Friday, December 11, 2015

It's a Doc's Life

There is an old expression "it's a dog's life" used to describe a life that is hard and unpleasant.  That expression is probably outdated; most dogs seem to live pretty comfortable lives.  Based on recent research, though, maybe we should be saying "it's a doc's life" instead.

It has kind of a certain ring to it, don't you think?

Let's look at some of the new research, starting with a study by the Mayo Clinic.  They updated a survey they did in 2011, and found a number of disturbing issues, including:

  • More than half (54%) of physicians report at least one symptom of burnout.  That compares to 45.5% in 2011.
  • Only 41% of physicians reported being happy with their work-life balance, compared to 48.5% in 2011.
  • Physicians fared worse on both burnout and happiness with work-life balance than the overall population, even adjusting for age, gender, relationship status and hours worked.
  • Pretty much every specialty showed declines on both burnout and work-life balance.
The authors believe that American medicine is at a "tipping point" due to the burnout and lack of work-life balance, and that there is an urgent need to address the underlying causes.  It'd be hard to disagree with them.

The study would be disturbing in its own right, but it is not the only such study that showed up just this month.  A study in JAMA by Mata, et. alia found that almost 30% of resident physicians reported depression or depressive symptoms.  As one of the authors said:  "What we found is that more physicians in almost every specialty are feeling this way and that's not good for them, their families, the medical profession or patients,"

No kidding.

The study was a meta-study, analyzing results of other studies, and the prevalence ranged from 21% to 43% in the various studies, so the 30% may be conservative.  As with the Mayo study, the problem appears to be getting worse, with the results showing a slight but statistically significant increase over the five decades analyzed.

An accompanying editorial called resident depression "the tip of a graduate medical education iceberg."  It notes that training itself has changed little from the 1950's or 1960's, while "the actual delivery of medical care in 2015 would be unrecognizable to those same physicians."  New care options and resulting ethical dilemmas, more pressures on reimbursement and on demonstrating value, malpractice concerns, EHRs, and increased patient demands create a world that the graduate medical education system leaves residents ill-equipped to deal with.

The editorial calls for a fundamental rethinking of our approach to the graduate medical education system.  Again, it'd be hard to argue with that conclusion (and the rethinking shouldn't be limited to graduate medical education).

If any further evidence of a problem was needed, the 2015 Commonwealth Fund International Health Policy Survey of Primary Care Physicians provides some.  I'll leave the international comparisons for another day, but I was struck by a few of the findings for U.S. primary care physicians.  Twenty-four percent report not being well prepared to manage patients with multiple chronic conditions.  Less than half are well prepared to handle patients needing palliative care or long term home care, or patients with dementia.  And less than a third are prepared for patients needing social services, those with mental health issues, or those with substance use issues.

Given that one in four of American adults have multiple chronic conditions, one in five have mental health issues, and about one in ten have substance use issues, well, I'd say primary care physicians should be pretty worried.

No wonder that only 16% of those U.S. primary care docs think our health care system works well (which was, by the way, by far the lowest across the 10 countries), or that 43% report their job is very or extremely stressful.  No wonder they're getting burned out.

Despite the above findings, another JAMA study found that at least one kind of primary care physician -- family practice residents -- still had high hopes.  Family practice residents reported that they planned to provide a broader scope of services than practicing family practice physicians, such as prenatal care and inpatient care management.  Whether that is recognition of a changing role or simply naive expectations remains to be seen.  As one of the authors told Reuters, "it may be that the previous generations have had these same intentions and for numerous reasons are not able to practice the way they intended."  

In other words, real world, meet residents.  Residents, real world.  Try to get along.

Look, I get it.  Being a physician is not what it once was.  No more physician-as-God, no more white coat mystique.  Their business model has radically changed from largely independent artisans to more typically being employees with productivity expectations, whose judgement is constantly challenged by patients, payors, administrators, and/or lawyers.  That must be hard to accept.

But, then again, I don't know many people who don't think their job hasn't changed significantly in the past twenty years, with more pressure, higher expectations, 24/7 demands, and more reliance on technology.    Physicians can rightfully argue that their role is different in that people's lives depend on their decisions, but other professions -- e.g., police officers, air traffic controllers, even civil engineers -- could claim the same.  

It's tough all over.

We should be worried that physicians are depressed.  We should be worried that they feel burnt out.  We should be worried that they don't feel ready to manage the kind of complex patients they are seeing more of.  These are problems that need to be recognized and addressed.  But the life of the physician isn't going back to what it was in the 1960's, and that is not a bad thing.  

It should be a great time to be a physician.  We've never known as much about what causes various health issues, never had as many diagnostic tools, never had as many treatment options, and never had as much potential for people to be educated about their health and to be an active participant in their care.  If all that isn't exciting to someone, perhaps being a physician isn't the right profession.

For what it is worth, both medical school applicants and enrollees have reached record levels.  Let's hope they're not in for a big disappointment when they find out what a doc's life is really like.

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