This past week, discussions of the U.S. doctor shortage dominated the health op-ed sections of the New York Times, Wall Street Journal, and Washington Post, among others. In the current Washington Monthly, as James Hamblin discussed here yesterday, Phillip Longman addressed the open secret that the most academically prestigious medical residency programs routinely train the fewest number of primary care physicians. Concerns about salaries, student debt, and physician burnout discourage these students from staying in medicine -- and, more importantly, from selecting primary care and preventive medicine specialties as a career.
Yet few if any writers addressing the doctor shortage describe a structural component of medical training that dissuades students and residents from long-term employment as physicians: American medical trainees receive next to no specialized training in worker health and safety.
Physician burnout -- a symptom cluster reflecting feelings of emotional exhaustion, low personal accomplishment, and depersonalization and isolation -- is a psychiatric epidemic in most industrialized countries. While burnout itself is not a DSM-5 diagnosis, the resultant anxiety disorders, depressive disorders, and suicide are. (For those interested in a more feeling version of this feeling, New York internist Danielle Ofri has characterized physician burnout in her new book What Doctors Feel .) Medical trainees work in an underfunded patient care system, then immerse themselves in the service of patients whose demands they cannot meet alone. Deprived of institutional supports in the medical community for burnout prevention, the experience of medical training detracts those who would try full-time practice, in particular primary care practice, from continuing.
Physician burnout is a key cause of the doctor shortage, and one we can reverse if we train happier doctors. Happier doctors are better educated doctors: A 2013 American Journal of Surgery pilot study of surgery residents suggests that residents are more likely to identify burnout in themselves if you teach them how to diagnose burnout. General surgery residents, as it happens, are more likely than most specialists to experience burnout. According to a 2012 study in the Archives of Internal Medicine, preventive care has the lowest burnout rate of any medical specialty in America . It is therefore no accident that many preventive medicine physicians specialize in worker health and safety, or "occupational and environmental medicine."
The National Institute of Environmental Health Sciences (NIEHS) health as "identification and control of the risks arising from physical, chemical, and other workplace hazards in order to establish and maintain a safe and healthy working environment," hazards that "may include chemical agents and solvents, heavy metals such as lead and mercury, physical agents such as loud noise or vibration, and physical hazards such as electricity or dangerous machinery." Occupational physicians support patients who suffer from work-related injuries. They work in the tradition of Irving Selikoff, the researcher at Mount Sinai Hospital in New York City who linked asbestos exposure to mesothelioma, a rare lung cancer. Their work may take them into political advocacy on behalf of large groups of workers who share similar pathology.
As preventive medicine specialists, occupational physicians are in high demand as primary care providers. The American College of Occupational and Environmental Medicine (ACOEM), founded in 1916, today represents just 4,500 American physicians, compared to the estimated 209,000 in primary care in the United States -- and 624,434 overall physicians involved in direct patient care . Occupational physicians may have a primary care practice, a consulting role on a corporate or governmental health and safety initiative, a supervisory position as a military officer overseeing risk factors for illness on and after deployments, or an academic research practice. They may enter the Epidemic Intelligence Service of the Centers for Disease Control on fellowships sponsored by the National Institute of Occupational Safety and Health. Entry into one of 28 accredited training programs in the US, covering only 20 states, requires at least a preliminary intern year, and ideally board certification in another primary care specialty (three or more years of training in internal medicine, family practice, etc.). Occupational and environmental medicine residencies, which are supervised by the Association of Occupational and Environmental Clinics, train fewer than 10 residents per class. And so many medical trainees don't know they exist.
Where does that leave me, the medical student who wants to be a primary care provider, but is worried she is going to burn out before the work begins?
When people ask me about my plans for medical residency, I sure don't tell people, "Oh, occupational and environmental physician!" the way one might say oncologist or cardiologist. They don't have that in American Girl or Playmobil and Richard Scarry: They have fireman and doctor coat and Huckle Cat. When my class got one of its few lectures on occupational health, it was in a short introductory epidemiology case study series thrown in a few free blocks during a course on host defense. An occupational physician was teaching us during the microbiologists' breaks to visit their labs and do lunch. Physical and mental health is formed by experience of the shift work environment, but the vast majority of students never work a job mandating a lunch break until they train on the hospital wards. How can we conceive of ourselves as workers--health care workers represented by a union, the SEIU's Committee of Interns and Residents, no less -- responding to a labor shortage with this knowledge deficit?
Working on my master's in public health, I specialized in occupational and environmental health and learned clinical skills I worry I will not be able to use again until I finish my planned residency in primary care. There is almost never time to ask patients about their jobs in a 15-minute "patient encounter." Work injury and underinsurance causes poverty as often as work helps one escape it. Patient care is patient disease is patient work: Eventually you're going to come across workplace-related asthma and musculoskeletal injury and stress after you rule out everything else (and not, one hopes, a career in primary care). If you don't have time to ask patients about their work, you do not get a correct diagnosis--and you do not get compensation, which a 2012 study from the University of California-Davis found was woefully inefficient cost-sharing. There were roughly 4,600 workplace fatalities in 2011, something like twelve workers a day, or 3.5 of every 100,000 workers in the United States. 729 of these workers were born outside the United States. 666 died from simple, fixable problems like slips, trips, and falls. Statistically speaking, it is more dangerous to be a commercial fisherman than to be a first responder, but the same is true of a camel going through the eye of a needle. And we need doctors aware of worker poverty in long-term jobs from which they can alleviate doctor shortages.
Occupational medicine, with its social conscience and its great lifestyle for good money, is the best-kept secret in American medicine. Salaries are higher than for most primary care specialties, hours are better, and burnout rates are lower --because these doctors know that they practice medicine right. Occupational medicine rethinks primary care by doing medicine the humane way: by providing doctors and patients with a financial and administrative safety net. Most occupational health patients are insured by their employers and covered by worker's compensation, which improves patient care, as well as physicians' lifestyles, as they do not bear the administrative fallout. The specialty is both good for the worker receiving the service and good to the one providing it. Expanding insurance was the whole goal of Obamacare, and we would do best to expand that vision further by expanding how we train our residents in preventive and occupational medicine.
With finance firms, tech start-ups, and biotechnology lobbies out to poach young, frustrated physicians from clinic, medical trainees must be exposed to worker health training so they can design and promote healthy work environments for their peers. It is in everyone's best interest. Physicians who know how to assess whether or not work environments are healthy, and to intervene medically when they are not, are more likely to stay fit for work themselves. We can only reduce doctor shortages with humane working conditions for doctors -- conditions occupational physicians can provide.