How the changing roles of hospitals are isolating physicians

Physicians nearing the end of their careers often mourn the loss of the hospital as it once was — the undisputed center of the health care universe. They remember a time when every community doctor rounded on patients in the morning, and every surgery was performed in one of the hospital’s main operating rooms.

Times, like hospitals, have changed. This article looks at how the changing role of the American hospital has left doctors (both old and young) feeling lonely, isolated and, increasingly, burned out.

How and why hospitals have changed

Today, two-thirds of surgical procedures are performed in outpatient “surgicenters” where patients are commonly discharged within hours of their arrival. Inpatient stays are becoming a thing of the past. New mothers who once spent a week recovering in the hospital after childbirth are now home within a day or two. Meanwhile, the role of the rounding doctor has been largely replaced by the hospitalist who provides inpatient care. In fact, less than a third of hospital-based care is provided by the patient’s personal physician nowadays.

Ultimately, two forces reduced the role of hospitals in 21st-century health care. The first dates back to the managed care movement of the 1990s, which gave birth to aggressive, for-profit insurance strategies like “utilization management” (often a euphemism for early discharge) and the denial of coverage for non-emergent procedures.

Alongside these cost-cutting approaches, new and improved surgical techniques led to speedier patient recovery and faster discharge. Once-complex procedures like gallbladder removal, total-joint replacement and appendectomy are now routinely performed on an outpatient basis.

Though these forces have enabled more efficient and effective care for patients, they’ve also fundamentally altered the way doctors in the community relate to one another.

Docs now feel isolated, lonely, burned out

It might be hard to conceive of medicine as a lonely profession. After all, physicians are surrounded by patients and office staff for 10 or more hours each day. But despite being in the constant company of others, 25% of physicians report feeling isolated at least once a week, according to a 2018 athenahealth survey of 1,400 practicing physicians.

Doctors today are suffering from the loss of meaningful contact with their colleagues. Rather than consulting face-to-face with physicians in other specialties, most collegial interactions take place by phone or email. Rather than bumping into dozens of fellow physicians during morning rounds at the hospital, most of today’s primary care physicians drive straight to their offices. And rather than performing nearly all procedures in an inpatient setting, specialists are using other outpatient venues, where they spend entire workdays isolated from their medical peers.

It’s concerning that so many physicians today feel lonely. But there’s more to it than that. The athenahealth survey also draws a clear line between feelings of isolation and the high rates of burnout physicians experience.

This link between isolation and burnout isn’t just bad for doctors. It’s also worrisome for patients, 99% of whom believe their doctor’s professional satisfaction directly impacts the quality of medical care they receive. They’re right. A national Mayo Clinic study found that physicians who report signs of burnout commit twice as many medical errors as those without burnout symptoms.

The lost place 

It’s important to point out that doctors haven’t always felt this way. A friend of mine — who practiced in the community for ten years before joining Kaiser Permanente 20 years ago — recently emailed me the following memory:

I remember very clearly the physician dining room. It had paneled walls, like a restaurant. The room was very pretty with white tablecloths and small, intimate tables for four or six people. Sometimes, you would see doctors chatting over X-rays, seeking a friend’s opinion. There was a staff of servers that stood at attention around the room in white starched uniforms. There were flowers on the table. The atmosphere was very calm and pleasant, the tones were hushed. I remember what a treat it was. I loved operating at that facility.

Physician dining rooms, like the hospital smoking lounges of antiquity, are all but extinct now. Still, they remain a powerful symbol how workplace changes can impact the physician’s psyche.

To borrow a phrase from sociologist Ray Oldenburg, the hospital dining room was akin to the doctor’s “third place” – a spot unlike home (the first place) or work (the second) where like-minded people would gather, build relationships and exchange ideas. The physician’s dining room (or lounge) served as a place where doctors of every rank and station could connect and collaborate. In that way, it took on the same cultural significance as the local coffee shop, neighborhood pub or community church.

These dining rooms were places where physicians discussed not only what they saw in X-rays, but what they saw happening in their personal lives and in the ever-changing landscape of medical practice. The doctors’ dining space also had cultural currency, signaling to physicians that hospital leaders appreciated and respected the years they sacrificed, gaining medical knowledge and expertise.

Looking back, what my friend really missed about the dining room wasn’t the free meal. She mourned the loss of camaraderie — the opportunity to share her ideas, hopes, and concerns with her colleagues. In that way, the doctor’s “third place” was the antithesis of (and possible antidote to) professional loneliness and emotional isolation.

Creating connections in a lonely industry  

As pointed out in parts one and two of this series, doctors who suffer from burnout categorically blame the health care system for their suffering. Indeed, these systemic challenges are real and need to be addressed. However, as these articles also demonstrated, there are other real and growing threats emerging from within the traditional culture of medicine. Doctors today too often resist scientific and technological advancements and find themselves at odds with changing societal norms.

Physicians must recognize that these clashes exist and then work together to resolve them. The loss of communal spaces in health care has hindered the evolution of medical culture. If we want to empower today’s physicians to rally and fight all the causes of burnout, they’ll need a gathering place where they can “start the evolution.” Third places have served this purpose throughout history — from the taverns of Colonial America to the churches and community meeting places that bred modern social movements.

Bringing back medicine’s third place 

The formal hospital dining rooms of the past won’t be revived in the future. There are too many social and economic forces standing in the way. But we can create places where doctors can coalesce, converse, and temper the feelings of isolation they experience today.

The Santa Clara Kaiser Permanente Medical Center, where I practiced as a surgeon, began addressing this challenge more than a decade ago. The facility had never housed a physician’s dining room, but as the medical center’s leadership team began to recognize the value of relationship-building and collaboration among doctors, they designated a room, and filled it with snacks and refreshments. Outpatient physicians visited it before their medical offices opened while inpatient specialists stopped by prior to the morning’s first surgery. There, doctors from all specialties would interact with colleagues they might not otherwise see. Similarly, for one lunch hour every month, the medical center opened up its largest conference room as a virtual physicians’ lounge. As physicians from every specialty arrived, they’d grab a sandwich and soda, gather in small groups and talk about what was happening in their personal and professional lives.

Of course, the close proximity of the hospital to nearby medical offices within Kaiser Permanente facilitated these solutions in ways they might not in other geographies. But given the isolation and professional loneliness so many doctors experience, I’m optimistic community physicians would be willing to leave their offices for an hour every month to reconnect with colleagues.

As CEO in Kaiser Permanente, I often said that “when two physicians talk, good things happen.” I still believe that to be true. But it’s happening less and less now due to the loss of the American hospital as a destination, and the loss of something just as important: A place where doctors can build relationships and rebuild their culture.

Robert Pearl is a physician and CEO, Permanente Medical Groups. He is the author of Mistreated: Why We Think We’re Getting Good Health Care–And Why We’re Usually Wrong and can be reached on Twitter @RobertPearlMD. This article originally appeared in Forbes.

Image credit: Shutterstock.com

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