Family PerspectivesHow physicians draw satisfaction and overcome barriers in their practices: “It sustains me”
Introduction
Major reorganizations in medical practice today create unique stressors, including physicians’ experiencing loss of control of their practices, inadequate time with patients, bureaucratic administrative requirements that diminish face-time with patients, and epidemic levels of burnout affecting physicians and other care-providers [1], [2], [3], [4], [5], [6], [7], [8], [9], [10], [11], [12], [13], [14]. Aspirationally, medicine is a moral enterprise guided by standards that require sacrifice and emotional energy to achieve the respectful, compassionate, culturally sensitive humanistic relationships that are therapeutic for patients, families, and others [15], [16], [17], [18], [19], [20], [21].
To help physicians approach these professional standards, it is important to understand factors that sustain and impede them. For example, burnout, reflecting stress in the practice, has become epidemic among physicians [11]. Bodenheimer and Sinsky proposed that improving the work life of physicians and other healthcare providers should join population-based health, patient experience and cost control as a fourth aim of the health care system [22]. A central component of coping with stress is finding meaning in one’s practice, which enhances resilience and resistance to burnout [23], [24]. Our study analyzes the central issue of meaning versus frustration in medical practice by addressing the sustaining and impeding factors to humanistic practice as a source of meaning [18]. We explored these factors in a group of faculty who had completed a multi-institutional faculty development program in humanism [25], [26], [27]. We studied these physicians because as humanistic exemplars, we expected their reactions would amplify our understanding of how stress in practice affects physicians’ abilities to navigate change, to practice humanistically and thereby find meaning. This information should enable us to suggest strategies to enhance medical humanism [17], [19].
Conceptually, we adopted the perspective of professional identity formation, ways of being and relating professionally that occur during the life course of physicians: how they develop their mature values and social identities over time [28], [29], [30], [31], [32], [33], [34], [35]. We utilized Kegan’s model where, at the highest level, self-internalized values, principles and standards guide mature physicians, who have become well adapted and socialized into their community of practice [28], [29]. Kegan’s theoretic and empirically studied model provides an ideal framework for studying humanistic physicians’ responses to today’s stressful practice environment.
Although medical humanism or its lack in medical students and residents has been explored previously, the focus has generally been on the negative side [36], [37], [38]. Only one other study identified motivating factors to embody humanism in medical school faculty members [39]. Chou interviewed 16 “highly humanistic” faculty members at a single institution [39]. However, no studies have examined this issue using larger samples across institutions or have used more open-ended questions to elicit humanistic physicians’ perceptions.
We asked study participants to write reflectively about what motivated them to practice humanistically, and the barriers that limited them. We employed qualitative thematic analysis of their responses to elucidate impediments, and having done so, to shed light on a key question for medical practice: what factors and strategies enable faculty physicians to provide humanistic care despite impediments?
Section snippets
Subjects and settings
Study participants at eight medical schools had completed a one-year small group faculty development program designed to enhance their humanistic teaching and role modeling [25], [26]. Site leaders/facilitators at each school (the investigators) identified and enrolled in the small groups, eight to twelve physician faculty members who were recognized as promising and respected clinical teachers and practitioners in their respective fields, were recommended by their department chairs, and often
Themes (Table 2)
Five themes were identified by consensus of the investigators. The first theme was mentioned by far most frequently; remaining themes were ranked by their perceived connectivity to the first theme: 1. identification with humanistic values: It is who I am; 2. providing the same care that I or my family would want; 3. connection to patients; 4. passing on my values through role modeling; and 5. being present in the moment. Themes were often linked and reinforced one another. We present the most
Observations of the study participants
Study participants voiced their commitment to being humanistic despite facing multiple barriers. They seemed committed to humanistic practice because it “sustained” them, suggesting that humanism provided meaning and was core to their professional identities as physicians, “It is who I am” [27], [28], [29], [30], [31], [32].
Humanistic care was often at odds with policies designed to improve efficiency and productivity. These policies created a bureaucratic culture filled with frustration and
Conflicts of interest
None.
Funding
This work was supported by the Arnold P. Gold Foundation [grant number FI-14-008].
IRB approval or exemption
Yes.
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2021, Journal of Interprofessional Education and PracticeCitation Excerpt :At the same time, healthcare institutions and systems, driven by economic and commercial forces, have experienced considerable changes in their organizational and practice environments. These changes can create discordance between the values and goals of humanistic clinicians and those of health systems,12,13 and significantly contribute to clinician burnout.14–16 Organizational values should align with and support core interpersonal values critical to humanistic care.13,17
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2019, Current Problems in Pediatric and Adolescent Health CareCitation Excerpt :Patients are only aware of the time that is spent with them which is often quite short, leading to the frequent situation wherein the physician has spent hours arranging and advocating for a patient's care, only to be met with the patient's frustration when aspects of that care fall short of being ideal or the patient's relationship with the physician feels less personal than they had hoped.14 Physicians often experience a sense of isolation in fighting the good fight alone.4 As more physicians are employed by large health-care organizations, the emphasis of medical care has tipped towards a business-focused model, at times crowding out the empathy and compassion that are foundational to the therapeutic relationship.15
Views of institutional leaders on maintaining humanism in today's practice
2019, Patient Education and CounselingCitation Excerpt :This would imply a lack of agency to effect change within the organization, trapped in a box or “iron cage,” as it were, as described by the sociologist Max Weber [39]. We found a similar lack of agency in our surveys of the clinical faculty physicians [14,15]. The system itself is failing if, as one leader stated above, “We might perfect the ability to bill and collect while, at the same time, lose all ability to care empathically for patients.”
Provider burnout and patient-provider communication in the context of hypertension care
2019, Patient Education and CounselingCitation Excerpt :Due to the small sample size of 26 providers assessed in the current study, it is possible that the providers included in the current analysis were selected from a lower-burnout group that is not representative of total the provider population. Another reasonable explanation may be that, as other studies have found, providers often under report stress [11,37], which may be a limiting factor in the accurate reporting of burnout. Also, personality characteristics may reduce likelihood of reporting stress or burnout (e.g., Type A personality) and explain the low proportion of burnout in our sample as other studies suggest [38].