Chandrakanth Are, MBBS, MBA, FRCS, FACS
Physician wellness is emblazoned upfront in the news with attention-seeking headlines on a daily basis. The fact that one or two physicians commit suicide every day in this country sometimes elicits more of a sympathetic acknowledgment than a committed call to address it. Moreover, these sobering statistics are often met with incisive academic minds intent on tackling the problem with data and research rather than a humanitarian response seeking to prevent it in the first place with common sense, pragmatism, and compassionate solutions.
We tell physicians we are committed to their wellness, but we make few systematic attempts to address the climate that foments it. At times, we
The amount of change has created an environment of cacophonic dissonance that brutally pierces all the sensory domains of a physician’s working environment.— Chandrakanth Are, MBBS, MBA, FRCS, FACS
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suggest to physicians that wellness lies in the eyes of the beholder. We tell them what we think wellness should be, with minimal tolerance for differences in opinions. Or we have intense intellectual discussions about the definition of wellness, in the hope that the convergence of various definitions will somehow address the issues at hand. When it comes to our trainees—the future of our bright profession—we may point the proverbial finger at millennials and blame them for their own ills.
Research and Preaching
An immense amount of effort is being invested, both nationally and locally, to improve wellness for physicians. We conduct high-quality, extensive, and expensive research on quantifying the burden, with repeated surveys that tend to state the obvious. We are often effective surveyors rather than attentive saviors. We undertake qualitative research to determine which of the multitude of approaches will help tackle the issues surrounding physician wellness. Short of mandating it, we nudge physicians to see counselors, even when some consider it a stigma or would likely not benefit from it. We have witnessed a burgeoning of wellness experts, speakers, and bureaus in a rapidly growing wellness industry.
At a more individual level, we educate physicians on how to reach the Utopian world of wellness. With competing levels for the most effective approach, we extoll the virtues of yoga, cycling to work, eating well, sleeping well, focusing on mindfulness, meditating, tackling work-life balance, and building support systems. We preach to them that wellness can happen if you build resilience, become more efficient at work, and somehow become a better clinician. We sermonize about the enormous benefits of electronic medical records to make their lives purportedly easier. Approaches ranging from biofeedback therapy and group sessions to out-of-work wellness sessions during their time off are sprinkled in to complete the picture. We have created campus-based programs specific to the promotion of well-being, equipped with tools and programs emanating from sophisticated research. Educational programs on wellness are rolled out on a regular basis, with clear goals, metrics, and objectives.
Although these efforts are needed and beneficial to some degree, what is needed more is a systematic review of our working climate. We need to address the negative factors.
Spiraling Vortex of Changes
At the broadest level, our health-care environment over the past few years has been a spiraling vortex of complex changes beyond anyone’s comprehension. This has created many changes, some seminal and generational and some not so. Some of these efforts may benefit patients, but what happens to them in the future remains to be seen. What is more discombobulating is the pace, magnitude, and more importantly, the unpredictable fluidity of the changes.
For a time, we were steering our entire health-care ship toward meaningful use, but before long, our community was notified that clinicians would no longer participate in the Medicare Eligible Professionals Meaningful Use program.1 Changes to the 340B drug program have impacted hospitals’ bottom lines, leading many institutions to make changes.2 Compression of the Evaluation and Management codes was about to add another layer of major change, but thankfully that has been postponed for now. Hospitals are closing down or consolidating at a pace not seen before. Mergers and acquisitions in health care are different from how they are conducted in other industries.
This vacillating environment of unpredictable changes with no fixed goal posts has affected physician wellness significantly.— Chandrakanth Are, MBBS, MBA, FRCS, FACS
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The amount of change has created an environment of cacophonic dissonance that brutally pierces all the sensory domains of a physician’s working environment. We probably need more physician leadership at the highest levels of health care to remind elected officials that their actions can have multiplying downstream negative effects on the physician’s working day. This vacillating environment of unpredictable changes with no fixed goal posts has affected physician wellness significantly.
All these changes have created a workplace environment that at times can feel like a massive tempest in a teapot. These changes have unleashed an avalanche of administrative tasks and obligations unrelated to patient care. The primary source of joy for most physicians is to interact with patients, and if not that, to immerse themselves in the pursuit of furthering their professional growth. If administrative obligations preclude those activities, we should not be surprised with the current prevailing mood of physicians.
Additional Administrative Tasks
We need to stop adding administrative tasks to the physician’s working day. It is not uncommon for us to sit on committees where decisions are made about what a resident or physician should be doing. It is also not uncommon for people in those rooms to lack in-depth knowledge of what the working day of a physician entails. Few health-care employees outside the physician world are aware that most of us work 60 to 80 hours a week at a minimum. As a result, many tasks are added with the comment, “This should take only 2 minutes for the physician to do.”
Although 2 minutes may sound trivial, a back-of-the-napkin calculation illustrates the exact opposite. On our campus, we have approximately 550 house officers. Few tasks that the residents or physicians perform are not repetitive. A “2-minute task” can conservatively be assumed to be repeated at least twice a day. Making 550 house officers undertake a new task of only “2 minutes” in duration twice a day results in astonishing numbers. On an annual basis, this translates to 803,000 minutes, 13, 383 hours, 557 days, or 79 weeks of lost work—just by adding a new “2-minute” task. This is time taken away from patient care, education, or personal activities, all of which has a detrimental influence on wellness.
For a long time, having autonomy in practice was one of the most cherished aspects of being a physician. The ability to see a patient, make a diagnosis, and build a relationship at a time, pace, and place of convenience was one of the most enjoyable parts of our profession. With the number of employed physicians surpassing self-employed physicians, as well as other changes, there has been a gradual draining of autonomy in our profession. Many physicians now work in environments where they have minimal control other than at the end-user level. The inability to have an influence on workday dynamics creates a reluctantly despondent feeling: I just come to work to get my job done and go home.
Culpability and Other Stressors
Physicians also occupy an enviably culpable (or, rather, culpably enviable) position in the health-care delivery chain. Although we have always worked in teams, recent changes have blurred some lines relating to domains of responsibility, authority, and culpability. It seems that faults relating to health care land at the doorstep of a physician’s office, although he or she has less and less control over how to change that. Physicians have the responsibility and culpability but little authority to address or influence any of the problems associated with the health-care landscape in the country.
If we keep adding requirements or tasks without deleting redundant or outdated duties, the time will have to be borrowed from somewhere. This is when time is taken away from personal activities, and not surprisingly, wellness suffers.— Chandrakanth Are, MBBS, MBA, FRCS, FACS
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We need to be more sensitive to defining stressors in our workplace environment. Some have suggested that we should no longer use the phrase “work-life balance.” The word “balance” suggests that for us to add something, we do need to remove something. It has been suggested that we instead use the phrase “work-life integration,” which may be more reflective of how we need to work.
That can be brushed off as semantics, but the consequences of that line of thinking are not trivial. Whether we call it “balance” or “integration,” there are only 24 hours in a day, and we cannot afford to lose track of that number. If we keep adding requirements or tasks without deleting redundant or outdated duties, the time will have to be borrowed from somewhere. This is when time is taken away from personal activities, and, not surprisingly, wellness suffers.
The Next Generation
All these effects are magnified for our residents and fellows. As faculty, we at least have some control of our time. In contrast, house officers have minimal, if any, control of their time. In addition, they are living under the constant shadow of the “millennial tree.”
We probably have one of the best graduate medical education environments in the world. That does not mean that we cannot improve it. In particular, changes need to be made to fit in with the changing health-care environment, and changes need to be suited to the current generation. Harking back to how we trained in days gone by is certainly not going to make the working environment any better for our current physician trainees. We need to take stock of current factors and modify the climate for our trainees based on what is applicable for today.
More often than not, the commonsense solutions to many of our problems with wellness tend to be simple and less expensive.— Chandrakanth Are, MBBS, MBA, FRCS, FACS
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For example, wellness happens when a young and accomplished female resident can come to her program director with utter joy, and not with nervous trepidation, to share the news that she is going to be a mother. Most of our house officers are in the prime of their youth. Our environment should support not only professional development but also personal growth. Asking them to hold their personal growth ransom to their professional growth can affect their wellness. All of this can be accomplished, I am sure, without compromising our mission—to train them to be the best physicians they can be.
It would be remiss on our part not to acknowledge that these issues are profession-agnostic and are affecting other professions in health care as well. There may be synergies that can be built by combining our strategies. That said, unique strategies are needed for the unique training and working environment of physicians.
As we continue on this wellness journey, it is evident that numerous issues need to be addressed at the federal, state, and institutional levels. Although federal and state factors may be to a large degree out of our hands, we can at least make small strides at the institutional level. Some of the simple maxims that can help to address the climate in which physicians train and work include:
More often than not, the commonsense solutions to many of our problems with wellness tend to be simple and less expensive. They also tend to be well within our reach. Let us reach for them if we want to save another physician from claiming his or her precious life for entirely avoidable reasons.
Dr. Are is the Jerald L & Carolynn J. Varner Professor of Surgical Oncology & Global Health; Associate Dean for Graduate Medical Education (DIO); and Vice Chair of Education Department of Surgery, University of Nebraska Medical Center, Omaha.
Disclaimer: This commentary represents the views of the author and may not necessarily reflect the views of ASCO or The ASCO Post.
DISCLOSURE: Dr. Are reported no conflicts of interest.
1. Office of the National Coordinator for Health Information Technology: Meaningful use and MACRA. Available at www.healthit.gov/topic/meaningful-use-and-macra/meaningful-use-and-macra. Accessed December 18, 2018.
2. Health Resources & Services Administration: 340B drug pricing program. Available at www.hrsa.gov/opa/index.html. Accessed December 18, 2018.