Physicians have the right and the responsibility to be physically and emotionally healthy, and patients deserve healthy physicians. Physicians who are unwell are less likely to provide quality patient care. To achieve better health for themselves and their patients, physicians must overcome the stigma attached to their own illnesses and allow themselves to be patients when appropriate. At a systems level, national stakeholders are demonstrating a commitment to physician health and wellness.
KEY WORDS: physician health, resiliency, burnout, patient safety, mental illness, stigma, quality of patient care, quality indicator
Physicians have long been interested in the quality of patient care, sometimes to the exclusion of other factors, such as cost, which can lead to tension between physicians and administrative health care leaders. The desire of physicians to do the best for patients to the exclusion of other considerations can also mean that they neglect their own health and well-being. This selflessness can have the unintended consequence of physician burnout.
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This paper explores this equation: physician over-dedication to patient care leads to fatigue and burnout. Because of the stigma around mental illness, physicians tend to keep working and not ask for help. When many physicians are unwell, the quality of care they provide decreases.
Physician wellness has been suggested as a quality indicator in the past.6 This paper describes some of the emergent changes at the macro-level of health care in Canada in this regard and points to an opportunity at the meso-level where quality indicators are decided and at the micro-level, among physicians themselves.
Scope of the problem
In November 2016, West et al.8 noted that burnout has reached “epidemic levels” for physicians in the United States. The latest American Physician’s survey9 states that “The majority of physicians surveyed, describe their morale as somewhat or very negative.” Top
Although Canada-wide data are outdated — the last Canadian Medical Association (CMA) survey was in 20083 — they are generally similar to those of the United States. The 2008 survey revealed that workload, coupled with incongruence between personal and workplace values, explained the increased risk of burnout in physicians. The survey revealed that 46% of respondents were at an advanced stage of burnout.
A recent review of physician health literature states: “Because of methodological differences, it is difficult to accurately determine the actual prevalence of mental health problems among physicians, but there is a higher frequency of burnout and death by suicide compared to the population as a whole.”1
Paradoxically, the public generally perceive physicians as a healthy group. As they are mostly self-employed, they have control over their time, ostensibly allowing them to attend to their self-care. Further, their workplace affords them access to knowledgeable colleagues, so they can quickly get an educated opinion on how to manage their own health.1
What is burnout? Top
Burnout is most frequently described and measured using the Maslach definition and inventory. The Maslach Burnout Inventory (MBI) scale measures the three components of burnout: emotional exhaustion, depersonalization, and a low sense of personal accomplishment.10
Depersonalization is experienced as a detachment, especially from emotions and thoughts, such that the person is aware they have emotions but cannot feel them, and their thinking can feel slowed and cloudy. Depersonalization is a defense mechanism also used by survivors of trauma to protect themselves from their experiences.
Not all physicians will experience burnout at the same rate even with the same experiences.1 The causal factors thought to underlie burnout are multiple and interdependencies between the factors create individual physician risk profiles. Roman and Prevost1 have divided these factors into three groups: factors intrinsic to the physician work place; factors extrinsic to the physician work place; and internal factors, i.e., intrapersonal characteristics that each physician brings with them into their work world. Top
Intrinsic factors
Intrinsic factors are those resulting from the physician’s workplace. They include: constantly working in an emotionally charged environment that involves suffering and/or death; dealing with patients who have chronic disease and unrealistic expectations; conveying bad news to patients and families; dealing with difficult patients and colleagues; the vicarious trauma of repeatedly witnessing death, dismemberment, and other suffering; making an error that results in patient harm or death; and always being held accountable for poor outcomes despite not having full control of a care team.1,3,11 In a Canadian study of physician stress, 28% of respondents identified intrinsic factors as major contributors to their stress levels.11 Top
Extrinsic factors, as a source of burnout, refer, “not to medical practice itself, but rather to how it is organized.”1 Examples include: the ever-increasing workload, rising expectations to be more than a medical expert, shortage of time required to do all things well, long duty hours and resulting fatigue, rapid changes in medicine as well as governance and structure, decreasing professional autonomy, lack of work–life balance, increasingly being called to take on management and leadership roles, and media reports on the low value for money of Canadian health care combined with the knowledge that physicians are one of the main drivers of health care costs.1,11
Lemaire and Wallace11 discovered that physicians identified extrinsic factors as the number one source of their stress. “Approximately one-half (43%) of the physicians indicated that the most stressful aspect of their work was related to feeling overwhelmed with their workload.” Top
Individual factors
Many authors have identified individual factors that put physicians at increased risk of burnout.1,12,13 Personality traits, such as perfectionism, are known to increase the risk of major depression in the general population, and physicians are no different. Myers and Gabbard13 describe a triad of personality traits, common to physicians that increase the risk of burnout and mental illnesses: self-doubt, guilt, and an exaggerated sense of responsibility.
Lemaire and Wallace12 found that 36% of the physicians in their sample self-identified as “control freaks.” Physicians with a high need for control can have a detrimental impact on their care team when something goes awry, such that others on the team are walking on eggshells trying to avoid the ire of the physician. This type of interpersonal dynamic can lead to poor communication between team members and a decrease in care quality.
Barriers to self-care
Barriers to care occur at the individual, organizational, and system level; however, individual barriers offer the biggest opportunity for change.
Dike Drummond (commonly known as The Happy MD) astutely observes that the medical education that physicians endure and require to be successful also sets them up for burnout.14 Physicians are trained to be “perfectionistic, superheroes, lone rangers and workaholics” and these ways of behaving and thinking can be adaptive — when they are used in the right place and at the right time. However, when these unconscious structures become automatic and generalized, they can lead to burnout, lost relationships, and ill health. Top
The stigma surrounding mental illness is an individual barrier to care. Stigma is an overarching term that includes labeling, separation, prejudice, and discrimination.15 Stigma against the mentally ill is widely identified as one of the biggest barriers to care.
Self-stigma comes about as an internalization of others’ beliefs. Self-stigma is understandably a major barrier for physicians who have signs and symptoms of burnout or mental illness. Doctors are well aware what a “formal diagnosis” might mean – scaling back workload, losing privileges, or being uninsurable.1 “Stigma is reinforced by teaching and encouraging physicians to place a low priority on their own health, to deny they have any health problems, to keep any concerns about themselves or their colleagues to themselves, and to deal with it on their own.”5
Stigma is highest inside health care itself.4,5 The Mental Health Commission of Canada (MHCC) has a project aimed at decreasing stigma inside health care for the very reason that they identified health care providers as highly stigmatizing.16
Physicians’ addictions and mental illnesses can come to light during the investigation phase of a patient complaint or an adverse event. When the adverse event is related to physician illness, the physician has traditionally been disciplined, which sends the message that “to be ill is to be bad,” further increasing stigma.5 Furthermore, among physicians with perfectionistic personality traits, this type of investigation can be traumatic and lead to increased risk of death by suicide.13 Top
“Self-treatment becomes a strategy that is accepted and even encouraged by colleagues, since it allows physicians to stay on the job and avoid the discomfort of having to assume the role of patient.”1
Drilled into physicians during their extensive and intensive training is the identity of caregiver or healer and the idea that physicians care for and heal “the other,” i.e., patients. This binary division sets up a false dichotomy between physicians and patients, which is adaptive when used appropriately and maladaptive when taken to the extreme. When physicians internalize the idea that needing help means being one of “them,” that coming forward with emotional concerns means losing your social identity as a healer, they use defense mechanisms like denial to defend against the resulting anxiety.17 Top
Quality of patient care
Systemic quality of care indicators are listed by the Canadian Institute of Health Information (CIHI) as: appropriate (evidence-based), patient centred, safe, and timely.18
These indicators are at the macro level, and it is up to individual provinces to model what they measure inside their own systems to align with them. In Alberta Health Services, for example, at the meso-level, the quality indicators are: appropriateness, acceptability, accessibility, effectiveness, efficiency, and safety.19 For each of these indicators, a set of measurements is taken on a regular basis. As an example, one of the safety indicators measured is adverse events.
In a Lancet article titled, “Physician wellness, a missing quality indicator,”6 the authors argue that, should physician wellness be a priority for individual physicians as well as for health care systems, improvements would be seen in productivity and efficiency, quality of care, patient satisfaction and adherence to treatment, medical errors, and recruitment and retention of physicians. They state that “measurement of provider wellness as a health-system quality indicator could be highly beneficial.” Top
Other authors have made the link between physician burnout and quality of patient care.20 A Canadian study revealed a connection between proper nutrition of physicians and the quality of patient care delivered.7 In an exploratory study, the authors found that physicians themselves do not recognize the relation between their own self-care and the quality of the care they provide.2 Some research reveals that physicians who have experienced the beneficial effects of a healthy lifestyle are better at promoting these benefits to patients.21,22
On the flip side of this coin, many studies have shown the effect of physician burnout: reduced efficiency and safety, especially medical errors. At the time this article was written, the Resident Doctors of Canada website included a link to multiple articles on physician burnout and its effect on quality of care.23 Wallace et al.6 also site numerous studies.
Moving physician wellness forward
At an organizational level, most provincial medical associations offer a range of health and wellness services to physicians. These services rely on self-identification and are anonymous, so few data are available. Some health authorities, such as Alberta Health Services, are beginning to incorporate physician wellness into their human resources strategy, recognizing that without healthy physicians, the goal of “patient first” health care is impossible to achieve. Top
At a systems level, national stakeholders have demonstrated their commitment to physician health and wellness. For instance, within the Royal College of Physicians and Surgeons of Canada’s “professional” CanMEDS role, residents must demonstrate a commitment to maintaining their own health as well as that of their colleagues. The Canadian Medical Association (CMA) is revising its 1998 policy on physician health24 and creating a forum that will bring together provincial and territorial health programs in Canada. Major initiatives have also been taken by other national organizations, including those representing students and residents. The Canadian Federation of Medical Students recently completed the first national survey of medical student health and wellness and the Resident Doctors of Canada is developing a resiliency curriculum, among other initiatives.23
The Mental Health Commission of Canada (MHCC) has been working in the area of stigma in the workplace for many years and provides hope for physician leaders. In the past five years the MHCC has developed, offered, and evaluated programs that help reduce stigma in the military and in first responders. Two programs — Opening Minds and Road to Mental Readiness (R2MR) — have been shown to decrease stigma and increase mental wellness in these two populations. Currently, the MHCC is working on implementing this training in Nova Scotia’s health authority (Dr. Laura Smith, Nova Scotia Health Authority, 15 Nov. 2016, personal communication). The Resident Doctors of Canada resiliency curriculum is based on the R2MR program.23 Top
Although the work of these regulatory and supporting bodies in physician health is important, physicians themselves have the biggest opportunity to effect change. The future will require physicians who value their own health and the quality of patient care at the same time. It will require physicians to let go of the binary, “us and them,” and tolerate the uncertainty of a continuum of identity. Empowering physicians to put their own health on an equal footing with patient’s health is but the first step.
Conclusion
Physicians have the right and the responsibility to be physically and emotionally healthy. Patients deserve healthy physicians. Health organizations must invest in this valuable human resource and consider measuring their investment as one of the indicators of quality patient care. The evidence surrounding the need for healthy physicians is mounting. How long can we afford to wait to take action?
References
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Author
Laura Calhoun, MD, FRCPC, MAL(H), CEC, is a psychiatrist and senior medical leader for Alberta Health Services. She currently works in human resources with a focus on physicians.
Correspondence to: Laura.Calhoun@ahs.ca