Integrity, compassion, altruism, continuous improvement, excellence, working in partnership—these are the values of medical professionalism, according to a working group formed by the Royal College of Physicians in 2005. More recently, ideas about professionalism have focused on the attributes required for a modern doctor to fulfil their roles as healer, innovator, researcher, and patient partner. But much of the thinking around medical professionalism remains rooted in an idealised, traditional, and paternalistic foundation of self-sacrifice and service to humanity, in which the perceived good doctor prioritises the care of their patient over all else. The mental and physical strains caused by living up to this standard can aggravate many of the factors that influence physician wellbeing, including balancing home and work life. When other aspects of professionalism, such as autonomy, have been eroded, are we left with a shell of values that have become harmful to doctors and their wellbeing?
A Review in The Lancet shows how mental illness, substance use, and suicide are leading issues in physician health. The evidence comes largely from self-reported observational studies, with very few data from low-income and middle-income countries. But in high-income countries, consistently, and regardless of geography or specialty, rates of depression, anxiety, post-traumatic stress disorder, and alcohol use tend to be higher than in the general population. The authors note that this trend is not unusual when surveying specific occupations. But suicide rates also appear to be higher among doctors than in other occupations, with female physicians at particular risk. In the general population men tend to have higher rates of suicide than do women, so this finding is particularly concerning. In the USA, estimates suggest one physician dies by suicide every day. Burnout is an additional but overlapping problem—the authors acknowledge that “it is possible to be burned out and not depressed, and vice versa.” The risk factors for many mental health disorders in doctors and burnout include sleep deprivation, excessive or conflicting job demands, long hours, and an imbalance of home and work life.
These risk factors are likely to intensify when trying to see enough patients and keep them safe in an overly stretched health system, which—due to increasing demand, ageing populations, and COVID-19—is most health systems. Balancing the needs of the physician and the need to safeguard and serve patients can be difficult. There are clear cases in which behaviour can be considered unprofessional because it risks patient lives. More often though, physicians with mental illness, or those simply struggling to balance their workloads, are not behaving inappropriately and are doing their job competently, but at the expense of their own happiness or wellbeing. Many surveys show that physicians are planning to leave an already understaffed workforce after COVID-19, possibly because it has become unsustainable to work as a doctor and to care for oneself and one's family.
There is great benefit in constructing a set of values around professionalism. It allows unity in a greater societal mission, and provides a framework and language for medical students and trainees transitioning into a complex world. It can also benefit patients and colleagues by forming standards of conduct. But there are downsides. The characteristics and rules of professionalism are made by leaders who are often selected from a narrow pool of candidates in terms of gender, ethnic origin, socioeconomic status, and sexual orientation, and who are not doing the heavy lifting of front-line work. The natural bias is to retain power, creating a set of expectations that only they and a progeny in their image can live by, thereby smothering diversity. There is comfort in being able to brand behaviours and characteristics as professional or unprofessional, but this type of professionalism can be punitive and sacrifices the psychological safety of physicians at work. Such simple thinking is holding back a conversation about doctor's wellbeing. It also supports a set of societal values that have consistently underinvested in health-care professionals by asking physicians to do more at the cost of their own health. The COVID-19 pandemic has only amplified these issues.
Modern professionalism must have self-care and self-awareness as one foundation, but those who lead health systems must adapt and—most importantly—invest to enable this transformation. Such an approach will improve physician health and help to retain experienced staff in the workforce. A professionalism that is reconstructed by combining the agendas of right to health, equity, social justice, diversity and inclusion, physician wellbeing, and workforce planning will be better for physicians and those in their care.
For more on suicide rates of physicians in the USA see https://www.medscape.com/viewarticle/896257
For the British Medical Association survey on exodus of physicians see https://www.bma.org.uk/bma-media-centre/thousands-of-overworked-doctors-plan-to-leave-the-nhs-bma-finds
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