Is Medicine still a "learned profession", or has it become "just another job"?
Is Medicine still a "learned profession", or has it become "just another job"?
Thoughts on why doctors are burning out
When chronic stress in the workplace is not properly addressed, the workers burn out, with symptoms including:
feelings of energy depletion or emotional exhaustion,
mental distancing (depersonalization) from the work, including feelings of negativism or cynicism related to one's job, and
a sense of ineffectiveness and lack of accomplishment.
Canadian doctors are burning out
In 2021, physicians in Canada were showing the signs of burnout.
Of course, at the time, we were one year into the pandemic, so you might think that would explain it. However, there was also a problem in 2017, well before the pandemic.
Given the way things have gone in the healthcare system since the pandemic, I have no reason to believe that the situation is improving. Things are more stressful than ever, and it’s hard to say that the systemic problems are being addressed.
Granted, physician burnout isn’t unique to Canada, but Canada is among the worst.1
What is burnout?
You might be thinking that medicine is, by its very nature, a stressful occupation, and that the increasing levels of burnout must reflect a problem with individual doctors who, for some reason, can no longer cope with their workload. Taking that a step further, where it affects younger doctors to a greater extent, you might even be thinking that it’s a generational problem.
However, as the experts explain it:
“We believe burnout arises from the increasing mismatch between workers and workplaces. As the WHO definition explains, the occupational phenomenon of burnout is the result when chronic workplace stressors have “not been successfully managed.” If conditions and requirements set by a workplace are out of sync with the needs of people who work there, this bad fit in the person–job relationship will cause both to suffer.”
“We’ve found that these bad mismatches often have their roots in erroneous assumptions about what makes people tick—what motivates them, what rewards them, and what discourages them. In other words, there is often a misunderstanding of basic psychology. The more that [working] conditions depart from employees’ aspirations or preferred ways of working, the more employees are vulnerable to burnout.”
So, burnout is NOT simply a pathological response of individual doctors to the normal demands of a stressful occupation in a functioning workplace.
You won’t stop physician burnout by “fixing” the doctors, one by one, perhaps by trying to improve their “resilience” or “adaptability”.
In fact, physician burnout is the INEVITABLE response to the EXCESSIVE and EVER-INCREASING DEMANDS placed on a stressful occupation in an INCREASINGLY DYSFUNCTIONAL system.
With half the physician workforce showing symptoms of burnout, we need to fix what ails the system.2
What makes doctors tick?
If we want to reset the healthcare workplace to be more “in sync” with the needs of the doctors who work there, then we’ll have to revisit what motivates, rewards, and encourages them.
First and foremost, although it sounds obvious, it bears repeating that the traditional role of medicine is to heal disease or sickness. As a society, we expect doctors to provide compassionate and effective treatments to unhealthy individuals. This role is quite specific (because there are only so many sick people) and somewhat limited in scope (because once the disease is eradicated and the patient is restored to health, then the job is done). For diseases that cannot be eradicated, like diabetes, the physician continues to treat the patient, the goal being to get them as close to normal as possible. Either way, there’s a relatively finite amount of effective work to be done, and there’s a “payoff” for the patient, who feels better, and for the physician, who contributed to the improvement. Making people better motivates doctors, and succeeding in that quest is a reward unto itself. Anything else is just “spinning the wheels”, with lots of smoke and noise, but no meaningful progress.
As healers, society expects doctors to be competent, respectful, altruistic, trustworthy, and accountable. Indeed, the people who get into medical school and eventually become doctors are specifically selected for those traits.3
Doctors, in turn, have some expectations of society, in recognition of their lengthy education and training process and the fact that they have chosen to apply their knowledge and skills to heal others.
They expect to be granted sufficient autonomy to act in the best interests of their patients, subject to local customs, codes of ethics, and legal constraints. They expect trust, status, and certain rewards. Having mastered a large body of complex knowledge, while upholding high standards of care, doctors expect to be granted a “monopoly” of sorts on certain aspects of their work, generally through a process of licensure.4 Recognizing all of that, the profession seeks the autonomy to regulate itself, within limits and according to guidelines established by law.
Most importantly, physicians expect to work within a functioning health care system, one which supports, not subverts, their traditional values as professional healers. They expect society to provide sufficient resources so that individual physicians can properly care for their patients.
In short, doctors consider medicine to be a “learned profession”, as defined by Wikipedia (emphasis added):
A profession is a field of work that has been successfully professionalized. It can be defined as a disciplined group of individuals, professionals, who adhere to ethical standards and who hold themselves out as, and are accepted by the public as possessing special knowledge and skills in a widely recognised body of learning derived from research, education and training at a high level, and who are prepared to apply this knowledge and exercise these skills in the interest of others.
Professional occupations are founded upon specialized educational training, the purpose of which is to supply disinterested objective counsel and service to others, for a direct and definite compensation, wholly apart from expectation of other business gain. Medieval and early modern tradition recognized only three professions: divinity, medicine, and law, which were called the learned professions.
Our healthcare system is broken!
Because the medical culture they are immersed in from day 1 emphasizes service to others, perfectionism (or “quality of care”), self-sacrifice, and delayed gratification, doctors have to be resilient and adaptable. They’ll strive to do their best for the patient, even when there’s personal cost.
Unfortunately, for far too long, our healthcare system has relied on that resilience and adaptability to keep things going. That’s a problem!
“People are the most adaptable element in any complex work system. This adaptability is essential in making things work, both in ordinary and especially in extraordinary circumstances, but it is generally invisible to both outside observers and actors in a field of practice; it is often “hidden in plain sight” because it works so well that it fades into the background. The tragedy is that this adaptability makes dysfunctional work systems and practices appear to be performing better than they actually are.
In the end, these invisible adaptations, filling gaps as they appear, can leave frontline workers ‘twisted like pretzels’ around poorly designed or frankly dysfunctional systems as they contort themselves to get their work done. Simultaneously, they leave managers with the false impression that things are going well….”
A large part of the problem is the overly simplistic approach we take in diagnosing and fixing the problems that plague the Canadian health care system.
“Clinical work systems have many of the characteristics of complex, self-organizing systems: they are comprised of a large number of mutually interacting elements, with multiple enhancing and inhibiting feedback loops; they are open to the environment, and their boundaries are hard to define; they operate far from equilibrium; they are path dependent (i.e. their past is partly responsible for their present behaviour); their structure does not come from a priori designs, and it changes dynamically to adapt to changes in their environments.
In these complex (as opposed to complicated) systems, it is not possible to predict the trajectory of the system from fundamental principles and its current condition; thus, overly ambitious efforts to standardize are likely to create disorder, either in the target area or elsewhere in the system. These problems are often euphemistically labelled ‘side effects’, or ‘unintended consequences’; while they are no doubt indeed unintended, it is important to note that ‘side effects’ are not a feature of reality, but a sign that our understanding of the system is narrow and flawed.”
Our health care system is unstable
In complex systems, there are “homeostatic mechanisms”, self-regulating processes that smooth out disturbances. Sometimes they work well, preventing disasters. At other times they get in the way, by stopping solutions from working to solve problems. When the homeostatic mechanisms are overwhelmed, things can spin out of control quickly.
One example would be “triage”.
Triage was originally developed as a way to manage situations in which the need for services and supplies temporarily exceeded the available resources. For example, in a battle, you might have more injured soldiers than available medics or lack the supplies to treat them. A triage process quickly determines which soldiers will benefit most from immediate intervention (while leaving the “hopeless cases” untreated, so as to conserve resources for those who might benefit the most). Battlefield triage isn’t complicated; there aren’t enough personnel to spend a lot of time triaging! Furthermore, when there isn’t a battle raging, triage isn’t necessary.
So, triage processes are a “quick and dirty” way to allocate resources from time to time when demand temporarily exceeds supply. They are a way to smooth out the bumps.
In health care these days, we dedicate resources to triaging everybody, all the time, everywhere, generally as a way of determining which patients can wait the longest. We do this because the demand for services almost always exceeds the supply. Unfortunately, it’s no longer temporary, it’s permanent. In many cases, we’ve made the quick and dirty triage process more complicated!5 Furthermore, because wait times are excessive, we end up revisiting the wait lists constantly, to make sure that patients on the list aren’t deteriorating (or dead!).6 Going one step further, we generate reports about the numbers of patients waiting and their average wait times, to be reviewed by the managers, who then exhort the staff to try harder.7
The homeostatic mechanism, triage, is no longer a self-regulating process to smooth out disturbances. Triage doesn’t heal, but we’ve made it business as usual, and in doing so we’ve made waiting for service the default condition in our health care system.8 Beyond that, rather than simply assessing the patient and dealing with their problem in a timely manner, we add work by assessing them up front to see how quickly they need to be assessed and treated! Triage has side-effects, and we are adding more resources to manage them!
But what happens when the wait lists grow further? What homeostatic mechanism do we have to deal with “even worse than usual” waiting times?9 How do we triage those in need to decide how badly they need to be triaged?
As things get steadily worse and the homeostatic mechanisms go from temporary and effective to permanent and time-wasting, the only thing keeping our system going is the workers, who are contorted beyond their limits, looking for ways to “work around” solutions that don’t solve anything, while living with the side-effects of those ineffective solutions.
The worker/workplace mismatch
Predictably, healthcare workers, doctors included, are burning out. Their chronic workplace stressors have most definitely not been successfully managed.
Maslach and Leiter have identified at least six ways in which things go off the rails, leading to burnout.
Let’s consider them one at a time, with some healthcare examples.
(1) Excessive workload
“The burnout shop is an “always-on” work culture, where job demands are high and continue to keep piling up, and resources necessary to meet those demands (such as time, tools, goals, support) are often insufficient. In many of today’s companies, the explicit directive to “do more with less” is demoralizing and confusing, and undermines employees’ energy, involvement, and competence.”
This is pretty well a textbook description of our current healthcare system, a 24/7 operation. Increasingly, we see hospital overcrowding, meaning that there are more patients than beds. Frail older patients can’t be discharged, because there aren’t enough nursing home beds for them to go to. Admitted patients then clog the emergency department. Inpatient staff are looking after nursing home patients, and emergency staff are looking after inpatients, all doing tasks below their skill level, not the job they were hired to do. Employees have to work overtime and do tasks not in their job description. Overwork is the norm.
Physicians are generally willing to work extra hours if they are needed and performing the highest-level services they are qualified to render. However, emergency physicians aren’t happy doing the day-to-day care of inpatients. Inpatient physicians aren’t happy looking after stable patients who should be in nursing homes.
In the community, with increasing delays for diagnostic testing, specialist consultations, and surgical procedures, family physicians end up seeing patients repeatedly for the symptomatic and somewhat ineffective management of problems that could and should be dealt with quickly and far more effectively. This “rework” is wasteful and demoralizing. It doesn’t make people better.
Layered over top of this is the electronic health record (EHR), something conceived of to improve patient care and the quality of health information. Unfortunately, research suggests that that EHRs are a leading cause of physician burnout, due to their poor design, the inbox that can never be emptied, and alert fatigue. The labor-saving tool increases the workload, turning doctors into stenographers and data-entry clerks!
(2) Lack of control or autonomy
“Health care is famously a profession in which high patient loads, along with stepped-up requirements for digital record-keeping, have left many physicians feeling like mere cogs in a machine over which they have no control.”
Christina Maslach and Michael Leiter, 2022
“On the contrary, when employees have the perceived capacity to influence decisions that affect their work, to exercise professional autonomy, and to gain access to the resources necessary to do an effective job, they are more likely to experience job engagement.”
Where we’ve become short-staffed, the patient load becomes too great, and quantity compromises quality. Doctors can no longer provide the level of service or treatment they feel they should. They find themselves looking after sick patients on stretchers in hallways and broom closets. They become callous, even cynical, simply “processing” clients or patients.
Going further, the complex and unpredictable nature of health and illness does not always lend itself well to “standardized care”. Experience in diagnosis and treatment gained over years in practice is an important aspect of medical knowledge. Doctors have been trained to be autonomous, custom matching the treatment to the patient. Increasingly, however, this “variation in practice” is seen as a problem, to be corrected with clinical practice guidelines, standards of care, integrated care pathways, care maps, and computer-aided information systems. Managers monitor productivity and quality of care. Others write policies and design systems to “encourage” the adoption of these standards (often leveraging the EHR, turning it into an electronic manager).
Physicians can no longer deal individually with the patient and their specific problem. There are too many others in the relationship, including employers, insurance companies, hospital managers, and government.
(3) Insufficient reward
“In burnout shops, people often feel they are not reaping sufficient rewards—financially, socially, or emotionally—for the hard and high-quality work they are doing. Of course, for many, the most important rewards are the intrinsic ones that come with making progress in meaningful and challenging work. They become frustrated and depressed to the extent that their jobs bog them down in trivial tasks and discouraging cases or projects…. They feel unrecognized and underappreciated, believing their accomplishments are routinely ignored, even when they have gone above and beyond what was needed. Positive feedback is rare, while negative feedback may be plentiful. Indeed, when asked to describe “a good day” on the job, many workers reply, “When nothing bad happens.” Evidently, having “something good happen” is too rare or unreasonable to expect.”
As noted earlier, physicians are healers, deriving their job satisfaction from the meaningful and challenging work of helping sick people to get better. They become frustrated and depressed when they get bogged down doing time-consuming, unrewarding tasks, like feeding the EHR or seeking out the specialist with the shortest waiting time. They spend more and more time trying to make the system work as it should for their patient, and less time healing.
Physicians no longer craft custom solutions; they have become technicians, with ever-diminishing control over their patient panel size, workload, and working conditions.
Taking this even further, the drift away from healing toward prevention10 means that doctors spend more and more time searching for and then treating numerical risk factors. Treating numbers, rather than diseases, turns healthy people into the “worried well”, and it isn’t, in the end, as emotionally satisfying as making sick people better. Sadly, payment systems and EHR’s have been “tweaked” to encourage exactly this boring sort of “box ticking” care.
“When the prevention of disease begins to assume greater priority than the relief of suffering, something very fundamental begins to go awry.”
“Family physicians sense patients’ increasing frustration and are caught between doing what they are supposed to do and feeling, somehow, both inadequate and irritated.”
(4) Breakdown of workplace community
“In burnout shops, the always-on culture of fear is particularly damaging when it poisons people’s relationships with their coworkers. Instead of viewing their colleagues as supportive and trustworthy, people may come to suspect that they are surrounded by people “only in it for themselves” and willing to do anything to get ahead.”
Christina Maslach and Michael Leiter, 2022
“The area of community has to do with the ongoing relationships that employees have with other people on the job. When these relationships are characterized by a lack of support and trust, and by unresolved conflict, then there is a greater risk of burnout.”
As their work becomes fragmented, doctors are losing their connection with patients, and with each other. The generalist who once managed almost all of his patients’ problems, 24/7, over many years, in hospital and out, at home and in the office, has been replaced by a variety of gig workers. These include emergency physicians, hospitalists, walk-in clinic doctors, and those proving virtual care. All of these people have a relationship with the patient that lasts only till quitting time. Their relationship with their colleagues is often limited to a brief clinical handover at the end of their shift. The money might be better in these various roles, but is the work as satisfying? Without continuity, is the quality of care as good?
As all physicians are now overwhelmed with work, there is less civility. As a family physician, I once knew the specialists in my community and could phone them up when I was worried about a patient. Increasingly, such calls are routed to the on-call doctor and/or their triage system, which may or may not result in the patient being seen in a timely fashion.
(5) Absence of fairness
“Fairness is the extent to which decisions at work are perceived as being fair and equitable. People use the quality of the procedures, and their own treatment during the decision-making process, as an index of their place in the community. Cynicism, anger and hostility are likely to arise when people feel they are not being treated with the appropriate respect.”
As physicians are pressured to sacrifice their autonomy, they increasingly feel like replaceable cogs in a machine. The devolution of physicians’ work to less skilled nonphysician clinicians continues. The public are told that midwives, nurse practitioners, nurse prescribers, pharmacists, counsellors, online help-line workers, and even internet chatbots can provide quality care comparable to that traditionally provided by doctors. Physicians’ work is less respected and valued over time. Any fool can do it, who needs training?
Similarly, doctors who once competed to gain access to medical school and then strove to master the profession are learning that medical schools are now accepting and graduating students based not on merit, but rather on their skin tone, ethnicity, or sexual preferences. Well-qualified white, male, cisgendered doctors are sometimes unable to apply for specific positions (like professorship or prestigious research chairs), based on DIE hiring practices. For some, there’s no hope to advance.
(6) Value conflicts
“Values are the ideals and motivations that originally attracted people to their job, and thus they are the motivating connection between the worker and the workplace, which goes beyond the utilitarian exchange of time for money or advancement. When there is a values conflict on the job, and thus a gap between individual and organizational values, employees will find themselves making a trade-off between work they want to do and work they have to do, and this can lead to greater burnout.”
While it’s well known that medicine is an ever-evolving body of knowledge, and that scientific enquiry requires people to continually question the orthodoxy, there’s a growing trend to limit specific lines of research, free speech and conscientious objection, as detailed in my previous post, “The evolving nature of medical practice”. Doctors who question the currently accepted approach to controversial topics like abortion, medical assistance in dying, and gender transitions are silenced, even punished.
So, is it really a surprise that doctors are burning out?
You can see how these issues played out in the 2017 Doctors Nova Scotia Physician Burnout Survey. At the time, doctors were not feeling respected, supported, safe, or in control. Medicine didn’t seem like a profession. It seemed like “just another job” with crappy working conditions.
Bear in mind that things are worse now than they were then. We’ve been throwing money at the health care system, including pay bumps for doctors and nurses, but little has been done to address the underlying rot.
Things don’t look hopeful!
“Since the start of the COVID-19 pandemic, people who work in health care have struggled with overwhelming workloads and longer work hours, resulting in mental and physical exhaustion, burnout and - for many - an exit from their profession.
In 2021–2022, hospital staff (excluding physicians) worked more than 26 million overtime hours - the equivalent of 13,000 full-time positions.
At the same time, Canada’s growing and aging population has an increasing need for care. This combination of short staffing and high demand could mean longer waits and deteriorating health for patients, and more burden on health workers.”
Yes, as recently as this month, we are still asking the workers to do more with less!
What we really need is a functioning health care system, but that would require somebody, somewhere to admit that what we have isn’t functioning! That’s a topic for the next post!
“All systems are perfectly designed to get the results they get; if you want engagement do not design for burnout, if you want success, do not design for failure.”
In a future post, I’ll explore this in greater detail. Other countries do things differently.
By the way, much of what I’m saying in this post applies equally well to other health care workers. As a retired family physician, I’ve chosen to focus on the group I understand best, primary care doctors.
At least they have been in the past. Increasingly, there’s a trend to prioritize other factors, like skin tone, sexual orientation, etc.
I’ll use my training, knowledge, skills and experience to look after your complicated medical condition(s), but I expect, in return, that society won’t let just anybody “practice medicine without a license”. This isn’t unique to medicine. We place similar restrictions on the work of lawyers, architects, engineers, carpenters, plumbers, electricians, etc. Sure, you can do some of these things as a hobby, but you can’t hold yourself out to the public as an “expert”, expecting payment in return.
For an example, I found an online training manual for the Canadian Triage Acuity Scale, which is used in emergency departments. It says “The goal of CTAS is to support and appropriately assign acuity scores that are valid across the broad scope of emergency department presentations ranging from major to minor trauma, cardiovascular complaints, mental health problems, eye pain, obstetrical emergencies, diffuse paediatric presentations and beyond. To achieve this CTAS is structurally simple, content rich and a significant challenge to commit to memory.”
Imagine telling a battlefield medic that the new casualty sorting method is so complicated they won’t be able to remember it! Clearly, the goal of assigning the “right” CTAS score (for statistical purposes) has taken precedence over using the tool to quickly decide which patient goes first.
Once in a while, we contact everybody on the list to make sure they are still alive and in need of the service. See for example, the Nova Scotia government’s recent “revision” of the “Need a Family Practice” registry.
For an excellent post about this, see “Managed to Death” at Pairodocs’ Collection of Heresy.
The default should be “see and treat”, an idea that popped up in the early 2000’s in European emergency departments and has been tested elsewhere since. The premise is that it’s quicker and easier to simply ask the patient what’s wrong and deal with it on the spot than it is to go through triage, registration, waiting, and then eventual assessment and treatment.
Believe it or not, sometimes we resort to making people in the emergency department wait to be triaged, hoping that they don’t collapse before we have the time to decide if they are really sick or not. Sometimes, we leave them in the hallway, with the paramedics, pretending that they aren’t really in the emergency department yet. At other times, we divert the ambulances to other hospitals.
Which is prompted, to some extent, by the pharmaceutical industry’s push to find new “diseases” to be treated.
Another thing that can help to alleviate the pressure on our system is multi-disciplinary health teams. Up until my semi-retirement a few years ago, I had always worked in this environment. We were a mix of MDs, NDs, TCMPs, nurses, and councillors. (I was the TCMP). This was a fantastic and intellectually stimulating environment to work in and very effective in healing people. There has been too much adversarialism and distain by the medical profession towards this approach. The bureaucracy also hasn’t helped. The system you describe is, for the most part, only MD focused and unfortunately dominated by bureaucratic “protocols”, lack of accountability of the pharmaceutical companies and not patient centred.