Incentivizing with money is a self-fulfilling prophecy of cynicism. We must promote compassion, courage, and wisdom among our physicians before we "make a sordid business of this high and sacred calling."
A colleague of mine in primary care medicine has decided to leave the practice of medicine. She is very well trained, has impeccable professional credentials, and works in a thriving practice. Over the past several years, however, she has noticed an unrelenting decline in the sense of fulfillment she derives from her work. She feels increasingly frustrated with what she calls the "bureaucratization" of medicine, and resents spending "more time filling out forms than caring for patients." My colleague is suffering from what is commonly described as burnout.
Last week Dr. Elaine Shattner described a new report in the Archives of Internal Medicine that indicates that rates of burnout among U.S. physicians significantly exceed those of the general population. This is a very serious issue with effects that will ripple throughout society, and it warrants widespread, earnest attention. The solution, though, does not lie in incentivizing physicians with money or restructuring systems to minimize stress on physicians -- it lies in finding earnest professional fulfillment.
According to psychologists, signs of burnout include decreased enthusiasm for work, growing cynicism, and a low sense of personal accomplishment. As the name implies, individuals suffering from burnout feel as though a fire that once burned inside them has dwindled, and perhaps even been entirely extinguished. In many cases, they report a sense of having "run out of fuel," and like my colleague, feel as though they "have nothing left."
Of nearly 7,300 physicians who participated in the Archives of Internal Medicine's national survey, 46% reported at least one symptom of burnout, and the overall rate of burnout among physicians was 38%, as opposed to 28% among other US workers. The highest rates of burnout were reported among primary care physicians, including family physicians, general internists and emergency medicine physicians.
Why should rates of burnout be higher among physicians? For one thing, physicians tend to work longer hours than other workers, on average about 10 more hours per week. Moreover, striking an appropriate work-life balance appears to be a bigger challenge for physicians, in part because they often tend to keep work and personal life more separated than other workers. The authors of the study speculate that such a high rate of burnout could only result from system-wide issues in medicine, as opposed to the personal susceptibilities of a few physicians.
The issue of physician burnout is important. As the US population grows and ages, the number of physicians needed to care for them increases. When burnout leads physicians to reduce or cease their practice altogether, patient access to medical care is diminished. Moreover, burnt-out physicians are likely to be less productive, make more mistakes, and generally deliver a lower quality of care than their fully engaged colleagues. Finally, physicians are human beings too, and their suffering should summon no less compassion and concern than anyone else's.
Physicians react to burnout in a number of ways. Some, like my colleague, withdraw from their practices, reducing their workloads or leaving the practice of medicine entirely. Others become less engaged with their patients and the profession and suffer a decline in the quality of their work. Still others turn to unhealthy and even self-destructive habits, such as alcoholism, excessive or inappropriate use of prescription drugs, and even illicit substances. Some consider suicide. Others may turn to colleagues, friends, or family for help, or seek professional counseling.
Unfortunately, individuals and organizations often respond to burnout by recommending coping strategies focusing on the reduction of stress. The rationale for this approach is straightforward: individuals suffering from burnout seem to be overly stressed. They feel overworked, excessively scrutinized, or overburdened with unnecessary or unfulfilling tasks. To combat burnout, some suppose, we need only reduce such stressors, by cutting back on working hours, relaxing intrusive oversight, and finding ways to lift the burden of "busywork" from the shoulders of physicians.
While useful in some respects, the stress-reduction approach addresses only the less important of the two sides of the problem. Reducing stressors in the work environment may offer real benefit, but often it does get at the problem's real roots. It is like providing symptomatic relief to a patient without ever addressing the underlying disorder or encouraging the development of life habits that foster a positive state of well-being. Instead of merely reducing the bad in medical practice, we need to enhance the good.
This approach is rooted in the work of the late Frederick Herzberg, a psychologist at the University of Utah. Herzberg found that two very different sorts of factors shape work fulfillment. One group of factors might be labeled dissatisfiers. These are factors extrinsic to the work itself, such as the orderliness of the work environment, the fairness of administrative policies, and compensation. If individuals feel ashamed of their workplace, unfairly treated, or undercompensated, their level of satisfaction will suffer.
As expected, reducing dissatisfiers will tend to reduce workers' level of dissatisfaction. Yet there is a limit to what can be accomplished by addressing such dissatisfiers, and merely reducing dissatisfaction does little or nothing to enhance intrinsic fulfillment. If we increase underpaid workers' compensation to a level they regard as fair, they will tend to feel less dissatisfied with their work. But further increases in compensation will not tend to improve either the sense of fulfillment they derive from their work or the quality of the work they do.
To enhance fulfillment and quality of work, it is necessary to focus on the work itself. In the case of medicine, do physicians recognize what they find most fulfilling? If they cannot see the target they are aiming for -- in this case, the aspects of their work that they find most meaningful and take most pride in -- they are unlikely to hit it. What does their best work look like? Are they making full use of their knowledge, skills, and innate abilities? Are they growing and developing as human beings? Do they feel that they are making a real difference in the lives of their patients and communities?
The key to combatting physician burnout is not to reduce stress, but to promote professional fulfillment. And promoting professional fulfillment is not merely a matter of reducing costs and error rates or increasing clinical efficiency. Nor is it a matter of protecting and promoting the incomes of physicians. As Herzberg reminds us, efforts to alter physician behavior through income-based incentives and disincentives are inherently demoralizing. The reason is simple: they imply that physicians care more about money than their patients. This constitutes a self-fulfilling prophecy of cynicism.
William Osler, perhaps the most admired physician in American history, understood well the recipe for demoralization and burnout: "The path is plain before you: always seek your own interests, make of a high and sacred calling a sordid business, and regard your fellow creatures as so many tools of the trade." To promote burnout among physicians, it is only necessarily to subvert their professional and personal priorities, so that they spend all their time on little things and suffer continually from a growing sense that they are neglecting the ones that really matter.
At their core, good physicians are not mere moneymakers. Good physicians are professionals. And though today we often forget it, being a professional means more than merely getting paid for what we do. Being a professional means above all professing something, declaring openly in work and life that we stand for something beyond our own narrow self-interest. The more we treat physicians as though they were self-interested money grubbers, the more we de-professionalize them. And a de-professionalized physician is inevitably a demoralized and burnt-out one.
Medicine is not a job. It is not even a career. At its heart, medicine is a calling. When it comes to physician burnout, an ounce of prevention is worth a pound of cure. We must begin early in medical education to help medical students and residents explore and connect with a sense of calling to the profession. Even late in their careers, physicians need to recall that they are summoned to something older, larger, and nobler than themselves. They must never forget that a career in medicine represents one of life's greatest opportunities to become fully human through service to others.
If we are genuinely concerned about physician burnout, we need to focus less on reducing stress and more on promoting what is best in physicians: compassion, courage, and above all, wisdom. Only by keeping what matters most at the forefront can we reap a full harvest of professional fulfillment. Burnout is not a disease. It is a symptom. To combat it, we must focus primarily on what underlies it. And here the key is not eradicating the disease but promoting professional wholeness, which flows from a full understanding of the real sources of fulfillment.
