There was no question that Joanne would become a doctor—not in her mind, and not in anyone else’s mind. Both of her parents and grandfathers were doctors, as were an uncle and two cousins. Even her maternal grandmother was a doctor; she had attended medical school in the 1920s and was one of only two women in her graduating class. Medicine was just what Joanne’s family did.
Joanne had entertained thoughts of becoming an architect, but that simply wasn’t an option in this family tree. Her father said that she could always change her mind once she’d finished medical school, but it was clear that he couldn’t imagine how anyone would not love medicine once that threshold was crossed.
Like her two brothers, Joanne trundled off to medical school after college, though she was younger than most of her classmates. With her sharp mind and her father’s encouragements, Joanne had graduated high school at fifteen and completed her undergraduate degree at nineteen at a women’s college near her home. The medical school she attended in Philadelphia was the last medical school in America to have gone co-ed—and there weren’t many co-eds there yet—so there was quite a bit that was new for her.
And yet, there was much that was familiar. Like other students who came from families steeped in the medical profession, Joanne already possessed a cultural framework for the field. Like a child brought up in a bilingual home, she had an instinctiveness for settling into the medical world, unlike students such as Curtis Climer, who were becoming the first doctors in their families. These students were like the greenhorns on Ellis Island—dazed and disoriented in the glare of the new world.
The first two years of medical school—the classroom years—were intellectually stimulating. It was exciting to learn what everyone else in her family knew. But what most defined her first two years of medical school was starting her own family.
Joanne had met Robert while she was still in college. They were already dating when she entered medical school. Robert was handsome, smart, and confident, clear that he was going to become a surgeon. Although he was one year older than Joanne, he entered medical school one year behind her, because of her academic acceleration.
They were married at the end of Joanne’s first year of medical school. Six months later, they were both surprised when Joanne became pregnant. They hadn’t planned on having a baby so soon, but here it was. Joanne came to take it in stride, as simply the way life was turning out, but Robert was not so sanguine. This was not what he wanted—not now, at least, not when he was just getting started in his medical training.
The third year of medical school—the meat of the clinical years—was an oddly exhilarating time for Joanne. She was finally out of the classroom, on the wards, and discovering the thrill of clinical medicine. “I’m a people person,” she said, “and I loved the chance to talk to patients.” This was when she really understood why her relatives had all become doctors—it was fascinating, stimulating, and it even seemed you could do some good at the same time. Jeremy was born in the middle of all this clinical excitement. So on top of learning how to insert IVs, put in sutures, and read CT scans, she had to juggle midnight feedings, changing diapers, and of course facing the ever-present challenge of babysitter coverage.
Nevertheless, Joanne managed to incorporate these strands of her life, hitting her stride in both medicine and mothering. Robert, however, found this unanticipated foray into parenthood unsettling and gradually began to distance himself. He seemed to wish that the baby had never arrived, or if it had to, that there would be a traditional wife/mother staying home with it.
Joanne began to suspect that perhaps Robert wanted to be the doctor in the family and felt competitive with Joanne (who was always one step ahead of him in training). Joanne had initially seen Robert as confident, cool, and together, but now these traits were starting to feel like arrogance. The stereotype of the surgery personality was coming to the fore.
Joanne chose to do rehabilitation medicine for her residency, figuring that this would offer relatively stable hours. After all, if Robert was going to have the demanding schedule of a surgery resident, then, for the sake of Jeremy and any future children, at least one parent had to have reliable hours.
But two things happened during her residency. The first was that she found rehab medicine to be boring and depressing. Her main caseload was young men with spinal-cord injuries from gunshot wounds who were never going to get better. She found herself longing for the excitement of real medicine, where things happened, where you could actually help patients. The second thing was that Robert bailed out.
Now Joanne was a single mother working in a field she hated. After two years in rehab medicine, she realized that this was untenable and switched to emergency medicine. The excitement was palpable—treating trauma victims, overdoses, heart attacks, acute strokes. It was so much fun that she didn’t even mind repeating internship. She was gaining the skills to handle anything at a moment’s notice, and this knowledge made her feel accomplished.
But the work was tiring, as was parenting a toddler. After finishing a full day in the emergency room and then coming home to care for Jeremy, she would be absolutely drained. She would drop onto the couch with a glass of wine after getting Jeremy to sleep, amazed that she had made it through the day. Her emergency medicine residency lasted three grueling years.
One day, during her final month of residency, her attending sat back in his chair and said, “The ER is yours. I’ll be here in case you need me, but you run the show.” It was a huge job, running an entire emergency room, but Joanne found that she was able to do it and do it well. Even while raising a preschooler singlehandedly.
“It all clicked,” she said. “I knew that this was what I wanted to do, and that I was capable of doing it.” Joanne had officially joined her family’s medical lineage.
She went to work in an urban emergency room in downtown Philadelphia in the late 1980s and early 1990s. These years coincided with the peak years of the crack and PCP epidemic—which took a toll on emergency rooms nationwide, with its exceptional violence, crack-induced psychosis, and generalized mayhem. It was also the turbulent early years of AIDS, before the powerful antiretroviral medications turned AIDS into a manageable chronic illness.
Crack, PCP, and AIDS certainly added to the stress of her days, but, ironically, what wore down Joanne the most was that ER medicine turned out to be—in her concise summary—“the same shit over and over again.” Once she got beyond the excitement of mastering most of the basic clinical scenarios during residency, everything began to feel repetitive. And worse, so much of ER medicine appeared to be the fallout of patients not taking care of themselves.
A cardiac patient would be lackadaisical about doctors’ appointments and then end up in heart failure. A drug addict would use a dirty needle and then show up in the ER with a disgusting, necrotic abscess. A diabetic patient would gorge on doughnuts and white rice, then end up semiconscious from hyperglycemia. An alcoholic would binge, then turn up with seizures. Homeless patients would show up whenever it got cold out, knowing that if they said the magic words chest pain, they would be guaranteed a bed and hot meals for at least a day or two. Heroin addicts would come to the ER when they ran low on their supply and try to wheedle narcotics for various invented ailments.
All of these patients needed, and in some cases demanded, immediate treatment. Joanne didn’t mind the medical treatment part so much, but it seemed to her that few patients took any responsibility for their role in their medical crisis. It was the sense of entitlement that drove Joanne crazy. “Patients didn’t take care of themselves,” she said, “and then they ended up in the ER and expected you to do everything for them.”
If her son, Jeremy, had a tantrum or threw his food on the floor, as a parent she could reprimand him with a time-out, and eventually he would learn the rules. But if her patients did careless or deliberate things that ruined their health, there was no avenue for “discipline.” Joanne had no choice but to take whatever her patients dished out, no matter how self-destructive.
She recalled a man who brought his kindergarten-age son to the ER. The father had given the son a firecracker to set off for a celebration. But the five-year-old couldn’t coordinate throwing the lighted firecracker at the right time, and so it exploded in his hand, burning off a few fingers in the process. Joanne was overcome with anger toward this father. How could he be so stupid? What the hell had he been thinking, giving a firecracker to a five-year-old? She wanted to grab the father and shake the idiocy out of him, shake him until his bones rattled. He deserved to lose a few fingers, not his kid. But there was Osler’s equanimitas again, advising doctors to curb their emotions. Joanne was required by professional duty to be neutral with him. But it made her stressful job all the more trying. It was a chore just to hold her voice steady and be civil to him.
Joanne recalled another patient, a sweet gentleman with terrible, end-stage emphysema. Every month or so, he would have an episode of difficulty breathing. His family would call 911, and the man would be intubated and brought to the ER. Eventually he would recover, and the breathing tube could be removed. Then it would happen again. The patient despised the tube in his throat and just wanted it out. He understood that the emphysema was incurable and that he would die from it. But his family bullied him into continuing treatment, and they called 911 every time, unable or unwilling to let him die.
Joanne would receive the patient in the ER each time, a tube in his trachea, and she could feel her fury toward the family members, who were letting their own issues take precedence and refusing to allow their father to die. She wanted to scream at them: Can’t you see what you are doing to your father? How can you be so goddamn selfish? This poor man wants to be at peace! She knew, deep down, that the situation was painful for the family too, yet she was so angry that there were times when she could barely stand to make eye contact with them.
The repetitive cycles of ignorance, willful self-damage, neglect, and then entitlement, wore Joanne down. She found herself endlessly frustrated with her patients, and increasingly angry at them. She had to bite her tongue to keep from saying what she really felt. She could sense her empathy level dropping and her temper rising. The nightly glass of wine to relax became two. And then three. When she worked an overnight shift and arrived home in the brightness of the morning sun, she found that she couldn’t unwind enough to sleep. And so her nightly drink also became her morning drink.
The night shifts themselves became their own torture. ER doctors, it seemed, never outgrew night work, the way internists and surgeons did as they moved along their career tracks. Seniority, per se, didn’t really exist in the ER. Even the attendings who had been around for years still had to do their share of night shifts.
Even one or two nights per week could disrupt sleep patterns for the whole week, which made parenting even more difficult. Joanne realized she was facing the prospect a lifetime of lousy sleep, that she wasn’t likely to have a decent night’s sleep until she turned seventy. “In those days,” Joanne said, “there was no support for doctors who were having a hard time. You were just expected to suck it all up.”
Alcohol became her only source of relief. At first it was a way of numbing the pain at the end of a shift. Soon it became the only way to steel herself for the day to come. About five years into her post-residency career, she began to have inklings that this was a problem.
For the next two years she felt the constant presence of a little voice in the back of her head saying, You might be an alcoholic. She heeded it a bit, making efforts to quit. She’d white-knuckle it for a few days, but then the need for a drink would be so overpowering in the face of her stressful time in the ER that she’d go right back to her pattern.
There were no major medical mistakes that Joanne can recall, but she knows that she could have been a better doctor during those years—more patient, more empathic. She knew that she wasn’t as sharp or as fast as she normally was, but she was able to get by. Still, she realized that she detested her job and that she was poisoning herself on account of it. Worse, she was putting her patients at risk.
Then one day, she arrived at work inebriated. No one noticed at first, and she grabbed a few charts and started seeing patients as usual. But within an hour, it was apparent to the nurses, doctors, interns, and orderlies all around her that she was unable to function. It was the first time she’d ever been too incapacitated to work, and now every person could see it. Stolen glances turned to whispers and then gaping stares and then finally urgent phone calls. An intervention was hastily arranged.
The chief of the emergency department was called in. “We need to draw your blood and check an alcohol level,” he said firmly to Joanne. “But you have to do something about this, or you will lose your job.” He said she could enroll in an outpatient rehab or a thirty-day inpatient program, but she had to do something immediately.
The best Joanne could muster was “I don’t know. I’m too drunk to decide.” She gathered her things with as much composure as she could rally, but it is hard to maintain a shred of dignity when you are completely plastered in front of your colleagues. The whole experience was mortifying beyond belief, a worst imaginable nightmare. But on some level, it was also a relief. She hadn’t planned to quit clinical medicine entirely—the hospital ended up firing her, despite the reassurances from her boss—but this drunken episode rescued her from what had become an unending source of misery.
Disillusionment in medicine is a complex issue that is bandied about in attention-grabbing headlines. Just about every published survey and news article about it leads with the finding that the majority of doctors would not recommend the field to their children, or would quit if they could, or are getting MBAs in droves.1 In fact, disillusionment is more complicated and nuanced than the media suggests. And it affects not just doctors but their patients, staff, students, and families.
Disillusionment can be a pervasive state of being, calling up complex emotions triggered by feeling that medicine wasn’t what you thought it was, that your ideals of being a doctor have come into conflict with reality, and that reality is flattening those ideals to the mat. Disillusionment has many causes and components. Joanne’s case illustrates what might be thought of as the purest form of disillusionment: frustration with the actual essence of taking care of patients, the feeling that many patients can’t be helped or don’t deserve to be helped.
Other doctors talk about external stressors that diminish the otherwise enjoyable experience of caring for patients—administrative headaches, time pressures, financial squeezes, family strains. But these all have in common the feeling of “This isn’t what I bargained for when I started medical school.” And they also have in common that patients feel the effects—whether subtle or major. Any doctor who is feeling anger at patients, or frustration, or boredom probably isn’t doing as good a job as he could be, and may, in fact, be causing harm.
Disillusionment among doctors is nothing new. But there is a sense that it is becoming more pervasive in recent decades. To some degree, disillusionment is a built-in stage on the medical trail. There’s pre-med, med school, internship, residency, clinical practice . . . and then somewhere along the line, there is disillusionment, as the rosy ideals that inspired students to enter medicine give way to the realities of daily work life.
Some of this is to be expected—for a decade or more of medical school and clinical training, the goal is to learn medicine. There is, by definition, a self-centered aspect to this, as each student has to be responsible for getting herself educated in the vast body of medical knowledge. This uphill climb is onerous, to be sure, but there is a sense of bettering yourself, with the ultimate goal of doing good for your patients.
Once the new physician is out in the working world of medicine, however, the focus necessarily has to shift outward. It is no longer about self-betterment; it’s about getting the job done.
This precipitous loss of focus on personal and professional enrichment can be disorienting. Doctors, who have typically been full-time striving students for a good twenty-five years before they get their first real paycheck, often aren’t prepared for the radical shift out of academic mode.
Initially, I did not notice this shift in my own career. For my first few years as a “real doctor,” post-residency, I still maintained the internship mentality, that working this hard was educating me and improving my skills in an exponential manner. It took a few years to notice that the betterment curve was flattening out. Education—even though I was in an academic setting as a faculty member—was a sideline to the primary business of taking care of patients. While we did have weekly lectures and journal clubs, it was clear that this was a perk, not the sine qua non it had been for the prior decade. Doctors taking care of patients, after all, brings in revenue to the hospital; doctors sitting in a lecture—even giving the lecture—does not.
But finding my stride as an independently functioning physician so dominated my life in these early years that I didn’t really notice this subtle but significant change. I was so busy trying to get comfortable treating the basic hypertension and diabetes of my clinic and developing my own style of practicing medicine that I didn’t have time to realize that I wasn’t actually learning as much as I had been.
In fact, I didn’t become fully aware of it until a completely nonmedical element entered my life—the cello. Shortly after my fortieth birthday, my five-year-old daughter Naava started violin lessons. I asked the violin teacher for advice on how to get a strong-willed child to practice. I expected her to discuss charts, stickers, and rewards, but instead she said, “The best way to get a child to practice is to see the parent practice.”
So, taking these parental obligations concretely, I dutifully purchased a cello and signed up for my own lessons. (I thought it best not to play the same instrument but a close cousin instead.) I began to practice in the evenings as soon as my kids were tucked into bed, so that they could hear me as I conscientiously modeled my exemplary practice behavior. Not only that, I’d be a parent nonpareil, serenading my children to sleep with live classical music. No cloying baby-music CDs for us. One evening, quite early in my cellistic adventures, I was practicing at bedtime, dutifully sawing away on the four open strings—I didn’t yet know how to position my fingers—when Naava called out plaintively from her bed: “Do you know any other notes?”
But the obligatory nature of practice quickly melted away, as I fell in love with the sonorous embrace of the cello. Suddenly, I was plunged back into in an avid learning environment, starting at the bottom and working my way painstakingly up the mountain. The thrill of learning and accomplishing stimulated me so much that the work was pleasurable. I found myself practicing more and more—to the detriment of keeping up with my medical journals—amazed at how much there was to learn. My desire to improve was so powerful that I practiced hungrily every single night. This pursuit of knowledge and betterment, along with an expert teacher, dedicated time and space to learn, and palpable reward for effort—reminded me of what medical school and internship had been like.
It suddenly dawned on me that this was what I was missing in my medical career now. This concentrated learning and exponential increase in knowledge was nearly absent in the real world of being a doctor. Sure, I was still learning a little here and there, but the intense gratification of getting better thanks to hard work had disappeared. In music I was clambering up over Fauré’s Elegy, Bruch’s Kol Nidrei, Schubert’s Unfinished Symphony, Beethoven’s first string quartet, the Bach suites—exhausted, but exhilarated. Inmedicine, the chronic illnesses of hypertension, diabetes, obesity, and depression remained as immutable and intractable as ever. Each “new and exciting” clinical trial was little more than a rejiggering of existing treatments with only incremental advances in the field. Nothing much seemed to change, and it all felt so dull and flavorless. But I could not articulate this loss until I rediscovered the pleasure of learning in another field.
The association became even stronger when I stumbled across an article in the Annals of Internal Medicine entitled “What Musicians Can Teach Doctors,” which was about the intense connection between music teacher and student, the continuous one-on-one feedback.2 It made the analogy that clinical medicine is, in some respects, a real-time performance. Doctors are onstage, in a sense, when they are with patients.
Musicians are constantly performing—whether in concert halls or in their own living rooms—always with the conscious mindset of paying attention to the performance and improving every aspect. Indeed, medical school and internship had some of that feeling, especially with senior doctors, grades, and exams to give you feedback. But all that had evaporated in the real world of medicine. There was only self-critiquing as a tool to help improve performance, and frankly, with the busyness of the hospital and the lack of a teacher waiting every week to assess my progress, it was easy to fall into a repetitive rut.
My cello teacher always warned against playing the same thing over and over just for the sake of repetition. “If you are not improving,” he said, “you are getting worse.” The same thing could be said about medicine.
One could certainly make the argument that this is somewhat self-centered—this desire for the stimulation of learning and betterment—but I do believe it is an under-recognized component of the disillusionment many doctors face in midcareer. And ultimately, it is patients who suffer most when their doctors are stagnating.
Whether medicine conditions us to need constant stimulation by dint of the long training or whether it simply selects for that hunger in individuals isn’t clear. But after a quarter of a century of intensely learning, of having that as the basis of existence, there is an odd blandness to life without it.
Of course, lack of stimulation and the diminishment of the drive to improve is only one aspect of disillusionment, and one that often doesn’t even register on the consciousness of many doctors. The one that does register—nearly constantly—is the aggravation of the work environment in medicine today. In a survey by the Physicians Foundation, 94 percent of nearly twelve thousand primary care doctors said that paperwork had been increasing in the previous three years. Most said that this was directly taking away from time with patients.3
In January of 2010, before health-care reform was signed into law, surveys indicated that a third to a half of doctors would consider closing their practices or retiring early if the bill was passed.4 The threat—real or imagined—of additional regulations, paperwork, and administrative hassles was enough to make a lot of doctors want to throw in the towel. The specter of half the medical force dropping out, of patients wandering endlessly in search of medical care, was played out in the news with postapocalyptic melodrama worthy of Wagner.
But what people tell surveyors they will do bears only a tenuous relationship to what they actually do. The health-care reform bill passed, and there was no mass exodus of physicians. Patients did not die in the streets. Doctors—like all people—vent their frustrations to pollsters, but these sentiments don’t necessarily reflect how they will behave. The polls do, however, confirm that disillusionment and frustration are nearly universal among doctors, at least to some degree. Even if doctors aren’t exiting in droves, the fact that so many think of leaving is dire. For patients, and for society in general, this is critical to address.
There are very few studies quantifying how many doctors quit clinical medicine because of disillusionment. One of the few done indicated that general internists left medicine at a higher rate than subspecialists. Overall, about one in six general internists had left internal medicine by midcareer (for any reason), compared with one in twenty-five specialists.5
This would come as no surprise to internists and other primary caregivers, who feel themselves disproportionately burdened by the administrative yoke of medicine. They are referred to as the gatekeepers of medicine, but they often feel more like medicine’s dumpsters. Any new clinical mandate (for instance, that every patient must be asked about seat-belt use or domestic violence or lead paint) nearly always falls on the shoulders of the primary caregivers. When patients have trouble with their insurance companies over denied claims, prior approvals, or prescription plans, they turn to their primary caregivers.
Specialists have the luxury of selecting which patient concerns they wish to handle; they can draw their practices’ scope as widely or as narrowly as they desire. Whatever they don’t want to deal with, they simply toss back to the primary care docs, who have to take whatever comes to them (and who, of course, get paid far less than the specialists).
For primary care doctor and specialist alike, though, the most onerous burden is paperwork. American doctors and their medical practices face an inordinate amount of paperwork by the mere fact of having to deal with multiple insurance companies, each with its own byzantine rules. A recent study showed that U.S. medical practices spend ten times as many hours on nonclinical administrative duties as comparable Canadian practices.6
The problem is that this paperwork eats directly into patient care, since doctors are not allotted time for this work and rarely have enough support staff to help with it. The 4.3 hours every week that each primary care doctor in a small private practice must spend haggling with insurance companies7 is 4.3 hours not spent with patients. This doesn’t even include time required for documentation (writing in charts), checking labs, ordering tests, and communicating with other members of the health-care team.
A study of hospitalists (doctors who work only with patients admitted to the hospital) showed that they spend only 17 percent of their day in direct patient care; that is, actually physically with a patient.8 The vast majority of their time (64 percent) is spent documenting, reviewing medical records, communicating with other staff members, and handling paperwork. For physicians, this “indirect patient care” is perceived as time they are spending on patients’ cases, but for patients, this indirect care is invisible. Patients are aware only of the time they actually see their doctor, and it feels like almost nothing—typically just a few minutes a day on rounds. The patients, rightly, feel shortchanged.
Doctors also feel shortchanged by this. Most would much rather be with their patients than sitting at a computer typing notes about them. But because there is so much documentation and paperwork to do, there is intense time pressure on doctors to rush their histories and physicals. All the doctors I know wish they could have more time with the patients and less time writing these hundreds and thousands of notes—though, as I was to discover, any one of these notes could become critical once lawyers start poking around.
In a commentary I once wrote about how the computer has become a wedge between doctors and patients, I described the hospital as “the 21st century equivalent of the 1950s secretarial pool: doctor after doctor hunched over the desk, dutifully pounding away at their keyboards.”9 This is an immensely disillusioning experience for people who entered medicine to help others. The paperwork and documentation requirements—which continue to increase—feel like a ball and chain keeping doctors away from their patients and from the ideals that brought them to the medical field in the first place.
Beyond the paperwork, medical care itself can seem like a never-ending time commitment. Medicine has always been a full-time occupation, even for part-timers. Patients do not confine their illnesses to business hours, so night and weekend work is part of the territory, especially for primary care doctors. Doctors understand that this is built into medicine, and it is part of the commitment for which they earn respect, as well as a salary higher than that of many other professions.
Nevertheless, as our society ages and illnesses become more chronic and complex (most people in developed countries no longer die of simple infections), the time required for medical care is expanding, and this spillover is affecting more and more doctors’ personal lives. It can be hard for physicians to voice a complaint about this, because it is part of the professional commitment. Yet at some point, this spillover can eat away at marriages, time with children, sleep, and sanity. Even when doctors are doing the clinical medicine that they enjoy and find meaningful, when it erodes the rest of their lives, they become disillusioned. Many consider quitting.
A group of researchers followed geriatricians—primary care doctors who take care of older patients—to see how much medicine crept into their personal lives. They found that nearly eight additional hours of medical care—patient care outside of office hours—was given each week, mostly in phone calls with patients and families.10 A similar study of internists showed that 20 percent of their total work was spent after hours.11 This is equivalent to almost a full additional day of work every week.
It’s hard to imagine a lawyer or plumber providing eight extra hours of work each week for clients just because it’s the right thing to do. And of course, it is impossible to imagine lawyers or plumbers not billing—heavily!—for it. But that is the expectation of medicine. Again, for most doctors, this is an understood part of the deal, but as these extra hours increase, they have a distinct negative impact. Eight more hours of work comes directly from the rest of the doctor’s life—family time, sleep, exercise, recreation. (Based on the standard American work schedule, that’s ten full weeks each year.) Many doctors’ lives are suffering because of this. And yet when your beeper goes off, or the hospital calls, or the answering service wakes you, there’s no other option. You must attend to it.
Because of the rigors and length of their training, many doctors start families later than other professionals. The “junior” swath of physicians—those in their thirties and forties—enter their prime career-building years at the very same time they are starting families.
A generation or two ago, there was no work-life balance issue, since most doctors were men, and they usually had wives who were home with the children. Today, of course, nearly half of all doctors are women,12 and almost none—men or women—have spouses handy to be home with the kids full-time. Additionally, most young male doctors recoil at the experiences of their predecessors; they don’t want to miss out on their children.
The desire to have control over one’s working hours—and especially those after-hours hours—is behind the trend of medical students drifting away from primary care specialties (internal medicine, family medicine, pediatrics, gynecology). Increasingly, students choose to stay—as the jargon has it—on the ROAD: radiology, ophthalmology, anesthesiology, and dermatology.13 This trend is far more alarming than the fears raised by the health-care reform bill. Doctors here are voting with their feet and moving away decisively from primary care. A survey of more than seven thousand physicians showed the highest burnout rates in front-line fields—internal medicine, family medicine, and emergency medicine. It also noted that doctors as a group demonstrate more burnout symptoms than workers in other fields.14 Many patients—and many doctors—are asking themselves, Who will be my doctor when I need one?
Disillusionment among doctors has a variety of effects. For the majority, it leads to low-level dissatisfaction and grumbling as a baseline to daily life. For some, it creates a full-blown bad temper, the type of physician both patients and fellow staff members quickly learn to avoid. There can be disruptive behavior, angry outbursts, and outright medical errors. A few doctors, of course, leave medicine and find careers elsewhere.
Some, like Joanne, turn to alcohol and drugs, a situation with substantial risk for patient harm. About 10 to 15 percent of all doctors will have issues with substance abuse at some point in their careers.15 The causes of substance abuse are multifactorial. There may be genetic components or situations where drugs are used to enhance academic or professional performance or to stay awake. But the large majority of these doctors—like the general population—start out by using these drugs to self-medicate the painful symptoms of depression, stress, burnout, and disillusionment.
Clinical depression is a specific medical diagnosis that falls outside the discussion of this chapter, but the facets of disillusionment that lead doctors to “poison” themselves—as Joanne described it—are critically important because patients ultimately pay the price. It is one of the most powerful examples of how doctors’ emotions directly affect medical care.
Because there are often few outlets for doctors to work through their disillusionment—other than staff-room gripings—quick relievers of the pain are sought. Alcohol (being legal) and prescription drugs (being easily available) are the top methods of self-medication for doctors. They rapidly take the edge off the pain. Of course, the source of the pain is continuous, so the self-medication becomes continuous and usually increases. Drug tolerance and physical addiction can quickly follow. Disillusionment also feeds on itself. When doctors feel as though they are falling short of the perfection that both they and society expect, when they feel that they are not the doctors they initially set out to be, the pain of disillusionment grows.
Of all the medical fields that face substance-abuse issues in their ranks, two stand head and shoulders above the others—anesthesiology and emergency medicine.16 Joanne’s story certainly attests to the stresses of the emergency room. Anesthesia—despite offering the cushy appeal of being on the ROAD—can be party to excessive stress. The hours and pay can be good, but the stakes are much higher than in the other ROAD careers.
An old hospital maxim is, “when the surgery goes well, you compliment the surgeon, but when the surgery goes badly, you blame the anesthesiologist.” Anesthesiologists spend their days with the lives of patients literally in their hands. They are controlling the breathing and the heart rates of their anesthetized patients. When things go wrong in anesthesia, they go wrong in a catastrophic way.
Of all the medical specialties, anesthesiology has the widest access to the most addicting medications. All day long, anesthesiologists are handling heavy-duty tranquilizers, narcotics, and anesthetics. It’s not hard to see how daily stress and easy access to such drugs is a dangerous combination.
Even without the complicating factor of substance abuse, stress alone can be damaging. In fact, one study found that disruptive behavior, inefficiency, and medical errors occurred just as frequently in stressed, burned-out doctors who were not substance abusers as they did in those who did have substance-abuse issues.17
Burnout also leads to a large swath of physicians who aren’t as empathic toward their patients as they could be. These doctors don’t listen as carefully or thoroughly as they should, and they may brush off patients’ concerns. Like Joanne, they may be overwhelmed by anger and frustration. Such characteristics directly affect patients.
There is also a growing body of evidence to suggest that burned-out and emotionally fatigued doctors commit more medical errors.18 Measuring this precisely is quite difficult, but the higher doctors score on measures of burnout, the more errors they admit to making. In contrast, doctors who are more engaged in their work and life report fewer errors.19
A seminal study by the Rand Corporation followed twenty thousand patients and their doctors for two years.20 These were patients with ordinary chronic illnesses—diabetes, hypertension, heart disease, and depression—not acutely ill patients in the hospital. Patients and doctors alike were extensively interviewed. One of the most intriguing findings of the study was that patients were much more likely to take their prescribed medications when they were cared for by doctors who were satisfied with their jobs and lives. This is one of the first studies that directly linked doctors’ inner feelings (as opposed to their concrete actions) with improved medical outcomes in patients.
When I think about the times I’ve been most stressed in my job, I realize that some of the absolute worst moments have occurred at the nexus of work life and family life. In fact, they often take place at the precise moment I am leaving the hospital to pick up my children.
One day, when I was already in my coat, bag packed, hand poised to flick off the light switch, there was the dreaded knock on the door. It was one of my patients with diabetes, worried about a small ulcer on her skin that she thought might be infected. I stood frozen in my tracks, feeling a metal vise click in place around my temples. My patient needed help—skin infections in diabetics can be life-threatening—but if I stayed with her for the time it took to do a proper evaluation, my children would be left stranded.
The vise closed steadily tighter, squeezing from both sides. Every moment I spent with my patient would directly subtract from time with my children. I could have sent her to the ER and gone on my way, but I knew that the ER would be a ten-hour ordeal for her. She’d be evaluated by doctors who didn’t know her, who’d have to start from scratch to piece together her complicated medical history. They’d probably end up overordering tests to compensate. She’d probably spend the night in the ER. I knew that she had a family to tend to and that she couldn’t afford extra medical bills. I couldn’t bear to put her through all that.
In the end, I did what most physicians do—I tried to do both things and did neither very well. I rushed through an exam with my patient, attempting to accomplish the bare minimum of adequate medical care, and then I rushed to daycare, hoping the minutes would stretch so that I would be only a little bit late. I sprinted the whole way, arriving flustered, sweaty, angry, out of breath, still second-guessing my medical assessment of my patient’s infection, arriving to see dejected children and tight-lipped, annoyed teachers who’d had to delay their return to their own families.
This feeling of being caught, of not having control over a situation, of having family life sacrificed, of being damned if you do and damned if you don’t is what makes so many doctors want to quit.21 The fundamental issue is that our medical system places doctors in impossible situations and thinks nothing of it. It is somehow a given in medicine that doctors are expected to be in two places at once or to do two different things at the same time. This basic premise accounts for much of how the system survives, without much consideration for the effects on the doctors or their patients. But it doesn’t have to be this way. A simple scheduling example illustrates this.
For as long as I can remember, medical residents have had a conference at noon followed by a clinic that starts at one. Noon conference is on the seventeenth floor of the hospital building. Clinic is on the second floor of the ambulatory care building. The hallway connecting these buildings is the length of two city blocks. The elevators in each building are always crammed, especially during lunchtime. In the hospital building in particular, the doors almost always open to reveal a sardined elevator. Typically, you have to wait for five or six to go by before you could exhale all remaining breath and shoehorn yourself in, becoming more intimate with fellow hospital staff than you’d been the night before with your spouse. Alternatively, you could jog down nineteen flights of stairs. (The seventeenth floor of the hospital is actually on the nineteenth floor, because the first floor is on the third floor. Don’t ask.)
Conferences are an integral part of education, so to prevent residents from skipping out of noon conference, attendance is taken and absentees disciplined. Residents have a responsibility to their patients, so if the residents arrived late to clinic, they are disciplined for tardiness. Somehow, everyone seemed to manage. The schedule had always been that way, and no one ever thought much about it
“We’ve basically set them up to fail,” a new residency program director told me. The minute she described it that way, I saw the situation differently. Although everyone seemed to manage, in fact, no one was managing at all. Residents would try to sneak out of conference a few minutes early in order to get to clinic on time. Or they would tiptoe into clinic via a side door so no one would notice them coming in late. They’d cram lunch while flattened in the elevators, then sprint through the halls.
We’d created an impossible situation for them: they were required to attend a conference that finished at 1:00 in one place and also to be hard at work at 1:00 in another place that was a quarter of a mile and two elevators away from the first. Short of being beamed down Star Trek–style, the resident was doomed to disappoint at one end or the other.
So the program director changed clinic to begin at 1:15 for the residents. Not exactly rocket science, but no one had thought of this in the twenty years I’d been at Bellevue. Magically, everyone now seems to be punctual. (If only some of the other challenges of medicine could be solved as simply . . .)
Being set up to fail describes much of how modern medicine works (or doesn’t work) and why so many doctors feel overwhelmed, frustrated, and eventually disillusioned.
But then, there is someone like Herdley Paolini, a psychologist whose petite build and soft-spoken manner belie her eighteen-wheeler energy. The type of energy that would propel a nineteen-year-old who had been raised in a traditional Brazilian family where women didn’t leave the home until marriage to voyage thousands of miles on her own to pursue her academic dreams. She managed to raise the funds to embark on an adventure that was beyond her financial means, convince a conservative father to come round to her point of view, successfully navigate life in the foreign United States, and excel in her field of psychology. Passion, persuasion, and creativity allowed her to buck the system, succeed in uncharted territory, and keep her serenity and good humor intact—all without alienating those she cared about. These skills presaged her ultimate, unexpected career niche.
Hospitals traditionally refer “impaired” physicians like Joanne to outside programs for help. They don’t much want to step into the muck. But in 2002, Florida Hospital in Orlando decided to start a proactive wellness program. The term wellness has a ring of new-age hokiness to many physicians, but it’s the idea that being well is more than just the absence of disease. Being well is finding yourself on the positive side of the ledger, with actual happiness and fulfillment in life in addition to physical health. It seems fairly intuitive that people who are satisfied overall in their lives will do better at their jobs than people who are miserable and disillusioned. That satisfaction can come from many aspects of life—career, family, hobbies, spirituality, exercise, having a meaningful life philosophy.
This may sound like stuff that should fall into the personal sphere of life, not the professional sphere. But the CEO of Florida Hospital had practical concerns about physician disillusionment. Good doctors were quitting, and this was destructive to morale, not to mention terrible for patients. So he created this wellness program to proactively help physicians. Unfortunately, barely any of the doctors acknowledged its existence; even fewer showed up to any of its programs.
Then one of the doctors on the organizing committee remembered the psychologist in Michigan who’d helped him through a difficult time in his life. “She’s the person you need,” he told the CEO.
When Florida Hospital called Herdley and offered her the job, she said no. She had been living in Michigan for seventeen years, was managing a thriving private practice, and had children in high school. But they pressed her to at least come for a visit.
When Herdley arrived, she was impressed by the CEO’s commitment to this idea of wellness. She’d never seen such robust support coming directly from the top. There would be no red tape, he promised her. She would be free to create the program she wanted, and he would personally assist in removing any obstacles she encountered.
Intrigued by this unique opportunity, Herdley uprooted her family and moved to Florida. But before making a single move to create the program, Herdley decided to shadow the doctors of the hospital. For eight uninterrupted months, she ate breakfast with them; followed them on rounds; scrubbed in for surgeries; spent time in the clinics, the emergency room, the radiology suite, the doctors’ lounge. She embedded herself in the doctors’ world. “I learned the language they used,” she said. “I saw how their experiences pinned them down.”
She observed a lot of what Joanne had experienced: how the emotional complexities of patient care could wear down even the most committed doctor. There was more busywork than meaningful time with patients. There were all sorts of competing interests—from insurance companies to hospital administration to commercial pressures—that were never addressed. The demands and liabilities of medicine were squeezing out the affirmations and rewards. She saw how the medical system seemed to milk out the last bits of humanity between doctors and patients, turning them both into commodities to be tallied, measured, and codified. Doctors had no training in how to deal with this, and there were certainly no tools provided for them.
In the evenings, Herdley devoured every piece of research she could find about disillusionment and doctors’ socialization. She read up on the sociology of medicine, the details of medical training, even the history of medicine. She ended up with ten massive notebooks and a conclusion that the system had done a profound disservice to doctors, and, by extension, to patients. Doctors certainly had a role in the creation of this system, but they were the ones now suffering the results and not able to give patients their best. “There was little joy left in medicine,” she said. “The general population of doctors was miserable, and many of them couldn’t even see it. What they needed to thrive wasn’t being provided.”
Her first task was to create a safe space for doctors to talk and share experiences. She set up a weekend retreat for doctors entitled Art of Medicine—Relationships. She decided to obtain CME (continuing medical education) certification for the program so that doctors could use her program for their annual licensing requirements. When she submitted her proposal to the CME office for approval, it came back with a terse reply: What does this have to do with medicine?
If Herdley were a trial lawyer, she would have been able to turn to the jury and say, “I rest my case.” The CME office had unwittingly demonstrated precisely what the problem was.
Not only the CME office, though. Everyone thought she was crazy. She was told repeatedly that no one would attend such a drippy, touchy-feely sort of thing, especially something with relationships in the title. But Herdley’s months of preparation and personal investment paid off. The doctors trusted her and believed that she had genuine concern for their welfare. They didn’t view her as the usual administrative window-dressing they were accustomed to.
Thirty doctors attended the retreat, ordinary staff doctors who would never consider seeing a psychologist or joining something as sappy as a support group. But these ordinary staff doctors were bursting at the seams with stories and experiences that they wanted—needed—to share.
Herdley’s retreat has become an established annual event at Florida Hospital. Spouses and children are invited to attend so that families can also have quality time together during the breaks. This sort of peer support continues during the year with Finding Meaning in Medicine groups, based on the work of Dr. Rachel Naomi Remen.22 Doctors gather at one another’s homes to share stories and reconnect with the parts of medicine that often get lost in the morass of practice.
In addition to these directly supportive efforts, Herdley organizes social, cultural, and education events for the physicians as well as the rest of the medical staff, designed to demonstrate the hospital’s commitment to the importance of staff members’ well-rounded lives. When Herdley sent out a notice proposing a staff musical concert (Physicians in Concert), her fax machine broke down under the weight of the replies. Nearly five hundred people attended the concert, which has become another annual event.
When I was invited by Herdley to address the Florida Hospital staff, the lecture was held not in the typical bland auditorium but in the local art museum. The program included dinner, a tour of the museum, autographed books for everyone, plus the CME credit needed to maintain licensure. None of these perks were “necessary” for a standard academic lecture, but they transformed the entire experience for everyone—including me.
The mere fact that the hospital was devoting resources and energy to physicians’ quality of life seemed to have a salutary effect on the staff. The doctors are proud of the program and regard it as a mark of the hospital’s enlightenment, not as a source of shame. There is a modest budget from the hospital, but most of the money comes from the doctors themselves, who contribute willingly.
Herdley also offers private counseling to physicians on everything from daily frustration to family issues to substance abuse to full-fledged burnout. Herdley’s message to the staff is “I’m available to accompany you on your journey,” whether it be in the hospital, with a patient, or in private life. Herdley also makes a point of meeting individually with every single new doctor hired. She wants to make each of them aware from the get-go of the hospital’s commitment to the staff. She wants them all to know where her door is and that there is a place to turn to even for small things. Certainly before things become overwhelming.
The hallmark of the success and acceptability of her program is that 99 percent of the physicians who attend counseling do so voluntarily, based on the positive experiences of colleagues; they don’t wait to be ordered into treatment by a supervisor after something terrible happens.
The program is not a panacea for all the ailments of medicine, but it is a powerful investment in the idea that physicians are whole people and that the odds of their providing superb medical care are enhanced by tending to not just their medical skills but also their emotional and psychological well-being. Many such programs are getting good results.23
Little of this existed when Joanne was going through her crisis. Nobody was interested in hearing from doctors who were having doubts, who were overwhelmed, who were unraveling. “Suck it up” was the modus operandi. Real doctors were supposed to be immune to this sticky side of medicine or, at the very least, able to handle it discreetly, covertly, alone.
For Joanne, her crisis was a solitary experience, a lonely buildup of misery that came to the attention of her colleagues and hospital only when her world came crashing down. And even then, the only concrete action the hospital took was to remove her from the premises and then fire her. The exact opposite of what Herdley Paolini would prescribe.
For Joanne, leaving the emergency room behind was cataclysmic and humiliating. But it was also a relief. She described it as throwing off an enormous, painful weight. Joanne realized that she was utterly miserable in her job, that what she’d loved as a resident had eroded away. The joy of solving medical mysteries and helping patients get better had been erased, replaced by a bitter and festering resentment of patients who didn’t seem to care about their health and simply tossed their problems into her lap.
On March 5, 1993—twenty-four hours after she’d been escorted out of the emergency room inebriated—Joanne checked herself into a thirty-day rehab. She flung herself at recovery with the same energy she’d applied to her medical studies. She discovered that her inner energy and reserve were still there, despite the recent difficult years. And, as in her academic sphere, her determination and hard work paid off: the rehab was successful on the first go-round. In the two decades since the intervention at the hospital, she has not had another drink.
During her rehabilitation, Joanne had to wrestle with who she was. Like all of her family, she’d always—and only—defined herself as a doctor. Now what exactly was she? Was she an ex-doctor? A failed doctor? A non-doctor?
Contrary to what she might have expected, she actually did not feel like a failure as a doctor. She could look back at her years in medicine—short of the last few abysmal weeks—and feel satisfied that she had delivered competent medical care to her patients. But she also had to accept the fact that she was completely burned out from clinical medicine, disillusioned with the realities of trying to help the challenging patients for whom the ER was a primary source of medical care.
It was during this recovery time that Joanne began to appreciate the irony of her situation. She had been so intensely angry at her patients for their self-destructive behavior, and yet she’d done the exact same thing. This perspective gave her more sympathy for those patients and brought her some peace about her decision to leave clinical medicine.
Though her health was returning, she still found herself afloat in terms of career. She knew she could not be the kind of doctor who worked directly with patients. But with support from her family, and with her own research, she learned of the myriad other ways that doctors could use their medical knowledge productively. Joanne enrolled in a master’s program in public health and found that she loved it. The idea of improving the health of large populations by addressing such broader issues as immunization, screening, access to care, and patient education was appealing. This was how she could help patients avoid ending up in the ER. It was the best medical education experience she’d ever had. She was able to engage in improving people’s health without the interfering black shadows of frustration and anger.
There weren’t any jobs in public health available when she graduated, so she started doing medical writing to support herself and Jeremy. She found that she was good at it and could address the medical issues that she felt were important. She ended up getting a job in the field of continuing medical education. It wasn’t what she had planned, but it has turned out to be a gratifying way to put her medical and public health experience to good use—helping other doctors stay current in the medical field. This was her way to be a real doctor: she was able to help patients by helping their doctors, and she didn’t have to deal with the brutal frustrations of the ER.
Most doctors who are burned out, though, do not shift careers. They stay in medicine because it is the only thing they know. For those lucky enough to find someone like Herdley Paolini, they often find a workable way of continuing. Peer support from colleagues or working with a psychologist or psychiatrist can help a doctor reconnect with what was important in medicine in the first place. Other doctors need to make changes in their work lives—switch practice settings, cut back on hours—or in their personal lives. Focusing more on family, scraping together a little time for clarinet or basketball, or finally attacking Ulysses can strengthen the girders for them to face the challenges at work.
It also takes creativity, flexibility, and commitment on the administrative side to modify some of the structural frustrations of medicine. Simple things—like shifting the clinic start time from 1:00 to 1:15—can go a long way. Bigger things—like on-site child care with flexible hours—can be lifesaving. But it remains a sad reality that many doctors will simply live with the festering burn of dissatisfaction, a burn that will ultimately be felt by their patients.
Joanne considers herself lucky to have found a compromise that allows her to help patients and doesn’t eat away at her soul. Plus, there are other perks. “I get to go to sleep every single night,” she said. This may seem as mundane as breathing for most people, but for doctors, nurses, and other caregivers who have worked the night shift, the simple act of sleeping each and every night is a victory akin to reaching the Promised Land after forty years in the desert. “And,” she told me with a grateful sigh, “no one has thrown up on me in years.”