My niece, whom we will call Anne, recently completed her residency. I remember Anne as a child…. always smiling, always happy, idealistic. She excelled academically and chose medical school despite my reservations. I watched Anne proceed through medical school and residency, transforming before my eyes into an anxiety-riddled, sleep-deprived, irritable, and jaded physician. She said to me late in her residency, “I’m afraid I am becoming an asshole.”
This is ironic because the training that crushes empathy development also demands it.
While Anne was in training, I was engaging in research and writing about physician burnout and wellness. I shared my expertise with Anne, but I was working against a well-established culture, The System.
I’ll jump early to my research conclusion: The System is winning.
My inquiry into physician burnout began because I wanted to understand its prevalence and origins. By late 2015, a significant amount of data had been amassed documenting the emotional and physical detriments associated with being a physician, as well as patient safety issues.
Despite this, not much has changed.
Sure, duty hours have decreased for residents. If you think about it, limiting work hours to just an average of 80 per week with a guarantee of 1 day off out of 7 isn’t much of a reduction. It brings me about as much comfort as knowing my airline pilot is limited to flying 80 hours a week with at least 1 day off. Any human working this kind of schedule would have enough sleep deprivation to cause cognitive impairment, not to mention emotional exhaustion. I wouldn’t want this professional flying my plane or managing my medical problems.
What I find disheartening is the over-emphasis on physician stress management education as the answer. The problem should not be solely owned by physicians. And, decreasing workload, though it is problematic, isn’t the entirety of the solution either. There are significant issues associated with the transformation of medicine from an art into a belt tightening business where physicians (who are the experts) have too little influence on the process.
Committees have formed. Conferences have been held. An industry has even developed to help organizations be able to better benchmark levels of physician burnout against normative data. Physicians have proven great sources of data.
While I appreciate the attention given to self-care for physicians, I see it as only part of the solution. I believe the research findings have been overgeneralized to suggest simple stress management courses and lunchtime meditation. Organizations can check off the box that wellness is covered.
Despite the ongoing conversations and hand wringing, nothing significant has changed. I could no longer look professionals in the eye and give the wellness pep talks. I would no longer contribute to a research literature that wasn’t being taken seriously. I lost my stomach for it.
Here is what I see. Caring people dedicate themselves to medical studies because they want to make a difference in the lives of others. They accumulate great debt in hopes that it will all be worth it. They enter an abusive system of training only to later find that physicians have been stripped of decision-making duties – relegated to worker bee status on the production line. The System dictates schedules, workloads, and access. The System pits physicians against patients under the guise of quality. The System has become a dictator, and at the end of the road, it is easy to feel like the soul of medicine is being lost.
(Consider how well that worked for childhood education and teacher satisfaction when lawmakers began mandating and underfunding educational methods for teachers while holding them solely accountable for outcomes.)
I’ve decided that if anything is ever going to change, physicians will have to collectively rebel, and I don’t know how this can happen. I think The System has a tremendous advantage over physicians. The System knows that physicians chose a career in medicine because they are dedicated to service. The System knows that physicians will not abandon patients. The System knows that physicians are trained to self-sacrifice. The System is a taker and is holding physicians hostage. It is a co-dependent relationship.
As a former faculty in academic medicine, I am incredibly sad. It doesn’t have to be this way, but here we are. As a patient, I am afraid because I know that the quality of my medical care is inextricably linked to a human being, one who is not superhuman, one who may be emotionally exhausted and suffering from learned helplessness. I am resentful that my tax dollars support a medical education system that is abusive and will likely start to attract people who are comfortable being robotic.
I don’t have the answer because there is no one solution. It probably starts with acknowledging our culture problem and giving physicians a more influential seat at the table. All I know is the culture is eating strategy. The System is culture, and it has taken on a life of its own. I hope we can change the culture before it devours everything and everyone else around it.
Also published on Medium.com and KevinMD.com.