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.

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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.

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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.

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  • Having worked in private practice for over thirty five years, I never experienced burnout. I have been retireed from my practice in gastroenterology for 9 years, but I think that I understand what is happening. The computer and not the interview has become the interface between the physician and his patient, and this alone has dehumanized the process, making medicine a commodity. Primary care has beeen hit particularly hard. Present day economics have made primary care particularly. A family member of mine always wanted to go into family practice, but changed his mind at the last moment and went into sports medicine. He indicated that current economics in primary care make its choice difficult. I am sure that there are a multiplicity of other reasons why people expeience burnout, including choosing the wrong profession, but I imagine that the computer has done more damage to the doctor-patient relationship than anything else, making burnout more likely.

  • The problem of long hours and high physical and emotional tolls is common in many, many professions and even in skilled trades. The number of people, both female and male who work before breakfast and after dinner, if they get one, is legion in American life. If you want to be a success and stay in your position, or maybe even get a promotion, you will want to push, push, push and that means all too rarely relaxing or getting to see your spouse, partner or the kids. And people on the line or making corporate decisions can injure or kill people, just in different ways, as can an exhausted physician, PA or Nurse Practitioner. Others will just lose a finger or a hand when concentration wavers.

    We aren’t just talking physicians, we are talking anyone who works hard and plays seldom. The big difference is that many will never earn like a physician can. Thus their vacations aren’t as nice and most also struggle, especially when young, with not being able to buy what they want, maybe even having to forgo the nice house or any house at all. We all need to rethink America’s work cultures and design the life-respecting culture that most of us would benefit from.

  • There is a common denominator that affects job satisfaction and burnout with both requiring a culture change. That commonality is the huge trend toward hospital control of the practice of medicine. The physician has no control over the patients he or she sees, the hours he works or those he works with. Not to mention that hospital control has led to higher costs. Many mistakenly think that income is the primary motivator in the workplace but surveys show that job satisfaction is number one. I have also noticed that older physicians who negotiate the sale of their group practice to the hospital tend to be satisfied for the same reasons. They are relieved to be relieved of their management duties and have more choice about what employees they work with and their own work hours. Bottom line is that younger physicians and women have formidable obstactles in their face.

  • The next step, I believe, is to recognize that physicians without children also need the flexibility. Unfortunately the current climate is often such that those without children are expected to be flexible to accommodate the needs of those who have, but it is not accepted/acceptable that the demands of a pet, or just one’s own need to attend important social events not related to children should be afforded the same accommodation with the same degree of respect and understanding

  • As one of those old docs (1983 Med School grad) I have only 1 question: Why?
    Why in the world do cases/offices have to start early morning? No good reason; spreading start time throughout the day is such a winning idea I wonder why no one thought of it before! (Oh, wait, there’s a WalMart.)

  • It is telling that this exemplary dean was ultimately mostly profoundly influenced by his observations of his own daughter. Well, certainly better then than never. Other deans will be more influenced by the bottom line. Which too certainly may benefit from having faculty/residents/students who have a life and do not burn out/drop out/or suicide. Here’s an equally compelling commentary by another exemplary dean: http://bit.ly/SchwenkMDWBandCaring

  • Thank you for this article. The reality you discuss is also present in my occupation of veterinary medicine. I’m sure all doctors appreciate your words of support.

  • Post-grad Residency should be a choice not a requirement.

    Also, Nurses should go back being nurses. Now everyone wants to be doctors. Whenever you go to hospitals or clinics until seeing batches noones knows whose who.

    • Doctors are not ready to practice independently upon graduating from medical school. I think that’s a terrible idea.

    • There does need to be a learning period/residency. I don’t think it should be in hospitals unless you are hospital based. It makes no sense to put family med, or the like in there. Same for GI’s. They really should have an office based/hospital based residency. In other words, teach them what life is like, not scut work for doing data entry.

  • Be aware that if your doctor has a better work/life balance, they are more likely to be on time, not overbook, and take proper care of you. I will add that unless your job is solitary, they don’t want you there when you’re sick any more than you want to be there. And if your job demands doctors notes for sick calls, see what you can do to change that; it’s stupid and short-sighted.

    • Better work life balance means patients can’t get early am appts. If they are off getting the kid off to school and are late, then they push all of us back late. No one cares about alerting the patients so they can not be late and not miss work (like if you work hourly, you cost us money) or miss less of work (or have to cancel other appts. because doc is running late). The ones who overbook are not the docs, that is the admin that you work for that do that.

      There are already people who complain they can’t get same day appts. Take off a 1/2 or hour in the am, and then they take off before school lets out? We’ll get the shaft again.

      I totally agree on the sick calls, but nothing I can do on that.

  • When you are asking so much of patients (show up 15-30 min. before hand, pay for missed appointments when you double/triple book, we have lives too) and costs are going way up, yes, you know what the job entails when you sign up. Once you break the social contract, don’t expect patients to treat you the same. I walk out on docs who can’t make appts. You prioritized your life. We’re not as important. We have jobs, we don’t have unlimited sick time. We can also lose money from waiting for your choices. It works both ways.

    • Be aware that if your doctor has a better work/life balance, they are more likely to be on time, not overbook, and take proper care of you. I will add that unless your job is solitary, they don’t want you there when you’re sick any more than you want to be there. And if your job demands doctors notes for sick calls, see what you can do to change that; it’s stupid and short-sighted.

    • I agree with you, Vic. One of the sacred things about the practice of medicine is supposed to be the willingness of the physician to put self aside in favor of the sick and afflicted whose issues do not care at all for someone else’s arbitrary schedule. As unfashionable as it may be to say so, full time doctors work full time when there is work to be done. Anything less is part time. There is nothing wrong with part time, but the doctor needs to be honest in negotiating a schedule, and part timers will have a price to pay for the time off, no doubt.

    • I dont have a problem with a part time doctor IF they put that up front. Problem is, don’t expect the other coworkers (male, single, or whatever “group” you want to assign) to cover the time for when a person is late. If I make an appt. with someone, I don’t expect that they doff me off possibly 1/2 the appts because they’re busy with their family life. That makes it hard to have continuity.

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