“Returning smiles” to medicine
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Very recently, Shetty and Arora carried out a national survey on the residents’ satisfaction level , and I applaud and compliment them for their efforts. They provocatively title their manuscript—Is someone listening? My riposte, or shall I call it repartee—Can we afford not to listen? Physician burn-out and attrition is now a well-established global phenomenon. Though burn-out may be ubiquitous across all professions and arenas of life, but it assumes a very special importance in relevance to medicine, as it does not stay individual but affects health-care delivery and thereby the health of the community. It thus assumes a much grander and larger scale, and as Tait Shanafeldt from Mayo Clinic, Rochester, Minnesota would have it put, “If it affects half of our physicians, it is indirectly affecting half of our patients.” Such is the seriousness of the issue that the New England Journal of Medicine (NEJM) catalyst published a series of articles in June 2017  exhorting medical profession—“Solutions are urgently needed.” However, to the very contrary, when asked what the organization is doing to address the issue of physician burn-out, many of the NEJM Catalyst Survey respondents replied, “nothing,” “not enough,” “paying lip service,” and “talking about the problem in committees but no action plan yet.” Already in India, we are struggling with an acute shortage of manpower and if we do not care of what we already have, we will end up with an attrition rate of almost one-third of medical professionals, extrapolating and going by the western standards .
The biggest issue with physician burn-out is that we seem not to recognize the problem. In its preliminary and occult avatar, it may take vicarious shapes like emotional exhaustion, de-personalization, dissatisfaction, and disillusionment with self, lack of personal accomplishment, and even substance abuse, especially alcohol, before it manifests as a full-blown “burn-out” and therefore frequently over looked or missed. Even in the NEJM catalyst survey, while nearly two-thirds of individuals recognized physician burn-out as a serious problem in the health-care industry, only one-third thought it to be a problem in their own organization!
The practice of medicine has changed and as Michael Schneck from Loyola, University, Chicago observes, “We take people who are highly trained, highly educated individuals, selected because of their motivation in terms of humanism and the ability to learn copious amount of material, and we turn them in to highly educated factory workers.” We ask them: How many patients have you seen in the OPD today? How many procedures have you done? How many angiographies or echocardiographies have emanated from your consulting room? How have you justified the pay you are getting? These are quality metrics (sic…. If I may be allowed to use this euphemism) that are being tracked by the administrators and promotors. These questions and the corporate philosophy of practice of medicine are an ante-thesis to what sensitivities toward the profession we have been brought up with. It touches the raw nerves of a sensitive brain and does not go down well with human sensibilities. Yet it is an open secret that these are mundane issues which every physician, especially in the corporate world, faces relentlessly on a day-to-day basis. No wonder then, that Schneck laments, “The physician has lost stature as a team leader and is just another cog in the machine.”
The burgeoning knowledge of medicine and a vast panoply of imaging modalities, which are yet to prove any outcome benefits, but are available freely, are becoming a pain, both to the society and the profession, rather than a boon. Indirectly, this puts extra pressure on the physician to keep pace with this ever marching and explosive new medical knowledge. To address this issue, we must come out with clear cut facts and recommendations for clinical use of only those forms of treatment and imaging modalities, which have shown outcome benefits. A physician should not be expected to keep track of all the data available of hundreds and thousands of trials going on, with no sense or meaning, and mostly being carried out with personal interest of either the principal investigator or the sponsoring authority in mind. Even the electronic health record (EHR) seems to have complicated life more than it has solved and may be contributing to the physicians’ woes. In fact, EHR is a top culprit in physician burn-out as pointed out by Krista Kaups, a past chair of American College of Cardiology (ACC) Governor’s Committee on Physician competency and health, “It’s the frustration of dealing with a system that wasn’t exactly designed by clinicians.” In this whole bargain, the poor resident doctor and the junior physician, in fact the work horse of the profession, are made a scapegoat for all mishaps, may be unintended one at that, just as when all the bouquets go to the seniors.
It has been said medicine lacks in three Ms—Manners, Morals, and Medicine. Sure the last bit—“Medicine” can be handled by the medical schools, but the first two components cannot be seen in isolation. After all, a doctor is a part of the society and the morals and manners of the society cannot be separated from those of the doctors. In fact, the doctor is a mirror where a society can see its own reflection. Most of us have become disengaged physicians, just going through the motions, and have no time for partnering with our patients or hand-hold and lead them through their illness. The doctor-patient disconnect, the ever lurking fear of a medico-legal litigation and of violence, and the community back lash for any untoward and unintended event make matters worse. Who is responsible and what came first is a chicken and egg quandary & best left un-debated. Suffice to say that Newton’s law of nature—every action has an equal and opposite reaction holds for everything in life. Patients’ attitude to the medical fraternity shall directly or indirectly be reciprocated by the medical professionals, just as vice-versa is equally true. Therefore, we need to change and march forward together and not in isolation.
What then needs to be done?
Only when we accept and realize the issue, would solutions come up. I think, just recognizing the problem and proactively looking for it will be half the solution. The trend of amalgamating various streams of medicine and the realization that mind, soul, and body are integral to health and use of such time tested, age-old techniques of relaxation like reading, good sleep, meditation, yoga, guided imagery, and bio-feedback for the management of stress and for self-awareness may help reduce the problem of physician burn-out, but will not be a permanent remedy.
There needs to be a paradigm shift in the way we view medicine as a profession. Altruism has been driven into us right from the day one that we entered the medical college, that the health of the patient comes first, be it at the cost of your own health. Sorry Sir, there should be no altruism in any matters in the world. Even in an aircraft, it is told that if oxygen mask falls off, first put it on your own self and then address the children and others. Till we have a healthy medical work force, the society cannot be healthy and therefore, giving a pass to this most obnoxious trait called altruism, (I am sure Ayn Rand will be smiling in her grave!), one must look after one’s own self and only then a healthy mind and a healthy body of a physician can look after the society.
The corporate world and the health administrators need to reduce the working hours of the residents and take non-clinical duties off their hands and involve them more in clinical and operative work, rather than non-productive filling of forms and data entry sheets in to the Electronic Health Records of the hospital. Off-hospital time, the so-called “Pajama Time,” should be the exclusive domain of the individual physician, with no clinical work load over ever carried into it.
Indian authorities will do well to be reminded of the American Board of Internal Medicine’s initiative called, “Returning joy to the practice of medicine.” Let’s get the smile back on the face of our profession, because ultimately, that would heal our patients more than just the technical fixes that currently we are providing. We need systemic solutions as so very succinctly expressed by Shanafeldt from Mayo Clinic, “We need to stop blaming individuals and treat physician burn-out as a system issue.”
Let us not regard our self as victims and let the society not treat us as villains. It’s just that we are redefining our self in medical profession and trying to have a fresh foot hold, in the paradigm shift that medicine as a profession has undergone recently, pari-passu with the changes in the society. The terms of engagement of a physician today are different from those a hundred years back. Both the society and the medical profession need to recognize that and develop some kind of bonding, a working relationship, a trust of mutual regard and respect, and move forwards. Let the doctor be just a human being, and let him not be escalated to that super humanly platform of a “Godly” pedestal, for neither he belongs there, nor can he sustain himself on that platform. It is only when such unrealistic expectations are made of a mortal human being that mistrust and disenchantment brews, and it is the root cause of a lot of maladies. Let us make realistic expectations—society out of the medical profession and medical profession out of the society.