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The Secret of the Care of the Doctor Is in Caring for the Doctor

  • Rachel B. Levine
    Correspondence
    Correspondence: Address to Rachel B. Levine, MD, MPH, Division of General Internal Medicine, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD.
    Affiliations
    Division of General Internal Medicine, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD
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      My first clinic appointment of the day runs late. After an initial greeting, my patient opens up about feeling overwhelmed. He is struggling to manage home and work responsibilities. In his professional sphere, he is experiencing pressure to be more productive and notes less energy and joy related to his work. At home, he is often too tired to spend quality time with his family. He worries that he is not supporting his spouse enough, who is at home with their young children. We discuss strategies to create better balance in his life. We never get a chance to talk about his medical issues. The next day I see my patient again. This time he is walking the halls of the hospital. He looks harried, but smiles and pauses to say to me in passing, “Thanks for letting me vent yesterday.” Today he is wearing his white coat; he is an attending physician overseeing the care of his own patients.
      In the current issue of Mayo Clinic Proceedings, Shanafelt et al
      • Shanafelt T.D.
      • Mungo M.
      • Schmitgen J.
      • et al.
      Longitudinal study evaluating the association between physician burnout and changes in professional work effort.
      use a prospective, longitudinal research design to explore the impact of physician burnout and low work satisfaction on reductions in professional effort in a single large health care organization. As the authors state, previous studies have linked physician burnout and low satisfaction with the intent to decrease work hours or to leave clinical practice altogether, suggesting a significant but unknown potential effect on the physician workforce.
      Using administrative and payroll statistics, Shanafelt et al discovered an overall increase in the number of physicians working less than full time during the study period (2008-2014). Women and primary care physicians were more likely to work less than full time compared with other physician groups during the study, and the authors noted an increase in the percentage of men older than 55 years working less than full time. Burnout and satisfaction were measured in 2011 and 2013 as part of an organization-wide physician survey. These results were then linked to full-time equivalent employment data to assess reductions in work effort prospectively. Physician burnout and low satisfaction predicted reductions in full-time equivalent over time. This was true for data analyzed in aggregate and at the individual physician level.
      The authors appropriately acknowledge that their study does not provide a complete picture; there are many reasons why physicians may choose to decrease their work effort, and although the Shanafelt et al research found an association between burnout and low satisfaction vs decreased effort, causality cannot be fully established. However, their findings provide further compelling evidence that now is the time to address physician burnout and diminished work satisfaction. We are currently facing projected workforce shortages, especially among primary care specialties, at the same time that our population is aging and there is increased demand to care for newly insured patients.
      Burnout and low work satisfaction are common among all types of physicians, although those in primary care and other frontline roles report the highest levels of burnout.
      • 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.
      In addition to reducing work effort, physician burnout has been associated with a variety of undesired physician behaviors and outcomes, including medical errors, decreased empathy, substance abuse, divorce, and depression.
      • Wallace J.E.
      • Lemaire J.B.
      • Ghali W.A.
      Physician wellness: a missing quality indicator.
      • Shanafelt T.D.
      • Sloan J.A.
      • Haberman T.M.
      The well-being of physicians.
      Concerns over physician burnout are widely held, as indicated elsewhere in this issue of the Proceedings, in the correspondence of Khoo
      • Khoo T.K.
      Factors affecting burnout in physicians.
      and Eiser.
      • Eiser A.R.
      Burnout and the ethos of medical practice.
      Physician burnout has a tremendous potential effect on our health care system in overall costs and the quality of care that we provide to our patients, not to mention the personal cost to physicians and the people and relationships in their lives.
      Although Shanafelt et al
      • Shanafelt T.D.
      • Mungo M.
      • Schmitgen J.
      • et al.
      Longitudinal study evaluating the association between physician burnout and changes in professional work effort.
      demonstrate that burned out physicians are more likely to reduce their work effort, the impact of working less than full time in the study group is unknown. Will these physicians eventually reenter the full-time workforce refreshed, not burned out, and more satisfied? Part-time physicians must still manage the challenges of the current health care system, such as requirements for increased documentation, lack of control over schedules, and working in low resource settings (common in primary care and emergency departments). Of note, in previous cross-sectional studies, control over schedule and fewer total work hours were associated with decreased burnout.
      • Keeton K.
      • Fenner D.E.
      • Johnson T.R.
      • Hayward R.A.
      Predictors of physician career satisfaction, work-life balance, and burnout.
      • McMurray J.E.
      • Linzer M.
      • Konrad T.R.
      • Douglas J.
      • Shugerman R.
      • Nelson K.
      The SGIM Career Satisfaction Study Group. The work lives of women physicians results from the physician work life study.
      • Mechaber H.F.
      • Levine R.B.
      • Manwell L.B.
      • et al.
      MEMO Investigators
      Part-time physicians…prevalent, connected, and satisfied.
      Following this narrative, the authors
      • Shanafelt T.D.
      • Mungo M.
      • Schmitgen J.
      • et al.
      Longitudinal study evaluating the association between physician burnout and changes in professional work effort.
      propose that reducing work effort may serve as a “safety valve” for physicians who are experiencing burnout and low work satisfaction. The safety valve option provides an alternative for physicians to leaving clinical practice altogether. Extending the safety valve metaphor may help to highlight the implications of physician burnout and low work satisfaction on the health care system and offer strategies to address them.
      Safety valves are designed to prevent catastrophic events by automatically releasing a substance, such as steam from a closed system, when certain limits are reached. Generally, safety valves work well in this type of setting. However, the more complex the system, such as in politics, labor relations, environmental protection concerns, and health care, the less effective a safety valve becomes. A safety valve works by averting an impending disaster, often at the last possible moment, not by addressing root problems or by changing the way a system functions. Safety valves rarely lead to sweeping innovation.
      Medicine as a profession has traditionally embraced the “ideal worker” role, in which physicians are available to work full time and without significant family obligations.
      • Williams J.
      Unbending Gender: Why Family and Work Conflict and What to Do About It.
      Typically, US physicians work, on average, 50 hours per week, with 30% working 60 hours or more per week.
      • Ly D.P.
      • Seabury S.A.
      • Jena A.B.
      Divorce among physicians and other healthcare professionals in the United States: analysis of census survey data.
      Reducing work effort provides a very real option for many individual physicians experiencing burnout or other types of distress, and in some situations has led to local novel approaches to traditional medical careers and clinical care.
      • Levine R.B.
      • Mechaber H.F.
      Opting in: part-time careers in academic medicine.
      For some physicians, the part-time option represents a proactive, conscious decision to “work differently,” for example by creating time to practice the self-care and healthy behaviors they encourage among their patients and to spend more time with family.
      • Harrison R.A.
      • Gregg J.L.
      A time for change: an exploration of attitudes toward part-time work in academia among women internists and their division chiefs.
      In fact, quality and satisfaction are not diminished (and are often improved) among patients of part-time physicians.
      • Parkerton P.H.
      • Wagner E.H.
      • Smith D.G.
      • Straley H.L.
      Effect of part-time practice on patient outcomes.
      • Panattoni L.
      • Stone A.
      • Chung S.
      • Tai-Seale M.
      Patients report better satisfaction with part-time primary care physicians, despite less continuity of care and access.
      However, as pointed out by the authors, physician reductions in work effort may increase pressures on our health care system to maintain timely access to care and continuous clinical coverage. If up to 50% of our physicians are burned out and burnout predicts reduction in work effort, we may be at risk for overwhelming the part-time safety valve option.
      To avert overwhelming our health care system, we must look beyond safety valves and address larger system issues—but where to start and on what foundation? In 1927, Dr Francis Peabody famously addressed what many at the time saw as an impending crisis in medicine: the triumph of scientific advancement to the detriment of humanism in caring for patients. Peabody wisely and simply reminded medical students, physicians, and the public that “the secret of the care of the patient is in caring for the patient.”
      • Peabody F.W.
      The care of the patient.
      Any effort to address burnout and low work satisfaction among physicians should begin with understanding the context within which we currently live and practice, and from a place of also caring about the physician. My patient (the physician described at the beginning of this article) is unlikely to choose part-time work for a variety of reasons, and so I fear he is at risk for burnout. How shall we care for him and others like him?
      An initial step to adequately address physician burnout is to measure it and to identify the factors that are associated with it. Mayo Clinic and the study authors should be commended for collecting and sharing these data at regular intervals. It is hoped that organizational leaders are using this information to develop and track efforts to address physician burnout and satisfaction at the systemwide level and in a way that values and cares for the physician. Other academic institutions and health care organizations are taking a similar path and have created wellness committees and programs to address physician burnout using a systemwide approach.
      • Linzer M.
      • Levine R.
      • Meltzer D.
      • Poplau S.
      • Warde C.
      • West C.P.
      10 bold steps to prevent burnout in general internal medicine.

      Acknowledgments

      The title of this editorial is a reimagining of Francis Peabody's famous statement, “for the secret of the care of the patient is in caring for the patient.”
      Details of the patient described in this editorial have been altered in compliance with Health Insurance Portability and Accountability Act of 1996 regulations.

      References

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        Burnout and the ethos of medical practice.
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        Predictors of physician career satisfaction, work-life balance, and burnout.
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        J Gen Intern Med. 2000; 15: 372-380
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        • Manwell L.B.
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        Unbending Gender: Why Family and Work Conflict and What to Do About It.
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        Am J Med. 2006; 119: 450-453
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        • Levine R.
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        J Gen Intern Med. 2014; 29: 18-20

      Linked Article

      • Longitudinal Study Evaluating the Association Between Physician Burnout and Changes in Professional Work Effort
        Mayo Clinic ProceedingsVol. 91Issue 4
        • Preview
          To longitudinally evaluate the relationship between burnout and professional satisfaction with changes in physicians' professional effort.
        • Full-Text
        • PDF
      • Factors Affecting Burnout in Physicians
        Mayo Clinic ProceedingsVol. 91Issue 4
        • Preview
          I appreciated the insightful data presented by Shanafelt et al1 in their article in the December 2015 issue of Mayo Clinic Proceedings, and I share the concerns about burnout rates among physicians in the United States. Although burnout is undoubtedly a multifactorial issue, one wonders about the role of recent federal mandates.
        • Full-Text
        • PDF
      • Burnout and the Ethos of Medical Practice
        Mayo Clinic ProceedingsVol. 91Issue 4
        • Preview
          The article by Shanafelt et al1 published in the December 2015 issue of Mayo Clinic Proceedings describes the very serious and worsening problem of burnout among American physicians, and the editorial by Ariely and Lanier2 attempts to elucidate the causes, noting asymmetrical awards, loss of autonomy, and cognitive scarcity. I could not agree more on one point that Ariely and Lanier made, that the “micromanaging of physicians' time and decisions” in the name of productivity by their corporate overseers is a major factor in the burnout and that it needs to be addressed.
        • Full-Text
        • PDF