Michael H. Gendel, MD

Medical Director Emeritus,
Colorado Physician Health Program (CPHP)

I’m sure you’ll be shocked to hear that the wellbeing of physicians is not at the top of the list of the priorities of your workplace. Sure, you thought when you were medical students and trainees that once you were out in the world, the world would welcome you and be oh-so-supportive. Yes, personal and professional life is stressful (as well as gratifying), but you knew that your commitment to patients, your knowledge and skill, could not go unappreciated by your work environment, and that appreciation would certainly take the form of good administrative and clinical support, realistic expectations, and a palpable feeling that you were valued. 

CPHP became aware and began to address work stress and burnout complaints among our participants in 1995. In 1999-2000 we conducted a study that demonstrated that the majority of those we worked with suffered from serious work stress. At the time, none of the institutions we worked with seemed aware of this problem, and none queried their physician community about it. The academic community was not interested. Years later, when Tait Shanafelt and his team at the Mayo Clinic began publishing their work on burnout – especially their finding that work stress was linked to suicidal ideation among doctors and medical errors – did workplaces begin to wake up, sort of. Now, all studies show that work stress and burnout symptoms are endemic among almost all specialties. I know, you’ve heard this before. 

What ensued, as we know, was an effort on the part of hospitals, health maintenance organizations (HMOs), workplaces, and some malpractice carriers to encourage physicians to be more resilient. (Right. Health insurance companies didn’t notice). At CPHP, we knew that physicians were already among the most resilient groups of people anywhere, and did not suffer from a resilience deficit. Far from it, our resilience contributed to our organizations believing that we were not suffering. Initially. Because we could take it. Still, CPHP studied the literature on work stress, developed interventions aimed at strengthening our ability to manage it, and we continue to utilize these in our work with our participants. 

Along the way arose the principles of wellness and work-life balance, and we wholeheartedly subscribe to evaluating and strengthening among our participants the areas of wellness: emotional, physical, occupational, intellectual, social, spiritual, and financial. I don’t mean to minimize the importance of this work. Most of our participants report they are helped by this help. But paraphrasing Wittgenstein in the introduction to his “Tractatus,” one of the most important things we’ve learned is how little is accomplished when we only address resilience and wellness. (I note that work stress, depression, and anxiety problems are often intertwined; CPHP is extremely helpful in these situations). That’s because our internal resources, strengthened though they can be, are insufficient to combat the problems posed by our work environments. This was finally recognized by the Shanafelt group, noting that the problem is systemic, not a problem of individuals and their resilience, and offering nine recommendations for workplaces. These are not often implemented.

The fact is that the ownership of health care institutions is concentrated in fewer and fewer hands, the larger corporate world. Profit and wealth are the goal. “Efficiency” is the operational imperative, though it does not refer to actual efficiency, but to bare bones. Do more with less. Even among the nonprofits, the bottom line is sacrosanct. Before the 1980s, which (unfortunately) is a period I remember well, health care was a loss leader, expected to cost the institutions of medicine but out of a humane mindset. Granted, there was little gerontology before Medicare benefits. But coverage should not be conflated with profit motive. 

Now, the fewer and larger the health care companies, the further down the list of priorities is the welfare of doctors. There is no sign that the pendulum is swinging the other way. And venture capital – well. Studies show diminished quality of patient care, but experience tells us that we sell our souls, much of the time, often motivated by too much leveraged debt, sometimes by exhaustion. Yes, certain health care companies and HMOs, certain hospital systems, certain venture capital groups, certain clinics, are oases. But not many. And this is not a burgeoning group.

And yes, there are now wellness committees, chief wellness officers, ongoing research into burnout prevention and management. All are well-intended. At CPHP we work with all these groups and do research as well. But the data on the effectiveness of wellness interventions in industry (in general) is depressing. Improvements in physician wellbeing brought about by these initiatives are for the most part on the margins of workplace challenges. What is often characterized as a struggle between the clinicians and administrators is oversimplified; it is really a struggle between ownership and everyone else, and rarely addressed. 

And of course, in real life, work is not the only source of stress. Although the World Health Organization defines burnout as a work-stress syndrome, in real life we know that chronic, sustained stress in any venue of our life can induce symptoms of burnout: emotional exhaustion, detachment from those we care about, and a diminished sense of personal accomplishment and value. So, it’s complicated. 

What to do? At CPHP, we will continue to apply what we’ve learned and continue to help. We know that a small improvement will feel big; a 15 percent reduction in stress will feel like a great relief. Burnout can and does resolve. But the forces opposed to our feeling better are granitic. Studies of physicians’ personalities show that we are a passive lot, though we don’t see ourselves that way. We gave up autonomy in our workplaces to organizations. We sat by while accountants and billing departments designed EHRs. To the extent we can assert ourselves and tackle workplace problems, let’s do so. Then, buckle up. Try to have fun at work. Look forward to seeing the patients you want to see and the staff you enjoy. Engage your colleagues. Talk and listen to your loved ones, family and friends. It’s up to us to manage it.