2015 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.

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