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Healthcare organizations need to focus on improving efficiency while still remaining supportive to physicians, selecting and developing leaders with the skills to foster physician engagement, helping physicians optimize work-life balance, and creating an environment that nurtures flexibility and other qualities that help cultivate physician wellness.
Rashmee Patil, MDI entered his bedroom; a familiar place from our childhood spent together. The bookshelf on the wall was lined with mystery novels, including Gone Girl and The Wind Through the Keyhole, his favorite genre. His bedside table was stocked with medications (Cedirinib, Lactulose, Morphine, the bottles read) and open, partially finished Ensure bottles. Each second that passed realigned my memory to the significance of this room. And then I laid eyes on him.
He was lying in his hospital bed, his favorite blanket perched over his frail body so that only his face was visible. He had lost a considerable amount of weight since I had seen him a month ago. His eyes now sunken and muscles wasted. His skin dry and flaked, a sign that he was not taking in much fluid or food. The nasal cannula prongs that administered much-needed oxygen to his body were not in place and I knew in that moment how perturbed he was by this. The swoosh of the oxygen humidifier machine startled me. I jumped and he mustered a smile.
After that trip, I came home one more time. My brother died during that visit, in that same room, in that same bed, under his favorite blanket.
Following his death I returned to work, gradually interacting with patients again. Medicine would provide me a sanctuary over the next five months, a concept that I was not privy to at the time. In helping others during their times of need, I was in essence healing myself. The harsh realities of grief, though, were not lost on me. Some days left me numb and catatonic. I tried to find meaning in the mundane tasks as a PGY-2 internal medicine resident: depression screenings, routine follow-ups for diabetes, smoking cessation counseling, etc. Admitting patients with grave diagnoses and seeing young people affected by cancer was not bearable for me for many months, and I turfed those patients to my sympathetic colleagues.
I searched for resources that could help me navigate what I was experiencing, but my efforts left me feeling discouraged and alone. I struggled for composure and collectedness in the chaos of my emotional turmoil so as to not appear “weak” to my superiors, a falsity that I would later regret. Though losing a family member during residency was arguably an extreme circumstance, I expected there to be more systemic support systems in place to ensure my emotional and physical well being as a physician-in-training. Though a handful of supportive colleagues continuously looked out for me during this time, much of the burden of assessing my wellness fell on me. It was in those moments that I realized that maybe the problem was bigger than my experience. Maybe a lack of system-wide emphasis on physician wellness was a symptom of a larger institutional gap. Or maybe physician wellness was not a quality indicator worth measuring at all.
Medicine is both a demanding and rewarding profession. As physicians, we are important members of healthcare systems. We spend more than a decade in higher-level education, work substantially more hours than most U.S. workers in other professions, and often struggle to effectively integrate our personal and professional lives. In a recent survey by Physicians Practice, 53% of physicians said they wished they worked fewer hours per week and 13% said a high stress level was their biggest frustration with being a physician.
Beyond workload and job-related fatigue, physicians work in emotionally charged environments and have to process and oftentimes compartmentalize their feelings to survive. Furthermore, with rapid changes in the practice of medicine (increased patient-care demands, growing bureaucracy, constantly changing guidelines, more regulation and less autonomy), physicians face many threats to their wellness. But much of this demand is offset by meaningful interactions with patients, intellectual stimulation at work, above-average compensation as compared to other U.S. professions, and the ability to join a prestigious group of colleagues who understand your experience. When these positive rewards of our profession do not outweigh the demands, it leads to increasing physician burnout and a trend toward many young physicians possibly opting out of traditional medicine for more non-clinical roles.
In a 2012 national survey from the Mayo Clinic, burnout and other dimensions of physician well-being were measured and compared to the general U.S. working population. Rates of burnout among physicians and dissatisfaction with work-life balance were found to be significantly worse, and more than half (54.5%) of U.S. physicians reported experiencing professional burnout. This study reiterates that burnout and satisfaction with work-life balance among physicians are getting worse. Factors contributing to burnout include increasing workload, fatigue, decline in autonomy and chronic work-related stress.
Though the reasons for burnout are multifactorial and require more systemic and evidence-based interventions to determine the driving forces behind this phenomenon, it is undeniable that high physician burnout not only individually affects the physician’s well-being, but also has significant negative effects on quality of care, patient satisfaction, patient safety and the overall condition of medicine as a profession.
Though the data on physician wellness is sparse, more studies are beginning to show the importance of developing metrics to measure it. The consequences of failing to prioritize physician wellness as a quality indicator include: worsening of an already large shortage of physicians in primary care by negatively affecting recruitment and retention into the field, reducing workplace productivity and efficiency, increasing medical errors, and ultimately impeding high quality patient care, patient safety, and patient satisfaction.
Even more importantly for the medical community, failing to address the fact that we have many un-well physicians will only lead to a worsening of the already staggering statistic that suicide rates for physicians are estimated to be more than three times higher than the general population. According to the American Foundation for Suicide Prevention, we lose around 400 physicians to suicide every year.
Healthcare organizations need to focus on improving efficiency while still remaining supportive to physicians, selecting and developing leaders with the skills to foster physician engagement, helping physicians optimize work-life balance, and creating an environment that nurtures flexibility and other qualities that help cultivate physician wellness. These interventions must address systemic contributing factors in our practice environment rather than focusing exclusively on helping physicians care for themselves and training them to be more resilient to the changing demands.
The incorporation of physician wellness as a quality indicator will best be promoted through continued dialogue amongst physicians, health system decision makers, payers and the general public. Increased awareness of the importance of physician wellness is needed and a shift in the culture to prioritize wellness will not come suddenly. The benefits of emphasizing this shift will not only affect physician wellness individually by increasing job satisfaction and reducing burnout, but will also help to encourage a more productive and efficient healthcare system that will ultimately benefit the quality of care patients receive.
The last time I went home to see my brother is forever imprinted in my memory. The moments before he died were peaceful yet surreal. His body frail and unrecognizable at the end, he breathed his last breaths with an almost anticipatory ease. The days, weeks and months that followed were numbing for me. But from my experience, I recognized the critical importance of self-awareness in assessing and promoting my own wellness.
As physicians we dedicate our lives to the service of others. We tend to the sick and nurture those in despair. We ease suffering with medical therapy and make daily decisions that carry weight far beyond the walls of the hospitals in which we practice. As important members of healthcare systems, we must continue to advocate for ourselves by opening dialogue regarding individual and organizational approaches to improving physician wellness. Though current medical practice focuses on quality metrics surrounding patient satisfaction and care, physicians who are not well cannot deliver efficient and empathetic care.
Physician wellness matters. Though we are slowly developing metrics to better understand it, wellness is a quality indicator we must learn to value and measure to improve the practice of medicine in the future.
Rashmee Patil, MD, is a board-certified internal medicine physician licensed and practicing in New York. She looks forward to pursuing a fellowship in hepatology and liver transplantation in the upcoming academic year. Her interests include narrative medicine and journalism.