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Physician support groups in a multispecialty group practice setting.

My medical group practice has many unhappy, annoyed, disgruntled, and even angry physicians. The numbers are growing rapidly. There are many turf battles, constantly recurring income division schemes being presented, and negotiations for income distribution beyond practical need. Work hours are increased to maintain income, as third-party payers alarmed at the rapid rise in health care costs, strive for control. There is a whole new accountability issue that physicians have not faced before--public publication of physicians' mortality and costs for specific disease entities, professional review organizations and their expanding federal mandate, and finally a sophisticated patient population that is demanding more explanations and that questions physicians' competency. The challenges facing physicians are legion. As a result, perspectives on professional and personal life have been lost.

The concept of peer support heretofore has been either nonexistent or ignored or passively accepted for only a short time. There is a dearth of information on peer support groups in the medical literature. Until Sarah Charles [1] wrote of her emotionally difficulties with a malpractice suit and through that understanding began to extend her help through group support to other members of the physician community, little was published. There is now a growing body of knowledge about peer support groups in residency programs. However, there is considerable information in the sociological and psychological literature about peer support.

There is a human need to share the impact of any major life event with an understanding fried, associate, or spouse. There is a considerable body of research that supports the notion that the impact of a major stressor is modified by social support. Just one conversation about the physician's emotional reaction may be sufficient to diminish the feelings of anger, isolation, shock, and dismay that result from being named in a lawsuit, for instance. [2]

Increased job stress and work-related frustrations among primary care providers may result in lowered producitivity and morale. Recent investigations have indicated that protracted stress may play a major role in the poor delivery of health services and is associated with the development of negative, cynical attitudes toward patients. [3] Communication, peer group support, and regular assessment remain the most effective means of preventing or treating burnout. [4]

Stress is an intrinsic part of medical practice. Nonimpaired physicians may make adaptations to the unalterable stresses of medicine that are productive and may actually improve the quality of medical care. Unfortunately, adaptations are often unproductive, resulting in poorer quality or uneconomical care, or they may adversely affect the personal lives of the physician and his or her family.

The reluctance of physicians and patients to discuss the effects of stress on physicians honestly is a major obstacle to investigating the effects of such stress. Having spent up to a third of their adult lives preparing to practice medicine, physicians are understandably reluctant to acknolwedge psychological discomfort with fundamental professional activities or the conflict between long-held expectations and the realities of daily practice. Patients, on the other hand, like to believe that caring for theil illnesses is inherently satisfying, and they rightfully point to physicians' generous financial and social rewards. [5]


Inherent in a physician's temperament and personality is an individualism that does not perceive the need for help in any crisis. This inner strength that pushes one through the rigors of medical school leads the physician to disdain help from anyone. Many of the character traits that contribute to physicians' success become risk factors for depression when amplified. The qualities of self-sacrifice, perseverance, competitiveness, and, to some degree, denial of feelings are essential for the passage of the physician through the stages of student to mature professional.

A balanced personality must be endowed with a capacity to play, to attend to feelings of rage and dependency, to express feelings, and to comfortably seek nurturance from others. The drive toward achievement might subvert these latter needs in many physicians. Inherent in the socialization of physicians are factors that reinforce this overachievement; in some cases these factors help produce doctors who can maintain self-esteem only through compulsive self-denial. Given the guilt associated with receiving nurturance from others and the shame provoked by feelings of being weak and needing help, the physician will only reluctantly turn to colleagues for professional assistance.

Medical education is the "rite of passage" on the way to becoming a member of the medical priesthood. I reinforces the novice's faith in the central tenet of religion: With enough workd, dedication, knowledge, and skill, suffering can be alleviated, disease can be overcome, and death can be defeated. In short, the impossible can be achieved. Ultimately, physicians must learn that cures are exceptional and death can only be delayed, but they often feel they have somehow failed and respond by spending more time learning more, trying harder, and working longer.

Medical education provides little help in dealing with these stresses. It favors cognitive mastery over interpersonal warmth. Personalities are deprecated and minimized. Self-denial, hard work, and suffering are the only route to accomplishment, wisdom, and the respect of one's colleagues. Many physicians secretly lack self-confidence. The aura of power and uathority with which they surround themselves is often a defensive posture designed to ward off daily reminders of fallibility--treatment failures, dissatisfied patients, continued pain and suffering.

Doubt, guilt feelings, and an exaggerated sense of responsibility form a compulsive triad in the personality of the physician. [6] This triad manifests itself in both adaptive and maladaptive ways. It is probably accurate to assert that compulsive traits are present in the majority of those individuals who seek out medicine as a profession. Most people agree that the process of medical education itself enhances and positively reinforces any preexisting compulsiveness. Compulsiveness is a highly adaptive trait that makes for diagnostic rigor. The sense of responsibility that physicians have, when taken to the extreme view that whatever happens to patients is part of it, may verge on omnipotence.

Physicians may use work as a primary method to enhance self-esteem and to gain social approval. Unable to say "no" to patients, these physicians cultivate few outside activities that bring pleasure or satisfaction. Ultimately, excessive demands cause factigue, which leads to decreased effectiveness. Lengthening the work day to compensate for the loss of effectiveness causes fatigue, so the physician eliminates exercise and relaxation and recreational time, which only tends to further decrease recuperative capacity, and the vicious cycle continues.

The increased work load these physicians impose on themselves causes a deterioration in their marriage and family life, undermining their main source of nonwork-related support. Their overloaded schedule causes patient complaints of inattention, the increasing possibility of errors, and even criticism from colleagues. [7]

Characteristically, physicians do not talk much about their professional stresses. During the years of clinical training, most physicians develop patterns of coping that enable them to deal with the problems inherent in their specialty. They are, however, often poorly prepared to deal with unanticipated traumata such as being sued. Only 11 percent of sued doctors indicated that they spike to their peers about the situation. [8]


As medical director of the Madison Hospice, I have been meeting with a team of clinical nurses, counselors, social workers, and pastoral workers in grief and bereavement training in a weekly review of current cases. In using the group support concept, this group, which takes care of more than 200 dying patients a year, has averted burn out among their members for more than ten years. Each nurse and counselor cares for 50-100 terminal patients and their immediate families annually. They really emote during these presentations, and often extra meetings may be called simply to afford the opportunity for concerns and tears to be shared. This sharing of feelings prevents exhaustion of reserve emotionall strength.

We have helped three departments organize the same type of informal meetings, again out of the formal professional setting, and encourage of the discussion and the voicing of feelings about that particular group's common problems. One of these groups provided the opportunity for three new women physicians to describe the manner in which male chauvinism was being practiced in two particular departments. This included unequal on-call assignments, physicians on call calling women physicians who were not on call to come into the hospital, male physicians criticizing in a very arbitrary fashion their women partners, open criticism of a physician's pregnancy, loud complaints about a paid maternity leave of a younger woman partner, and frequent comments about women physicians' inability to work as hard as their male counterparts.

Another senior physician and I were present for these meetings, and our effort at first was confined simply to listening. We were subsequently able to facilitate some changes in the call schedules. However, these new probationary partners were fearful of retaliation when their departments voted on their acceptance as new members after a two-year trial period, so we were cautious. We have since been able to help them line up separate call schedules with others sympathetic physicians. Once all physicians are informed of unfair practices, we find that fairness in assignments on call and an inviolate off-call status has been attained. The group has not found a need to meet subsequently, so, in a sense, we really provided only a problem solution. We hope to active the group again, however.

We have formed another group of younger physicians in a particular specialty where on-call assignments in an intensive care unit are not shared by all the members of that department. They perceive this and their reimbursement as unfair. Again, meeting with older members of another group practice who will simply function as listeners, and who are authorities on the corporate culture of the organization, will probably lead to an effective resolution of the problem. All this must be accomplished without fear of retaliation.

The area in which we have been most effective is a malpractice support group. As malpractice suits began to proliferate in the medical center, it became apparent that physicians who were sued had a great need to share their feelings and experiences with colleagues with similar experiences. The impetus for this effort came when two of us in the same office were suffering severe depression and private feelings of rejection. After discussing the implications of the suits and the effects on us as individuals, we realized the effectiveness of talking about the emotions evoked by these suits. It was reasonably] easy to attract several other physicians to a support group because of their immediate need. However, our first attempt was ineffective because we allowed the discussions of each malpractice suit to be about the injustice the unfairness, and the legal technicalities. The first meeting ended in a resolution to have the organization retain its own malpractice lawyer.

Subsequently, with guidance from Charles' book, [1] from many articles, and two particularly effective videotapes on the subject, we have reorganized. We now use smaller groups of three or four, and they have been more effective, particularly in the area of sharing emotions. We have been unsuccessful in gathering a large group of physicians being sued, and I suspect that this will take time.

We have been able to interest a smaller number of physicians who have been through rehabilitation for substance abuse to meet in groups of twos or threes with a physician who has just been identified with having such a problem. This generally has been has been very helpful for the involved physician.

I believe that these efforts should be extended to on-call groups within the larger departments; to smaller departments of some specialties; to physicians with particular problems that are shared by others; to any group physicians who are interested in the entire concept of support; to those in particular need, i.e., oncologists and physicians being sued; and to those with particular family problems, i.e., divorce. These would be efforts to decrease sleep deprivation, encourage physicians to share call and therefore to share patient responsibilities, to help the organization form an ethics committee to both train and educate physicians, to help to destroy the myths of physician invincibility, to encourage family counseling, and to recognize the achievements and the public services of our physician members. Performance feedback should be directed to all members. We could make available training in stress reduction methods. Retreats could be offered. Social events could enhance the culture of the organization. The hospital has already formed an alumni reunion physician group that meets monthly.

In the general matter of coping with the stress of professional life, these groups should discuss the priorities of life and the time available for expenditure, with emphasis on the need for personal time. The need to value and to cherish self is important. We have already discussed the objective of sharing feelings and venting frustrations. Goal setting should also be part of these meetings. Reminders are needed that patients who do poorly or who die are not necessarily a manifestation of professional failure. Fellow physicians are more able to point out unrealistic expectations on the part of their partners. Walker has listed four suggestions [9]:

* Remind yourself that once a reasonable economic security security is established, improving your intellect and personality is more important than acquiring material possessions.

* Seek time to be alone.

* Cultivate spiritually rewarding friendships.

* Allocate time for reading classical literature.

Another remedy is to remind doctors that they must scrutinize the inner workings of their own minds rather than attempt to live up to a grandiose image of themselves as omnipotent heroes--an idea that is false and hides insecurities. Grandiose expectations of possessing unlimited power and protective capabilities can oftenlead to dangerous self-neglect. Many doctors have tried to split off feeling of irritability, anger, and frustration and unconsciously locate them in their patients, whom they then complain about. [10]

Implementation Plan

The first step in establishing support groups is to determine where the problem areas lie and what people are mostly likely to accept such measures early. The obstacles are many. The psychological make-up of physicians, both in the type of people who select medicine as a profession and the medical training itself, produces a person clearly not able or willing to accept external assistance. This results in a significant resistance to the whole concept of support that must be overcome.

One of the techniques is to utilize the theories of psychological crisis treatment, where it is well documented that people in trouble are more readily open to support from their colleagues during the first weeks of the crisis. A psychological crisis is the response of a person to a hazardous event. It tends to mobilize powerful reactions to help the person alleviate the discomfort and return to the state of emotional equilibrium that existed before the event took place. If this step is accomplished, the crisis can be addition, the patient can learn to use adaptive reactions that can serve the patient well in the future to achieve a state of mind superior to that which existed before the onset of the psychological difficulties. If the patient's reactions are maladaptive, the painful state intensifies, the crisis deepens, and a regressive deterioration takes place, giving rise to psychiatric symptoms.

Action Alternatives

As we are presented with the growing emotional problems of unhappy physicians, we can choose from the following actions:

* Continue to do as we have before and simply try to counter problems individually or in small groups when they arise.

* Ignore the problem, because it appears that every physician in the country is suffering from it.

* Counsel individuals as their support structures and coping begin to fail.

* Try to move the entire medical group to understanding origins, mechanisms, and effective therapy of stress through visiting experts.

* Form peer support groups, beginning on a small scale, and attempt to teach physicians to cope, to manage time effectively, and to accept inevitable changes in the medical profession.

If we choose noneffective strategies, we will probably find that our group will begin to disperse. At first, highly mobile people, especially higher earners, will try to find a practice setting that they feel will at least preserve their income and perhaps make them happier. It is apparent to me that equating self-worth with income will be an ineffectual endeavor for most everyone.


I believe that, with some training and a plan and by starting on a small scale, one could utilize peer support groups. The benefits should be large. The cost, except in time to those who organize the strategy, would be small. I further believe that physicians can profit greatly by participating in such function. At this point, there seems little else that can afford physician relief from the stresses that are now occuring in our profession. Escape from such stress seems unlikely, unless one leaves medical practice entirely.

I think that the effort can be facilitated by one individual, keeping costs at a minimum. Of course, this must be proved productive or busy physicians won't feel that the time is worth spending. By starting with a small group of physicians who are particularly sensitive but who also are troubled, one can introduce the concept. As the effort becomes successful, it can spread to other, less-interested groups of physicians within the organization. At worst, the whole concept will simply be rejected by the physicians.

I have found one thing to be true. Physicians do not like the term support group. It implies that they need help. At least early in the onset of such activities, they have resisted our efforts. We therefore use the expression "peer group" or "discussion group" so as not to frighten away those who are not willing to admit that they need to avail themselves of outside help. Whatever the term used, the concept can be effective helping physicians adapt to these troubled and rapidly changing times.


[1] Charles, S., and Kennedy, E. Defendant: A Psychiatrist on Trial for Medical Malpractice. New York, N.Y.: Free Press, MacMillan, 1985.

[2] Charles, S. "Psychological Reactions to Medical Malpractice Suits and the] Development of Support Groups as a Response of Professional Liability." Adapted from the "Physicians' Support Group Brochure." Chicago, Ill.: Illinois State Medical Society, 1987, Chpater 35, pp. 289-92.

[3] Maslach, C. "Characteristics of Staff Burnout in Mental Health Settings." Hospital and Community Psychiatry 29(4):233-7, April 1978.

[4] Orlowski, J., and Gulledge, A. Critical Care Clinics. 2(1):173-81, Jan. 1986.

[5] McCue, J. "The Effects of Stress on Physicians and Their Medical Practice." New England Journal of Medicine 306(8):458-63, Feb. 25, 1982.

[6] Gabbard, G., and Menninger, R. Medical Marriages. Washington, D.C.: American Psychiatric Press, Inc., 1988.

[7] Walker, J. "Coping With the Stress of Medical Practice." Connecticut Medicine 45(9):594, Sept. 1981.

[8] Charles, S. "In Response to Malpractice Crisis. A Physician's Support Group Formed." Illinois Medical Journal 167(6):454-5, June 1985.

[9] Walker J. "Coping With the Stress of Medical Practice." Connecticut Medicine 45(9):593-6, Sept. 1981.

[10] Joffe, H. "Physician, Heal Thyself." Australian Family Physician 17(1):9-10, Jan. 1988.
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Title Annotation:Interpersonal Relations
Author:Rock, William
Publication:Physician Executive
Date:Mar 1, 1992
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