August 2007 | Back to Table of Contents
Clinical and Health Affairs
Physician Well-being and Professionalism
By Colin P. West, M.D., Ph.D., and Tait D. Shanafelt, M.D.
Abstract
Physician professionalism is influenced by both environmental and personal factors, one of which is physician well-being. Yet, a variety of stressors inherent in medical training and practice can erode a physician’s sense of well-being and contribute to distress. This article reviews the epidemiology of physician distress; describes what is known about the relationships between distress, well-being, and professionalism; and discusses personal and environmental factors that contribute to professionalism among physicians.
J.S. began his medical training after demonstrating a strong work ethic, a sense of integrity and altruism, and academic excellence in college. During medical school, he willingly sacrificed some of his outside interests such as competitive tennis and playing the violin in order to succeed. During his residency and fellowship, his drive to succeed allowed him to develop into a knowledgeable, highly trained specialist. However, he found that his workload left him unable to pursue the things he once enjoyed. Now, after 4 years in a busy medical practice, he finds himself wondering if he made the right choices. His wife tells him he seems irritable much of the time. He sees his young daughter less often than he would like, but he is too tired to be more engaged with his family. Furthermore, he has become less excited about caring for patients, the one aspect of his work that he used to find most meaningful. Patients who previously sent letters of praise are now beginning to question whether he is devoting enough attention to their care. His colleagues have seen a change in his behavior and have occasionally noticed inattention to some aspects of patient care. J.S. senses his wife and colleagues’ concerns but does not know how to respond to them. He would like to renew the passion he once had for his work, but he does not know where to look for help. He has begun to wonder whether he should leave medicine to pursue a different career.
Professionalism is one of the fundamental competencies associated with being a physician. It encompasses the core principles of social justice, patient autonomy, and primacy of human welfare, and requires a commitment to competence, integrity, and humanistic care. Although much has been written about the characteristics of a professional, the factors contributing to the development and maintenance of professionalism are less well-defined. Organizational and personal factors influence professionalism, and physician well-being is one factor that is essential for professionalism to flourish. In this article, we review what is known about the relationship between physician well-being and professionalism and suggest ideas for future research on this relationship.
Epidemiology of Physician Distress
Stress is a normal part of medical training and practice. In limited amounts it may enhance necessary skills. For example, exposure to high-stress environments during training might improve future performance in emergency situations that require a doctor to make immediate decisions. Such exposure might teach physicians to prioritize tasks and manage multiple issues simultaneously. However, excessive stress may impair performance.
It is increasingly evident that many trainees and clinicians suffer from unhealthy levels of distress, defined as physical, mental, or emotional suffering. A recent systematic review found increased levels of depression, anxiety, and impaired mental health among medical students relative to the general population.1 Similarly, studies of residents in multiple specialties have uncovered epidemic rates of distress. For example, depression is common among residents, with rates possibly exceeding 30%.2-4 Burnout—a syndrome of emotional exhaustion, depersonalization, and a sense of lacking personal accomplishment that leads to decreased effectiveness at work—is also common among residents across specialties. Studies of residents have shown prevalence rates for burnout to be above 50%.3-7 Such problems may persist and even worsen when physicians enter practice. Burnout rates of more than 60% have been reported among physicians in private practice.8 High rates of burnout also have been reported among academic department chairs and deans of colleges of medicine.9,10 Depression also remains prevalent among practicing physicians, and the suicide rate among physicians may be up to 6 times that of the general population.11
The causes of physician distress are numerous, and loss of control over the practice environment is frequently cited as a contributing factor.8,12 Other factors include a physician’s workload, specialty choice, and experience with suffering, death, and medical errors.4,8,13 In addition, interpersonal relationships in the workplace can contribute to distress. For example, a majority of medical students and residents report being mistreated by peers, educators, and patients. This erodes humanistic attitudes and leads to the development of anger, cynicism, and depression.14-16 Personal factors such as debt, poor self-care, and maladaptive coping strategies (eg, substance abuse) and stressful life events such as divorce may also lead to distress.8,13 The potential for tension between personal and professional goals and responsibilities also appears to play a fundamental role in the erosion of physician well-being.8,12
Relationships between Distress, Well-being, and Professionalism
The effect of distress on professionalism in medicine has become clear in recent years. The well-documented decline of crucial elements of professionalism, including empathy and humanism, during medical training appears to be related in part to personal distress experienced during medical school and residency.5,17,18 Unfortunately, this decline continues as physicians move into practice, where distress also is associated with decreased compassion and empathy.19,20
Among both trainees and practicing physicians, burnout and stress also have been shown to contribute to suboptimal patient care practices ranging from minor mistakes to potentially serious medical errors.4,19,21 Other practices related to distress include premature discharges, incomplete or rushed patient communication, and irritability with patients.4,5,19,20 As noted previously, some physicians develop depression or resort to maladaptive behaviors such as substance abuse that can further erode professionalism and result in poor patient care.4,19
On the other hand, it has been proposed that personal well-being may actually enhance aspects of professionalism such as empathy, compassion, and quality of care. These ideas are supported by a limited-but-emerging body of research using validated survey tools to show that increased well-being may promote professional attributes such as empathy and the ability to provide compassionate care.17,18 Concepts of mindfulness, self-awareness, and positive psychology have been suggested as being important to promoting well-being, but little is known about the quantitative impact they may have on well-being or professionalism.22-24
The link between distress and well-being is further clarified by theories on optimal human functioning suggesting that burnout, depression, and anxiety represent only one end of a quality-of-life continuum (Figure 1). At the positive end of this continuum, well-being requires more than the absence of distress; it also involves satisfaction across multiple domains of life such as family, community, spirituality, and health, and experiences that stimulate personal and professional growth.25 Efforts to promote professionalism, therefore, not only must reduce distress but also promote well-being.
Factors Contributing to Physician Well-being and Professionalism
These relationships have led us to develop a broader list of factors that contribute to physician well-being and professionalism (Figure 2). Initiatives to promote professionalism will need to address the interactions among these factors to be effective.
Reported approaches to fostering professionalism among physicians include formal coursework in ethics and humanism, development of role models, required community service activities, and personal and shared reflection.26-28 Organizational reforms that promote a true culture of caring and institutional policies consistent with this goal are also necessary. For example, policies that promote work-life balance and restore physician autonomy within the practice environment are important to maintaining physician well-being.8 Further research on effective methods for promoting well-being and professionalism is necessary, including outcomes studies evaluating the effect of these strategies.
To further this goal, the Mayo Clinic Department of Medicine initiated its Program on Physician Well-being in July of 2007 to complement its existing Program in Professionalism. The goals of these programs include the development and testing of evidence-based interventions that promote both well-being and professionalism. These concepts are interrelated, and we believe each is integral to our ability as physicians to provide outstanding patient care. The Mayo Program on Physician Well-being will evaluate the full spectrum of personal, professional, and organizational elements that influence physician well-being, satisfaction, and productivity to identify factors that can be modified for the benefit of physicians and patients. Examples might include modifying physicians’ daily work schedules, providing curricula on well-being and professionalism, and offering training on awareness of distress and well-being. Other potential domains of study are suggested in Figure 2. We believe the lessons learned from these efforts may stimulate a revival of physician well-being and professionalism.
Conclusion
Physician well-being is the foundation of professionalism. It is the responsibility of both individuals and institutions to maintain and enhance staff well-being and, in so doing, support professionalism and promote optimal patient care. It is worth noting that the Joint Commission on Accreditation of Healthcare Organizations requires hospitals to have processes in place to promote physician wellness. Additional research is needed to determine the most effective approaches to promote physician well-being.29 Every physician and health care organization has a vested interest in better understanding the relationship between physician well-being and professionalism. Through these efforts, medicine’s time-honored traditions of professional excellence, service, and trust may be maintained. MM
Colin West is an assistant professor of medicine at Mayo Clinic College of Medicine and co-director of the Mayo Program on Physician Well-being. Tait Shanafelt is an assistant professor of medicine at Mayo Clinic College of Medicine and director of the Mayo Program on Physician Well-being.
References
1. Dyrbye LN, Thomas MR, Shanafelt TD. Systematic review of depression, anxiety, and other indicators of psychological distress among U.S. and Canadian medical students. Acad Med. 2006;81(1):354-73.
2. Hsu K, Marshall V. Prevalence of depression and distress in a large sample of Canadian residents, interns, and fellows. Am J Psychiatry. 1987;144(12):1561-6.
3. Rosen IM, Gimotty PA, Shea JA, Bellini LM. Evolution of sleep quantity, sleep deprivation, mood disturbances, empathy, and burnout among interns. Acad Med. 2006;81(1):82-5.
4. West CP, Huschka MM, Novotny PJ, Sloan JA, Kolars JC, Habermann TM, Shanafelt TD. Association of perceived medical errors with resident distress and empathy: a prospective longitudinal study. JAMA. 2006;296(9):1071-8.
5. Shanafelt TD, Bradley KA, Wipf JE, Back AL. Burnout and self-reported patient care in an internal medicine residency program. Ann Intern Med. 2002;136(5):
358-67.
6. Thomas NK. Resident burnout. JAMA. 2004;292(23):2880-9.
7. Goitein L, Shanafelt TD, Wipf JE, Slatore CG, Back AL. The effects of work-hour limitations on resident well-being, patient care, and education in an internal medicine residency program. Arch Intern Med. 2005;165(22):2601-6.
8. Shanafelt TD, Sloan JA, Habermann TM. The well-being of physicians. Am J Med. 2003;114(6):513-9.
9. Gabbe SG, Melville J, Mandel L, Walker E. Burnout in chairs of obstetrics and gynecology: diagnosis, treatment, and prevention. Am J Obstet Gynecol. 2002;186(4):601-12.
10. Mirvis DM, Graney MJ, Ingram L, Tang J, Kilpatrick AO. Burnout and psychological stress among deans of colleges of medicine: a national study. J Health Hum Serv Adm. 2006;29(1):4-25.
11. Center C, Davis M, Detre T, et al. Confronting depression and suicide in physicians: a consensus statement. JAMA. 2003;289(23):3161-6.
12. Linzer M, Visser MR, Oort FJ, Smets EM, McMurray JE, de Haes HC. Society of General Internal Medicine Career Satisfaction Study Group. Predicting and preventing physician burnout: results from the United States and the Netherlands. Am J Med. 2001;111(2):170-5.
13. Dyrbye LN, Thomas MR, Shanafelt TD. Medical student distress: causes, consequences, and proposed solutions. Mayo Clin Proc. 2005;80(12):1613-22.
14. Daugherty SR, Baldwin DC Jr, Rowley BD. Learning, satisfaction, and mistreatment during medical internship: a national survey of working conditions. JAMA. 1998;279(15):1194-9.
15. Caldicott CV, Faber-Langendoen K. Deception, discrimination, and fear of reprisal: lessons in ethics from third-year medical students. Acad Med. 2005;80(9):
866-73.
16. Ginsburg S, Hachan N, Lingard L. Before the white coat: perceptions of professional lapses in the pre-clerkship. Med Educ. 2005;39(1):12-9.
17. Shanafelt TD, West C, Zhao X, Novotny P, Kolars J, Habermann T, Sloan J. Relationship between increased personal well-being and enhanced empathy among internal medicine residents. J Gen Intern Med. 2005;20(7):559-64.
18. Thomas MR, Dyrbye LN, Huntington JL, Lawson KL, Novotny PJ, Sloan JA, Shanafelt TD. How do distress and well-being relate to medical student empathy? A multicenter study. J Gen Intern Med. 2007;22(2):177-83.
19. Firth-Cozens J, Greenhalgh J. Doctors’ perceptions of the links between stress and lowered clinical care. Soc Sci Med. 1997;44(7):1017-22.
20. Haas JS, Cook EF, Puopolo AL, Busrtin HR, Cleary PD, Brennan TA. Is the professional satisfaction of general internists associated with patient satisfaction? J Gen Intern Med. 2000;15(2):122-8.
21. Baldwin PJ, Dodd M, Wrate RW. Young doctors’ health – I. How do working conditions affect attitudes, health and performance? Soc Sci Med. 1997;45(1):35-40.
22. Epstein RM. Mindful practice. JAMA. 1999;282(9):833-9.
23. Novack DH, Suchman AL, Clark W, Epstein RM, Najberg E, Kaplan C. Calibrating the physician. Personal awareness and effective patient care. Working Group on Promoting Physician Personal Awareness, American Academy on Physician and Patient. JAMA. 1997;278(6):502-9.
24. Yamey G, Wilkes M. Promoting well-being among doctors. BMJ. 2001;322(7281):252-3.
25. Spilker B. Quality of life and pharmacoeconomics in clinical trials. New York: Lippincott-Raven, 1996.
26. Wear D, Castellani B. The development of professionalism: curriculum matters. Acad Med. 2000;75(6):602-11.
27. Stephenson A, Higgs, R, Sugarman J. Teaching professional development in medical schools. Lancet. 2001;357(9259):867-70.
28. Gordon J. Fostering students’ personal and professional development in medicine: a new framework for PPD. Med Educ. 2003;37(4):341-9.
29. Joint Commission on Accreditation of Healthcare Organizations. Medical Staff Standards. MS.4.80. In: Comprehensive Accreditation Manual for Hospitals: The Official Handbook. Oakbrook Terrace, Il: Joint Commission Resources, 2005.