Physicians' views on quality

by Larry Vickman, M.D.

Much of the angst physicians feel today has to do with our perception of the many changes we are encountering in our current system of health care delivery. Despite the great technical advances in American medicine, there remain a staggering 44.2 million of our citizens without health insurance, which is usually seen as the ticket to health care access. Despite all our successes, as a society we still have many choices to make as regards how to deal with these painful issues. As physicians we must continue to play a significant role in the evolution of our system and not give up with frustration or impatience.

Consider the following report from Newsweek: "In a survey of 4500 physicians, researchers found that 31% would choose a different profession if given a chance to start over. Factors such as work stress and poor control over their environment weighed heavily in their opinions. The other study demonstrated a high level of emotional exhaustion in about one-third of doctors. It is impossible for physicians to bear witness to a constant barrage of pain and death while remaining unaffected. This is a timeless problem, but recent changes in our healthcare system have exacerbated it." (1)

It is my belief that much of what we feel today has to do with changes in the way we have done things in the past, in how we were trained to interface with the systems of the past, and the needs of practice in today's world. If we never knew any differently, we probably would not feel so much pain. Consider the most recently trained generation of physicians, some of whom are employees of large health systems, and who operate within significant constraints. This is then the model of practice these physicians find familiar, and it is in stark contrast with the private practice model. This is quite a difference from the independence associated with private practice.

If you are wondering if it is all still worth it, just take a look at what we are allowed to do with patients:

• We often interface with patients at times of crisis; we are afforded the opportunity to apply our training, skills, and humanism to effect a diagnosis and a treatment, and to improve symptoms.
• We enter patient's lives in the most intimate ways, both emotionally and physically.
• We physically enter any of a number of body openings; if there is not one we can use, we create it with surgical instruments.
• We are given trust, respect, authority, and responsibility.

There are no other professions that are accorded this level of personal intrusion, given this level of trust and this level of responsibility, and who have so many great tools at their beck and call.

Change is painful, and in our profession it seems doubly so. We are not only suffering multiple economic interventions, but interventions in the very fabric of what we, and many others, see as the basis for our work lives: our professionalism. I believe that these intrusions upon our professionalism provide some insight into our current situation.

Professions have long been recognized to consist of three essential characteristics:

• Expert knowledge (as distinguished from a practical skill)
• Self-regulation
• A fiduciary responsibility to place the needs of the client ahead of the self-interest of the practitioner.(2)

Most physicians would agree that the boundaries have blurred within each of these areas in the medical profession. "Expert" medical knowledge is now available from a whole host of individuals with less training and experience than physicians; many of whom also have more effective marketing tactics. Our ability to self regulate is constantly challenged by a multitude of outside agencies, both private and governmental. The area where we really hit the wall is with Characteristic Three---the responsibility to put the patient ahead of our own personal interests. I believe most of us do this. It is obvious that any profit making business that is in the equation will put making profits and economic growth ahead of other responsibilities. These agencies and businesses are constantly involved in the system of health care at many levels, and yet we are the ones that are consistently held to put the patient first when many others do not. I believe this is a major source of discontent for all of us in practice.

Four other attributes are commonly recognized as essential to professionalism:

• Subordination of one's self-interests (to the interests of patients)
• Adherence to high ethical and moral standards
• Response to societal needs
• Demonstration of evincible core humanistic values (e.g. Empathy, integrity, altruism, trustworthiness).(3)

This is a high set of standards to live up to. If we are to be held to these levels of social performance and others working within the system of health care delivery are not, we are once again set-up for more distress and conflict. This is a major responsibility for anyone, but to work effectively, the whole team must play this way. I venture to say some of the many teams with which we work do not operate as professionals as defined in this manner.

An additional approach to understanding professional dissatisfaction can be drawn form the work of Maslach.(4) She describes six areas over which we must have some balance in our workplaces in order to flourish and to avoid burnout. These six areas are:

• Excess workload
• Lack of adequate control over one's work setting
• Breakdown of the workplace as a supportive community
• Inappropriate reward systems
• Lack of fairness in organizational decision-making
• Conflicting values

This list is rife with opportunities to understand physician distress today. We are working harder for less pay. Control over our work lives is a constant wrestling match with outside organizations. With the large volume of work, we are spending less time together as physicians enjoying one another's company, and thus the community of physician spirit has given way to competition and less personal support. Rewards in terms of remuneration depend increasingly on how you document what you do and less upon what you actually do. Fairness issues abound as insurance companies make decisions that often leave patients last. Values or operational belief statements that describe who we are and how we do business vary across the board for many of us who are trying to do the same thing: take care of patients. Frequently they are unstated and are in conflict with our professional goals.

It is still worth it. Absolutely YES. No one else is able to do what we do. We can not only survive this major social evolution, but also flourish by remembering what professionals are and what they are supposed to do. I personally am proud to be a physician. It is by remaining together, by doing the right thing for the right reason, that we will, in the final analysis, be able to hold our heads high. It is by understanding what part we have played in arriving to this point that we may be guided to more effective actions in the future. It is by taking responsibility for our part and not by blaming others that we can rise above all of this. We must not lower ourselves to the rank and selfish behavior of others. We must continue to behave with honor and dignity, and by putting our patients first. We need to look out for one another and support our colleagues. Continue to make your voice heard, participate even when you are angry or frustrated, and you will be able to hold your head high. It is through our professional organizations and through our continued participation with honor and distinction that we can be successful. ---TP
 
References:
1. The Silent Anguish of the Healers, Zeev E. Neuwirth, MD, Newsweek, September 13, 1999. P. 79
2. Ludmerer, JAMA, 2082:9, 881. Sept. 1, 1999.
3. American Board of Internal Medicine, Project Professionalism, ABIM, 1995., from Swick, et. al, JAMA, 282:9, 830, Sept. 1, 1999.
4. Maslach & Leiter, The Truth about Burnout, Jossey-Bass, 1997.