Physician resiliency? (Physician Executive Leadership).

WHETHER VISITING WITH PHYSICIANS IN THE doctors' lounge, weekend social events, or on the chairlift at the ski area, common themes are heard: Medicine is not fun, physicians are angry, and it's not their fault. Many physicians talk openly of early retirement, believing that with just a few more years of steady income, happiness will come with a complete exit from the profession. Most physicians feel trapped in their clinical practices, having spent many years getting highly technical training to become competent at their specialty. They believe that they would somehow dishonor their responsibility to patients, and to their colleagues, if they consider career options other than clinical practice.

The profound changes in the health care industry have led to the anger, frustration, and unhappiness that physicians are feeling. It is important to examine physicians' responses to the threats to their professional autonomy, image, lifestyles, and relationships with their patients. The "learned helplessness" behavior exhibited by physicians is astounding, considering the education, status, and reputation of physicians as healers for those in need. This article explores the concept of resiliency among physicians and describes why physicians as a group may be less resilient than other individuals. In fact, the structure and training of the medical profession stacks the deck against those who want to change or to be resilient in the face of the changing environment.

Obstacles to physician resiliency

Resiliency is "the capacity to bounce back, to withstand hardship and to repair yourself." Resiliency asks the question, "Why do some people do so well when faced with adverse situations, while others flounder?"

The structure of medicine as a profession makes it hard for physicians to be resilient. Beginning with medical education, students are taught concepts of responsibility to others (patients) which date back to Hippocrates. Responsibility to the sick through selfless dedication to the healing profession is noble, but it is often taken to extremes in medical training. The student, resident, or fellow who spends endless hours at the hospital, often at the expense of his or her personal life, is considered a role model by the faculty. The drive to know the latest literature, to be knowledgeable about even rare diseases, or understand the latest surgical techniques consumes the life of the conscientious medical apprentice.

Professional embarrassment is commonly used as punishment for not performing to the satisfaction of faculty, which instills guilt for not devoting adequate time and effort to medical learning. How many times has a physician gone to a social gathering of non-physicians and found it uncomfortable because medicine was the only topic that he or she could discuss with competence, while the rest of the guests discussed a wide range of interesting topics? Have you ever wondered how your life might have been different if you had spent more time learning other things as a medical student, and less time studying medicine, or working on the wards? The self-sacrifice demanded of physicians starts in training and continues throughout their medical careers.

Medicine is at its core a profession: An occupation that regulates itself through systematic, required training, collegial discipline, that has a base in technical, specialized knowledge, and that has a service rather than a profit orientation, enshrined in its code of ethics. (2) In other words, it's a self-contained, self-regulating entity.

Medicine became a profession in the early part of this century, as scientific knowledge gave it legitimacy, and increased regulation gave physicians control over hospital admissions, prescription drugs, and other treatments. In addition to being self-regulating, it has tremendous power over an important social good-the treatment of disease.

The very characteristics that make medicine a strong and proud profession also sow the seeds that trap physicians. Medicine is a profession of service to others which comes with heavy obligations.

Medicine is a jealous master. It leaves little time or energy for hearing new ideas, reading odd books, or simply laying in the sun thinking. Your colleagues are often people who have similar backgrounds and lifestyles--people who value education, who work very hard, whose jobs have traditionally been fairly secure, and who have similar economic issues. Your relationships with other professionals, such as nurses, are often focused on work. Your discussions with patients are based on their health, rather than on all the other things that make their lives interesting. In this cocoon of hard work, it's easy to be so involved with the world of medicine that you have little energy or opportunity to gather different perspectives and even less energy to let those ideas float into different patterns until a useful image emerges. Medicine doesn't leave you time to regenerate.

To be resilient, you have to change. Change involves both the often painful process of allowing yourself to give up your current way of looking at things, allowing an open space where new ideas can form and reform patterns and eventually begin a new perspective. (3) And fresh perspectives come from many different ideas, often conflicting, rarely organized, which float around in your mind until they suddenly form new patterns for living that you haven't seen before. People trained in the science of medicine may not have much appreciation for such an unstructured and open process.

Resilience needs a supportive environment. When you change, you try things you've never done before. A few of those things won't work. You have a much better chance of succeeding if you have a support system that legitimizes your early attempts. But medicine doesn't encourage supportive relationships. To be a doctor, you have to inspire the confidence of your patients and the people who work with you. Your status is an important medical tool in helping patients, but high status undermines supportive relationships and prevents you from trying new things.

Medicine often requires warm but vaguely distant relationships. You have to keep your distance from patients so you can make objective medical decisions. Your relationship with other health professionals may be as head of the team, the decision-maker. It's hard, even with friends, to suddenly drop the confidence-inspiring behavior, to drop the habit of professional distance, and to abandon your professional role. Most of us don't like to feel vulnerable. There are few peers with whom you can talk openly, and often even those peers are caught in the same medical head lock. Physicians are very good at giving support, but the profession doesn't make it easy to ask for support in return.

Medicine has a special code of ethics. First, do no harm. Always make sure your patients are cared for when you are unavailable, by having someone on call or hiring a locum tenens to cover. Keep up with the latest journal articles, medicines, and new treatments. Your reputation depends on knowing the professional literature and treating patients. Physicians in administration aren't seen as real physicians." The physicians who leave medicine completely are seen as abandoning their higher calling. Retirement is honorable, but you have to be the right age for retirement to be acceptable. Once you have entered medicine, it tries hard to keep you within the fold. There are few honorable ways out. But resiliency requires some free space to explore, and may even mean you stop treating patients. Medicine often punishes such rebellious behavior.

Conclusion

Physicians are angry that non-medical people make the decisions about HMOs and health policy. They valiantly defend their profession, and angrily react to any force trying to impugn their motives or restrict their treatments. But defensiveness prevents physicians from seeing the paradoxes which are key to a solution. (4) Battle means staking out your positions, rather than understanding other points of view. Managed care and the government have taken control, rather than face continued upward pressure on medical costs. Medical ethics, focused on the individual patient, doesn't give physicians a structure for helping HMOs or the government with the cost problem. While you may not like their tactics, the structure of the medical profession does not provide a way for physicians to get a place in those community-based discussions.

Resiliency is not just accepting a situation.

Resiliency is using the energy from the uncomfortable situation to help you change.

Medicine has very strict informal and formal rules that tell you which change is acceptable. Long hours of work are acceptable, free time to think is not important. Your first obligation is to individual patients, not yourself or even your community. If the change you need doesn't fit within the rules, the cost of change becomes very high. Physicians are caught in between the structure of the medical profession and their own needs. The themes you hear in the doctors' lounge and on the ski slopes are caused, in part, by a profession that isn't structured to allow its members to change, and medical care is on a collision course with an environment where change is the only acceptable answer. No wonder physicians are angry.

References

1. Wolin, S.J. & Wolin, S. The Resilient Self: How Survivors of Troubled Families Rise Above Adversity. New York, New York: Villard, 1993.

2. Starr, P. The Social Transformation of American Medicine. New York, New York: Basic Books. Inc., 1982.

3. Bridges, William. Transitions. Reading, Massachusetts: Addison-Wesley Publishing Company. 1980.

4. Muldoon, Brian. The Heart of Conflict. New York. New York: 3 P Putnam and Sons, 1996.

Barry Silbaugh, MD, MS, is the Medical Director of The St. Joseph Healthcare Delivery System in Albuquerque, New Mexico. He was a Co-founder of New Mexico Medical Group, and formerly Medical Director at New Mexico Blue Cross and Blue Shield. He is also a Principal in Physicians' Management Resource, a physician practice management company based in Santa Fe. He can be reached at 505/244-2818 or via email at [e-mail].

Janet Winchester-Silbaugh spent 14 years in health insurance and managing an HMO, watching the struggle of good organizations trying to make sensible changes in health care, with all its conflicting goals. She now works as a consultant with many organizations that are trying to make change less painful and more effective. She is also on the faculty of Webster University's Health Services Management masters program. She can be reached by calling 505/286-2210 or via email at [e-mail]