Family Perspectives
How physicians draw satisfaction and overcome barriers in their practices: “It sustains me”

https://doi.org/10.1016/j.pec.2017.06.004Get rights and content

Highlights

  • We studied what motivates or poses barriers to humanism.

  • Strongest motivator was humanistic values embedded within professional identity.

  • Barriers were time, stress, culture, and episodic burnout.

  • Personal values were more highly developed than social role.

  • Resolving the barriers requires partnering with others to address system issues.

Abstract

Objective

Major reorganizations of medical practice today challenge physicians’ ability to deliver compassionate care. We sought to understand how physicians who completed an intensive faculty development program in medical humanism sustain their humanistic practices.

Methods

Program completers from 8 U.S. medical schools wrote reflections in answer to two open-ended questions addressing their personal motivations and the barriers that impeded their humanistic practice and teaching. Reflections were qualitatively analyzed using the constant comparative method.

Results

Sixty-eight physicians (74% response rate) submitted reflections. Motivating factors included: 1) identification with humanistic values; 2) providing care that they or their family would want; 3) connecting to patients; 4) passing on values through role modelling; 5) being in the moment. Inhibiting factors included: 1) time, 2) stress, 3) culture, and 4) episodic burnout.

Conclusions

Determination to live by one’s values, embedded within a strong professional identity, allowed study participants to alleviate, but not resolve, the barriers. Collaborative action to address organizational impediments was endorsed but found to be lacking.

Practice implications

Fostering fully mature professional development among physicians will require new skills and opportunities that reinforce time-honored values while simultaneously partnering with others to nurture, sustain and improve patient care by addressing system issues.

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.

References (61)

  • B. Landon et al.

    Leaving medicine: the consequences of physician dissatisfaction

    Med. Care

    (2006)
  • M. Linzer et al.

    Organizational climate, stress, and error in primary care: the MEMO study

  • J.J. Stoddard et al.

    Managed care, professional autonomy, and income: effects on physician career satisfaction

    J. Gen. Intern. Med.

    (2001)
  • A. Montgomery et al.

    Connecting organizational culture and quality of care in the hospital: is job burnout the missing link

    J. Health Organ. Manag.

    (2011)
  • L.N. Dyrbye et al.

    Physician burnout: a potential threat to successful health care reform

    JAMA

    (2012)
  • T.D. Shanafelt et al.

    Burnout and satisfaction with work-life balance among US physicians relative to the US population

    JAMA

    (2012)
  • A. Spickard et al.

    Mid-career burnout in generalist and specialist physicians

    JAMA

    (2002)
  • M.R. Privitera et al.

    Physician burnout and occupational stress: an inconvenient truth with unintended consequences

    J. Hosp. Adm.

    (2015)
  • C. Sinsky et al.

    Allocation of physician time in ambulatory practice: a time and motion study in 4 specialties

    Ann. Intern. Med.

    (2016)
  • G.L. Engel

    The need for a new medical model: a challenge for biomedicine

    Science

    (1977)
  • E. Pelligrino

    The Philosophy of Medicine Reborn. A Pelligrino Reader

  • Project of the ABIM Foundation et al.

    Medical professionalism in the new millennium: a physician charter

    Ann. Intern. Med.

    (2002)
  • W.T. Branch

    The ethics of patient care

    JAMA

    (2015)
  • P. Arnold Gold Foundation

    What Is Humanism in Medicine?

    (2017)
  • P.F. Weissmann et al.

    Role modeling humanistic behavior: learning bedside manner from the experts

    Acad. Med.

    (2006)
  • T. Bodenheimer et al.

    From triple to quadruple aim: care of the patient requires care of the provider

    Ann. Fam. Med.

    (2014)
  • J. Zwack et al.

    If every fifth physician is affected by burnout, what about the other four? Resilience strategies of experienced physicians

    Acad. Med.

    (2013)
  • R.M. Epstein et al.

    Physician resilience: what it means, why it matters, how to promote it

    Acad. Med.

    (2013)
  • W.T. Branch et al.

    A good clinician and a caring person: longitudinal faculty development and the enhancement of the human dimensions of care

    Acad. Med.

    (2009)
  • W.T. Branch et al.

    Faculty development to enhance humanistic teaching and role modeling: a collaborative study at eight institutions

    J. Gen. Intern. Med.

    (2014)
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