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Sustaining Engagement, Finding Fulfillment as a Physician

By Bruce Gewertz, MD
Surgeon-in-Chief, Chair of the Department of Surgery

"That which does not kill us makes us stronger."
  — Friedrich Nietzche, German philosopher

The topic of physician burnout is now inescapable. The issue has been written about extensively in the popular press and medical journals in recent years, while numerous specialty societies in medicine have addressed it in lectures and panel discussions at national meetings.

Disturbing data support the concern for this phenomenon. Physician depression and suicide rates far exceed those of a matched population, with particularly high rates among female physicians (twice national averages). Over the past decade, surveys by the American College of Surgeons found that up to 40 percent of surgeons had significant signs of depression, and nearly two-thirds felt their work did not allow for a rewarding personal life.

One of the costs of this occupational stress has been the early retirement of many middle-aged physicians, which is particularly worrisome in several surgical subspecialties predicted to be in greater demand with the aging of the baby boomer population.

The drivers of burnout are becoming more clear. A recent study by Christine Sinsky, MD, and colleagues, funded by the American Medical Association (Annals of Internal Medicine, 2016; 165:753-760), measured the allocation of time in ambulatory practice among physicians in family medicine, internal medicine, cardiology and orthopedics, who were practicing in Illinois, New Hampshire, Virginia and Washington state.

The data is compelling: For every hour in which physicians provided direct clinical interaction, they spent two hours updating electronic health records and doing other desk work! This reality contradicts the simple yet thoughtful recommendation of Shanaree Brown and Richard Gunderman, MD, PhD (Academic Medicine, 2006; 81:577-582): "To increase fulfillment of physicians, we need to ensure that the intrinsically fulfilling aspects of the work are accentuated, not suppressed."

I think we can agree that the time distribution documented in the AMA study cannot possibly lead to much fulfillment.

Having had the privilege to chair two distinguished departments of surgery for more than 25 years, I have opinions on this subject. And as you know, "surgeons are occasionally wrong, but never in doubt."

Too many "burnout" discussions have an unfortunate side effect of casting physicians as victims. Yes, we have new and important challenges to our autonomy and daily functions, but portraying surgeons as victims seems incompatible with our personalities and personal commitments. I would rather recast the problem in a more positive light: Instead of talking about how to avoid burnout, let's figure out ways to find and sustain more fulfillment from the environments in which we find ourselves.

Fault does not lie with our personal characteristics. Physicians as a group do not lack resilience or "grit." Indeed, the gantlet of medical school and residencies we passed through testifies to that fact. Efforts to improve our character so we can better withstand the challenges we face are unlikely to work or to be well received. This is not to say that the issue should be ignored. Indeed, our candid discussion regarding attitudes and behaviors that might help us deal with stress at work can be effective and uplifting.

The only real solutions lie within the fabric of our institutions. As noted by Tait Shanafelt, MD, and John Noseworthy, MD, (Mayo Clinic Proceedings, 2017 Jan;92(1):129-146) there are substantial limitations to self-improvement strategies. These researchers argue that maintenance of an engaged and emotionally balanced physician staff requires meaningful organizational changes. To this end, they strongly suggest regular assessment of physician wellbeing, the careful weighing of incentives to avoid overwork and, most important, strengthening the leadership skills in these areas.

Empower caregivers to spend more time tending to patients and less time typing! What is elusive is determining how to accomplish this goal, given the demands for our services and the documentation now required by the medical-industrial complex.

Finding solutions for each highly specific practice situation will require your input. This month's faculty survey is one place to start. Even more to the point, our department leadership will be incented to address this problem with adjustments to our workplace. We need to redouble our efforts to structure clinic workflows to put doctors and patients together while reducing time spent on documentation requirements. New technologies being pioneered in our innovation center may help, including enhanced voice recognition programs and other platforms. Another essential ingredient is our own determination to provide strong and well-reasoned "surgical" input to solve these problems.