Oct 3rd, 2013 by
In my previous column, I reported on the problem of widespread burnout among doctors and medical students — and I described a response that, in recent years, has spread to half the nation’s medical schools: a course called The Healer’s Art, created by a physician, Rachel Naomi Remen, to help doctors and students discover and reconnect to the deep meaning of their work and maintain their commitment for it. The article touched a sore spot. Hundreds of readers — patients, medical students, doctors and spouses and children of doctors among them — contributed comments describing their personal experiences, many of them raw with emotion. Some of the most poignant notes came from doctors themselves, and their words revealed a deep sense of betrayal.
The ability to derive meaning from our work can transform our daily experiences.
“I am a primary care doctor who started idealistic, and am disillusioned and dejected,” wrote one reader from New York City: “By far, the biggest barrier to being a compassionate healer in our current working environment is time. We simply don’t have the time we need to do our jobs well. And we all lose.”
The husband of a doctor from Huntington, Pa., wrote that his wife, who worked 70 to 110 hours a week, was “constantly chafing against the demands for ‘productivity,’ the necessity to spend hours fighting insurers to get treatment for her patients and the fatigue that results from hours of work doing electronic ‘paperwork’ long after the patients have been seen.”
“Yes, changing the culture of physician training is important,” he added. “But we also need to turn back the disastrous process of the McDonaldization of healthcare.”
The toll begins early. Holly, a fourth-year medical student, from Maryland, wrote: “I am emotionally exhausted and suffering from burnout. I realize how scared and vulnerable my patients must be feeling. Unfortunately, I am unable to spend the time I’d like with each patient because I have so many other patients whose needs must also be met.”
In my reporting on The Healer’s Art, I interviewed numerous medical students and doctors, who reported that the course provided them with a unique opportunity to talk about their personal and family experiences as patients, doctors, or doctors in training, and to share their fears, joys, rewards and struggles. They said the course allowed them to reflect on these experiences alongside peers and teachers in a safe setting that was unavailable elsewhere in the medical curriculum. Many added that the experience enabled them to maintain their spirits and their sense of “wholeness” during their training, and, later, dealing with a dysfunctional health system that seemed designed to “beat the humanity” out of them.
“The reasons people go into medicine are often woven deeply into who they are,” explains Remen, who has taught The Healer’s Art at the University of California—San Francisco for more than 20 years. “Despite difficult and sometimes impossible demands placed on them, they will continue to try to do their best to care for people, but the system always asks them to function far below their level of personal excellence. When you compromise your best self on a daily basis, something gets extinguished in you — and that something is what has kept the profession of medicine alive for thousands of years.”
The Healer’s Art doesn’t purport to fix the health care system. “It’s about how to help the people in medicine survive the system,” adds Remen.
People who are caught in oppressive systems adopt various stances toward them, consciously or unconsciously. They may choose to abandon the systems; today many doctors are doing just that. Several wrote in to say that they had already quit medicine, or were planning to quit soon. “I retired early from medicine, was glad to get out, and don’t regret fleeing a broken system,” wrote J. Skinner from the Midwest.
Others remain in the system, but they build walls of protection, growing cynical or detached. They experience low satisfaction with their work, become depressed or abuse drugs. Suicidal ideation is significantly more common among surgeons than among the general population, for example.
But there is a third way: the ability to derive meaning from our work can transform our daily experiences. Doctors may be individually powerless to change the system, but they do have tools to rediscover and strengthen their capacity to practice wholeheartedly. One such method is to cultivate “mindfulness” — the ability to be present in a nonjudgmental way. Not only do improvements in mindfulness appear to improve doctors’ sense of well-being, they seem to improve their patient-centeredness, as well — something known to be associated with better, safer and more satisfying care, explains Michael S. Krasner, an Associate Professor of Clinical Medicine at the University of Rochester School of Medicine and Dentistry, who has co-written a study on the topic.
The Healer’s Art teaches mindfulness and also helps medical students explore meaning through exercises in which they share their personal experiences in patient care and reflect on their sense of calling and the effect of compassion at times of loss. In my previous column, I mentioned some instances where doctors expressed their caring directly to patients — even crying silently alongside them — and a number of readers raised a red flag.
Individual doctors have the tools to rediscover and strengthen their capacity to practice wholeheartedly.
“Most of us do not want a doctor who is caring and concerned,” wrote Tim Kirn, the son of a doctor from Sacramento. “We want a doctor who is competent. It seems highly unlikely that someone who is emotionally invested, and therefore stressed, is going to function better than someone who is cold.”
This is a common misconception. As I reported, being emotionally attuned can help a doctor, or anyone for that matter, function better. Indeed, the notion that a doctor is an objective, Spock-like, scientist whose job is to come up with the one best solution to your problem is a view that is out of step with research on medical outcomes and much of what is known about the therapeutic aspects of the patient-doctor relationship. People are not widgets; medicine cannot be reduced to cutting and sewing or putting chemicals into the body; it’s full of mystery. Doctors can often make a difference in how patients feel simply by being caring and concerned.
Consider a study that examined the effects of placebos on patients suffering from irritable bowel syndrome — a chronic gastrointestinal disorder that causes constipation and pain. Researchers separated patients into three groups: the first received no treatment, the second received a placebo — fake acupuncture (using a retractable needle); the third received the same placebo, but administered by a practitioner who was highly caring, empathetic and confident. The proportion of patients reporting relief were 28 percent, 44 percent and 62 percent, respectively.
Placebos frequently elicit subjective improvements among patients, possibly by triggering a release of dopamine in the brain. What was unusual about the study was that the relational context influenced the response. Now consider that some 100 million Americans suffer from chronic pain. Many become addicted to painkillers. Could more caring doctors bring therapeutic benefits to some of them?
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What about the therapeutic benefits that patients could confer on doctors? More and more people are living with incurable diseases that would have killed them a short time ago. As the population ages, more health care will be directed to patients with chronic or terminal conditions. For doctors, care will become less a question of curing a disease than helping their patients to live as well as possible in the face of their illnesses. That’s not the job they train you for in medical school. But in this emerging context, the doctor patient relationship becomes even more central. It may be the quality of this relationship that determines whether doctors can cope with, and derive satisfaction, from care that involves far less clinical certainty or control.
Over all, readers were not optimistic about the prospects for reforming medicine, but some of those who did see potential for change placed the main responsibility with the doctors themselves. “A lovely and touching article,” wrote Steven Frucht a reader from New York City. “Unfortunately it won’t change anything in the real world. Why? Because physicians do not control the way medicine is practiced.”
He added: “Physicians must stand up, specialty by specialty, and refuse to accept this ridiculous system that rewards electronic care, rather than patient care.”
Another, Les from Bethesda, Md., wrote, “What we — the doctors and the patients — have to decide is what we want medicine to be. If we want it to be an artful profession that deftly merges compassion and science we can do that … But as some of have noted, we have to stand up and demand this.”
The idea that doctors might find the inner strength to voice their deepest beliefs is in keeping with the focus of Remen’s work.
“The greatest of all stresses does not come from a lack of sleep or time,” she observes. “It comes from believing deeply in one set of values and finding that you are trapped into living by another set.”
In The Healer’s Art, she says, she envisions “enabling people to recognize the gap between doctors’ professional service values and the values of the health system, so that it becomes more possible for doctors to speak out on behalf of patients, and rise up as a community and simply say, ‘You know, when people are in pain and facing something unknown and potentially life altering, being told that you have seven minutes to understand their unique issues and strengths in order to find effective ways to help them is just wrong. It is simply unethical — and I am not doing this anymore.”
Could physicians come together to overthrow the current order — to start a movement to, say, Occupy Medicine? If they did, what would be the unifying cry? Down with health insurers? Tort reform or bust? Or would it begin by expressing the thing that is most precious to them that has been lost: the opportunity to practice medicine in a way that is worthy of their dedication and love. Reclaiming a sense of meaning in medicine could be the first step to rescuing the profession.
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David Bornstein is the author of “How to Change the World,” which has been published in 20 languages, and “The Price of a Dream: The Story of the Grameen Bank,” and is co-author of “Social Entrepreneurship: What Everyone Needs to Know.” He is a co-founder of the Solutions Journalism Network, which supports rigorous reporting about responses to social problems.