Thursday, November 17, 2011

Medicine's next-generation doctors have different priorities

Doctors are, famously, workaholics. That's just the way it's been forever, at least as far back as my memory goes. You work crazy hours in residency, you graduate and work like a dog to establish your practice or to become a partner in your practice, and then you live out your career working long hours because there just aren't enough hours in the day to do everything that needs to be done. I remember, growing up in the '80s, that my friends whose parents were doctors were latchkey kids whose dad (usually the dad, then) was never at home when we were hanging out in the rec room playing Atari.

Yeah, Atari. Look it up, kids.

Not much had changed by the time I went to medical school. There was recognition of the fact that burnout was an issue, that divorces, alcohol abuse and suicides were more common among physicians than in other professions. The unspoken implication was that being a doctor was difficult and stressful, which increased the risk of these consequences of an over-burdened professional life.

These stresses were accepted as part of the turf, as a necessary part of "being a doctor." It wasn't optional, and indeed, most physician teachers that addressed the matter chose to sublimate it into a mark of nobility. Being a physician was a calling and a duty, and a physician must gladly subordinate his or her own happiness and well-being to the service of their flock.

But things have changed, or at least a slow shift is in progress. It was probably ongoing when I was in training, though I was pretty oblivious at the time. I see it more and more clearly as time goes on. Young physicians have different priorities now, and they are making career decisions based on a more self-centered set of values.

For example, a study in American Medical News, cited by @Skepticscalpel, revealed that graduating residents place "free time" and "lifestyle" as their top priorities in choosing a position, above even financial considerations. Young doctors are opting for large multispecialty practices and for hospital employment in droves, stable and predictable practice environments, and the practice model of small group or independent practitioners withers on the vine. At the same time, driven by slightly different motives, residency hours are being restricted.

This has provoked a chorus of curmudgeonly disapproval from many, especially from within the surgical specialties. Skeptical Scalpel himself mused: "Does all this bother anyone else? I wonder what people expected? Did they not know that being a doctor involves commitment and self-sacrifice?"

One commenter was rather more direct: "Being a doctor is not a job like being a banker or contractor. It is a life. The decision to become a doctor should carry as much weight as the decision to enter the priesthood. Medicine is not a dilettante's profession. Make the commitment or get out."

Which, I think, aptly summarizes the position of the "old guard," the guys who paid their dues and expect the next generation to do the same. But we (and I still include myself in this group) who are younger don't agree, at least not entirely. It seems like the demands of this profession are, in part, not intrinsic to the job but rather culturally and institutionally generated, and thus, subject to change.

Why should I spend my entire career working 60 hours a week? Is that necessary to maintain my skills? Is it worth the cost to my family and my personal life? Is it more important to me that I be a "good doctor" than it is that I be a good father and a good husband? I don't think so, and in fact, personally, I identify myself more as a father than a doctor.

Note that I am referring to a career, not to training, where there is some argument in favor of intense experience. That is a different topic.

So I am entirely in favor of the movement towards more humane and livable practice environments for physicians. And I do not think this movement is going to reverse itself, but rather, will become the new standard going forward. The phenomenon of cohort replacement, or "the replacement of old guards of organizational members and leaders with newer cohorts who have different beliefs, opinions, and values," will likely slowly but inexorably change the culture of medicine towards one in which the accepted, default position is that physicians have robust extra-professional lives.

John Mandrola, an electrophysiologist, is cautiously supportive of this transition, but poses the unsettled question of whether this is good or bad for patients.

To some degree, it's a clear win for patients. A well-rested surgeon performs better. An ER doc who is suffering from burnout is not the one you want treating your child. An internist who retires at age 50 because the office life is too demanding represents "brain drain" as the most experienced and valuable docs flee the workforce.

The surgical and procedural-based specialists seem to have the most resistance to this change, and they do have some valid points. There is a correlation between how many times you do a procedure and how well you do it. You can learn to do a lap chole in residency, but you may not be really good at them until you have done a few hundred in the first few years of your practice. Further, surgeons have a different relationship with their patients, usually shorter duration but much more intense. This makes it harder to place boundaries on intrusion of their practice into their personal lives.

However, these hurdles are logistical barriers which can be overcome, at least in part. The use of trained and experienced physician extenders can greatly streamline the non-operative elements of care and allow the surgeon to focus his or her time where it carries the most value: in the OR and at the bedside.

The greater question of whether this is good for patients relates to the looming physician shortage. If physicians, as a group, are cutting back on their time at work, this will require a larger workforce to deliver the same amount of care. There are some efficiencies that can be gained, especially through the use of PAs and NPs, which may mitigate the matter. However, it's hard to escape the conclusion that the trend towards a firmer life-work boundary for doctors will exacerbate the physician shortage.

I don't think that's an argument against greater work-life balance in medicine. That's still good policy. The consequences need to be acknowledged and addressed, and it's worrisome because little is being done to address the physician shortage in the first place. But it doesn't change the fact that the ability of doctors to have stable and fulfilling extraprofessional lives is good for both doctors and the patients we serve.

And in any case, the argument of whether this is a good thing or a bad thing is about as important as a debate over the tides. It's happening, as the result of thousands of individual docs all making the same personal choices, and it's very unlikely to change. So we had best recognize it and make plans to deal with it.

This post by Liam Yore, MD, appeared at Get Better Health, a network of popular health bloggers brought together by Val Jones, MD. Better Health's mission is to support and promote health care professional bloggers, provide insightful and trustworthy health commentary, and help to inform health policy makers about the provider point of view on health care reform, science, research and patient care.

Labels: guest post, medical education, work hour restrictions, work-life balance

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Thursday, November 17, 2011

Medicine's next-generation doctors have different priorities

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