Politics of health care are pulling doctors down

Physician Executive, Nov-Dec, 2006 by Niranjan Kissoon, David Matheson

Physicians of all ages, nationalities, and specialties are disillusioned with the present state of their profession. They are unhappy to the point that many have stated they would discourage their children from pursuing a medical career.

The reasons for this dissatisfaction include heavy workload, unreasonable patient expectations, loss of autonomy and an inability to fully understand and deal effectively with non-clinical aspects of practice.

These corrosive influences are not new nor did they sneak up unnoticed. Yet many of us are unprepared. It is also obvious that, at least in the foreseeable future, these factors will continue to exist. How then can the negative impact of these factors on medical practitioners be minimized?

Non-clinical impact

An examination of the differences in stress and burnout between pediatric generalists and subspecialists is instructive in pinpointing reasons for stress. Generally stress and burnout occur to a higher degree in physicians who spend a greater part of their professional life working in inpatient services.

An extensive survey by the Career Satisfaction Study Group suggested the need to balance outpatient and inpatient hours in order to relieve stress. (1) Having spent most of our lives in the inpatient arena we can appreciate the reasons for these differences. It is not that stress is absent in outpatient practices or in private practice but that these practitioners may have a greater feeling of being in charge.

Another reason for stress in inpatient settings may be the lack of formal training in dealing with issues such as managing conflicts within teams and managing stress effectively. (2)

A study of the metamorphosis from medical student to seasoned professional unearths some of the reasons for disenchantment in inpatient settings. These sentiments are condensed from thoughts expressed to us by medical students, residents, and junior and senior colleagues for many years.

Here's a look at the changes:

Medical school -- I will treat my patients according to the Hippocratic oath. I will have an exciting career and the sky is the limit. I am ecstatic by my choice of career. I will be too busy curing diseases to involve myself in "politics" and will leave those to others.

Residency -- I will do a good job, I will continue to treat my patients at the exclusion of everything else. I am happy with my choice of profession. I will not get into the politics of this business because it is not medicine.

Early years on staff -- I will treat patients well. I will do what is right for my patients and my family. I am getting dissatisfied with my job. I will tackle some political issues because it seems to be important to enable me to take care of my patients.

Later years on staff -- I am unable to do right by my patients. I am disillusioned and stressed. I am drawn deeply into the politics of our organization that I do not understand or feel trained to handle. I want to get out of medicine.

We contend that while there are myriad factors that may lead to disillusionment in physicians, the root cause is inadequate preparation in their formative years to deal with political, non-clinical issues.

It is difficult to stay silent when the conversation with a medical student or resident finally comes around to the politics of medical practice. It is difficult because we admire unbridled enthusiasm and wide-eyed innocence in treating patients.

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Enlightened physicians realize that attention to patients and grappling with politics are not mutually exclusive. However, one of our failings as educators and mentors is we protect our trainees from the realities of practice.

Medical students and residents are self-selected, highly motivated individuals who are eager and impassioned to do good, to push back the frontiers of science and change the world to benefit their patients.

They are idealist and driven to do what is right. They usually have a clear vision of what a physician should be. They adhere to the Hippocratic oath and have for the most part a romantic notion of medical practice.

They learn physiology, biochemistry, anatomy, have high IQs, high emotional intelligence and, like professional athletes, they hone their skills in a narrow field. At this stage of their career they think in terms of diagnosis pathophysiology and treatment of diseases.

Invariably they are shielded from the day-to-day personal interactions that we face. They are shielded from the radiologist or laboratory refusing to do a particular test, the transfer of patients out of the ICU as a response to pressures rather than the dictates of good care.

It is not uncommon to have in-depth discussions of pathophysiology and diagnosis for hours while many equally important issues relating to socialization, professionalism and market imperatives are shrugged off with the refrain "when you get out there you will see." (3)

Consequently, the realities of competing commitments in administration, research and patient care are foreign to them. Indeed both parties contribute to this neglect because, when invited to discuss these issues, trainees are reluctant because it is perceived as unpleasant and unrelated to medical care.