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Back to Table of Contents | January 2011

Commentary

Eight Suggestions for Promoting Physician Well-Being

Ways to make medicine more satisfying for doctors and better for their health.

By Bill Manahan, M.D.

Regular exercise, a healthy diet, not using addictive substances, and having less stress in our lives are essential components of wellness, whether for physicians or patients. But as I practiced medicine over the years, I realized that the system and culture in which we live and work also significantly affects our health and well-being. When I felt I was doing what I was called to do and was able to work in a way that felt congruent with who I am, I had energy and a sense of accomplishment. I felt good and, therefore, found it easier to take care of myself and stay healthy. When my practice felt out of control, my habits and health slid.

Around year 10 of my career, I noticed that I had gained 12 pounds. I felt tired by mid-afternoon and was having heartburn and indigestion. Caring for patients had started to feel more like a business than a calling. I was irritable and felt that I, rather than my patients, was in charge of their health. I sometimes ordered tests out of fear rather than because of good sense and good science. Even though I was exercising regularly, eating well, and practicing meditation, I felt as if I were falling apart. It was then I began to realize that the culture of medicine was affecting my health.

I had once run my own primary care practice. I spent as much time with a patient as I needed, sometimes wrote off the bills of those who were having financial troubles, and felt a sense of unity with the people who worked in my office. It was like we were a family. Our patients felt recognized and honored for who they were, and I felt good at the end of the day. But things changed when I became part of a larger medical group. At first, I was delighted with not having to deal with the administrative concerns of running a clinic. However, after a year or so, I missed not being in charge. My nurse and the person at the front desk were hired by the business manager, not me. I was told I could no longer write “no charge” on the bill of a long-time patient who was struggling because the clinic had a department to work with people who couldn’t pay. I had to attend meetings where decisions were made based on what was best for the business rather than what was best for the patients. My income rose nearly 25 percent during that period; but practicing medicine this way turned out not to be good for my body and soul.

Since then, I’ve realized that certain things in the culture of medicine harm physicians. And I’ve come to believe that unless we make some changes, neither physicians nor patients will thrive. Here are eight suggestions for improving medical practice.

1. We need to view medicine as a calling as well as a business.

Prior to the 1960s, medicine, nursing, and other health care professions were primarily thought of as callings. Most practitioners felt it was an honor and a privilege to serve people in such an intimate way. Many would even go so far as to say that there was something sacred about being a doctor, nurse, or other health care provider. 

During the 1970s and 1980s, larger clinics and hospitals began buying up practices and followed the lead of many other U.S. corporations and made the maximizing of profits a high priority. Managed care and HMOs came on the scene. And doctors became employees—“providers” who served “clients.” Medicine was becoming a business rather than a calling.

As a group, physicians blamed managed care for this shift. I believe we could have said “no” to a lot of these changes, but we didn’t. Although we may never go back to the way things were, we again need to start viewing medical practice as a sacred calling. That must be balanced with a sensible approach to profit, so that physicians feel less pressure to “produce.” I hope and pray that the federal health care reform act starts us down this road.

2. We need to become more collaborative and less competitive in our approach to the delivery of health care.

Competitiveness is reflected in all realms of our society, including health care. We ask “What’s in it for me?” not “What’s good for all of us?” I believe that in health care we need to move away from this dominator approach and become more collaborative. A majority of the people who go into medicine are inclined to be heart-centered rather than head-centered; that is, they want to relate to, rather than rule over, others; but the existing culture of practice demands otherwise. Consequently, for some physicians, going into practice is like entering into a marriage and finding out that your partner and you think quite differently about most things. It is difficult to feel a sense of well-being in that kind of a relationship.

To change that, physicians, health care organizations, insurance and pharmaceutical companies, and patients need to sit down together and figure out a model for care delivery that works for everyone—one where health care is accessible to patients without driving up costs. We need to discuss what we can do to make careers in primary care—the lifeblood of medicine—more appealing to medical students who might be tempted by the high salaries of some subspecialties. I think Michael Moore said it best in the movie Sicko when he asked: “Are we a nation of me, or a nation of we?” We need to become better collaborators in order to make health care better for all of us.

3. We need to emphasize both the art and science of medicine.

Since Copernicus proved in the 16th century that the earth was not the center of the universe, the western world has recognized science as the major paradigm. Unfortunately, I believe we have shifted too far toward a material and mechanistic world view. Almost left out of the equation for our understanding of how things work, including the human body, are consciousness, mindfulness, and spirituality. Just as it is important for us to find a balance between viewing medicine as a calling and a business, we also need to find a balance between understanding medicine as an art and a science.

We need science, of course. We need to know that after a heart attack there are certain medications to take. If a patient has abdominal pain in the right lower quadrant, the evidence will say he needs surgery. But when it comes to treating chronic and recurrent conditions, there frequently is not a good evidence base, and we often need to rely on our instincts. We talk so much about evidence-based medicine that we sometimes forget that the majority of what we do is still an art.

4. We need to shift our focus from the health of the individual to the health of the community.

Public health initiatives related to clean water, sewage disposal, environmental safety, and food processing have accounted for the majority of improvements in Americans’ health and longevity over the years. But during the 1940s, when antibiotics were discovered and many other surgical and pharmaceutical developments occurred, we shifted our priorities. We put our resources and energy into preserving the health of the individual rather than the health of the community.

We need to change our way of thinking about what has the most impact on health. A number of studies show that 50 percent of what influences our health is our behavior and lifestyle, 20 percent our environment, and 20 percent our human biology (genetics). Only 10 percent is driven by medical care. What this means is that as a physician, my chance of making a significant difference in a single person’s life is about one in 10. It’s frustrating to see patient after patient who is overweight and at risk of one day developing high blood pressure, high cholesterol, and type 2 diabetes. If we put more resources into prevention and public health, it would lessen the pressure on physicians to constantly be encouraging individuals to make lifestyle changes that they may not be ready to make.

5. We need to set realistic expectations about what medicine can do for patients.

As new medications and surgical procedures were discovered, people began to have unrealistic expectations about what medicine could do for them. Medicine can indeed cure many illnesses that have a clear cause. It is not nearly as successful for long-term and chronic diseases, however. Yet since pharmaceutical companies began advertising directly to the public in 1995, patients’ expectations for medicine have increased dramatically. People see ads and think all they have to do is take a pill in order to solve their health problems.

But is this realistic? And is it really the best way to get a chronic condition under control? When a 45-year-old patient would come in with high blood pressure, I’d get excited. I knew there was a good chance the condition had been brought on by lifestyle. I’d tell him that if we worked together, we could likely get his blood pressure back to normal without medications. I’d tell him there was certainly a chance the strategy might not work, and then I would ask, Wouldn’t you rather try changing your life than taking medication every day for the rest of your life? Many people would say, Yes, let’s give it a try.

6. We need to stop doing the wrong things for patients.

In his 2008 book Worried Sick, Nortin Hadler, M.D., describes what he calls Type II medical malpractice. Type I malpractice is when we do the right thing the wrong way. Type II is when we do the wrong thing the right way. Hadler says physicians increasingly are performing inappropriate procedures and ordering tests and treatments that are not evidence-based. He lists as examples some coronary artery bypass grafts, arthroscopy for arthritic knee pain, some back surgeries, long-term hormone replacement therapy, using drugs for decreased bone density as a first-line therapy, routine prostate-specific antigen screening, and some cancer treatments, all of which may do more harm than good no matter how skillfully they are handled. Hadler’s conclusion is that more than half of medical care provided in the United States could be considered type II malpractice.

Type II malpractice has a number of causes. Practicing defensive medicine is one of them, but this accounts for only a small percentage of the tests that are ordered. The primary cause is the way we’re trained. As medical students and residents, we are taught to look for zebras. We don’t want to miss anything. When someone comes in complaining of headaches, rather than asking about stress, whether they’re getting enough sleep, or whether they’ve had a neck injury or muscle tension, the doctor thinks about brain tumors. We are trained to not miss serious and significant disease, which is good. Unfortunately, that leads us down a path that sometimes makes it quite difficult to actually figure out what is causing the patient’s problem. We are trained in and practice disease care, which is necessary, but that pushes us away from figuring out the actual causes of many of our patients’ problems.

Type II malpractice happens when we look for zebras and there are deer all over the place. Our training encourages us to be perfectionistic. But by attempting to be perfect, we can miss simple causes of patients’ problems. We need to change how we train primary care physicians so that they don’t overlook the obvious.

7. We need to learn to accept illness and death as a normal part of life.

Until the early 20th century, it was not uncommon for a couple with eight children to see four of them die before reaching adulthood. Nor was it uncommon for adults to die before reaching their 50th birthday. As advances in public health and medicine allowed people in the United States to live longer, we changed from having a fatalistic acceptance of illness and death to having an almost hysterical fear of illness and death. Some people believe that this paradigm shift may be the single biggest problem with our health care system.

The stress and anxiety people feel about becoming ill can lead them to seek excessive testing and treatment, sometimes worsening the illness itself. Often physicians, being healers, continue to treat patients even though there may be no hope of recovery. The fatalism of our forefathers regarding illness and death is, of course, no longer appropriate; but neither is our current morbid fear of illness and death. As physicians, we’re trained to always do as much as we can to save a patient. And if we can’t save them, we sometimes feel as if we have failed. We need to learn how to have conversations about death and the end of life so patients can have a say in how they want to spend their final days and physicians can feel good about the care they’re providing during that time. That is beginning to happen as society accepts palliative care.

8. We need to understand and accept that many diseases have multiple causes.

Approximately 70 percent to 80 percent of health care spending in the United States is related to chronic disease. Every chronic disease is caused by a long list of contributing factors; yet the medical system is designed for patients with single-factor illnesses (eg, trauma, broken bones, emergency medical problems, and many infections). Physicians are often unsure how to handle patients with chronic illnesses. Add to this the frustration of attempting to take care of those patients in 15-minute office visits and it is understandable why many physicians become discouraged and stressed.

We can do things to change this. Group Health in Seattle, for example, now has group sessions for patients with diabetes. Physicians meet with patients individually, then those patients get together as a group with a nurse or diabetes educator to go over information they’ve learned, share strategies for managing their condition, and provide support to each other. Studies have shown that patients who take part in group sessions are more likely to stick with their treatment plan and have fewer hospitalizations and emergency department visits than those who do not. And they love being part of the group. We need to set up our payment system so we can do more of this type of thing.

In dealing with my own frustration, I realized that I could not wait for all of these changes to occur, so I made some that enabled me to continue to work within a system that was not always conducive to my health and well-being. My wife and I took a sabbatical and did work in another country. I stopped doing obstetrics because of the stress of being on call at all times for deliveries. I began to schedule more time for patient visits, even though it meant my salary would decrease. I began to work a four-day week in the office. And I tried not to force patients to make changes they were not ready to make.

I gradually lost the weight I had gained, my mid- afternoon tiredness disappeared, and my heartburn and indigestion vanished. As my work life became more congruent with what I needed as a person, my physical and mental health gradually improved.

It is important that physicians embrace a plan for their own wellness that is more expansive and comprehensive than just exercising and eating right. We need to reshape how we see our profession and how we understand our role. And we need to help patients understand the role we play as well. I’ve identified eight suggestions for changes in how we practice medicine that could help us be healthier and happier physicians. I believe that physicians have the power to make these changes happen. The question we need to ask ourselves is, Do we have the will and the courage to do so? MM

Bill Manahan is assistant professor emeritus of family medicine and community health at the University of Minnesota.

A version of this article was first published in Integrator Blog News and Reports.

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