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.
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?
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.