The Privilege of Being a Physician and the Immutable Values of the Medical Profession

Abstract

The medical profession has been, is, and will continue to be under siege by a variety of sources most of which are external to the profession and not under our control. The consequences of this unrelenting pressure are leading to burnout, early retirement, and low career satisfaction. Arguably, these and perhaps other not-well-recognized factors has influenced the well-being of physicians and culminated in a high suicide rate in the profession. However, the pressures that our profession have been under over the last 2,500 years, albeit less pronounced than the current ones, have been successfully navigated by going back to the foundational values of medicine that are both intemporal and immutable. We should stand by these principles and defend the description of the Ideal Internist; these principles should guide how health care is delivered as they are rooted in the fiduciary commitment our profession has made to society since the Hippocratic Oath was written.

INTRODUCTION

Contemporary medicine has brought to patient care amazing changes most of us would not been able to forecast even two decades ago. Despite such prodigious advances and their positive impact on patient outcomes such as mortality and quality of life, the medical profession feels under siege. However, this unrelenting pressure on physician well-being and satisfaction is not new and seems unlikely to lessen in years to come.

The concern about physician burnout and career dissatisfaction has become an increasingly louder outcry of practicing physicians (1). Even more devastating, the risk of committing suicide among physicians is twice that of the general population (2); as of 2009, it is estimated that 300 to 400 physicians, or the equivalent of three to four graduating medical school classes, are lost to suicide. Such stark realities prompt me to reframe my thoughts about the medical profession in terms of the challenges of practicing medicine in the 21^st century.

My first encounter with the conundrum of how to better prepare a general internist for the practice of medicine was while serving as a chief medical resident in 1987; at that time a Task Force at Henry Ford Hospital was created to attempt to define what the best training ought to be based on the attributes of the Ideal Internist (3). It is intriguing to notice that the challenges identified by the Task Force 30 years ago have great similarities to those we have grave concerns about these days. It is even more intriguing to see as a response to these challenges attributes that have been espoused since antiquity (Figure 1). Since 1987 I have held the belief that medicine has immutable and intemporal values that are under constant siege from external forces that I will argue are both mutable and temporal.

Fig. 1.

The tension between the substance and style of medicine.

On the next few paragraphs I will elaborate on the tension between the immutable and intemporal values of medicine and the external pressures imposed on the contemporary practice of medicine. I will review troubling data regarding the practice of medicine, suggestions of how we ought to train 21^st physicians, concerns about such recommendations, and share with you what being a physician has meant to me and why the values that fuel my pride for the profession should be preserved as motivators for being a physician because they serve as the best predictors of our patients’ wellbeing.

Our young colleagues joining the practice of internal medicine, be it specialists or subspecialists, face daunting obstacles as they are being judged by the amount of “relative value unit” (wRVU) produced, which in turn is based on how well the documentation of services is captured on the electronic health record (EHR). Add to these requirements those related to multiple chronic medical conditions and the “meaningful use” of the EHRs, and you can understand the growing dissatisfaction with the practice of medicine. It would be fair to say that the world in front of them looks something like cluttered with words and acronyms that are at least confusing (Figure 2). The image of the caring physician so well captured by Fildes in his painting “The Doctor” seems foreign (Figure 3).

Fig. 2.

The overwhelming current health care delivery environment.

Fig. 3.

“The Doctor” by Luke Fildes. On display at Tate Britain, London, England.

Hence, faced with such dissonance, it should come as no surprise the amount of data quantifying the burnout and satisfaction with work-life balance among practicing physicians (4,5). Nationwide, surveys of physicians have found that the general internist’s level of burnout is second only to that emergency room physicians and their satisfaction with work-life balance feels more like that of a general surgeon. Furthermore, as a profession, our measures of both burnout and work-life satisfaction are some of the lowest across all major professions. More recent data suggest that the level of burnout is worsening.

One explanatory variable for such levels of burnout and dissatisfaction could be the inordinate amount of time spent by physicians in four specialties in the care of patients (6). In these high-functioning practices, the physician spends 2 hours for each hour of direct patient contact. Remarkably, more than 60% of that time was spent reviewing the EHR. In addition, for those physicians who kept an after-hours diary, an average of 1 to 2 hours was spent in EHR documentation after leaving the office. This professional environment affects the work-life balance of physicians in serious ways.

Despite such compelling and sobering data, the pressure on training programs continues to mount in terms of addressing perceived shortcomings in training programs so that our graduates may be adequately prepared to enter this new and much trumpeted improved health care delivery system.

In a widely quoted paper published in the journal Health Affairs, chairs of different clinical departments at a large health care organization opined that graduating physicians were ill-prepared to face the exigencies of modern practice (7). Noted were shortcomings in a large number of domains, with the conclusion that training of the new generation of physicians needed to incorporate such domains during residency. Such calls for reducing the so-called training-practice gap have been requested for more than a decade, and the ongoing debate of how internal medicine residents ought to be trained rages; the skill set at the end of training that would address the training-practice gap would emphasize cost containment, physician order entry mastery, and familiarity with decision support systems. While each of these skills is indeed important to practicing physicians, they should not become the pillars of training nor guide how physicians ought to be trained.

Some of us have vigorously opposed such calls for training reform as we have the strong-held belief that the well-trained internist, perhaps best represented by the Oslerian model of generalism and supported with appropriate incorporation of modern tools, is what is lacking and what is needed (8).

The real conundrum for me is to understand if we are, in a subliminal way, replacing the immutable and intemporal values of medicine with the temporal and mutable tools of medicine which can be in many cases subversive to the core of who we are. I feel the profession should be guided by the immutable values of the profession and not allow the temporal and mutable aspects of what we do become the guiding principles (Figure 1). During the last 50 years William Hurst and Tinsley Harrison have warned about the eroding skills and values that an internist ought to have to be able to practice the art and science of medicine (9,10).

What are these values and why do I argue that they have exerted such a powerful influence on us? I would answer the latter question first by arguing that what is fulfilling to us makes us better. It is well known that all of us respond differently to motivators, being those intrinsic or extrinsic. However, and thanks to seminal work presented by Daniel Pink (11) in his book Drive, there is ample evidence that intrinsic motivators trump external motivators. Such internal motivators are mastery, autonomy, and purpose. As such, the bar of soap from the indigent mother of a patient I cared for during my Acting Internship in my native Peru or the bubble gum from a Japanese speaking patient in the wards of a Kyoto hospital are among the most memorable triggers and most powerful motivators I can think of in my long career.

How can these thoughts and reflections make a difference on the training of the future generation of physicians? After all, while such memories can be inspiring, they are largely not helpful unless I can articulate the reasons why such experiences had impacted me and provided the intrinsic motivation to embrace the medical profession. The question became: Is virtue something we can teach or role model? If so, how can I translate into something that can be taught and shared?

After long deliberations with colleagues and countless hours of self-reflection, I have concluded that it is the influence of mentors, personally for me over the last 35 years, and as a profession for the last 2,500 years, that have created the foundations upon which the edifice of medicine has been built and that such principles are worth fighting for and preserving. I’m sure such heroes or mentors are integral parts of the careers of most physicians and hopefully the conclusion to be reached is that the ideals and values they so transmitted were provided to them by similar mentors and that possibly such ideals and values can be tracked in time.

Hippocrates of Cos who lived around 500 BC, and is recognized by many as the Father of Medicine, is a great starting point as a beacon for the medical profession. While Hippocrates’s theories of health and disease have long ago been disproved, many of the traditions and virtues he so eloquently espoused in the Oath endure 2,500 years later. While the Hippocratic Oath has important shortcomings, the sense of duty, integrity, ethical behavior, and selflessness that permeates the document have survived the many turns and twists humanity has gone through since its writing.

Hundreds of years later, Avicenna the great Islamic polymath, preserved the thoughts of Hippocrates and Galen through the dark medieval times and the Jewish scholar Maimonides wrote himself a powerful rendition of the meaning of the medical profession. Moving forward to the 20^th century, heroes and mentors like Sir William Osler, Francis Peabody, and Tinsley Harrison continue to remind us, in their uniquely eloquent styles, the importance and centrality of the well-being of our patients and the immense responsibility of transmitting such ideals and values to future generations.

Needless to say, Osler and Harrison never had a chance to drink wine with Hippocrates or Maimonides, and certainly my mentors never had a chance to spend time with Osler during his time at Hopkins. Not even the iconic Harrison had the opportunity to work directly under Osler although he was deeply influenced by his teachings and views. Those who have so deeply influenced my career were also deprived of interacting with such individuals, yet their values and principles were embraced by them and transmitted to many others and me.

I found remarkable that 2,500 years later, many of us tell our students and residents the importance of the fiduciary bond we have to our patients, the importance of our observing ethical principles, the immense responsibility of teaching the future generation of physicians, and the importance of excelling at what we do by being lifelong learners. The only conclusion I can reach from these musings is that there are certain values of medicine that are immutable and have been carried forward despite rather diverse religious, philosophical, and political points of view. I have a difficult time imagining any other profession, other than perhaps religion, that has the capacity of making its values last for such a long time.

During the last few years I have spent the vast majority of my clinical time within the confines of a Veterans Administration Hospital; I called this institution, without a doubt with a great deal of cynicism, the last bastion for the academic clinician educator. I say so since I can practice the sort of medicine that best embodies my beliefs and hopefully those of my mentors. I spend too much time writing long daily progress notes that will never be “savvy” enough to get a high billing code. Similarly, my admission notes, while comprehensive in many ways, might not include the details needed to codify accurately for a high comorbidity index. I write such antiquated notes because I want my trainees to understand the importance of expressing diagnostic and management in a logical manner. Finally, and hopefully serving as a role model, I spend sizable time counseling, consoling, and explaining choices to the veterans I so proudly serve.

Does such a view of medicine make me virtuous? If so, it is the byproduct of those who have influenced me during my formative years and my professional career. As such, and while I am a supportive and active member of quality care and patient safety committees, and a believer of the rational use of resources, I would continue to espouse and be a role model, to the best of my abilities, for the intemporal and immutable values of medicine.

Hence, I would like to continue to strive to appreciate the meaning and privilege of being a physician similar to the one that Tinsley Harrison described so eloquently and poetically more than 65 years ago:

No greater opportunity or obligation can fall the lot of a human being than to be a physician. In the care of the suffering he needs technical skill, scientific knowledge, and human understanding. He who uses these with courage, humility, and wisdom will provide a unique service to his fellow man and will build an enduring edifice of character within himself. The physician should ask of his destiny no more than this, and he should be content with no less (12).

DISCUSSION

Higgenbotham, Philadelphia: Probably embedded in your learning to learn is opportunity to collaborate with others as we move into team-based care, if you will, and that could actually perhaps ameliorate some of the physician burnout. So, I actually see The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) as an opportunity to move from volume to value and really elevate that opportunity to collaborate with others. Do you want to comment?

Heudebert, Birmingham: I don’t want to overemphasize MACRA and I think we will hear some of it from Bob Doherty tonight. But let me tell you that for small practices in Alabama, trying to just get to MACRA is going to be extraordinarily difficult. So, yes I think they are going to benefit from high-value care, and I believe that is a step in the right direction. I am just concerned that 10 years from now we will be talking about something else, and I want to be sure that when we talk about something else it’s always got to be driven by who we are and not necessarily by what people are telling us we should be doing. So, I am not against MACRA, although I think it will be difficult to implement it in small practices.

Thibault, New York City: Thank you for that excellent presentation: Telling us about challenges but reminding us about core values; and I think you got it right. Let’s hold on to what is dear but let’s do the other things that are variable. We have just finished six regional conferences on GME innovations. And we have heard about a lot of exciting innovations. We can’t keep on trying to train people on yesterday’s way and address these problems. I think we can have our core values but we need to look at new ways to do the training that are more longitudinal or community immersive; more team based. So, we need to let go of some things, but not our values, but we need to embrace the innovation and training that will better prepare people for this changing world. Thank you for reminding us of that.

Heudebert, Birmingham: I am with you 1000%. We are going to have to figure out how we are going to manage GME funding which is so difficult to accommodate. To be able to put in our residents in practices that allow them to really enjoy being a general internist. It can be done.

Ludmerer, St. Louis: Thank you for those remarks. A footnote might be useful. ACGME is taking the issue of physician and resident wellness very seriously. It has created a task force on physician resident wellness. I happen to be serving on the task force. Our first meeting was in September, and it might be helpful to point out two things: the first thing that burnout is different from depression and suicide. The two are often conflated and that is an error. And secondly, it also might be helpful to point out that many have the problems that you correctly indicated. They are not new and they go beyond the electronic health record as important as that is. But there does seem to be something in our training environment that is hostile, that is a hazing process, and sociologists since the time of Robert Merton and Renée Foxx in the 1940s pointed out the development as cynicism among residents and students coming from the learning environment and the hazing process and everything associated. That too might bear some attention.

Heudebert, Birmingham: Absolutely. We just finished actually getting data from the Maslach Burnout Inventory across all our almost 1,000 residents. And we’re doing the same with the medical students. And the faculty actually tend to be the forgotten third piece that we are not looking at. And we’re conducting this survey because we really would like to know what is in the learning environment that is causing our trainees to experience so much burnout. So, I am 100% with you and I think we need to move quickly. The cynicism sets in at very high rates during residency training.

Baum, New York City: Just to put this in numerical perspective, the burnout starts before the flame has been lit. Fourth-year students get a graduation questionnaire, and one of the questions is: “Were you to have a chance over again, to go to medical school, would you?” Nationwide, the result was that 10% of the students graduating from medical school say either “No, I would not do it again” or “I am not sure whether I would do it again.” The burnout, therefore, is starting quite early.

Heudebert, Birmingham: For the last 2 years we actually have now a year-2 questionnaire and a year-4 questionnaire. Unfortunately, they start very idealistically. But at year 2 they are already taking a hit. But it’s actually those two clinical years where they actually start to make up other questions regarding satisfaction with the career choice. It seems to be the last 2 years. I don’t know about hazing, but it seems to be some signal in the last 2 years of the medical education system.