Physicians just want to practice good medicine. In 2008 the renowned author Malcom Gladwell presented a talk at a national medical conference titled “The duality of being a doctor”.¹ In his presentation he highlighted the productive personal side of being a physician rewarded by a mission driven spirit, dedication and commitment, and the idealism of helping people get better. He then discussed the growing conflicts generated by the impersonal side of health care business economics which negatively affects physician attitudes and threatens the future of medicine. How right he was. Over the past several years physicians have become increasingly frustrated with the practice of medicine and it has negatively impacted their attitudes and behaviors toward patient care. This is a serious situation. Physicians are a precious resource. In order to keep them going we need to gain a better understanding of the factors influencing their thoughts and emotions and provide the necessary resources to help them better adjust to the pressures of today’s health environment.

Behavioral Influences

In order to change perceptions and behaviors we need to gain a better understanding of the factors contributing to ones disposition. Table 1 provides a list of internal and external factors that can influence individual values, perceptions, biases, attitudes, and behaviors that can impact personal and work relationships.

Age and generational issues are based on values and reactions reinforced by the current affairs of the environment in which the individual grew up. Differences in views as to work ethic, commitment, views of authority, and work life- balance are different for each of the groups (Millenniums, Generation X, Baby Boomers, Veterans) which under stressful situations may lead to conflict in the workplace environment. Gender differences may also affect the way individuals react in stressful situations. Males are typically more assertive, task oriented, and domineering, and under pressure tend to dig in. Woman are more socially oriented and under pressure will look for consensus opinions to support their points. Ethnic, cultural, and religious beliefs may present with different views on spirituality, hierarchy, power, and communication styles that can lead to misunderstandings that can be accentuated in stressful situations. All of these factors combined with genetics, geographic mannerisms, and other life experiences help to shape an individual’s personality.

These internal factors have a deep seated impact on a person’s character and disposition and may be more difficult to address than some of the external factors to be discussed in the next section. Strategies for improvement should focus on introducing a variety of different training programs designed to enhance personality and relationship management. These programs might include such topics as sensitivity training, diversity management, cultural competency, mindfulness, generational gap values, personality traits, conflict management, stress management, anger management, sexual harassment training, customer satisfaction, and improving overall communication and collaboration skills. In a recent article in this Journal I highlighted the value of providing special training in the area of Emotional Intelligence.² Each of these programs have value, but success will depend on the specific situation, underlying organizational dynamics, culture, and leadership commitment.

The external factors include current day circumstances that influence present state perceptions. For physicians one of the key factors is the training environment. Some equate this with a fraternity/ sorority hazing type environment where individuals are harassed to the point of losing self- esteem. In response the trainees try to develop knowledge and technical competencies through exhaustive independent study. As a consequence there is no focus on developing personal skills or team collaboration mechanics which leads to a lower degree of sensitivity and emotional intelligence which is a definite liability in today’s complex multi-spectrum health care environment. The problem is further exacerbated by the traditional hierarchal health care system with dedicated roles and responsibilities and set boundaries between the different health care disciplines. Health Care Reform has added another level of disturbance. Where physicians used to pride themselves on their ability to provide best practice care with autonomy and control, the introduction of new care restrictions, utilization controls, changing incentives, and performance accountability metrics based on a series of “questionable” variables has forced many physicians to reassess their positions and change models of care. The end result is the growing amount of stress and burnout in physicians and its impact on willingness to continue to practice medicine.

There are movements in place to try and deal with these external hazards. At the training level, medical schools are now looking for more “well- rounded” students who are majoring in something other than the traditional math and science tracks. The MCAT (Medical College Admission Test) now includes questions on sociology and humanities. Some of the more progressive medical schools are adding training programs that focus on building personal and team collaboration skills that start in the freshman year. The overall goal is to build personal relationships and develop team competencies along with clinical expertise. In regard to Health Care Reform, while it’s unlikely that we’ll be able to change the system, but providing education about why this is occurring, what the projected impact will be, and providing support to help physicians become more compliant in meeting the objectives will help then better adjust to the situation. Dealing with stress and burnout has the greatest potential for success.

Recent studies have shown that more than 50% of physicians report a significant amount of stress and burnout that has led to increasing irritability, cynicism, apathy, fatigue, dissatisfaction, and in some cases more serious depression, behavioral disorders, and even suicidal ideation.³ As a result many physicians have either changed practice settings, joined different groups, or moved into salaried positions. Others have either left the profession entirely or chose early retirement. Not a good situation particularly with the looming physician shortage.

So how do we deal with stress and burnout? The first problem is physician awareness. Many physicians are unware that they are working under stress and the physical and emotional toll it’s taking on their livelihood. If they do admit that they are under stress, they accept it as being part of the job and rationalize that they have been working under stress all their lives. Even if they think they may need some outside help they are reluctant to ask in fear of concerns about their competency, confidentiality, or a blow to their ego. These are significant barriers that need to be addressed before moving forward. If physicians are reluctant to admit or receive assistance, we need to look for the organizations that they are associated with to take a more pro-active stance in trying to provide support.

Table 2 presents a list of recommended steps to help physicians better adjust to the pressures of today’s health care environment.

1. Recognition/ motivation/ priority:

-Addressing barriers 

2. Organizational Culture/ Work environment:

-Leadership commitment/ structure and process/ champions
-Mutual alignment around goals and objectives
-Champions

3. Education:

-Awareness/ Responsibility/ Accountability

4. Relationship training:

-Diversity/ Sensitivity/ Stress/ Conflict management
-Emotional Intelligence/ Mindfulness/ Customer satisfaction

5. Communication skills/ Team Collaboration training
6. Behavioral policies and procedures/ Reporting
7. Intervention:

-Tiered approach: Informal/ Formal/ Disciplinary

8. Staff support:

-Administrative/ Clinical/ Behavioral (EAP/ Wellness Committees/ Coaching/ Counseling)

9. Physician Well- Being:

-Awareness/ Reflection/ Self- care/ Relaxation/ Limitations/Commitment

10. Physician engagement:

-Input/ empathy/ responsiveness/ alignment/ recognition/respect

Table 2 Recommendations.

The first step is that we all need to recognize how serious an issue this is and then provide motivation for action. The key motivation factor should focus on the priority of delivering best practice care as a core physician value. There are a number of published articles attesting to the consequences of physician distress and dissatisfaction leading to compromises in patient safety.^4,5 In today’s complex multidimensional healthcare environment, freeing individuals up from frustrations and other distractions will improve communication, collaboration, and task achievement and reduce the likelihood an unwanted downstream negative event. Be sensitive to the barriers that impede physician action by making it convenient, assuring confidentiality, and focusing on we’re help to help you succeed.

The next step has to do with the image and support of the underlying organizational leadership and culture.⁶ Having a strong supportive and empathic culture goes a long way in creating a positive work environment. Having a respected internal champion to help drive the process will help improve the likelihood of success.

The next step is to educate physicians about the changing world of health care economics and business imperatives. As discussed previously, providing training programs designed to improve relationship management by improving self-awareness, enhancing communication skills, and reducing conflict will improve both satisfaction and clinical outcome improvement for all parties involved.

In cases where disruptive behaviors or other types of unprofessional behaviors occur it is important to have a consistent process for event reporting, incident review, and appropriate follow up intervention conducted by individuals skilled in facilitation and conflict mediation.^7,8

The next step is for the organization to provide pro- active support. Remember, we can’t leave it up to the physicians to take action on their own. Support can come from a number of different directions. First is to provide the necessary logistical and administrative support to make work- life balance a little easier to achieve. Be more empathetic as to scheduling, capacity demands, productivity requirements, and other non- clinical responsibilities being imposed on physicians. Provide clerical assistance to help reduce time spent on non-clinical tasks. For issues related to the EMR (Electronic Medical Record) provide additional training or utilize scribes to help with data input. From the clinical side provide support by utilizing and expanding the roles of Medical Assistants, Nurses, Care Managers, Physician Assistants, and/ or Nurse Practitioners to help free up time for the physicians to deal with more complex medical issues. From a behavioral perspective we already addressed the value of group training programs designed to improve care relationships, communication efficiency, stress management, anger management, and conflict management, but for some physicians, one on one individualized attention may be may in order. These programs can be offered through Physician EAPs (Employee Assistance Programs), through Wellness Committees, coaching, or counseling services. More deep seated issues may have to be dealt with through specialized behavioral modification programs.

One of the key steps is to focus on physician well- being. There is a growing momentum to extend the Triple Aim (enhancing the patient experience, improving population health, reducing costs) to the Quadruple Aim to include a focus on improving the work- life of health care providers.⁹ Recent articles have stressed the importance of recognizing the signs and symptoms of stress and burnout and the consequences of its physical and emotional impact on physician well- being.¹⁰ Encouraging physicians to take the time to reflect and self- assess the status of their lives is the first step to opening the door for guidance. Programs that reinforce the concept of mindfulness have been particularly beneficial in this regard.¹¹ Physicians need to understand the importance of adequate sleep, good nutrition, regular exercise, and time for relaxation. They need to be able to set limits and they need to be able to commit to compliance. It’s extremely helpful when the organizations promote these efforts through on-site wellness activities and on-line educational support resources.

The final step is that of enhancing physician engagement.¹² The primary concern with physician engagement is to give them a voice. Rather than just unidirectionally telling them what they need to do, give them an opportunity to be heard. This can occur through Town Hall meetings, Department meetings, special committees or task forces, or through one on one meetings. Listen to what they have to say and respond to their concerns. Show empathy and provide a rationale for why things are the way they are and how we can address the situation working together in a collaborative manner. Appeal to their core instincts by aligning goals around best practice care. Show respect, reinforce their purpose, give them motivation, recognize their efforts, and thank them for what they do. There is a dramatic linkage between input and involvement, engagement, well- being, improved relationships, career satisfaction, and best patient care.¹³

Physicians are a precious resource who are just trying to survive in today’s complex health care environment. There are a number of deep seated internal and external factors influencing physician values, perceptions, attitudes, and behaviors toward patient care. Over the past several years these factors have contributed to increasing levels of stress and burnout which can adversely impact both physical and emotional states that can negatively affect work relationships and patient care. We need to do something about this. Many physicians don’t recognize the problem and/ or are reluctant to take action on their own. We need the organizations which they are affiliated with to provide pro-active support. By providing appropriate administrative, clinical, and behavioral support the goal is to enable physicians to better understand and adjust to the pressures of today’s health care environment, improve their satisfaction and well- being, and improve their motivation and engagement to enhance relationships that foster best practice care. We need to re-energize their passion for becoming a doctor.

None.

Author declares there are no conflicts of interest.

None.

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