By C. Richard Patterson, MD
I’d like to get a couple of things straight at the beginning:
1. For the past hundred years or so, being a doctor in the US has been and continues to be one of the most privileged existences and pursuits one could imagine. This blog is not about evoking sympathy for American doctors. What I am after is empathy, i.e. understanding. No matter what happens in healthcare reform, you’re still going to need doctors, and what is affecting them is going to affect you.
2. Not all doctors are grieving. Some are but are not aware of it (denial). The threat to all of us is that those most likely to be affected are those we consider mid-career, the center of the physician workforce that we will depend upon for the next twenty years, the ones with sufficient experience to be very good and youthful enough to deliver on that capacity for more than the near-term.
3. The reasons for physician grieving are multiple, but they all come down to the same banal rubric: change. The changes are fundamental, though, and they will affect all of us. By understanding what is happening to the white-coated canaries in the healthcare cave, we can begin to prepare ourselves.
Before we get to the reasons for grief, let’s brush up on the stages of grief:
1. Denial: when we hear a threat, the first instinct is to shut down and ignore it. This is still very common among physicians, who keep whistling, “It cannot happen”. If you engage a denying doctor on the topic, you are going to hear a variation on that theme. The “it” is a radical realignment in the traditional structure and systems of medical practice. More on that later.
2. Anger: when the threat can no longer be denied, anger is commonly the next phase of grieving. Patients are not as likely to witness physician anger as are hospital and clinical staff, who may be the targets of the doctor’s sense of helplessness, rage, and frustration. This is not a trivial phenomenon, and The Joint Commission has made “disruptive behavior” a top priority for hospitals seeking accreditation. It is not only unpleasant and unprofessional; disruptive behavior erects barriers to effective communication and collaboration and threatens patient safety.
3. Bargaining: physicians may hope to appease the monster by throwing concessions at it while clinging to the most valued aspects of their practice: “I’ll do more committee work, I’ll participate in the quality forums, I’ll volunteer for the health fairs…just don’t take away my office, don’t make me use an electronic record, don’t make me go to work for the hospital.”
4. Depression: when physicians perceive themselves as helpless, when they sense that they are flotsam in a tsunami, they experience situational depression (normal reaction) that may progress to clinical depression (pathologic state). Sadness, the blues, a sense of being ineffectual, changes in appetite and activity…all are signs of depression. The depressed physician may drag himself through the day but will not relish the triumphs and will shrug off the losses as the norm. There is likely an increased risk of suicide during this phase. There is certainly an increased risk of losing the doctor to premature retirement, and that risk has implications for all of us in access to experienced, accomplished physicians. About five years ago, I told my CEO of a survey in which more than half the doctors said they would retire immediately if they were financially able. The CEO replied he thought that would be true of most people. I didn’t disagree about most other people. The point is the traditional problem in medicine had been to get the elderly physicians to retire before they hurt someone. That survey signaled a sea change in physician temperament, one that persists and is growing and resonates in the numbers of doctors who say they would do something else if it were possible and who do not encourage their children to enter the profession.
5. Acceptance or accommodation: the successful resolution of grieving lies in recognizing the opportunities to deal with the new reality. The very young doctors are spared the necessity, because they have never experienced anything else. The very old doctors are so close to the finish line, it is unrealistic and unfair to expect them to take leadership roles in reforming the system and redefining their place in it. It is the intermediate group, those with ten to twenty-five years of practice ahead of them who will be critical to the transition.
That’s enough “grief” for one blog. I’ll follow with a bit more detail on the reasons for physician grieving and then with some speculation on where we are headed as a society deeply dependent upon an effective healthcare system.
- Richard Patterson is a retired surgeon who blogs at dailydudley.com.