Why Is Physician Well-being Declining? It's the System, Stupid

Peter M. Yellowlees, MBBS, MD


September 06, 2019

Taken from one perspective, physician health appears to be quite good. Physicians generally look after themselves well and live, on average, 2 years longer than age-matched nonphysicians in the general population.[1] The reason for this may be because many of us apply the same behavioral advice to ourselves that we give our patients. In my experience, we tend not to smoke. We tend to eat reasonably well and exercise regularly, and as a result, we tend not to be as obese as the general population. The consequence is that we have less chronic cardiovascular and respiratory illnesses than the general population, which leads to our relative longevity.[1] This is despite the fact that we frequently treat our own medical maladies and many of us do not even have a primary care practitioner (personally, I've found a long-term relationship with my own family physician extremely helpful).

Yet how do physicians compare with the general population when it comes to mental health? Not so well, unfortunately. I describe the tragedy of the approximately 400 physicians who commit suicide annually as being the metaphorical equivalent of canaries in a coal mine; many end up demonstrating severe distress as a result of inhabiting a system with major problems and inadequacies.[2]

Do we suddenly develop burnout because of some bizarre internal developmental shift that only affects doctors?

In trying to account for these distressing numbers, it is important to consider when issues with mental health typically arise in our profession. Most medical students begin medical school between the ages of 22 and 24 years, and they have been shown to be more resilient and less depressed than equivalent graduate students in other disciplines.[3] We start out well, often having overcome the rigorous path required for medical school acceptance. We are feeling good and doing great. However, this begins to change within a few years of our white coat ceremony.

It is now widely acknowledged that 10-15 years after entry into medical school, the average physician has significantly higher levels of burnout than professionals in other fields.[4] What happens between this point and our resilient early 20s? Have we changed? Do we suddenly develop burnout because of some bizarre internal developmental shift that only affects doctors? Those of us who teach medical students, residents, and junior faculty see the changes over time as many of our brightest and best are transformed from bright eyed and optimistic to sleep deprived and skeptical. The answer is quite simple; it is the organizational pressures and stressors, and especially the increased time and pressure at work that we face that have changed us.[5]

In terms of our general mental health, physicians have all the same problems as community controls except in relation to three areas.[2] Physicians tend to have a smaller prevalence of schizophrenia than the community because this disease is usually symptomatic prior to the age physicians enter medical school. That said, the rate of bipolar disorder in both populations is similar.

On the other hand, both male and female physicians exhibit the same higher rates of completed suicide. In the community, men typically commit suicide at a higher rate than women. However, female physicians commit suicide at twice the rate of non-physician women, whereas male physicians commit suicide at 1.4 times that rate. We know that these rates of suicide are related to depression often caused by chronic exposure to trauma on a daily basis, even though we strenuously deny the impact of this trauma as profession. Finally, although physician rates of alcohol use disorder match those of the community, physicians abuse prescribed drugs, such as narcotics and benzodiazepines, more often than non-physicians; they abuse nonprescribed drugs, such as methamphetamine, heroin, and cocaine, significantly less often.[2]

Getting to the Root Causes

Physicians face many organizational stressors on a daily basis, such as time spent on electronic medical records, "note bloat," and extra administrative tasks that waste time. These are well-established problems in today's healthcare system, and most of us cope with them relatively well. Another crucial stressor is that patients are more often chronically ill and better informed, and medical practices are increasingly sophisticated and complicated, but the time allowed for a typical patient consultation has not evolved in tandem with these developments.

A number of prominent authors have detailed other causes ranging from the polemical but insightful writing of Danielle Ofri, MD, PhD,[6] who argues that the business of healthcare demands the exploitation of doctors and nurses, to Adam Kay's masterful description[7] of the adverse impact of long hours on residents and how they train themselves to accept this self-sacrifice. What other profession in the 21st century would think that "limiting" residents to a maximum of 80 hours per week could be seen as rational or reasonable? Kay's heartbreaking bestselling book detailing his work as a resident should be mandatory reading for all those in positions to make pivotal decisions about the inhumane hours imposed on trainee physicians. I cannot think of another profession where the incumbents are proud of their often 7-day accessibility and of their sleep-deprived capacity to perform physically arduous and demanding technical work such as surgery for shifts of more than 12 hours at a time.

If we are to positively impact physician mental health, resilience will not be the answer. Although resilience techniques can be successfully taught, it is not generally possible to "resilience yourself" out of highly stressful situations. Yoga, mindfulness, and meditation can help, but only so much.

From my perspective as a chief wellness officer, it is clear that organizational, systemic, and cultural change is required in the many environments where physician stress or burnout is highly prevalent. We have to have time to show our compassion and care for our patients. It is time to maintain our own sense of self-respect in work well done. It is time to think. We need more time than is available in brief, increasingly complicated consultations when we are exhausted and sleep-deprived from too much pajama-time work late at night. These organizational issues are well described in a comprehensive collection of papers on the topic of physician burnout published in NEJM Catalyst, as well as on the website of the National Academy of Medicine Action Collaborative on Clinician Well-Being and Resilience.

However, the first change that has to happen is for physicians to learn that it is not necessary to sacrifice themselves on the altar of wildly excessive hours of work. When it comes to burnout and mental health—and to recapturing the enthusiasm of a wide-eyed medical student—the solution is changing the system, stupid.

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