Matteo LoPreiato, MD, a pediatrician now based in Berlin, Connecticut, admits there are trials and tribulations affiliated with being a doctor nowadays, but he takes the hassles philosophically. “Name me one profession that doesn’t have more regulations,” he says. “The job is what you make out of it and the fact is there are a lot of professionals who aren’t as fortunate as we are, getting to do what we want to do day in and day out.”
Physician work/life balance study
Unfortunately, there are any number of indicators that too many physicians no longer share LoPreiato’s balanced outlook on their profession. The Physician Work Life Study published in 1998 found a significant number of physicians—especially females—unhappy with their work. Among the most critical factors in their dissatisfaction were increased time pressures, more complex patient cases, and lack of control over workplace issues.
A 2004 survey of 50- to 65-year-old physicians by the national search firm Merritt, Hawkins & Associates was equally discouraging. It found that the number of physicians who were finding their jobs “less satisfying” was a disheartening 76 percent, up from 54 percent in the year 2000.
The numbers are not only bad for doctors but also they’re bad for this country. The Merritt, Hawkins survey found that a small majority of respondents were somehow going to change their practices, with methods ranging from not taking on new patients to getting out of medicine altogether. With 38 percent of America’s physicians in the 50-plus age group, the surveyors say that could leave the United States with a significant physician shortage in less than 15 years.
While administrative and regulatory changes could undoubtedly help, the fact remains that doctors have to find more personal paths to staying happy in their work. LoPreiato seems to indicate it is still possible. Is he just an exception, or is there hope for other physicians as well?
Acknowledging the complexity of physician happiness
William J. Hall, MD, the director of the Center for Healthy Aging at Highland Hospital in Rochester, New York, admits that, “You ask doctors generically ‘Are you happy?’ and many physicians respond negatively.” But if you dig a little deeper, he says you’ll find a much more complex series of responses.
Even seemingly mild issues can cause physicians to get discouraged, depressed, even angry in one way or another. Michael Krasner, MD, an internist in Rochester, New York, is now part of a larger group practice. “I can’t decorate the office the way I want it. The employees don’t answer to the partners, they’re responsive to the major medical center.” In the grand scheme of things these are minor annoyances—but enough “minor” annoyances and doctors find themselves stressed, weary, even angry and depressed.
LoPreiato feels that the advent of nurse practitioners has in some ways been a detriment to physician satisfaction. It’s not that NPs aren’t great professionals, he emphasizes, but if they do most of the one-on-one work then “you don’t build a relationship with your patients.” In pediatrics, for example, “The parent senses you don’t have a handle on their kid,” or at the very least feels you don’t care enough to treat the child personally.
Part of the problem is finding a way for doctors to balance doing enough themselves so as to keep in touch with the real work of medicine, versus emphasizing a God complex that makes them believe they have to do everything. Nancy Church, MD, an ob/gyn based in Chicago, points out, “You can’t know everything…but that’s the exact opposite of what doctors are taught.”
And there are perhaps the greatest depressants like one Church highlighted. She remembers finding aggressive ovarian cancer in one of her 37-year-old patients. The only thing Church could do was to provide that patient with emotional support, such as ways to talk to her children about her dying. While Church was doing that, however, she also found herself grappling with de-energizing business hassles, including malpractice insurance that keeps skyrocketing (more than 100 percent in the last two years).
What keeps physicians happy?
Yet for every doctor like the ob/gyn Church talks about who left medicine and went into teaching science, there are still many like her who stay, and others still coming into the profession. What keeps them optimistic and even happy?
Church admits she’s a natural optimist, but that alone isn’t always enough. She takes a variety of steps, from paying for a more expensive dry cleaner because it picks up and delivers (thus reducing one stressor in her life) to going out regularly with other female doctors to relax and trade experiences. Friends keep her balanced, too. When she had to cope with that young mother dying of cancer, she says, “I called a friend and said ‘I’m so bummed. You have to come take me out to dinner.’” And that’s what happened.
Sometimes the answer to restoring an upbeat attitude is simple: Take a vacation—a real one. That means not tapping into your e-mail every few hours or calling into the office regularly, both of which doctors say have become major obstacles to re-energizing. W. Lee Wan, MD, an ophthalmologist with Coastal Eye Specialists in Oxnard, California, says that taking family vacations (he’s married 22 years, with two children) helps. Europe was a good spot because, even with all the technology, he says, “with the time differences it was harder to reach me!”
Other times restoring contentment requires more radical approaches. For Wan and his group, it meant no longer accepting managed care patients. He says managed care caused too much of a “disconnect with the patients” which he believes is one of the leading causes of unhappiness among physicians. “Patients came here because they had to see us instead of someone else, or we had to administer a certain treatment whether or not we believed it was best for our patient.”
LoPreiato is also making a pretty major move—literally. At the time we spoke he was getting ready to relocate from his established practice in Pittsford, New York, to Berlin, Connecticut, where he’s starting with no income, no practice. Why? Because it’s nearer to his family, which not only helps him personally, it gives his daughter the extra support of grandparents and cousins. “If in 10 years her life isn’t what I’d hoped it would be, my conscience will be clear,” that at least he did everything he felt he could.
The importance of family
Having a stable and happy life outside the office is critical, experts say. For male doctors that may be easier. Church says, “The majority of male doctors have a wife or partner who takes care of their daily needs,” like getting the clothes to the cleaner, sending out the birthday cards, and so on.
Women doctors aren’t so fortunate. A 2000 Case Western University study looked at 1200 physicians in their 30s. More than 60 percent were male physicians, and 22 percent of them were married to a doctor. Of the women, 44 percent were married to physicians and were still primary caregivers for the children. The Physician Work Life Study found female physicians were 50 percent more likely to suffer burnout compared to their male counterparts.
Michael Myers, MD, is a psychiatrist and a clinical professor in that field at the University of British Columbia in Vancouver, Canada. He’s also an expert on physicians’ health. He’s been in practice for 30 years and for 15 of them he has been treating doctors and their families. “When I lecture physicians I tell them I couldn’t do my work if I didn’t have access to their partners or spouses. That way I get the complete picture. Sometimes I only meet with the spouse. They have tons to say about medicine” and what makes it hard for them to maintain a satisfying home environment.
Myers has been married to a nurse for 35 years. They work at the same hospital and he remembers years when one of them worked nights, the other days. You’d think that would have been a strain on their relationship, but they looked at it as a positive. “We didn’t have paid child care and this way one of us was always home.” To put aside personal time for each other, Myers and his wife decided that every two weeks they’d hire a babysitter and go out. These “dates” not only helped reinforce their relationship and kept them happy, but it was also one of many ways they conveyed to the kids that their relationship as husband and wife was important.
LoPreiato admits that while his family helps him keep his center, it’s not always easy for them, especially with his erratic hours as a pediatrician. There’s no doubt in his mind that “physicians’ spouses and family have to understand the sense of duty doctors have,” but the doctor has to give somewhat, too. “You have to treasure your family.” Here’s one way the LoPreiato family stays together even when he’s seeing patients on a Sunday: “We go out to breakfast together. They come back to the office and wait for me and then we all go out together to do the shopping, see a movie”
Jennifer Virmani, DDS, actually spends an inordinate amount of time with her husband, Mohit—he’s her dental partner in Maryland. You’d think they’d get on each other’s nerves being together day and night, but Mohit Virmani says, “When we’re at work we don’t see each other that much, so we get together at lunch.” Both he and his wife say that playing to each other’s strengths at work and at home enhances both relationships. Mohit says, “I’m better at ordering supplies, for her it’s office design.” Jennifer agrees, saying “He likes researching on the ‘Net and does the accounting on the computer. I actually pay the bills and do more of the creative work.”
Rethinking the profession
It’s also critical for physicians to take stock regularly of how they’re practicing medicine. There are often things they can change that will decrease stress and increase their sense of contentment and satisfaction.
LoPreiato says that in pediatrics, “Many of the traditional illnesses—polio, measles, mumps—have been eliminated.” Instead of treating illnesses we can throw a pill or vaccine at, he says, “We’re coping with new morbidities: ADD, drug abuse, asthma. Many of these don’t have easy solutions, or can’t be treated using the pure scientific method.” Some doctors eschew this as a sad diminishing of their profession, but LoPreiato prefers to see it as giving him new challenges to tackle.
Krasner says, “Take a very good look at what you’re doing versus what you’re willing to do.” That may mean doing some serious rethinking as to the kind of work you’re doing. Krasner didn’t start his career as an internist. He was in the ER. “I wasn’t feeling like I was really helping people,” at least not in the long-term way he wanted. “There was no continuity in the relationship, whereas now I work with them through all the times of their life.” He adds that this relationship energizes him: “The energy’s not just flowing in one direction; I meet their needs and they meet mine.” For another doctor the solution may be exactly the opposite: Work in the quick pace of an ER, so when the patient moves on, that’s it.
Support for physicians
One way for doctors to get re-energized about work is to make the patient an ally. Too many physicians still see the educated (and demanding) patient as a competitor. Krasner sees the knowledgeable patient as a good thing. “They start understanding the complexity of your job.” Those who come in with an article are often more motivated to do what’s needed for their treatment.
As a pediatrician, LoPreiato faces confrontations regularly, as parents come in demanding an inappropriate treatment because of something they read or saw; for example, seeking an antibiotic for their child’s cold. Rather than getting into an ego match, LoPreiato says,”I get them actively involved in the decision. I’ll say, ‘I tell you how I think we should handle this,’” and he suggests the “plenty of fluids, watchful waiting” scenario. Then he adds, “If at the end of a few days you truly think he hasn’t improved, bring him back and we’ll reconsider our options.” Most parents agree and, of course, the child usually does improve. The crisis passes because the parents feel they’ve been a part of the decision.
Regularly it is emphasized that a good staff is critical to helping doctors stay sane and allowing them to do the work they truly love doing. Wan says that he couldn’t keep his schedule (which includes not only 40 hours a week for his practice, but also work with the local hospital and medical society) if he didn’t “have staff I’m really proud of.”
Church agrees. “While dealing with life-threatening situations for my patients I also have to fight the insurance companies, but how much energy does one have? I had a patient bleeding profusely and then you come back to that nonsense” in the office. A good staff saves her sanity, which is why, she says, “A good amount of my income goes to pay my staff salary so they stay stable,” and she isn’t retraining every two weeks.
A formal approach to improving physician satisfaction
More and more there are programs to help physicians rekindle their happiness with their career choice. Wan is the chair of the physician well-being committee at St. John’s Pleasant Valley Hospital and St. John’s Regional Medical Center in Ventura County, California. One thing the hospitals are using to increase physician satisfaction is a “physician complaint line.” He says, “A doctor often has a valid reason for being upset, such as certain lab tests not being ready.” But if the doctor simply rants, it often makes the situation worse and becomes detrimental to patient care when the lab or nurse is afraid to call an easily-upset doctor. “When the complaint line gets a call, it’s triaged to the person who can get the problem fixed or find out why it can’t be done. Then, a supervisor is required to call the doctor and submit a written follow-up, so the physician knows there’s been some action.”
Robert Rufsvold, MD, is the director of the “Finding Meaning in Medicine” (FMM) program for physicians and med students that comes out of the Institute for Study of Health & Illness (ISHI) at Commonweal in Bolinas, California. (www.meaninginmedicine.org) “It helps them remember the core values of the healing profession: caring, compassion, reverence for life,” and others. Rufsvold says too often today those values are being replaced by what he calls “marketplace values,” for example, being rewarded for caring more about cost-efficiency than the patient.
According to Rufsvold, one of the sad things is how quickly young residents become disillusioned in ways they didn’t expect. Take the financial issue: Many older physicians have seen dramatic income cuts since managed care, but Rufsvold says today’s students grew up with that system. “If you have conversations with first-year students, they really want to serve, it’s what has drawn them into medicine. They know there are better ways to make money now.” So they’re going into medicine for the same reasons their elders did: to heal and provide care.
Yet six months into med school, he says, “They’re becoming more depressed and cynical” as they find a dissonance between their Hippocratic values for healing and what they’re truly allowed to do for patients.
Many doctors take FMM workshops and then go out and found their own groups. There are from 60 to 100 around the country, plus a “Healing Arts” program being given at medical schools. Others log onto the Web site where they can find all the resources for beginning, plus online discussions. (Rufsvold calls the FMM group process “simple and easily replicable” through the online resources.)
He emphasizes that group meetings are not gripe sessions about insurance problems or daily hassles. Instead, participants come to address a topic that’s been chosen—compassion, spirituality, joy, privacy, even fear. They bring stories from their own lives to convey their feelings on the topic in ways that connect with the deeper meaning of day-to-day doctoring experiences. Rufsvold says, “We lead far more meaningful lives than we often know…it just needs a little teasing to remember it. That can help strengthen the doctor’s commitment to service,” even when the work is tough and sacrifices great.
Several years ago Krasner started a similar stress reduction program. His is based on one developed by Jon Kabat-Zinn, PhD, at the University of Massachusetts’s Center for Mindfulness in Medicine, Health Care, and Society (www.umassmed.edu/cfm/). It’s still taught there and Krasner says it’s now used around the world. Krasner originally developed the program to help his patients, but more recently he has modified it for physicians. “It’s a six-week course with 22 CME credits.” In it doctors learn and practice together mindful meditation and learn to bring it into as many aspects of their life as possible. Many of the graduates have continued to meet colleagues every other month outside the seminar. In this forum, based partly on the FMM model, they combine meditation with discussing topics such as mistakes, loss, and compassion.
Hall took part in Krasner’s seminar. “It’s meditation, focused thoughts, centering yourself.” He admits it might have been easier for him to accept since he was already into Zen, but adds such sessions, “create a very safe environment in which to think about one’s personal values.”
Krasner highly recommends meditation, but if that’s not your thing, fine. “Exercise, find a hobby,” anything that clears your mind so that you can remember “why you went into medicine in the first place.” For the radiologist who dreads looking at one more mammogram, instead remember the miracle that gives you that film and how you can help someone’s life with it.
Church refers to a note from a grateful patient, the kind that she says, “wipes out 10 nasty things.” She also takes time to truly appreciate the stunning sunrises from her windows overlooking Lake Michigan.
Concludes LoPreiato, “Too many physicians focus on their trials and tribulations. You have to focus on the joy of a kid’s face when he sees you, the trust of your patients. That’s priceless.”
Wendy J. Meyeroff is a nationally published medical writer since 1981, she lives near Baltimore, MD.