Hostile dependency: The real reason for physician burnout

A piece recently appeared in the New York Times entitled “Who Will Heal the Doctors?”

The piece is written by Donald Borstein and I encourage all to read it. Mr. Bornstein offers a solution to the doctor burnout problem in health care, a course called “The Healers Art,” now being promoted in US medical schools that uses “mindfulness” as his means of creating compassionate, caring doctors as a way forward.

I should say at the outset, that I do not disagree with the concept that doctors should not be more attuned to the circumstances for which they are being trained. But the overall argument that such “mindfulness” practices can repair his so-called “McDonaldization” of medicine is somewhat disingenuous concept.

It skirts the very real challenges doctors have today when caring for patients and the many layers of bureaucracy and paperwork, both electronic and manual, along with the hidden costs that their patients are subject to as a result of doctor orders entered on a computer as they try to follow certain care standards.  Blindsiding one’s patients doesn’t make for the best of relations.  Still, as bad as these realities are, they are probably not the reason most doctors are turning away from medicine.  I think there’s another issue that is even bigger.

I believe the overriding reason doctors leave medicine is because there is a  growing hostile dependency patients have toward their doctors.

I have mentioned this concept of hostile dependency before.  The theme is like an adolescent who realizes his parents have feet of clay.  In adolescence, he comes out of his childhood bubble and realizes his parents have failures and limitations because they are human beings.  This results in the adolescent feeling unsafe, unprotected and vulnerable.  Since this is not a pleasant feeling, narcissistic rage is triggered toward the people he needs and depends on the most.

Yet (and this is important) none of this occurs at a conscious level.  Most of us understand this behavior simply as “adolescent rebellion,” not understanding the powerful issues at play.  So when we spotlight doctor burnout, or, say, the lack of patient safety in hospitals without acknowledging the realities health care workers face like looming staffing shortages and pay cuts, we risk fanning the flames of narcissistic rage against the very caregivers whom we depend on the most — the very caregivers who are striving to do more with less, check boxes while still looking in the patient’s eyes, meet productivity ratios, all while working in a highly litigious environment.

A comment from “Victor Edwards” posted after Mr. Bornstein’s article demonstrates this growing hostile dependency toward doctors perfectly:

Doctors? I no longer afford that kind of respect: I call them “medical services providers.” They and their families and the medical cabal created this mess when they got control of med schools so that the wealth of a nation would remain in the hands of a few medical elites and their families. The very notion that doctors are smarter, more productive, more anything than others is ludicrous. They are among the worst sluff-offs of our society, yet the richest at the same time. It is an unreal world they have created themselves and they are now watching the natural outcome of such a false system.

How do we fix this attitude toward doctors?  Who would want to work in an environment where patients perceive their doctors so?

Yet this is what we’re creating with our increasingly consolidated “McDonaldization” of medicine.  Given where things are heading, I’m not sure this will be an easy fix as doctors are shoved farther away from the patients.

But let me be perfectly clear: if you want to keep doctors from getting burned out quickly  in medicine, it is this growing hostile dependency that patients have toward their doctors that must be addressed head on.

Wes Fisher is a cardiologist who blogs at Dr. Wes.

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  • Deceased MD

    Not sure all the hostile dependence is from pts though. It seems to be coming from all over. Whether it’s through government regulations via EHR’s, or insurance and pharmacy hassles. I think pts do pick up on the difficulties with access to care and their feelings of lack of availability of the physician.

    During your first meeting, pts feel jealous of the EHR as one is typing. After all there is a competing pt in the room; the EHR. Sort of like sibling rivalry.

    OK strange thing to say but there is a third pt in the room that is mandated to be treated by Uncle Sam. All the pt knows is that it is taking time away from the pt that is alive in front of you and attempting to give their history. So pts are naturally often ticked off from the start.

    They have no clue why you need to type. They have no idea the headaches that are being thrusted upon you the physician. all they know is they are not feeling heard or getting their needs met like they used to. Who else to blame? but the physician right in front of them.

    I’m way past the burnout stage. I’m already dead.

  • Guest

    I wish Victor Edwards could experience the joys and wonders of medical school and residency.

    And that was a punishment I used to think I wouldn’t even want my worst enemy to face.

  • Original_Cait

    People are about to have their insurance premiums jacked up, and their co-pays, deductibles & out of pocket expenses raised, and they’re going to try to get in to see their doctor but be shuffled to a nurse instead, and they’re going to take it out on the fact in front of them.

    People unhappy with Obama’s “healthcare reform” have seen image after image in the media of all those happy white-coated sycophantic stunt-doctors Obama likes to surround himself with at any photo op regarding his glorious plan, and they hear that the AMA is fully behind his “reforms” without realizing that the AMA represents only a small minority of doctors, and again, they’re going to hold the whitecoat in front of them (who’s staring at their computer and tap-tap-tapping away on a keyboard rather than paying them any attention) responsible for it all.

    I don’t like the direction any of this is going, for either doctors’ well-being or for patients’.

  • southerndoc1

    Disagree completely.

    Doctors blaming patients, and patients blaming doctors, for this mess is exactly what the real villains – CMS and the insurers – want.

    • May Wright

      Some of the political rhetoric out there hasn’t helped either, siccing the public onto those evil greedy overpaid one-percenter doctors who would rather amputate your foot than treat your diabetes, or yank your kids’ tonsils rather than treat their allergies, because they get more money that way.

      There’s plenty of blame to go around.

  • Shirie Leng, MD

    Wes – I got castigated on this very site for comparing the doctor-patient relationship to parent adolescent! Doctor-hatred is real, mistrust is high. As long as check boxes and money are between the patient and the doctor, this will remain true

    • NPPCP

      Dr. Leng,
      I would never ever approach a relationship with one of my patients based on the “parent/adolescent” relationship. Hostile dependency may or may not be appropriate. Treating a patient as an adolescent is not appropriate. You are mixing and matching two different issues. This would never happen or be allowed in my clinic.

      • Shirie Leng, MD

        Arrgh! That’s not what I meant at all! Of course no doctor would approach the patient in this manner. I was responding to Wes’ reference to adolescent rebellion.

        • NPPCP

          Got it, sorry for the misunderstanding. Thought you were comparing the two. :)

    • May Wright

      You’re not going to win over many patients by presuming yourself their parent and treating them like adolescents. Even if there were no “check boxes and money between the patient and the doctor”, nobody reacts well to a doctor treating them like a child.

    • http://www.myheartsisters.org/ Carolyn Thomas

      Dr. Leng, you were castigated on your previous post here because of your unfortunate and inappropriate decision to compare patients to unruly teenagers. Nothing to do with “check boxes and money” – simply a misguided use of semantics.

    • Suzi Q 38

      Mistrust is high, because of the doctor not having the time to properly listen to h/her patients. Then they subsequently make too many errors with mistreatment or non treatment. This is a big deal that sometimes results in injury or death.

      This is one of the many reasons that mistrust is high.
      Doctor-hatred? I wouldn’t go THAT far.

      I am just being far more cautious than I ever would have been in years previous.

  • buzzkillerjsmith

    Most (certainly not all) of us have been de-professionalized or almost so. The idea of doctors’ unions is interesting although perhaps quite unpleasant to hospitals and health systems.

    Looking down the line, unionization could even cause lots of these health systems to break up as they prove unable to meet the demands of their workforce for autonomy, good working conditions, and adequate compensation. Isolating and attacking so-called disruptive physicians (docs who tell the business types irritating facts) might not be so easy.

    What’s admin going do, replace a couple hundred docs who decide to say no? Are the business-trained administrators going to take out the ischemic bowel? Not likely. Patients would have to be diverted and would scream to high heaven.

    It’s a notion, nothing more. But if docs within a given system got together, the power dynamic would change.

    • Deceased MD

      The business trained admins are the ischemic bowel. But agree whole heartedly with the rest of it.

  • Suzi Q 38

    My friend’s daughter was describing a well-known OB/GYN the other day.
    She said: “I know Dr. B, he delivered so many babies that I know of (the prior generation). Our friend highly recommended him, so I figured that I could go to him too.
    Well, he was terrible. He had no time for me, and I was pregnant with my first. His hand was literally on the doorknob as I was just beginning to ask my questions. I wonder how he could have changed his practice so quickly, but I notice he is with an HMO group now. I had to change doctors.”

    Welcome to our world.

    • Melissa Travis

      This is the point I was trying to make. When your worlds change so do ours. We suffer when you suffer. And we also suffer from our illnesses. Your improved world makes our better. So do your improved self-care and improved environments, fewer insurance hassles, etc.

  • Melissa Travis

    First, anytime we point a finger at someone and compare the relationship to a parent/child when it is NOT a parent/child relationship it is paternalistic at best. Secondly, when we blame our own burnout on the on the dis empowered party well, yes – WE need to get out of our profession OR do more self-care and reflection about what we need.

    I have been a voice for team work and non-advesarial relationships for a long time. Times have changed. My dad’s family doctor could point his finger at my grandmother and tell her what to do. And she did it. He also knew every single thing about everyone in our family. But he lived moderately and had a single paneled office because he chose to work as a small rural doctor among the poor.

    Now doctors work with EMR’s and big hospital corporations and insurance companies. You send me conflicting form letters that you never know I get. If you’ve spent time making a relationship with ME as a patient, I over look it. But it still annoys me and I feel like a number. After all, don’t think that for one second I’m suffering from just a disease. I suffer from every burden you suffer from too. The insurance companies treat me badly and I feel like they are waiting for ME to die. I always have.

    I can never quite trust which medicines I’m taking because they are absolutely necessary and which ones are making you money. I can never tell which side effect will give me more diseases to treat. And yes of course, you fight with my other six specialists and want me to listen to ONLY YOU. But I have six other specialists because I have other illnesses. And you don’t trust each other and I know you don’t. You don’t QUITE say so but I can tell from the way you talk or the way you act or the disrespect you write each other. Or worse, I worry that the nicey-nice way you treat each other that you’re not double checking each other’s work and something will get missed.

    And I’m just supposed to blindly TRUST you? When you don’t even trust each other?

    I’ve spent years with the discussion on teaching patients how to be patients. People are not born with the knowledge of how to do it. Especially people who do not want to be sick. Patients (people of many diverse class and cultural backgrounds) are suddenly expected to “behave” a certain way and that will never happen.

    What doctors are feeling NOW is what teachers and professors have been feeling for many years, even in the classrooms. Our education level doesn’t matter. FINALLY- you’re feeling what it feels like to be treated like every one else. It doesn’t feel good. It isn’t fair. But that’s how it is.

    Everyone has a story. The difference is – when we are “professionals” – we’ve got something we’ve dedicated our life too… something bigger than “wanting respect” BECAUSE WE ALL DESERVE THAT. And we should all be giving that to each other. Even the dirty people. Even the addicts. Even the women and kids who smell like pee. Even the loud nasty people who we want to snap in half.

    Something makes us WANT to be better. Something drives us… and what we can’t find that inside anymore… you’re right– it’s time NOT to be a professional anymore. And I disagree with you Dr. Wes — it ISN’T a parental relationship all gone wrong. It’s something else. And I don’t know quite what it is and if I knew – I wouldn’t be here working along with you.

    • http://www.myheartsisters.org/ Carolyn Thomas

      “Especially people who do not want to be sick…” Well, I think that would pretty well cover all of us. ;-) Melissa, you are utterly correct in objecting to the paternalistic comparison here of a patient’s “hostile dependency” to that of some kind of acting-out child indulging in “narcissistic rage” towards authority.

      The contemptible “Victor Edwards” comment in response to Bornstein’s article is appalling, and hardly representative of the average patient’s valid concerns about health care. But to clutch onto that personal example as some kind of rationale to engage in patient-bashing seems just as contemptible.

      • Melissa Travis

        Victor Edwards sounds angry. I’ve been VERY ANGRY at many people throughout my life when dealing with healthcare and the entire industry. I’ve even been unfairly (and sometimes fairly) angry at my doctors. Edwards is also getting paid for opinions. And we all have those. And we all know what those are worth.

  • Sherene

    Hostile dependence is a pretty aggressive sounding term. Patients only become upset when they don’t think their doctors are doing their best to help them.

  • http://www.zdoggmd.com ZDoggMD

    Burnout sucks, whatever its primary cause. It’s a fundamental threat to our entire healthcare system, in my opinion.

    http://www.zdoggmd.com/tedmed-zdoggmd/

    That being said, there’s hope. I think if we can address the culture of medicine head on, remove the bureaucratic entanglements as much as possible (this is actually doable!), and enter into true partnerships with patients, much of these problems melt away.

  • dlo

    Stanford and other academics from DC to California are focused on dialogue on compassion. TEDtalks is an excellent venue and I have found stories that have the potential to help all of us in this difficult race of humanity. Also note Stanford’s Center for Compassion at http://ccare.stanford.edu/

    The issue is to keep perspective, utilize the political power that may be going untapped, find yourself nurtured by people who understand that human empathy helps us transcend the most difficult issues and times of our lives. Medicine and health care is a precipitous path, especially in this era of intense polemics, but also a rewarding one that has the unique potential of growing the soul in this brief journey called life.

  • Jennie Hitchcock

    I think doctors have forgotten who is getting paid in the relationship. The notion that the customer needs to change his/her attitude is a fatal mindset for the physician industry.

    • Melissa Travis

      I’m not a customer or a consumer. I’m a patient. :) And I think BOTH patient and doctors can be team members and work on relationships. But I do agree with you – patients get slammed with their role, get unwanted and unexpected diagnoses, and doctors take it from there. The dance begins.

  • Suzi Q 38

    This is not a problem for me. I know who is the doctor and who is the PA, as they are wearing a badge. I don’t call the PA “doctor.” We call her by her first name, as she has requested.

    Most of us understand the difference.
    As a patient, I am not angry about that.

  • Zackary Sholem Berger

    I confess I have difficulty with this piece. First, I am not sure what the author means by the term “hostile dependency.” I clicked the link in the article above, but got basically the same paragraph. It seems to mean patients who criticize doctors too much. I don’t think there’s anything wrong with defending our profession and realizing that working doctors are beset by innumerable difficulties – while at the same time admitting that our health care system (to quote Michael Fine, MD) is neither healthy, nor caring, nor a system. Iatrogenic error and its attendant morbidity and mortality are real. Patient criticism of providers’ failures and shortcomings should not be reflexively dismissed.

    Perhaps the “growing hostile dependency” is a projection onto patients of our increasing realization that something is amiss with healthcare in this country. If we doctors blame patients for pointing out what we all know to be the case, we will be shooting the messenger – pretty hostile, I think.

    • http://www.myheartsisters.org/ Carolyn Thomas

      THANK YOU, Dr. B.

  • http://drpauldorio.com Paul Dorio

    Interesting perspective, Wes. Anything that attempts to improve the doctor-patient relationship is ok in my book. Of course, if disgruntled people like Victor Edwards could point me to those riches I’ve been missing out on, I’d really appreciate it. At least then I might deserve his rancor from a financial standpoint. And I guess I’ll have to ask him for forgiveness for thinking, incorrectly according to his perspective, that I achieved my degree through hard work, productivity and maybe a modicum of intelligence….”medical cabal??”

  • http://drpauldorio.com Paul Dorio

    One thing more to echo and agree with southerndoc1 — Doctors and Patients are in this thing together. We are one and the same. It is a mistake to diminish or ignore the ongoing insurance company and federal government “anti-care” onslaught that puts both livelihoods and lives at risk.