Health care reform and physician stress.

I am so ashamed to be here," said Dr. Y, a 35-year-old primary care physician employed for 5 years by a staff-model HMO in Connecticut. She had been referred to the Center for Physician Development (CPD) by her physician manager because of her disruptive temper outbursts at work, which had necessitated her placement on probation.

At the time of her referral, Dr. Y had been in productive psychotherapy for five years. Despite the resulting improvement in her self-esteem and mood, her persistent frustration with work had led her to consider both a trial of an antidepressant and a career change out of medicine. Instead, Dr. Y joined a peer education/support group and began career counseling at CPD. Over the next three months with support and guidance, she was able to identify her major source of frustration as her lack of control over her schedule and the secretary who managed it. This lack of control, combined with rising productivity demands, was consistently the last straw that triggered her temper outbursts. Unfortunately, her efforts to rectify the problem through existing organizational channels were unsuccessful.

There is no question that Dr. Y's psychotherapy was extremely useful in managing the stresses of her life. Traditional treatment modalities, however, carry with them the implicit message that one must learn to live with things the way they are, because the external realities cannot be fixed. In Dr. Y's case, as in many cases we see at CPD, it is clear that treating the individual is not enough. Indeed, the wrong patient is often on the couch.

These changing times offer a wonderful opportunity to reassess the medical model of physician wellness and stress management. Many of the most toxic sources of stress lie in our work environments. Although, admittedly, some of the stresses result from issues embedded within larger societal forces over which we cannot have control, many arise from the poor operational structures, roles, and relationships that rule our daily lives in organizational settings. Structural redesign of systems to enhance efficiency and effectiveness, reduce malpractice risk, and strengthen collegial alliances is an essential, yet often neglected component of physician well-being and stress management programs. Providing organizational time and financial and educational resources to facilitate real physician participation in such reshaping processes offers an effective treatment modality for both individuals and systems.

Clearly, addressing the sources of organizational stress, although of vital importance, is only a part of the answer. The ideal model strives for a balanced approach, where individual, intrapsychic factors are considered in tandem with external stressors. And, in keeping with this approach, access to supportive interventions targeting the individual physician must be improved. Physicians should have competent, confidential clinical and career development resources systematically available to them. The professional culture and the unusual role doctors play within organizations create certain unique human resource needs. An astutely run system will recognize these needs, prioritize them, and seek guidance from those with appropriate expertise.

Through Dr. Y's exploration process, she gained new insights into her working style and how to assess that of her organization. These vital tools are not offered in medical training. Dr. Y ultimately moved to a new practice setting. This practice, while not perfect, was flexible on issues of primary importance to her. Notably, the assistant who managed Dr. Y's schedule reported directly to her. At one-year follow-up, she reports that, despite the pace and demands of the job, she is delighted with her work transition and her restored capacity to enjoy patient care.

Increasingly, organizations define the context in which physicians work. Organizations that respond to change by reshaping their operational structures and support systems with an eye to physicians' needs will have a competitive advantage in the marketplace in terms of recruitment, retention, organizational morale, and patient satisfaction. Given that the recruitment of another primary care physician to replace Dr. Y cost the HMO $150,000, it is easy to see why organizational cost-containment and cost-leveraging strategies must be tightly linked.

Clinical and educational supports that enhance the self-awareness, career development, and stress management skills of individuals are invaluable, and physicians must have access to such resources. But focusing only on support resources is insufficient. A comprehensive wellness program also offers effective vehicles for identifying and targeting ailments in the system. Ignoring the sources of stress or assuming that the problems are refractory to treatment is costly to individuals and organizations and has critical implications for the outcome of the health care reform process.

Gigi Hirsch, MD, is Director, Center for Physician Development, Brookline, Mass. She may be reached at One Brookline Place, Suite 426, Brookline, Mass. 02146, 617/735-2999, FAX [phone]. Dr. Hirsch thanks Barry Stein, PhD, and Paul Tortolani, PhD, Senior Associates, and Katherine Corry-Hines, Administrative Assistant, for their editorial assistance.