Sending in “tougher canaries” won’t fix the problem of physician well-being

Many surveys and reports have acknowledged that physicians are unwell, and their numbers have reached crisis proportion. “We aren’t going to fix this problem by noting that canaries are dying in the coal mine and … sending out for tougher canaries,” remarked Gary Price, MD, an attending surgeon at Yale-New Haven Hospital in Connecticut and president of the Physicians Foundation, a physician empowerment organization.

Price’s remarks were actually in response to a survey of medical and nursing students in the headlines recently. That survey reported that students were exposed to high-stakes pressures, including the financial burden of school, their first exposure to the clinical setting, and the current dysfunction in those settings. By the time those students enter residency and practice, more than half will be burned out, according to various sources. However, that’s where most surveys miss the mark on what to do about physician well-being: they’re either silent or don’t know how to fix it. I have a three-pronged approach.

The first thing to do is totally revamp medical education. We take students who want to be doctors and lock them away in study groups and libraries with endless review videos and flashcards full of useless details. Then we submerge them in “simulations” and send them into patients’ hospital rooms unsupervised and without contemporaneous feedback about their interactions with patients. After they see patients, students are left alone to process their emotional experiences and any trauma associated with their visits. They are forced to wear a false bravado as they are pimped and put down by residents who, themselves, are psychologically distressed, even damaged. The system of learning is insufferable for medical students. Should we be surprised that many come out depressed, having lost interest in serving patients, and pessimistic about their future?

Next, we need to redo the system for training residents. Clinical training based on hands-on attentive care of the patient, under close supervision by very experienced clinicians, has all but evaporated. Attendings who have shied away from extensive rounding with students and residents, or have faded into the fabric of research and pharma consulting, or simply would rather be elsewhere – anywhere other than at the patient’s bedside – explains why trainees fail to fully grasp the concept of doctoring and why medical care today is so disjointed, patient-unfriendly, and often riddled with errors and failed oversight. Only altruistic physicians who are dedicated to full-time academic teaching – and are fairly compensated for it – need to show up.

I’ll never forget my first night on call during my junior clerkship in surgery. I was assisting a fifth-year resident in the operating room as he repaired several lacerated tendons in a young woman’s hand (her “boyfriend” brandished a knife and cut her during an argument). The surgery took place roughly between 2 and 4 a.m. Several hours later, the attending arrived for morning rounds, only to discover the resident had operated without his knowledge – that is, the attending’s knowledge; there was no one to pass judgment about the resident’s knowledge of intricate hand surgery. The attending went berserk, scolding the resident for not being notified prior to performing the delicate procedure. The attending said he would have come in from home to assist the resident had he known. We need more of those attendings!

Finally, we need to restore pride to the medical profession. Doctors used to go into medicine for several reasons. They wanted to take care of patients because they liked people, they loved helping others, and they welcomed the challenge of making diagnoses, performing procedures and surgery, and especially, for psychiatrists, doing psychotherapy, which is now a lost art abrogated to non-medical “therapists.” Physicians liked the autonomy and collegiality of medicine, and they knew they were going to make a good living at it. All this while essentially making their own hours, working on their own terms, and withstanding the challenges of – even looking forward to – being on call. What happened?

What happened was government interference, overburdening physicians with ridiculous documentation mandates and infrastructure issues, and the corporate domination of medicine forcing private physicians to be employed, among other woes of transitioning to the medical-industrial complex. This took away physician’s autonomy and their earned status to the point of simply being another hospital employee or employee of a large health system. This caused physicians to not just be responsible to patients but to corporate entities and the government. This total conflict of interest places physicians between medicine and management, where they do not belong. There is no reason to treat smart, ambitious doctors this way. (Jerry, I hear you singing: “Don’t wanna be treated this a way …”)

On top of treating doctors shabbily and with disrespect, physicians were forced to accept increasing liability and were expected to perform with perfection, so that now huge malpractice settlements deter organizations from hiring doctors – and God forbid lawyers should let physicians apologize to patients and families for mistakes. Also, continued cuts in Medicare and other health insurer’s fees signaled that physicians were not valued. It all seems so surrealistic – a bad nightmare and no longer worth the price of admission to practice. Many physicians are leaving the profession in droves, and scores intend to exit over the next several years. Why should anyone be surprised that 25 percent of medical students intend to use medical school as a stepping stone within – or outside of – medicine rather than practice it?

Virtually everything I’ve read when it comes to medical students, residents, and physicians attaining well-being puts the problem squarely on them, holding doctors accountable for making the necessary changes – for example, ensuring work-life balance; encouraging healthy eating and regular exercise; practicing mindfulness; implementing regular work breaks and resilience programs; building a supportive culture; regularly assessing well-being, etc. We’re too frigging busy to “build” anything. There is nothing “regular” about the practice of medicine that we should take for granted. I want to gag myself with a spoon every time I read this crap.

I see the same BS in articles suggesting structural solutions to making physicians well again, such as changing workloads and schedules; streamlining administrative tasks; enhancing team-based care; addressing financial pressures; improving workplace culture; and advocating for policy changes. Who’s going to do that? Politicians and lawmakers? Hospital MBAs? They’re the reason we’re in this mess! Measuring physician “burnout” and holding health systems accountable for reducing its incidence is a somewhat novel idea, but let’s face it, the only thing health systems are really accountable for are their bottom lines and those who back their equity.

It’s time to end the rhetoric and stop pretending that coaching and coddling physicians will make them better. Broken physicians won’t get fixed by sending in tougher canaries. Broken physicians may get better by breathing in fresher air.

This profession we call medicine is a sailing ship to the Devil’s Triangle. Unless a course correction is imminent, unless we right the ship, there will be no more canaries to send in.

Send in the clowns.

Arthur Lazarus is a former Doximity Fellow, a member of the editorial board of the American Association for Physician Leadership, and an adjunct professor of psychiatry at the Lewis Katz School of Medicine at Temple University in Philadelphia, PA. He is the author of Every Story Counts: Exploring Contemporary Practice Through Narrative Medicine.


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