A talented young physician was concerned about her job at Michigan Medicine, where we both work. She thought she might have to leave the organization because she could not meet mandatory early-morning start times for procedures or outpatient visits. She was especially discouraged by colleagues who said her attitude reflected a lack of commitment and “was emblematic of her generation’s fixation on lifestyle.”
Her problem did involve commitment — to her two children, who needed to be dropped off at school. She and her husband had decided to prioritize his medical career, and between his clinical and academic schedules, she was the glue that held their young family together.
Ten years ago, as the product of an old and still-powerful medical culture, I probably would have sided with her colleagues. But her story hit home thanks to my daughter, who finished her residency in pediatrics in 2017. She’s now in a practice alongside three other women pediatricians, all of whom work an average of 75 percent time.
She knows she could make more money working full time, and even more by joining a practice that demands more patient visits per physician. But she decided long ago not to take that road. She works hard, but she also wants a sustainable life.
It was my daughter’s experience, more than anything else, that finally opened my eyes to the peril health care faces as the traditional culture of medicine increasingly fails to meet the needs of younger practitioners.
In many occupations, this work/life conundrum has been recognized and addressed. Scheduling is flexible and accommodations are made to maximize the innovation and skills of the workforce. In medicine, despite much posturing, such change is slow. That is a major reason why physician burnout — especially among women — is alarmingly high.
As the stories of these two young physicians illustrate, the problem is far deeper than scheduling issues. It involves the bedrock rules and culture that guide medicine. Those are what must change, not physicians’ family lives, if we want to continue to improve the quality of medicine.
As an old-timer in medicine, I have two favorite times of day — early in the morning and late at night. These are about the only times that are my time, when I can meet the demands of the day without others making demands on me. It’s when I am free to stop and think. It’s why so many of my emails go out at 4 a.m. or 10 p.m.
I’ve been this way at least since medical school; fortunately, I don’t need a lot of sleep. I’m not alone: Many of my friends and colleagues stretching back to medical school follow similar schedules.
We do this because of the culture of medicine: always on call, never say no to any request, make your job your priority, accede to every demand, your time belongs to the calling. The idea of begging off clinical duties because kids had to be dropped off at school or to meet other family commitments never would have occurred to us. Many of us missed a lot of school plays and soccer matches.
The mythology of medicine — including residency programs that feature 48-hour shifts —demanded that every doctor be Superman or Superwoman. Saying no was not just a sign of weakness, but a betrayal of the profession.
Physician burnout has always been a reality. It just wasn’t an issue. It was a problem to be dismissed rather than addressed. Such denial is no longer viable as a new and growing body of evidence reveals the extent and dangers of burnout.
In a recent study that tracked more than 4,000 individuals from their first year of medical school in 2010 and 2011 through their residencies, 45 percent reported symptoms of burnout and 14 percent expressed regret at choosing medicine as a career.
This is a major concern because burnout is associated with medical errors and lapses in care. Burnout is also connected to the decision to switch jobs or leave medicine altogether — an ominous trend as the U.S. experiences a growing doctor shortage.
These and other factors — especially the challenges of balancing work-home obligations — take a special toll on female doctors, whose burnout rates are twice as high as their male colleagues, making them more likely to leave the profession.
The other sobering reality is that this has created a tension between old-school physicians and hospital administrators who expect physicians to plough through their challenges, and younger physicians who are not so willing to sacrifice their physical and emotional health to their jobs. That dichotomy was difficult for me to understand and embrace; it was only after many conversations with my daughter, that I “got it.”
Going forward, the needs and demands of younger physicians to strike a healthy work/life balance will only intensify.
In response, health care systems across the country are adopting policies aimed at creating more responsive, less rigid workplaces. These are a good thing and represent progress. For instance, last fall Michigan Medicine began offering to new mothers, fathers, and guardians six weeks of paid leave after the birth or adoption of a child. We are expanding child-care support and reviewing scheduling procedures to provide more flexibility to our caregivers without compromising patient care.
Recognizing that sharp increases in administrative paperwork are a major contributor to burnout, Michigan Medicine is testing the effectiveness of using scribes to handle some paperwork chores as well as new approaches to decreasing the time tax on physicians that accompanied our shift to electronic health records. We are also testing how to lessen physicians’ workloads by distinguishing between types of care only they can deliver and services that physician assistants and other trained personnel can effectively provide.
New policies like these are helpful, but I am convinced they are not enough. We must also do the hard work of confronting the powerful cultural forces that see these opportunities and seeking work/life balance as signs of weakness. Such messages are common in a profession where war stories often center on sleepless nights and dedication is defined by single-minded focus.
I don’t know exactly how to change this culture. Acknowledging the problem — writing and talking about it — is a necessary but anemic first step. A much harder next one will be for leaders to embrace and model the new culture that will be necessary to effect change. That is made even more difficult because it must be done in an era of decreased reimbursement and a focus on reducing costs. That said, multiple studies indicate that the cost of replacing physicians in the work force far exceeds the cost of increasing flexibility and reducing work hours.
The resolution of the case of the young physician I described at the start of this essay is telling. She is now able to drop off her kids at school and meet her professional responsibilities. But this took months of back and forth negotiations at the highest level of her health care system.
That must and will change. But it won’t be easy.
Marschall S. Runge, M.D., is the executive vice president for medical affairs at the University of Michigan and dean of the University of Michigan Medical School. He receives funds from Eli Lilly for his work as a member of its board of directors.
My oldest child is now 24 and my youngest is 6. There is a reason why my kids are spaced out so much… exactly as you outlines above. In the last 24 yrs though nothing has changed. Even now in the 21 st century I am punished by not being given referrals because I am constantly late to early morning meetings and tumor board Because of having to drop off my special-needs kindergartner.
How are others treated if they are “constantly late to early morning meetings and tumor board”?
I would like to make it clear when it comes to the benefit offered to the more than 1,200 resident and fellow physicians; employees doing their required specialty and subspecialty medical training at Michigan Medicine.
The non-birthing parents are considered secondary care-givers and are only eligible for two weeks of paid time off. Prior to 2017, this group was only allowed four days of paid “Paternity” leave. The union which represents the residents and fellows pushed very hard for three weeks of paid leave, in what was a very contentious contract negotiation, by any measure, and settled for two.
I’m encouraged by what Dr. Runge wrote. It gives me hope that the trainees which I represent, and who work as much as 80-hours a week and suffer from burnout, too, might have the option of taking 6 weeks of paid time off to bond with their infants, also.
That’s great but what are you doing for those who have to pull the workload when their fellow residents are gone? When they have to work more and lose family time, are you giving it back to them?
I appreciate this post. A leader has acknowledged his need to change, and describes the personal experience it took him to make that change.
There are two major issues driving burnout.
The first driver is the workload, which has increased due to increasing complexity of patients, the complexity of new knowledge, and the onerous processes of documenting and providing the care of each patient.
The second is a work environment which exacerbates the other five drivers of burnout as defined by Maslach. Physicians experience less control, less respect and recognition, less community and collegiality, less trust in management, and increasing values conflicts with health system leadership.
In the good old days, we sacrificed too much, but did so in service to a mission to our patients, colleagues, and profession. In the current work environment decreasing respect, control, and values alignment leads to disengagement.
We need balanced workloads and lifestyles, and healthy workplace cultures.
It’s up to healthcare leaders to change themselves and change their organizational cultures and management systems.
Change is hard. Leading change is every leader’s responsibility. Until leaders fully engage, we will see worsening of clinician burnout and its sequelae – depression, family dysfunction, substance abuse, and suicide.
This is another unnecessary article from academia about how we need to treat young physicians better. I have seen many good changes that allow young mothers and fathers take time needed for their family such as flex hours and job sharing but, the fact remains that physicians are in a service industry and need to be available when our patients are. I am so glad your daughter can work 3/4 time, but what about the poorly paid secretary in an office that can’t afford to take time off to have his or her children seen. They need appointments before or after work. Who is going to see them? How am I as a manager of a private practice going to balance who wants what schedule against the patient’s schedules. Medicine will and always should be about the treating the patients. If we can make it easier on the physicians, so much the better, but that shouldn’t be the priority
I completely disagree with Mr. Dunlevy. Physicians are humans and they have a life and a family. Nobody should be punished because they are in the service industry. A tired and unhappy physician will deliver poor quality of care and make medical errors. Yes, patients’ come first but that does not necessarily mean that we cannot find out of the box solutions for those who have priorities that need to be taken care of. It is the failure of the health system to be unable to understand that the needs and demands of today cannot be met by the rules laid down years ago. I as a physician value my life, my family and my profession and I want to have a balance and if an institution cannot respect and meet my needs than it is the loss of the institution because I have the capacity to create my own institution. It is a shame that after an epidemic of physician burnout, depression and suicides, we still do not get it…
The author quoted a study of medical students followed through residency and 45% had burnout. That’s not surprising and probably could be higher. All medical students and residents are burnout at one point or another. More important data would be from completion of residency through 5, 10, 15, 20 + years of practice.
It is not a coincidence that physician burnout has become a major issue since the practice of medicine has been taken over by computers, insurance companies and bureaucratic hospital bean counters. They have taken away what we went into Medicine for- the right, and privilege, to take care of our patients, and to be recognized and respected ( I didnt say “paid”, just respected) for our dedication and effort. We have lost control of our profession, and now are told what we can prescribe, what tests we’re allowed to order, and how many patients per hour we must see. Oh, and your “doctor”! May just turn out to be a nurse practitioner.
The only people who still think we are in charge are the malpractice attorneys. Want to cure burn out? Claw back control of our profession.
It’s not happening. We won’t be clawing anything back, short of unionizing.
And if the younger (or older) crew thinks that goes can be scaled back without consequence, think again. Loss of pay goes without saying, but there is also loss of clout within the organization. And someone will be making up those hours… Either a hungrier doctor, or even more likely an extender (or “co-provider” if you prefer).
I guess fortunately there are still youngsters out there with the dream of doctorhood. They won’t know any differently. I tell them to strongly consider the PA route first… Wonder who will take care of us?
Female physicians on average see 25 percent less patients per week than their male counterparts. Motherhood certainly plays a large part in this. With women outnumbering men in medical school now this substantially worsens the doctor shortage. But don’t worry we have NPs and PAs to take up the slack(not) .
Another case of one step forward and two steps back. Another reason why academic physicians have absolutely no clue when it comes to properly managing the nation’s health system.
They badger physicians with board renewals and through short sighted policies have pushed primary care into the hands of far less trained PAs and NPs who make the profits of corporate owned medicine higher but leave the patient in a diagnostic no man’s land