'Professional existentialism' and low morale.

The November/December 2006 issue of The Physician Executive (Vol. 32, No. 6) was dedicated to a special report about "Discouraged Doctors." Based upon a recent survey of physician executives, the theme of the journal was on low physician morale, pondering its implications for the profession and musing as to its causes.

The concerns expressed in The Physician Executive are not new ones, however. How many surveys have polled us through the years, asking the same sad questions year after year: "Would you want your son or daughter to be a physician?" "If you had to do it all over again, would you go into medicine as a career?" The answers are never encouraging.

The common denominator in all of these surveys is the evaluation of the demoralized physician from the perspective of his or her social identity. The morale loss is a symptom of status anxiety. American society is ostensibly a meritocracy. The medical profession has traditionally been one of the top rungs of the meritocracy. In a society where hard work, perseverance, intelligence, and social beneficence are valued, physicians have been rewarded and honored with high status.

[ILLUSTRATION OMITTED]

But social status is dependent upon the socioeconomic factors of the society that sustains it. The untenable growth rate in health care expenditure has led to all sorts of pressures to change the way in which it is delivered. HMOs, managed care, capitation, P4P are all understandable attempts for market forces to gain some control over the exponential rise in the proportion of our gross domestic product invested in the health care industry.

In a market-driven society, economic pressures will be asserted upon social factors, altering social patterns of distribution of wealth and status. This is the underlying etiology behind what physicians are currently experiencing as status anxiety.

I would hope that physician executives might be in a better position to observe and lead the inevitable transition in this physician identity crisis than other physicians, for, if our specialty is not an oxymoron, then it should at least be one that has had some preparatory work in understanding the implications of socioeconomic factors in the business of health care, and we claim to be in the position to lead it.

The market-driven, consumer-focused, results-based health care system of the future will only understand physicians in terms of value, not status. Value is a very different concept than status. Status relates to one's identity, whereas value relates to one's worth. Status is a social construct. Value is an economic construct. By understanding the difference between the two, physicians may be able to emerge from the inevitable transformation in the current health care system, with their morale in tact, if not their status.

Others with high status have not had the problem differentiating their status from their value. Professional athletes, such as Michael Jordan and Mia Hamm, have obtained high status in the American meritocracy as a result of the value of their excellent athletic abilities. This is not a class effect, however.

Like the two of them, I was a UNC varsity athlete, but their status comes from their value on the athletic field, and mine, a one-year walk-on marginal track and fielder, most assuredly does not. Only those athletes who offer superior value are given superior status. Yet physicians seem to assume that their identity as physicians should give them a certain status, regardless of what value we are offering the society in which we play a part.

It makes absolutely no difference to that society that a general internist making $160,000 year may be treating complex patients and saving lives, while Mike and Mia are playing with balls. If society is paying billions of dollars a year for health care, but has a system with a high rate of medical errors, long waits, poor access, and inequitable distribution, the cost of a few basketball or soccer tickets to pay a few highly valued athletes is still a deal.

In the mid-twentieth century, Abraham Maslow outlined his theory of the five hierarchal needs of human motivation, namely, basic physiologic needs, safety, love/belonging, status, and ultimately "actualization."

From this sociologic approach, the physician loss of status is the etiology of the physician demoralization problem, and ultimately, will prevent the higher levels of functioning necessary to be "actualized."

Ultimately, our solution is professional existentialism. We must as a profession, or at least as individuals within it who have choices in how we live our lives, rise above defining ourselves by our status, and create our status through the value we create for others. This will mean embracing the changes in the health care industry driving our discomfort and leading the transformation that is generating our status anxiety.

If we who are gifted with so many skills that have let us rise to the top of the current unstable meritocracy do not lead the change, we will be relics of the past.

Grace E. Terrell, MD, MMM, CPE 

High Point, N.C.