From The Desk of Nan Gallagher – Physician, Heal Thyself: Physicians and the Medical Profession Are in Crisis

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By: Nan Gallagher, JD, Esquire

Physicians, your profession is in crisis—and so are many of your peers. If you are like many of them, you too may be having a difficult time reconciling the demands of the modern-day healthcare system with patient care, the motivation that drew you to medicine in the first place.

Indeed, the system requires you to limit the time and attention you are paying to your patients. There are far too many reports of bad patient outcomes—even morbidity—that have resulted from these limitations. The result is that as a physician, your mental health could be at risk.

The reports are alarming. According to the Professional Assistance Program of New Jersey (PAPNJ), an organization serving licensed healthcare professionals in New Jersey for burnout, there are approximately 648,400 licensed physicians in the United States, and 64,000 of them are suffering from impairment conditions, among them alcoholism and other substance abuse and/or behavioral problems.

Even worse, the number of physicians who commit suicide is more than twice that of the general population. Physician suicides total 28 to 40 per 100,000 compared with is 12.3 per 100,000 in the general population.  Sadly, that statistic seems to have grown during the COVID pandemic.

Contradictions Abound

As frightening as these statistics are, they are also ironic. How can individuals whose mission it is to help others be experiencing such widespread instances of despair? For starters, as a rule, a physician’s commitment to help others is not always combined with the ability to turn a lens inward for self-help.

But the system, too, has failed.  On the one-hand, speaking out about individual impairments is often frowned upon. In fact, in the past, physicians who have sought out assistance for mental health problems have had to do so anonymously, traveling to other states to see mental health professionals and paying by cash to prevent any trace of treatment.

In addition, there has been the band-aiding and the years of borrowing the burnout line from other industries. That line implies that an individual in some way lacks the resilience or resources to withstand the work environment. You are taught in medical school that tireless commitment and long hours are the required physician “MO”.  Therefore, suffering from burnout can be a consequence of personal failure, and you are required to solve your own problem.

Words Matter. Call Foul on Burnout. It’s Moral Injury.

But In 2018, Dr. Wendy Dean, a psychiatrist, and Dr. Simon Talbot, a surgeon, called foul on burnout. Elevating the situation to one of public health proportion, they insisted that the profession as a whole take a long, hard look at physician mental health. The important first step, they said, was to reframe the discussion. According to Dean and Talbot, words do matter, because correctly identifying the problem paves the way to solutions that work. And so they discarded the term burnout, borrowed a term from the battlefield, and insisted on the term moral injury instead.

Moral injury is the damage done to one’s conscience or moral compass when that person perpetrates, witnesses, or fails to prevent acts that transgress their own moral beliefs, values, or ethical codes of conduct.Dean and Talbot and others like Dr. Zubin Damania have become harsh criticsof a dysfunctional healthcare system that relegates individual physicians to feeling powerless to change … a system, that in Damania’s words, “ends up doing stuff to patients instead of for [them].” 

Tools, Resources, Autonomy Lacking

Moral Injury, then, more aptly describes the problem that exists in today’s practice of medicine. It stems from the fact that you know the care patients need but you are often hamstrung to provide it because of systemic circumstances beyond your control.  In essence, you are not given the tools, resources, and autonomy you need to address the individual challenges of your patients.  After all, you have been trained to give the best care possible regardless of a patient’s race, socioeconomic status, specific illness, or their gender, and to deliver care with full focus on individual patients and their problems.

But modern-day medicine requires you to have other masters: insurance company bottom lines, hospital system revenues, and reimbursements based on relative value units (RVUs) which evaluate your work, practice expense and malpractice expense and combine these factors with your geographic practice cost index (GPCI). Beyond this, you are subject to increased scrutiny from health insurance payers and Medicare concerning medical necessity, documentation, coding, and commercial and government financial quality assurance audits.

More Administrative Work, Less Healing Medicine

All these variables net out to the fact that you are seeing more patients but spending less time with each patient during visits that are watered down to begin with. In compliance with data-driven healthcare, you are required to stare at your computers instead of giving eye contact to your patients as you check off the boxes that require entry on a patient’s electronic medical record (EMR). Plus, in the evening or on weekends, instead of spending quality time with family or enjoying leisure activities, you are likely slogging through copious paperwork and enslaved to the EMR.

More work, more patients, less time and attention to each of your patients. To compound this issue, you’re receiving lower reimbursements which can make it harder to make ends meet. Today, the rampant spread of COVID-19 has compounded the problem. Physicians are dealing with less face-to-face care or take on double duty on hospital frontlines, helping those stricken with the corona virus to overcome the disease, even worse losing patients to the virus.

A Breach of Patient Best Interests Stings With Moral Injustice

Every time, you are forced to make a decision that breaches your patients’ best interests, you feel a sting of moral injustice. Over time, these repetitive attacks to your value system could amass into moral injury that has serious consequences to your well-being. If this has not affected you, you likely know of peers who have been. As a result, talented individuals are leaving the profession too early and lesser numbers of individuals are entering the profession. In fact, a recent Association of American Medical Colleges reports that there will be a shortage of over 100,000 physicians by 2033.

In some cases, too, disruptive physician behavior emerges. Such behaviors create situations in which abusive verbal or nonverbal conduct has harmed or intimidated others to the extent that quality care, patient safety, and staff morale are compromised. In addition, disruptive physician behavior has been an ongoing challenge to medical staffs and can compromise earnings, image, and the trust of the community in a hospital’s mission.

Family Life Suffers

None of this bodes well for family life either or the work-life balance society tells us is essential to mental health. Two-income families are already stressed to adequately adopt childcare planning and to allow for down time and quality family time. It is fair to say that with stressors both at home and on the job, today’s physicians are strained beyond measure.

So what can be done? While the system needs redressing, there are some actions you can take to keep yourself in check.

Every initiative you take for your own well-being does give you individual empowerment.

• Practice Mindfulness and Self-Reflection. When we’re mindful, we reduce stress, enhance performance, gain insight and awareness through observing our own mind, and increase our attention to others’ well-being. Short pauses you can insert into your everyday life can help you to regroup and become centered and gain/regain equanimity as you move on with your workday.
• Modify Your Schedule. Know your limitations and understand what you must eliminate to make way for family time as well as time for yourself, whether it’s pursuing a favorite hobby, practicing yoga, or joining a team and playing a sport. These not only serve as outlets for stress, but also can replenish your sense of well-being simply because you know you are taking care of yourself and doing something you love.
• Know Thyself. Recognize your shelf life and unplug. Decide when it’s important to decompress and to consider a vacation or staycation in which you simply spend time at home or take day trips with your family.
• Delegate Skillfully Because You Have Implemented a Team Mindset. Train your staff and reinforce conduct through a policy manual that memorializes the requirements of each team member. When your staff knows what is expected of them, they will more easily rise to or exceed the requirements of their function, making it easier for you to clear your plate by transferring appropriate tasks to qualified team members.
• Mine the Resources of Advocacy Organizations.  There are organizations available to you that can provide assistance. The Professional Assistance Program of New Jersey (PAPNJ) is one such organization and serves licensed healthcare professionals in New Jersey for burnout (a/k/a moral injury), substance/alcohol abuse, addiction, and behavioral issues. PAPNJ provides rehabilitation services and the monitoring that keeps physicians on track with their rehabilitation. Also, PAPNJ is contracted with the New Jersey Board of Medical Examiners, the licensing agency for New Jersey physicians. The Physician Wellness Committee for the Medical Staff of Morristown Medical Center, one of the state’s top hospitals, is another regional resource that offers support to physicians.

Expansive System Reform Also Needed

Individual remedies alone are not sufficient.  Professionals like Dean and Talbot as well as Damania, who speaks under the stage name “zdoggmd” on YouTube, say more expansive system reform is necessary. According to Damania, for example, the next evolution in healthcare delivery, a strategy he calls Healthcare 3.0, will come when clinicians are given the tools, resources and autonomy to address the individual challenges of their patients.

With that goal, too, you can make a difference by communicating meaningfully around significant objectives.

• Call your Legislator. Competing with hospital systems and big pharma with their humongous lobbying arms is a formidable task. Still, establishing lines of communication with those who have the power to enact large-scale change is an imperative. Physician leaders (chief wellness officers, department chairs, medical society president and the like) have a responsibility to communicate with legislators about the needs of patients and the role physicians and legislators play in fulfilling those needs. You and those who represent you must sit at the table at which the decisions that impact clinical care are made.
• Partner with Administrators. More often than not, the decisions affecting patient care are being made by administrators, many of whom are not trained in medicine, but exclusively in business. And, in health, it is not just business. You have taken and comply with the Hippocratic Oath, which requires that you use all the measures and resources available to treat the sick. This includes practicing medicine as an art and not just science and the fulfillment of other data requirements. Incorporating empathy in many situations equals, complements, and perhaps outweighs surgery or prescription drugs.  Having administrators spend time in your office or accompany you on rounds may lead to greater understanding about how to treat patients and how humanization and not just data must characterize all patient interactions.
• Advocate for Making Physician Satisfaction a Financial Priority. Organizations must be held accountable to ensure care team well-being is a priority.  As patient satisfaction is already linked to clinician compensation, it may also be prudent to bond clinician satisfaction to executive compensation in medical and hospital systems.

Reestablish a Sense of Community Among Fellow Clinicians

As resources shrink, physicians often compete against each other. Physicians vie for referrals, while advanced practitioners like Physician Assistants and Nurse Practitioners compete with doctors for patients. The result is that everyone feels stressed. But when the endgame changes, and we understand that we are all working toward a common goal to give patients the best possible care, barriers diminish. As the old saying goes, it is necessary for all of us to have each other’s backs.

As General Counsel to PAPNJ and a member of the Physician Wellness Committee for the Medical Staff of Morristown Medical Center, I am knowledgeable about the components and requirements that lead to physician well-being. At The Nan Gallagher Law Group, we understand that collaboration, collective voice, activism, and professional assistance are the necessary first steps to making change.Call us at  973.998.8494 for the guidance and support you need as a solo or on-staff practitioner or as an executive leader in a medical or hospital system.