- Medicine

Medicine needs a culture change to retain talented physicians – STAT

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.