These are some of the ‘high points’ of a talk I gave last Summer at Michigan ACEP and last week at Wisconsin ACEP. I hope you find them useful.
There are a lot of unhappy physicians in a lot of bad situations. I know because I write for them, and they write to me. The thing is, we deal with ‘patient satisfaction’ all day long. Why not work harder on ‘physician satisfaction?’ I want my colleagues to have a higher ‘physician satisfaction score.’
So first off, what makes us dissatisfied? What lowers that score for the hard working physicians of America, and indeed much of the world?
Poorly designed electronic medical records, customer satisfaction pressures (along with Joint Commission,CMS, Press-Ganey scores, etc.) The misery of the pain scale (which in part brought us the wonders of the opioid epidemic). Endless new regulations, enacted by committees who have next to no idea what we do in clinical medicine, or what we need, but always feel good about one more rule or requirement enacted over a lunch meeting. (As the emergency department or clinic or OR was stressed to the breaking point.) How about lack of backup? We can’t get more staff, we can’t afford more specialists, we can’t pay for more beds. We may not even have a secretary, much less more physicians or nurses! How about the increasing complexity of care? It’s not what medicine was 25 years ago, I can tell you.
Here are some more. What about those who try to tell us we can’t have food or drinks at our work stations? (A thing that has been shown to be simply unnecessary and not required by Joint Commission.) Not only no food or drinks, but no time for breaks! And constant time entering orders and documenting on computers. All of these steadily, daily, weekly and yearly lower our ‘physician satisfaction scores.’
What about the fact that our lives are driven by metrics? The day after a shift in the ER or clinic, nobody really cares how hard it was or what a good job we did. They want us to know that our EMR in box is full and that we have unsigned charts and orders. (If they aren’t signed, how can the billing folks collect?’
Exhaustion is a factor, right? Medicine is hard. Medicine is tiring. Medicine happens 24/7. Those who do it seldom have time to really, truly rest. Days in clinic or the OR. Nights on call. Early mornings and late nights. Not a prescription for a healthy life.
But it’s more than that, isn’t it? Part of our dissatisfaction is that physicians often can’t leave medicine, can’t change jobs, because their debt level is so high. The average student now graduates medical school with around $200,000 in loans. This robs young physicians of options. It affects specialty choices so that primary care is harder to justify. It affects practice location, as young physicians after residency have to find the highest paying job to make their payments. Especially if they have any hope of having a home, a family or any free time. And in practice? The indentured servitude of debt leaves physicians trapped. Unable to cut back, change or quit if they find themselves dissatisfied or frankly miserable. Or depressed. Or suicidal.
Other things make us dissatisfied. For instance, the specter of lawsuits always lurks behind every chart, in every encounter, every procedure. In every transfer, every ‘left without being seen,’ every angry, violent patient who has to be treated with kid gloves. Lawsuits that keep us up at night, and make us shudder when we come to work and a co-worker takes us aside and says ‘remember that lady you sent home with chest pain?’
It appears that exploding corporatization across medicine also leaves physicians dissatisfied. It leaves us frustrated because it was our individual drive and initiative that allowed us to succeed in medicine, but that drive, those skills are suddenly owned and coopted by others, by a collective. And by people who have no idea how we think, what we do or what we endure except to the extent that it affects the financial bottom line. This leaves us out of control.
Practices purchased, hospitals purchased, physicians essentially purchased. Physicians, commoditized, who exist to produce the product, the bottom line that is demanded by share-holders and by administrations. Physicians, who along with nurses, techs and others engage in the only thing that produces money for a hospital. Patient care.
It’s this top-down, paternalistic control, coupled with the burden of debt, that leaves physicians unable to resist constant new time stamps, new algorithms, new nursing rules, new billing and coding requirements. Unable to say ‘no’ to one more person saying that they can’t have a break, or so much as a drink at their desk. It leaves them unable to speak their minds, or even speak the truth of the science they were hired to practice. Unable to say no to wearing ‘RFID’ badges that track them like animals being studied on the tundra.
All of this helps explain the 300 physician suicides every year in America. And the rising sense of ‘burnout,’ whatever that is. It helps explain the exodus from medicine, the early retirements, the desperate scramble to do something non-clinical, or less clinical. Look around! The signs are everywhere.
Of course, much has been written about this. Wellness initiatives are all around. Corporations, some of them at least, are looking at ways to make physicians more satisfied. And it makes sense. Happier physicians are more productive and make happier patients. That is, customers. Hey, if that gets things to change, then it’s better than nothing!
I am no medical economist. And certainly no MBA. I have no idea how to undo corporatism. I can’t program an EMR. I hope that over time we can push back, steadily, against bad ideas. We seem to be winning a small battle over drinks at our desks. That’s good. We have successfully lobbied to decrease the demands of board certification. That’s also good. We even seem to have made our point that giving opioids just because ‘it’s a ten’ is and always was a bad, dangerous idea.
The political and economic restructuring will have to be left to someone smarter than I am. however, there are things we can do. There are ways to improve our ‘physician satisfaction scores.’
The first I have tried to do. To simply state them. To call them out into the light so that physicians aren’t bullied into thinking that they’re alone, or that they’re complainers. So that hard working, frustrated physicians can say ‘yeah, I feel that way too!’ Shine the light on the demons and they scatter. And look smaller than we thought when we stand together.
But there are other things we can do. And these are important. Whether one is a director or a partner, or just a lonely locums physician wandering the world like a wild west gunslinger, we can make things better for one another.
The best part is, these things do not require committees or the movement of large corporations. They require that we care for ourselves and for others.
Remember, always, that medicine cannot be the sum total of our identities. When it is, we set ourselves up for inevitable failure. Every mistake strikes at the core of our being. Every bit of frustration or disappointment, every time we think we’d like to quit, we lose who we are if physician is all we are. This has to start in college, and go on in medical school, residency and beyond.
We are human beings. We are complex and varied. We are children and parents, we are spouses and lovers. We are artists and business people. We are scientists and humanists and children of God. We are physicians, but so much more.
What else? When we are part of groups of physicians, we can pay attention to the personal needs and wounds around us. Our co-workers may rise to every occasion and never call in sick. But there may be pain in their eyes. Maybe from a mistake. Maybe from litigation. Maybe from a hard, heart-wrenching case. Perhaps they’re weary of arguing with other physicians or administrators.
Maybe they owe money. (We should remind our young physicians to be wise and spend less than they think they should.)
Maybe their marriage is in trouble. Sometimes their family members are sick. Or their children are wayward and prodigal. Or simply normal teenagers, which is hard enough.
We need to talk with them. Take them to dinner. Fill in when they’re stressed. Avoid criticizing their metrics during these times, and remember they are more than physicians. They are people suffering like the patients we care for each and every day.
Be there to fill in for weddings, funerals and sickness; for kids’ plays and graduations. Connection with family is critical and when it is lost, isolation can be toxic. We have to help our partners maintain this.
It can be helpful to have group family dinners! Or for directors to meet with spouses now and then! They will speak the truth because they know the story and want their partner to be whole again.
Remember that a physician represents a family. Not just a person. And family is the anchor everyone needs to weather the storms. Family is paramount and when it is displaced by the idolatry of medicine, everyone suffers.
Furthermore, time is the most precious currency of all and we must spend it on the ones we love. Every shift worked, every procedure performed, no matter how much money it’s worth, has an equal or higher value in time away from those we love. It must be calculated.
Next? Whether director or not, we need to stick together and ‘go to bat’ against ridiculous rules and regulations. We need to advocate for one another in an era of ‘death by clipboard.’ Too many people walk around making too many rules for us. And it’s past time to push back against those who add work to already overwhelmed physicians.
This isn’t easy; but I know of group of physicians in a major trauma center who flatly refused to use the EMR the hospital purchased. In the end? They got a new one. They leveraged their value, their skills and dedication. They won. We need more of that.
We need less genuflection before patient satisfaction scores. My former director (may he rest in peace) said ‘if you don’t make someone mad once a day you’re not doing your job right.’ That’s not a popular opinion. But it’s true.
Another thing; what is burnout? We’re told to watch for it. Maybe it’s like they used to say about pornography. ‘You can’t define it, but you know it when you see it.’ I have a theory that much of burnout in medicine is just being tired of seeing pain, suffering and sadness. It’s a kind of ‘low grade’ PTSD. And sometimes not so low grade…
When a 20-year-old soldier comes back from Iraq and says ‘I think I have PTSD,’ we believe him. It doesn’t matter if he was combat infantry or a mechanic. When a physician says it, the world says ‘well sure, but you’re helping people and you make a lot of money,’ And back to work she goes. Sad, anxious, stressed and ghost-haunted by years of giving bad news and seeing bad things.
We need to have mercy on one another to improve our ‘physician satisfaction’ scores.
The thing is, we don’t seek help. We don’t go to counselors. We don’t admit our deep wounds and we suppress our all-too-human mistakes for fear of litigation.
And by the way, what if we are sued? Errors are not sins. They’re the result of being human; that thing we often forget we are and replace with the word ‘doctor.’
In the end, we must remind ourselves and our friends that litigation is a financial transaction and is sadly sometimes part of the cost of being a physician.
However, we will help vastly more people over our careers than we ever, ever harm. That’s worth remembering. For every angry patient, for every mistake, there are hundreds, or thousands, who benefited from our care. And who are grateful.
From what I see every day, from the complexity, the rules, the charting, the limitations of human memory and cognition, the endless interruptions, it’s a true miracle that more mistakes don’t happen.
The funny thing is, physicians can’t even admit when they do well. I asked a bunch of young doctors in residency if they had ever saved a life in three years of training. They wouldn’t raise their hands. If I had asked about mistakes, every hand would have gone up.
How harshly we view ourselves! That has to stop.
It’s important, for our satisfaction, not only to spend time with precious loved ones but to spend time alone and with hobbies outside of medicine. (Reading journal article doesn’t count as a hobby.)
I used to blacksmith and the contrast between emergency medicine and hitting hot iron was beautiful and soul-cleansing. Sometimes I shoot a bow in the back yard. Or throw an Atlatl. Hobbies are good. Solitude is good too, at times.
Now this is extremely vital. In order to be happier and healthier we also need ways to process what we see. I believe we all need a philosophy or theology to help us cope with the suffering and pain around us and with the deep emotions we feel inside of us. To help us process evil and loss and grief, and offer us hope whether in this life or another. It’s so easy to say ‘I’m a scientist, I don’t need all that hocus-pocus.’ And yet, that hocus locus, those things that we call ‘the humanities’ have sustained humanity for ages and ages beyond what we measure or recall. We need insights into what it means to be human and what it means to hope in something beyond our trouble.
Art can help here. Music, paintings, sculpture, theater, film, all of these address the human condition and can offer us ways to process it all.
Finally, medicine is hard. I give you permission to quit if it’s just too much or you’ve just done it too long. But physicians have enormous inertia and have difficulty leaving a job once they’ve started. The very dedication that gets us into medicine is a trap which causes us to stay in jobs and locations where we are unhappy. When it’s time to leave, leave. And when it’s time to quit, remember all the good you’ve done and move on down the road.
How should we treat other physicians, and patients? My daughter and son have an interest in medicine. So I’d like this to be the way we handle others:
‘Do unto others as you would have others do unto your children.’
That should go a long way toward improving everyone’s ‘physician satisfaction score.’