How medical students can change the culture of medicine

“All of you want to help people and save the world now. But, by the end of medical school, only two of you — if we’re lucky — will remain idealistic.”

Within the first three days of medical school, I had heard three different lecturers tell me that I would lose my compassion and empathy. By the end of the first three weeks, that number had grown to six. During the seventh such talk, I became frustrated. Why were my instructors telling me of “the inevitability of disillusionment” before I even hit the clinics? Why had there been so much media attention on physician burnout recently? Did these articles exaggerate the extent of disillusionment in this career path? If not, what were the drivers behind my future profession’s general malaise?

According to a 2012 national study, the prevalence of burnout among American doctors was significantly higher than that among non-physicians, as measured through the Maslach Burnout Inventory. Professional burnout is defined as a “loss of enthusiasm for work (emotional exhaustion), feelings of cynicism (depersonalization), and a low sense of personal accomplishment.” Almost half of all participating physicians reported at least one symptom of burnout.

Moreover, the study found that while physicians generally work long hours and may experience more difficulties with work-life balance than other professions, whether a physician works at the front line of care (emergency medicine, general internal medicine, and family medicine) is a more significant predictor of burnout.

The effects of professional burnout among physicians are multifold. Over the past few years, several studies and articles have documented the higher rates of depression and suicide among physicians than the general population. Burnout may also result in a lower standard of care delivered to patients, due to a loss of empathy and resultant insensitivity in the doctor-patient relationship. Indeed, a study of over 2,500 American medical students found that those who experienced burnout were more likely to engage in dishonest behavior, such as changing patients’ test results, and view their future careers with less altruism than those without burnout. Such physicians may no longer see their patients as people, but rather as “diagnoses or objects.”

The causes and consequences of burnout have been well described in personal narratives. In his book, Doctored: The Disillusionment of an American Physician, Sandeep Jauhar traces many of his own frustrations to finances. Struggling to pay off his medical school debt, Jauhar delineates his difficulties in adhering to his principles in choosing cardiology as his discipline — namely, that he wanted to build meaningful and lasting relationships with his chronic patients. In an effort to pay his Manhattan apartment rent and enroll his child in private school, Jauhar, as the sole financial provider for his family, feels forced to engage in private practice to supplement his hospital salary. He reluctantly follows his peers’ examples by over-ordering tests and establishing referral networks with “friends” in order to make financial ends meet. Thus, Jauhar becomes disillusioned with the course his profession has taken.

Jauhar traces his disillusionment to systemic changes — most notably, changes in payment structures. Jauhar contends that “you have to motivate doctors to do the right thing … nothing today influences physicians’ behavior (even if unconsciously) like hard cash.” He suggests that in the past, physicians were not only given more autonomy in their medical decision-making, but also earned high salaries that afforded them luxurious lifestyles and respectable statuses in their communities. Jauhar documents several conversations among his peers who recognize that they are contributing to wasteful expenditure, sometimes at the expense of their patients; but, similar to Jauhar, these physicians feel justified in doing so in order to provide for their families.

Jauhar’s experiences are, unfortunately, not unique. As I read more case studies of physician behaviors, I could not help but wonder: When did a patient become dehumanized and depersonalized to a source of revenue instead of a human being? In their NEJM perspective piece, Drs. Hartzband and Groopman write that “price tags are being applied to every aspect of a doctor’s day, creating an acute awareness of costs and reimbursement.” In an effort to improve efficiency and decrease moral hazard, physicians are often made aware of the services rendered, profits collected, and losses accrued. But this hyperawareness may actually detract from the value for money and quality of care delivered as physicians place increasing importance on financial transactions.

These unintended consequences may derive from tensions between social or communal interactions, in which an individual is expected to provide assistance regardless of whether compensation is offered, and market or exchange interactions, which rely on financial incentives. Even the suggestion of money can change the nature of an interaction from communal to exchange. The health care industry requires both types of relationships — health care workers are, in fact, paid for their services, but must work with one another and prioritize the patient’s needs in order to optimize outcomes. The authors suggest that a cultural shift has occurred which, in the name of efficiency, has emphasized market relationships over communal ones.  This shift is something that I find, at least in this idealistic stage of my education, uncomfortable.

The majority of physicians in Jauhar’s book, and indeed many researchers and authors who have written about physician disillusionment seem to blame external factors for the cultural shift. But are physicians not, at least in part, to blame as well? Jauhar’s financial frustrations arise from his desire to live what is considered in today’s day and age to be a luxurious lifestyle. He even describes one wealthy physician who continues to over-order tests simply because one can never make enough money. It is only toward the end of his book that Jauhar mentions that we need to manage our expectations and recognize our own faults.

“Managed care alone didn’t create medicine’s midlife crisis,” he writes. “Indeed, this crisis was also spurred by the abandonment of professional ideals in the pursuit of profit that made managed care necessary in the first place.”

So how can we facilitate a cultural shift back to communal over exchange relationships? How can we reverse trends in physician burnout and disillusionment? Our happiness can be improved when we focus on the few aspects of our lives over which we have control. Toward the end of his narrative, Jauhar suggests that we perhaps the solution lies in focusing on the one aspect of our profession that distinguishes it from others — our relationships with our patients and our abilities to make differences in their lives. If we focus on why we wanted to be doctors in the first place, and if we see our patients as people rather than objects, perhaps we can boost morale among the medical community, and, as a result, improve health outcomes.

In his book, Jauhar suggests that medical students, unencumbered by expectations, may be the best positioned to manage the systemic changes affecting the field of medicine — and I agree. Most students who pursue residencies at the frontline of care have likely matriculated into medical school at least in part out of their desire to interact with patients. While financial considerations and the promise of a comfortable lifestyle may have consciously or unconsciously factored into our decisions, perhaps it is time to define what exactly that comfortable lifestyle entails.

Perhaps it is time to educate ourselves early that, like any job in any field, our work will require administrative work and negotiation with stakeholders with whom we would rather not interact. Once we set realistic expectations and work toward achieving them, whether that requires lowering our bar from historical images of grandeur and autonomy, perhaps we can focus on what truly lies at the center of our professions: patient care.

Pooja Yerramilli is a medical student.

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