“When pestilence prevails, it is their duty to face the danger, and to continue their labors for the alleviation of the suffering people, even at the risk of their own lives.”
–American Medical Association, Principles of Medical Ethics, 1903
I found this quote in a biomedical ethics textbook. It was presented as an example of how medicine had changed over the years and how this change had been reflected in their code of ethics. Physicians, the author contended, were no longer expected to die in the line of duty because the line, “even at the risk of their own lives” was removed from their official code in 1949. And in a practical sense, this was true. After the Great Influenza of 1918, our knowledge of infection control and sanitation gained enough headway that it was able to curb the rate of infections among doctors, and with the advent of antibiotics the doctors of the time must have felt invincible or at least gained an understanding that they might not need to die in order to serve the public. After all, there are no anti-handwashing martyrs; no heroes who live above the use of personal protective equipment.
When I realized that this sentiment had been stricken from the American Medical Association’s code of ethics I was disappointed. It may no longer be codified, but I told myself I would stop at nothing to treat my patients, even if it cost me my life. To me, medicine was a hero’s profession and as such required great personal sacrifice. When I got to medical school I was surprised how wide-reaching this idea actually remained. Personal sacrifice, delayed gratification, and self-denial were unofficial pillars of the profession and the practices of not taking sick days, sleep deprivation, emotional repression, and skipping meals the implicit virtues. At first, I was relieved, the profession that I had idolized retained its central mantra and it seemed that it had lost none of its vigors. But after a while, I began to see the cracks in this mythology. I felt the specter of burnout that hung over my classmates and professors, and we all developed an understanding that we were entering a profession with a recognized risk—no longer from external invaders but from a pandemic of a different character. The rates of physician suicide are 1.41 times higher among men and 2.27 times higher among females than the general population according to a metanalysis by Schernhammer and Colditz, and this rate has increased so drastically that once again Medicine is recognized as a deadly profession.
Some of the causes of this epidemic are inherent to the profession, but many, if not most of these risk factors are modifiable. Practices like mindfulness, meditation, and a positive disposition have all been showed to reduce rates of burnout as well as decrease the incidence of suicidal depression, but the implicit virtues of medicine that I mentioned seem to have the opposite effect. The evidence stacked against this philosophy has been mounting for decades and in my nascent experience with medicine, I feel the stirrings for change. Sleep deprivation can result in states of inebriation that have been shown time after time to result in more medical errors (the 3rd leading cause of death in the United States). Skipping meals is known to impact decision-making ability. For example, in one study reported by Kahneman, Israeli judges’ blood glucose level was found to be directly related to the harshness of sentences that they passed. Refraining from staying home when ill results in the direct inoculation of vulnerable patients with potentially fatal diseases, adding to the risk for hospital-acquired infections. And emotional detachment, whether it be in the form of closing off from friends and colleagues or in refusing to recognize the need and seek mental health care caused a decrease in the physician’s quality of life. All of these so-called virtues conspire to dive up the rate of physician suicide and overall decrease the quality of patient care. These issues have been addressed by restrictions on resident hours, increasing the availability of healthy foods, mandatory masking of sick personnel, and increased availability of counseling and other mental health services. These have all contributed to the resolution of this problem, but the implementation has been haphazard and has been met with much resistance.
The common notion is that good doctors work through sickness, tiredness, hunger, and sadness and are still able to take care of patients so therefore why waste valuable time and money with a focus on wellness? But the reality is precisely the opposite. Sick, tired, hungry and sad physicians are not good physicians, and in the long term, these states may be unsustainable. Burnout directly contributes to the number of medical errors according to the “Minimizing Error, Maximizing Outcome” (MEMO) study by Williams et al., and in order internalize this report and improve patient outcomes, medicine needs a new cultural shift.
Again, the temptation is to claim that this is unreasonable. The economics of healthcare would seem to conspire to create an unfavorable environment for such a change, but in fact, a heavy investment in physician wellness actually saves money in the long run. The increases in efficiency brought about by an increased focus on physician wellness would eventually allow these programs to pay for themselves. According to an article by Shanafelt et al., physicians who report higher rates of burnout have a lower self-perception of efficiency, and rates of physician burnout are correlated with higher rates of turnover. This is significant because in the process of hiring training a new physician the hospital will incur a cost that is on average 2-3 times the annual salary of that physician. Other studies have shown the loss of an employee puts their former colleagues at higher risk of burnout as well, multiplying the cost to the institution. By devoting resources to wellness programs, hospitals could stand to save a significant amount of money by investing in their employee’s wellbeing and reducing the rates of burnout among physicians.
A pestilence is prevailing, but the conventional wisdom would have us refuse to wash our hands. Some hospitals across the country have begun instituting wellness programs that focus on physician burnout, but despite their good intentions, most programs lack the resources and administrative commitment to be successful. Often this wellness effort is led by a handful of psychiatrists or psychologists against resistance and representing administrations that have historically been more interested in the theory of these practices rather than in the actual implementation. This epidemic will not be solved with a few yoga classes and a tentative embrace of positive psychology, but these are emblems of a culture shift that must drive medicine forward into a new age where the mental health of the physician is paramount and in so doing, the patient is put into the optimum position to be cared for.
