The unbearable unhappiness of the ObGyn: A crisis looms

Dr. Weinstein has no financial relationships relevant to this article.

“I CAN’T GET NO SATISFACTION”—Mick Jagger and Keith Richards, 1965

“FOR THE TIMES THEY ARE A-CHANGIN’”—Bob Dylan, 1964

The lyrics of two songs written more than 40 years ago are an excellent way to describe today’s physician workforce. Regrettably, many physicians who grew up listening to these performer-philosophers have yet to heed the words of Bob Dylan. Instead, they echo the sentiments of Mick Jagger and Keith Richards without doing much to correct the problem.

Why the decline in work satisfaction? Many reasons have been cited, including:

• loss of autonomy
• economic pressures
• an increasing degree of government and insurer control over practice
• the liability crisis
• a divergence between professional and personal expectations
• physicians’ own high career expectations
• a desire for more time for family and self.¹

The growing level of dissatisfaction with the practice of medicine has, clearly, reached crisis level: Twenty percent of all physicians report that they are dissatisfied with their career.^2,3 And lack of fulfillment appears to be developing much earlier in the life of a physician than has so far been appreciated. Not only is it showing up in residents, job dissatisfaction is evident even among medical students. It is quite revealing—and depressing—that 40% of young physicians would choose not to go to medical school if they had to choose again.

In this article, I examine the characteristics of the dissatisfied physician, explain the apparent reasons for this lack of fulfillment, and propose a number of steps that can be taken to salvage the situation, lengthen the time that a physician works, on average, and add flexibility and variety to work life.

Ultimate effect of dissatisfaction? Loss of a physician

An unhappy physician is two or three times more likely to leave the profession or decrease the number of hours worked than a satisfied physician is.⁴ And when a physician leaves the workforce, we lose a valuable resource. The estimated replacement cost for a physician in 1992 to 1999 dollars was $250,000, and that cost is at least 50% higher today.^5,6 Besides the monetary loss, there is disruption to other members of the practice group and to patients when a physician leaves the profession.

Landon and colleagues found that the average age of a physician working full-time was 47 years, compared with 53 years for a physician who was working fewer than 20 hours a week and 63 years for a physician at retirement.⁴ However, these data are approximately 7 years old; current figures are likely to show curtailment of work hours at even younger ages.

It is not realistic to expect that 1) the educational system will increase medical school class size and 2) enough physicians will finish training and develop a mature practice in the time necessary to offset the number of physicians now altering their workloads or exiting the workforce.

Does gender influence the satisfaction rate?

The profession of medicine has changed strikingly over the past 20 years. Once male-dominated, it now is gender-equal and, in some specialties, female-dominated.

This rapid gender shift in medicine has received much of the blame for the decline in physician satisfaction. However, data suggest that, among full-time academic faculty who do not have children, productivity and career satisfaction are the same for women as for men.⁷ A recent study of internists found few gender differences in work-life balance, work hours, and attitudes toward patient care.⁸

Among surgeons, an equal percentage of each gender believes that the work schedule leaves too little time for personal and family life.⁹ Although it has been suggested that women prefer to work fewer hours than men, evidence indicates that younger men have the same desire to work less and spend more time with family.¹⁰

That said, there are some gender-related differences in medical workforce characteristics:

• Women reduce their clinical activity during childbearing and childrearing and retire 5.5 years earlier than men do⁴
• In obstetrics, women younger than 40 years are four times more likely to reduce work hours or completely stop practice than male obstetricians are¹¹
• Among surgeons, 90% of women live in dual-career households, compared with 50% of men⁹
• When the surgeon is male, children are cared for by spouses in 63% of households; when the surgeon is female, children are cared for by an employee in 88% of households⁹
• Among surgical subspecialists, women are more likely to be divorced or separated and to have fewer or no children; 34% spend 21 to 40 hours weekly on household management.¹²

Despite these differences, a review of the literature on physician dissatisfaction suggests that the gender shift in medicine is not responsible for the growing level of dissatisfaction.

Age is the determining factor

The Baby Boomer generation (born between 1946 and 1964), which had largely controlled all aspects of medicine, especially leadership roles, is rapidly being replaced by physicians from Generations X and Y (born between 1965 and 1980, and 1981 and 2001, respectively), who value personal time and lifestyle much more than “Boomers” have.¹³

These younger physicians demand flexibility and variety in their careers. They grow dissatisfied when these aspects of their work lives fall out of their control. And when it comes to choosing a specialty in which to practice, these physicians see a balanced lifestyle as the key variable.¹³

Much of the discussion of dissatisfaction in medicine has contrasted Baby Boomers with subsequent generations. The Boomer physician typically has a traditional marriage, with the spouse doing most of the parenting and managing household duties. The Boomer physician is more likely to be male, work long hours, and see professional life as the overall driving force of daily existence.

However, the perception that a Boomer physician is immune to career dissatisfaction is incorrect. Dissatisfaction and departure from practice are directly related to age, with those who are 50 or older more likely to experience them.¹⁴ In another study, age and dissatisfaction were the principal factors positively associated with intention to leave practice.¹⁵

For Generations X and Y, time is the overarching issue

Generations X and Y physicians are an equal mix of genders, with the majority of couples having dual careers. Their desire for balanced work and family life has made time the primary issue in rising dissatisfaction with medicine. There is less time for each patient encounter, more time required for documentation to justify reimbursement, more time necessary to deal with practice management, and less time to handle family issues—especially personal well-being.¹⁶ These issues have also contributed to rising dissatisfaction among Baby Boomers.

Enter, the 80-hour workweek

In 2003, the Accreditation Council for Graduate Medical Education instituted the 80-hour workweek in an attempt to improve patient safety and the lifestyle of physicians in training. Many senior physicians believed that work-hour restriction would erode the quality of training, but this does not appear to have occurred.

Work-hour restriction among surgical residents has had no effect on academic performance but has markedly decreased psychological distress.¹⁷ Among medical residents, work-hour restriction has improved career satisfaction and decreased emotional exhaustion—but residents perceive restrictions to have impinged on patient care and resident education.¹⁸ Although surgical residents believe that restriction has reduced overall stress, improved quality of life, and provided time in which to manage their personal life, they are concerned about the limitation on exposure to patients—yet 96% of these residents would not be willing to add an additional year to their training.¹⁹

There is evidence that about one third of a resident’s time is spent performing activities of marginal or no educational value.²⁰ By eliminating these activities and making better use of simulators and patient surrogates, the workweek could be reduced even further, allowing the physician in training more time for interaction with patients and providing a better balance between work and personal life.

Burnout is widespread

If the goal is to retain physicians in the work-force, it is more important to reduce dissatisfaction than to increase satisfaction. Why? People who are dissatisfied are more likely to change what they are doing than those with any level of satisfaction.⁴

The profession must understand that burnout is common and directly related to increasing dissatisfaction.²¹

Burnout typically occurs when one has a highly demanding position with limited autonomy. A physician experiences burnout when one or more of the following is present:

• emotional exhaustion
• feelings of inadequacy in terms of personal accomplishment
• depersonalization
• increasing cynicism in personal interactions.²¹

This is an accurate description of the current state of medical practice.

Because “the times they are a-changin’,” it is necessary that leaders within the medical profession drastically change the way that medicine is taught and practiced.^22-24

Any further changes—beyond work-hour limitations—should be carefully designed with a mechanism in place to evaluate effects on both physicians and patients. A new approach to the practice of medicine is desperately needed to allow a better work-life balance while maintaining the focus on quality and safety.

Ways to reduce dissatisfaction

Dr. Abigail Zuger summed up the feelings of many when she wrote: “The profession of medicine has taken its members on a wild ride during the past century: a slow, glorious climb in well-being, followed by a steep, stomach-churning fall.”²⁵

I offer the following proposals for discussion. My primary aim in developing these suggestions was to give physicians more of that most precious of commodities: time. More time has the potential to change the work-life balance and improve both professional and personal satisfaction at the same time that it decreases dissatisfaction.

Again: The key to retaining physicians in the workforce is to decrease dissatisfaction. That is more likely to have the desired effect of a larger, stable workforce than is increasing the number of medical students and physicians in training. As is true in most aspects of life, it is easier and cheaper to improve what you already have, recycle what you can, and replace only what is absolutely necessary.

Recommendations—for practitioners, academic and private

• Limit work hours to 50 or fewer per week. Many physicians work too many hours; this is not beneficial to them, their families, and their patients.²⁶ For both patient safety and physician well-being, it is time to voluntarily restrict our work hours before federal legislation creates limits for us.
• Develop new models of practice, such as the use of a laborist for obstetric coverage. The implementation of a hospital-based laborist program allows a safer environment for the patient, a rapid-response team presence, and a controlled lifestyle for physicians who desire to practice obstetrics.²⁷ Structured properly, such models are revenue-neutral for the institution. (See OBG Management’s recent article, “The laborists are here, but can they thrive in US hospitals?” in the August 2008 issue, available at www.obgmanagement.com.)
• Create part-time professional liability insurance policies. Premiums for these policies should be prorated according to the amount of clinical time worked and the physician’s work record. Insurance policies also need to be written to cover a slot rather than a particular individual, so that several physicians can share the same position to equal one full-time practitioner.
• Increase job sharing and part-time employment so that these options become more attractive. With job sharing, two physicians work 50% of the time, adding up to one full-time practitioner. This option will reduce physician dissatisfaction and has the potential to increase the work life of the practitioner while improving patient safety.²⁸ Job sharing will also facilitate recruitment and retention of the current workforce.²⁹
• Acquire time- and money-management skills. Most practitioners need to develop these abilities because so many stressors are related to limits on time and money.
• In academic medicine, revamp the current career trajectory. The timeline that includes tenure and unrealistic expectations for promotion is archaic and needs to be eliminated. Most Generations X and Y physicians find it to be inflexible at exactly the wrong time in their life. Forced to choose between work on one hand and family and personal well-being on the other, they will almost always choose family and personal life first.³⁰ Similar changes are recommended for the private practitioner under consideration for partnership.

Recommendations—for physicians in training

• Limit work hours to 65 or fewer per week. The current 80-hour week is not conducive to improving physician satisfaction or safe care. There is evidence that work exceeding 18 hours a day may impair a physician.³¹ No physician likes working long hours, and it is clearly not safe for patients. Elimination of responsibilities of no or marginal educational value would make a 65-hour work-week practical. Training institutions will need to add more support staff, including physician extenders, to implement a shorter week.
• Increase the use of teaching simulators. This improvement would assist in the development of technical skills. The training institution would be responsible for developing a simulation center. In areas with multiple training programs, a central location would be developed, with cost shared by all parties. Some of the cost would be recouped by the time saved in the operating room. There is also the potential to prevent medical errors and reduce liability cost. (See OBG Management’s recent article, “How simulation can train, and refresh, physicians for critical OB events,” which describes, among other issues, the use of regional simulation centers. The article appeared in the September 2008 issue, available at www.obgmanagement.com.)
• Teach physicians in training time- and money-management skills. Many of the stressors experienced by these young physicians relate to understanding how to budget time and money.
• Sponsor 24-hour, on-site child care at reasonable or no cost. This recommendation for the training institution is important because child care for the dual-career couple is difficult to arrange, often incompatible with the couple’s schedule, and expensive. Any training institution that sponsors a residency program and benefits from this low-cost workforce should be required by the Accreditation Council of Graduate Medical Education to fund this benefit. It is the right thing to do and is certainly a valuable recruiting tool. It will make physicians who have children feel more comfortable working the hours required for their training while removing a major stressor—worrying about their child.
• Supply extra support for residents when a co-resident is on maternity or paternity leave. The training institution should implement this protection to prevent working residents from being penalized when it is necessary for a co-resident to be on leave.
• Create the option of job sharing during residency. In the business world, job sharing has become common and increases satisfaction and productivity. A resident would work half-time, with salary and benefits prorated so that the cost to the sponsoring institution is revenue-neutral. This would be a valuable recruiting tool among residents who are willing to accept a prolonged period of training.

We need a dialogue on these and other recommendations Such a conversation will allow the medical profession to continue to attract and retain the best and brightest professionals. As the satirical poet Auguste Marseille Barthélemy pointed out, way back in 1832: “The absurd man is he who never changes.”

Dr. Weinstein has no financial relationships relevant to this article.

“I CAN’T GET NO SATISFACTION”—Mick Jagger and Keith Richards, 1965

“FOR THE TIMES THEY ARE A-CHANGIN’”—Bob Dylan, 1964

The lyrics of two songs written more than 40 years ago are an excellent way to describe today’s physician workforce. Regrettably, many physicians who grew up listening to these performer-philosophers have yet to heed the words of Bob Dylan. Instead, they echo the sentiments of Mick Jagger and Keith Richards without doing much to correct the problem.

Why the decline in work satisfaction? Many reasons have been cited, including:

• loss of autonomy
• economic pressures
• an increasing degree of government and insurer control over practice
• the liability crisis
• a divergence between professional and personal expectations
• physicians’ own high career expectations
• a desire for more time for family and self.¹

The growing level of dissatisfaction with the practice of medicine has, clearly, reached crisis level: Twenty percent of all physicians report that they are dissatisfied with their career.^2,3 And lack of fulfillment appears to be developing much earlier in the life of a physician than has so far been appreciated. Not only is it showing up in residents, job dissatisfaction is evident even among medical students. It is quite revealing—and depressing—that 40% of young physicians would choose not to go to medical school if they had to choose again.

In this article, I examine the characteristics of the dissatisfied physician, explain the apparent reasons for this lack of fulfillment, and propose a number of steps that can be taken to salvage the situation, lengthen the time that a physician works, on average, and add flexibility and variety to work life.

Ultimate effect of dissatisfaction? Loss of a physician

An unhappy physician is two or three times more likely to leave the profession or decrease the number of hours worked than a satisfied physician is.⁴ And when a physician leaves the workforce, we lose a valuable resource. The estimated replacement cost for a physician in 1992 to 1999 dollars was $250,000, and that cost is at least 50% higher today.^5,6 Besides the monetary loss, there is disruption to other members of the practice group and to patients when a physician leaves the profession.

Landon and colleagues found that the average age of a physician working full-time was 47 years, compared with 53 years for a physician who was working fewer than 20 hours a week and 63 years for a physician at retirement.⁴ However, these data are approximately 7 years old; current figures are likely to show curtailment of work hours at even younger ages.

It is not realistic to expect that 1) the educational system will increase medical school class size and 2) enough physicians will finish training and develop a mature practice in the time necessary to offset the number of physicians now altering their workloads or exiting the workforce.

Does gender influence the satisfaction rate?

The profession of medicine has changed strikingly over the past 20 years. Once male-dominated, it now is gender-equal and, in some specialties, female-dominated.

This rapid gender shift in medicine has received much of the blame for the decline in physician satisfaction. However, data suggest that, among full-time academic faculty who do not have children, productivity and career satisfaction are the same for women as for men.⁷ A recent study of internists found few gender differences in work-life balance, work hours, and attitudes toward patient care.⁸

Among surgeons, an equal percentage of each gender believes that the work schedule leaves too little time for personal and family life.⁹ Although it has been suggested that women prefer to work fewer hours than men, evidence indicates that younger men have the same desire to work less and spend more time with family.¹⁰

That said, there are some gender-related differences in medical workforce characteristics:

• Women reduce their clinical activity during childbearing and childrearing and retire 5.5 years earlier than men do⁴
• In obstetrics, women younger than 40 years are four times more likely to reduce work hours or completely stop practice than male obstetricians are¹¹
• Among surgeons, 90% of women live in dual-career households, compared with 50% of men⁹
• When the surgeon is male, children are cared for by spouses in 63% of households; when the surgeon is female, children are cared for by an employee in 88% of households⁹
• Among surgical subspecialists, women are more likely to be divorced or separated and to have fewer or no children; 34% spend 21 to 40 hours weekly on household management.¹²

Despite these differences, a review of the literature on physician dissatisfaction suggests that the gender shift in medicine is not responsible for the growing level of dissatisfaction.

Age is the determining factor

The Baby Boomer generation (born between 1946 and 1964), which had largely controlled all aspects of medicine, especially leadership roles, is rapidly being replaced by physicians from Generations X and Y (born between 1965 and 1980, and 1981 and 2001, respectively), who value personal time and lifestyle much more than “Boomers” have.¹³

These younger physicians demand flexibility and variety in their careers. They grow dissatisfied when these aspects of their work lives fall out of their control. And when it comes to choosing a specialty in which to practice, these physicians see a balanced lifestyle as the key variable.¹³

Much of the discussion of dissatisfaction in medicine has contrasted Baby Boomers with subsequent generations. The Boomer physician typically has a traditional marriage, with the spouse doing most of the parenting and managing household duties. The Boomer physician is more likely to be male, work long hours, and see professional life as the overall driving force of daily existence.

However, the perception that a Boomer physician is immune to career dissatisfaction is incorrect. Dissatisfaction and departure from practice are directly related to age, with those who are 50 or older more likely to experience them.¹⁴ In another study, age and dissatisfaction were the principal factors positively associated with intention to leave practice.¹⁵

For Generations X and Y, time is the overarching issue

Generations X and Y physicians are an equal mix of genders, with the majority of couples having dual careers. Their desire for balanced work and family life has made time the primary issue in rising dissatisfaction with medicine. There is less time for each patient encounter, more time required for documentation to justify reimbursement, more time necessary to deal with practice management, and less time to handle family issues—especially personal well-being.¹⁶ These issues have also contributed to rising dissatisfaction among Baby Boomers.

Enter, the 80-hour workweek

In 2003, the Accreditation Council for Graduate Medical Education instituted the 80-hour workweek in an attempt to improve patient safety and the lifestyle of physicians in training. Many senior physicians believed that work-hour restriction would erode the quality of training, but this does not appear to have occurred.

Work-hour restriction among surgical residents has had no effect on academic performance but has markedly decreased psychological distress.¹⁷ Among medical residents, work-hour restriction has improved career satisfaction and decreased emotional exhaustion—but residents perceive restrictions to have impinged on patient care and resident education.¹⁸ Although surgical residents believe that restriction has reduced overall stress, improved quality of life, and provided time in which to manage their personal life, they are concerned about the limitation on exposure to patients—yet 96% of these residents would not be willing to add an additional year to their training.¹⁹

There is evidence that about one third of a resident’s time is spent performing activities of marginal or no educational value.²⁰ By eliminating these activities and making better use of simulators and patient surrogates, the workweek could be reduced even further, allowing the physician in training more time for interaction with patients and providing a better balance between work and personal life.

Burnout is widespread

If the goal is to retain physicians in the work-force, it is more important to reduce dissatisfaction than to increase satisfaction. Why? People who are dissatisfied are more likely to change what they are doing than those with any level of satisfaction.⁴

The profession must understand that burnout is common and directly related to increasing dissatisfaction.²¹

Burnout typically occurs when one has a highly demanding position with limited autonomy. A physician experiences burnout when one or more of the following is present:

• emotional exhaustion
• feelings of inadequacy in terms of personal accomplishment
• depersonalization
• increasing cynicism in personal interactions.²¹

This is an accurate description of the current state of medical practice.

Because “the times they are a-changin’,” it is necessary that leaders within the medical profession drastically change the way that medicine is taught and practiced.^22-24

Any further changes—beyond work-hour limitations—should be carefully designed with a mechanism in place to evaluate effects on both physicians and patients. A new approach to the practice of medicine is desperately needed to allow a better work-life balance while maintaining the focus on quality and safety.

Ways to reduce dissatisfaction

Dr. Abigail Zuger summed up the feelings of many when she wrote: “The profession of medicine has taken its members on a wild ride during the past century: a slow, glorious climb in well-being, followed by a steep, stomach-churning fall.”²⁵

I offer the following proposals for discussion. My primary aim in developing these suggestions was to give physicians more of that most precious of commodities: time. More time has the potential to change the work-life balance and improve both professional and personal satisfaction at the same time that it decreases dissatisfaction.

Again: The key to retaining physicians in the workforce is to decrease dissatisfaction. That is more likely to have the desired effect of a larger, stable workforce than is increasing the number of medical students and physicians in training. As is true in most aspects of life, it is easier and cheaper to improve what you already have, recycle what you can, and replace only what is absolutely necessary.

Recommendations—for practitioners, academic and private

• Limit work hours to 50 or fewer per week. Many physicians work too many hours; this is not beneficial to them, their families, and their patients.²⁶ For both patient safety and physician well-being, it is time to voluntarily restrict our work hours before federal legislation creates limits for us.
• Develop new models of practice, such as the use of a laborist for obstetric coverage. The implementation of a hospital-based laborist program allows a safer environment for the patient, a rapid-response team presence, and a controlled lifestyle for physicians who desire to practice obstetrics.²⁷ Structured properly, such models are revenue-neutral for the institution. (See OBG Management’s recent article, “The laborists are here, but can they thrive in US hospitals?” in the August 2008 issue, available at www.obgmanagement.com.)
• Create part-time professional liability insurance policies. Premiums for these policies should be prorated according to the amount of clinical time worked and the physician’s work record. Insurance policies also need to be written to cover a slot rather than a particular individual, so that several physicians can share the same position to equal one full-time practitioner.
• Increase job sharing and part-time employment so that these options become more attractive. With job sharing, two physicians work 50% of the time, adding up to one full-time practitioner. This option will reduce physician dissatisfaction and has the potential to increase the work life of the practitioner while improving patient safety.²⁸ Job sharing will also facilitate recruitment and retention of the current workforce.²⁹
• Acquire time- and money-management skills. Most practitioners need to develop these abilities because so many stressors are related to limits on time and money.
• In academic medicine, revamp the current career trajectory. The timeline that includes tenure and unrealistic expectations for promotion is archaic and needs to be eliminated. Most Generations X and Y physicians find it to be inflexible at exactly the wrong time in their life. Forced to choose between work on one hand and family and personal well-being on the other, they will almost always choose family and personal life first.³⁰ Similar changes are recommended for the private practitioner under consideration for partnership.

Recommendations—for physicians in training

• Limit work hours to 65 or fewer per week. The current 80-hour week is not conducive to improving physician satisfaction or safe care. There is evidence that work exceeding 18 hours a day may impair a physician.³¹ No physician likes working long hours, and it is clearly not safe for patients. Elimination of responsibilities of no or marginal educational value would make a 65-hour work-week practical. Training institutions will need to add more support staff, including physician extenders, to implement a shorter week.
• Increase the use of teaching simulators. This improvement would assist in the development of technical skills. The training institution would be responsible for developing a simulation center. In areas with multiple training programs, a central location would be developed, with cost shared by all parties. Some of the cost would be recouped by the time saved in the operating room. There is also the potential to prevent medical errors and reduce liability cost. (See OBG Management’s recent article, “How simulation can train, and refresh, physicians for critical OB events,” which describes, among other issues, the use of regional simulation centers. The article appeared in the September 2008 issue, available at www.obgmanagement.com.)
• Teach physicians in training time- and money-management skills. Many of the stressors experienced by these young physicians relate to understanding how to budget time and money.
• Sponsor 24-hour, on-site child care at reasonable or no cost. This recommendation for the training institution is important because child care for the dual-career couple is difficult to arrange, often incompatible with the couple’s schedule, and expensive. Any training institution that sponsors a residency program and benefits from this low-cost workforce should be required by the Accreditation Council of Graduate Medical Education to fund this benefit. It is the right thing to do and is certainly a valuable recruiting tool. It will make physicians who have children feel more comfortable working the hours required for their training while removing a major stressor—worrying about their child.
• Supply extra support for residents when a co-resident is on maternity or paternity leave. The training institution should implement this protection to prevent working residents from being penalized when it is necessary for a co-resident to be on leave.
• Create the option of job sharing during residency. In the business world, job sharing has become common and increases satisfaction and productivity. A resident would work half-time, with salary and benefits prorated so that the cost to the sponsoring institution is revenue-neutral. This would be a valuable recruiting tool among residents who are willing to accept a prolonged period of training.

We need a dialogue on these and other recommendations Such a conversation will allow the medical profession to continue to attract and retain the best and brightest professionals. As the satirical poet Auguste Marseille Barthélemy pointed out, way back in 1832: “The absurd man is he who never changes.”

Dr. Weinstein has no financial relationships relevant to this article.

“I CAN’T GET NO SATISFACTION”—Mick Jagger and Keith Richards, 1965

“FOR THE TIMES THEY ARE A-CHANGIN’”—Bob Dylan, 1964

The lyrics of two songs written more than 40 years ago are an excellent way to describe today’s physician workforce. Regrettably, many physicians who grew up listening to these performer-philosophers have yet to heed the words of Bob Dylan. Instead, they echo the sentiments of Mick Jagger and Keith Richards without doing much to correct the problem.

Why the decline in work satisfaction? Many reasons have been cited, including:

• loss of autonomy
• economic pressures
• an increasing degree of government and insurer control over practice
• the liability crisis
• a divergence between professional and personal expectations
• physicians’ own high career expectations
• a desire for more time for family and self.¹

The growing level of dissatisfaction with the practice of medicine has, clearly, reached crisis level: Twenty percent of all physicians report that they are dissatisfied with their career.^2,3 And lack of fulfillment appears to be developing much earlier in the life of a physician than has so far been appreciated. Not only is it showing up in residents, job dissatisfaction is evident even among medical students. It is quite revealing—and depressing—that 40% of young physicians would choose not to go to medical school if they had to choose again.

In this article, I examine the characteristics of the dissatisfied physician, explain the apparent reasons for this lack of fulfillment, and propose a number of steps that can be taken to salvage the situation, lengthen the time that a physician works, on average, and add flexibility and variety to work life.

Ultimate effect of dissatisfaction? Loss of a physician

An unhappy physician is two or three times more likely to leave the profession or decrease the number of hours worked than a satisfied physician is.⁴ And when a physician leaves the workforce, we lose a valuable resource. The estimated replacement cost for a physician in 1992 to 1999 dollars was $250,000, and that cost is at least 50% higher today.^5,6 Besides the monetary loss, there is disruption to other members of the practice group and to patients when a physician leaves the profession.

Landon and colleagues found that the average age of a physician working full-time was 47 years, compared with 53 years for a physician who was working fewer than 20 hours a week and 63 years for a physician at retirement.⁴ However, these data are approximately 7 years old; current figures are likely to show curtailment of work hours at even younger ages.

It is not realistic to expect that 1) the educational system will increase medical school class size and 2) enough physicians will finish training and develop a mature practice in the time necessary to offset the number of physicians now altering their workloads or exiting the workforce.

Does gender influence the satisfaction rate?

The profession of medicine has changed strikingly over the past 20 years. Once male-dominated, it now is gender-equal and, in some specialties, female-dominated.

This rapid gender shift in medicine has received much of the blame for the decline in physician satisfaction. However, data suggest that, among full-time academic faculty who do not have children, productivity and career satisfaction are the same for women as for men.⁷ A recent study of internists found few gender differences in work-life balance, work hours, and attitudes toward patient care.⁸

Among surgeons, an equal percentage of each gender believes that the work schedule leaves too little time for personal and family life.⁹ Although it has been suggested that women prefer to work fewer hours than men, evidence indicates that younger men have the same desire to work less and spend more time with family.¹⁰

That said, there are some gender-related differences in medical workforce characteristics:

• Women reduce their clinical activity during childbearing and childrearing and retire 5.5 years earlier than men do⁴
• In obstetrics, women younger than 40 years are four times more likely to reduce work hours or completely stop practice than male obstetricians are¹¹
• Among surgeons, 90% of women live in dual-career households, compared with 50% of men⁹
• When the surgeon is male, children are cared for by spouses in 63% of households; when the surgeon is female, children are cared for by an employee in 88% of households⁹
• Among surgical subspecialists, women are more likely to be divorced or separated and to have fewer or no children; 34% spend 21 to 40 hours weekly on household management.¹²

Despite these differences, a review of the literature on physician dissatisfaction suggests that the gender shift in medicine is not responsible for the growing level of dissatisfaction.

Age is the determining factor

The Baby Boomer generation (born between 1946 and 1964), which had largely controlled all aspects of medicine, especially leadership roles, is rapidly being replaced by physicians from Generations X and Y (born between 1965 and 1980, and 1981 and 2001, respectively), who value personal time and lifestyle much more than “Boomers” have.¹³

These younger physicians demand flexibility and variety in their careers. They grow dissatisfied when these aspects of their work lives fall out of their control. And when it comes to choosing a specialty in which to practice, these physicians see a balanced lifestyle as the key variable.¹³

Much of the discussion of dissatisfaction in medicine has contrasted Baby Boomers with subsequent generations. The Boomer physician typically has a traditional marriage, with the spouse doing most of the parenting and managing household duties. The Boomer physician is more likely to be male, work long hours, and see professional life as the overall driving force of daily existence.

However, the perception that a Boomer physician is immune to career dissatisfaction is incorrect. Dissatisfaction and departure from practice are directly related to age, with those who are 50 or older more likely to experience them.¹⁴ In another study, age and dissatisfaction were the principal factors positively associated with intention to leave practice.¹⁵

For Generations X and Y, time is the overarching issue

Generations X and Y physicians are an equal mix of genders, with the majority of couples having dual careers. Their desire for balanced work and family life has made time the primary issue in rising dissatisfaction with medicine. There is less time for each patient encounter, more time required for documentation to justify reimbursement, more time necessary to deal with practice management, and less time to handle family issues—especially personal well-being.¹⁶ These issues have also contributed to rising dissatisfaction among Baby Boomers.

Enter, the 80-hour workweek

In 2003, the Accreditation Council for Graduate Medical Education instituted the 80-hour workweek in an attempt to improve patient safety and the lifestyle of physicians in training. Many senior physicians believed that work-hour restriction would erode the quality of training, but this does not appear to have occurred.

Work-hour restriction among surgical residents has had no effect on academic performance but has markedly decreased psychological distress.¹⁷ Among medical residents, work-hour restriction has improved career satisfaction and decreased emotional exhaustion—but residents perceive restrictions to have impinged on patient care and resident education.¹⁸ Although surgical residents believe that restriction has reduced overall stress, improved quality of life, and provided time in which to manage their personal life, they are concerned about the limitation on exposure to patients—yet 96% of these residents would not be willing to add an additional year to their training.¹⁹

There is evidence that about one third of a resident’s time is spent performing activities of marginal or no educational value.²⁰ By eliminating these activities and making better use of simulators and patient surrogates, the workweek could be reduced even further, allowing the physician in training more time for interaction with patients and providing a better balance between work and personal life.

Burnout is widespread

If the goal is to retain physicians in the work-force, it is more important to reduce dissatisfaction than to increase satisfaction. Why? People who are dissatisfied are more likely to change what they are doing than those with any level of satisfaction.⁴

The profession must understand that burnout is common and directly related to increasing dissatisfaction.²¹

Burnout typically occurs when one has a highly demanding position with limited autonomy. A physician experiences burnout when one or more of the following is present:

• emotional exhaustion
• feelings of inadequacy in terms of personal accomplishment
• depersonalization
• increasing cynicism in personal interactions.²¹

This is an accurate description of the current state of medical practice.

Because “the times they are a-changin’,” it is necessary that leaders within the medical profession drastically change the way that medicine is taught and practiced.^22-24

Any further changes—beyond work-hour limitations—should be carefully designed with a mechanism in place to evaluate effects on both physicians and patients. A new approach to the practice of medicine is desperately needed to allow a better work-life balance while maintaining the focus on quality and safety.

Ways to reduce dissatisfaction

Dr. Abigail Zuger summed up the feelings of many when she wrote: “The profession of medicine has taken its members on a wild ride during the past century: a slow, glorious climb in well-being, followed by a steep, stomach-churning fall.”²⁵

I offer the following proposals for discussion. My primary aim in developing these suggestions was to give physicians more of that most precious of commodities: time. More time has the potential to change the work-life balance and improve both professional and personal satisfaction at the same time that it decreases dissatisfaction.

Again: The key to retaining physicians in the workforce is to decrease dissatisfaction. That is more likely to have the desired effect of a larger, stable workforce than is increasing the number of medical students and physicians in training. As is true in most aspects of life, it is easier and cheaper to improve what you already have, recycle what you can, and replace only what is absolutely necessary.

Recommendations—for practitioners, academic and private

• Limit work hours to 50 or fewer per week. Many physicians work too many hours; this is not beneficial to them, their families, and their patients.²⁶ For both patient safety and physician well-being, it is time to voluntarily restrict our work hours before federal legislation creates limits for us.
• Develop new models of practice, such as the use of a laborist for obstetric coverage. The implementation of a hospital-based laborist program allows a safer environment for the patient, a rapid-response team presence, and a controlled lifestyle for physicians who desire to practice obstetrics.²⁷ Structured properly, such models are revenue-neutral for the institution. (See OBG Management’s recent article, “The laborists are here, but can they thrive in US hospitals?” in the August 2008 issue, available at www.obgmanagement.com.)
• Create part-time professional liability insurance policies. Premiums for these policies should be prorated according to the amount of clinical time worked and the physician’s work record. Insurance policies also need to be written to cover a slot rather than a particular individual, so that several physicians can share the same position to equal one full-time practitioner.
• Increase job sharing and part-time employment so that these options become more attractive. With job sharing, two physicians work 50% of the time, adding up to one full-time practitioner. This option will reduce physician dissatisfaction and has the potential to increase the work life of the practitioner while improving patient safety.²⁸ Job sharing will also facilitate recruitment and retention of the current workforce.²⁹
• Acquire time- and money-management skills. Most practitioners need to develop these abilities because so many stressors are related to limits on time and money.
• In academic medicine, revamp the current career trajectory. The timeline that includes tenure and unrealistic expectations for promotion is archaic and needs to be eliminated. Most Generations X and Y physicians find it to be inflexible at exactly the wrong time in their life. Forced to choose between work on one hand and family and personal well-being on the other, they will almost always choose family and personal life first.³⁰ Similar changes are recommended for the private practitioner under consideration for partnership.

Recommendations—for physicians in training

• Limit work hours to 65 or fewer per week. The current 80-hour week is not conducive to improving physician satisfaction or safe care. There is evidence that work exceeding 18 hours a day may impair a physician.³¹ No physician likes working long hours, and it is clearly not safe for patients. Elimination of responsibilities of no or marginal educational value would make a 65-hour work-week practical. Training institutions will need to add more support staff, including physician extenders, to implement a shorter week.
• Increase the use of teaching simulators. This improvement would assist in the development of technical skills. The training institution would be responsible for developing a simulation center. In areas with multiple training programs, a central location would be developed, with cost shared by all parties. Some of the cost would be recouped by the time saved in the operating room. There is also the potential to prevent medical errors and reduce liability cost. (See OBG Management’s recent article, “How simulation can train, and refresh, physicians for critical OB events,” which describes, among other issues, the use of regional simulation centers. The article appeared in the September 2008 issue, available at www.obgmanagement.com.)
• Teach physicians in training time- and money-management skills. Many of the stressors experienced by these young physicians relate to understanding how to budget time and money.
• Sponsor 24-hour, on-site child care at reasonable or no cost. This recommendation for the training institution is important because child care for the dual-career couple is difficult to arrange, often incompatible with the couple’s schedule, and expensive. Any training institution that sponsors a residency program and benefits from this low-cost workforce should be required by the Accreditation Council of Graduate Medical Education to fund this benefit. It is the right thing to do and is certainly a valuable recruiting tool. It will make physicians who have children feel more comfortable working the hours required for their training while removing a major stressor—worrying about their child.
• Supply extra support for residents when a co-resident is on maternity or paternity leave. The training institution should implement this protection to prevent working residents from being penalized when it is necessary for a co-resident to be on leave.
• Create the option of job sharing during residency. In the business world, job sharing has become common and increases satisfaction and productivity. A resident would work half-time, with salary and benefits prorated so that the cost to the sponsoring institution is revenue-neutral. This would be a valuable recruiting tool among residents who are willing to accept a prolonged period of training.

We need a dialogue on these and other recommendations Such a conversation will allow the medical profession to continue to attract and retain the best and brightest professionals. As the satirical poet Auguste Marseille Barthélemy pointed out, way back in 1832: “The absurd man is he who never changes.”