These are not isolated sentiments. Many, perhaps most, doctors share them. Consider the results of two recent studies. In a survey of 4,500 physicians, researchers found that 31 percent would choose a different profession if given the chance to start over. Factors such as work stress and poor control over their work environment weighed heavily in their opinions. The other study demonstrated a high level of emotional exhaustion in about one third of doctors. It is impossible for physicians to bear witness to a constant barrage of pain and death while remaining unaffected.
This is a timeless problem, but recent changes in our health-care system have exacerbated it. Among them is the increasing prevalence of managed-care organizations, each with its own set of rules and restrictions, and seemingly endless piles of referral forms and documentation. Physicians, battered by the loss of professional autonomy and the intrusion of administrative directives into the doctor-patient relationship, now find themselves reduced to generic “providers” and disfranchised “gatekeepers.” Meanwhile, the constant threat of malpractice litigation has created a culture of vulnerable physicians who must view each patient encounter as a potential legal and financial threat.
Physicians’ distress clearly degrades the quality of their personal interactions with patients. A typical day for a doctor includes listening to patients’ stories of suffering, fielding streams of good questions that often have no good answers, offering hopeful but sometimes uncertain advice, yielding decisions and performing procedures under the duress of time and sharing in patients’ most frightful and despairing moments. Physicians who are themselves feeling harried and abused will be far less capable of establishing communicative and empathetic relationships with their patients.
The importance of a concerned and caring doctor-patient relationship is only now beginning to be understood. In fact, scientific research is discovering that patient-health outcomes are most correlated with the quality of the relationship that doctors establish with their patients. Consider the results of a 1998 study of more than 6,000 patients and their doctors conducted by researchers at the New England Medical Center’s Health Outcomes Institute. They found that patient satisfaction, adherence to medical therapy and improvements in patient health were most correlated to patients’ trust in their physician, and physicians’ knowledge of their patients’ home life, health beliefs and personal values. In another study also published last year, researchers at the University of California, Davis, School of Medicine reported very similar correlations.
Our health-care system has hardly begun to absorb these lessons. Considering the potential consequences of physician stress on patient health, it’s surprising how little has been done to remedy the situation. Prevention, one of the most potent tools of modern medicine, has yet to be introduced into this arena.
Part of the problem is resistance inside the medical community. If you bring up the topic among doctors, the room clears out, possibly because of the pain it brings to the surface. Nonclinicians are no better. I tried to talk about physician stress with a respected layman, and his comment was that he was tired of hearing doctors whine.
Still, addressing the silent anguish of physicians will be necessary if we are to restore the caring and healing alliance between physicians and patients. Michael Balint, the renowned Tavistock Clinic psychiatrist, put it well when he wrote, “The doctor and the patient are influencing each other all the time and cannot be considered separately… the doctor must be able to carry on his work sufficiently at ease with himself.”
Society will have to learn to see the practice of medicine as an imperfect and evolving science. Patients, for their part, will have to accept that medical failure does not always stem from incompetence or lack of concern. Medical schools and residency-training programs will have to encourage and teach young physicians not only to care for their patients but also to care for themselves and their families. Hospitals, managed-care organizations and other health agencies will have to commit the resources to study and address this problem of physician stress and its impact on patient care. Finally, physicians will have to recognize and accept the emotional burdens they incur as a consequence of their work.
A growing number of progressive hospitals and university medical centers have already begun to address this last issue by holding seminars for medical staff focused on dealing with the strong emotions evoked in the care of the sick and dying. Changing this situation, however, will require more than a few isolated discussion groups. It will require a dialogue that has never before occurred in the public domain.
