Physicians constantly advocate on behalf of patients. But why don't physicians who are struggling advocate for themselves?
Given the alarming rates of physician burnout, moral injury, and self-harm, one would think that physicians interested in preserving their wellness and professional satisfaction would be well-versed and experienced in self-advocacy. Yet physicians have been dangerously silent with regards to speaking out about their plight and demanding the external and internal changes required to keep them practicing and enjoying their work.
A Google search for “physician self-advocacy” reveals no helpful information on the topic. A ChatGPT inquiry about the same describes “patient advocacy” and “ethical advocacy” before mentioning anything about physicians.
After a life-threatening explosion rocked the Apollo 13 spacecraft en route to the Moon, Jack Swigert, the command module captain, offered one of the great understatements to Mission Control: “OK Houston… we’ve had a problem here.” When combined with anticipated major shortages of physicians in the coming decade, our current problem with physicians struggling to sustain their practices support a similarly grave and understated warning: “America, we have a problem here… and it is putting the health of all Americans at risk.”
Unconvinced that we have a problem with the status quo? Consider these three scenarios: your grandfather is undergoing emergency surgery for a ruptured aortic aneurysm; a young child has been rescued from a raging home fire and is being triaged in the emergency room for severe burns and respiratory failure; a beloved preschool schoolteacher presents with an acute stroke and is being considered for thrombolytic therapy. In each of these cases, there is a 50 percent chance that the treating physician is emotionally exhausted, detached from the humanity of their patient, or suffering from crippling low self-esteem. Not only do we have a problem, we have a problem that is killing people.
Why don’t physicians who are struggling advocate for themselves?
One reason is our misinterpretation of the Hippocratic Oath. Many of us remember it as a promise to do anything within our power to help our patients live longer and better lives, even at the cost of disregarding our own basic needs for rest, good nutrition, exercise, and a life outside of medicine. For this reason, even when we are experiencing burnout, we have a deeply rooted and fundamentally flawed belief that self-care is selfish.
An under-appreciated call to self-care is found in the Oath’s closing admonition:
“May I always act so as to preserve the finest traditions of my calling, and may I long experience the joy of healing those who seek my help.” So yes, we should embody the very best of our profession for our patients. At the same time, we have a responsibility to be available to our patients for decades rather than years, but that is only possible if we engage in the self-care that empowers us to sustain our effort.
Our ranks are also filled with personality types, defined by the Myers-Brings Type Indicator, that predispose us to suffer in silence. Thinker/Judger types (INTJ, ENTJ, ISTJ, ESTJ) are career oriented, sometimes to the point of workaholism; you always feel the need to prove yourself and will push forward until your energy is depleted and have nothing left to give. Feeler/Judger types (ISFJ, INFJ, ESFJ, ENFJ) don’t want to let anyone down, so even if you’re buried under a mountain of unanswered emails and unaddressed lab results, you don’t feel secure enough to ask for help or admit that you have exceeded your capacity for quality work. INFJ types — one of the rarest MBTI types and known as “the Advocate,” who identify as idealistic, organized, and dependable — are especially at risk of not seeking help under duress, because they are petrified by the prospect of being shamed by peers as an imposter who falls short of what a good doctor should be.
Dr. Frederick Van Pelt, of Brigham and Women’s Hospital, points out that our anemic self-advocacy is also a product of longstanding survival strategies modeled by our mentors.
“During our training, care providers are taught to distance themselves emotionally from our patients through empathy, that is to say, to understand and acknowledge how our patients feel without becoming personally involved,” Dr. Van Pelt says. “This process of numbing down blunts the ability of the caregiver to understand and acknowledge the emotional impact that adverse events have on patients, families, and themselves.”
In other words, we are trained to survive the emotional roller coaster of a medical career by distancing ourselves from emotions, including our own, to our own demise. While I have frequently heard that the word “retarded” has no place in language, given the ignorant and mean ways it has been used in the past, I would argue that physicians as a group are retarded, as in slow and delayed, with regards to self-advocacy. And our hesitancy to speak up for ourselves is not limited to our interactions with superiors, patients, and society. We also have difficulty speaking truth to our inner voice.
Just to be clear, you are not asking for the moon when you advocate for change. Starting from the bottom up, our brainstems are requesting mere safety and survival because we are regularly victims of abusive patients and overbearing business demands. Our subcortex pleads for morsels of professional autonomy and satisfaction because those have been stolen from us by non-physicians making clinical decisions. And finally, our neocortex calls for reconnection with our patients and colleagues, because life-enriching time that we used to spend with them is now being spent instead in front of a computer screen on soul-sucking documentation.
The three reciprocal domains of joy and meaning in medicine have been described well, by Dr. Tait Shanafelt, Dr. Bruce Bowman and others, as a healthy culture highlighted by psychological safety, efficient operations that include all members of the team having a voice in continuous quality improvement, and a generous menu of self-care interventions that include mindfulness, physical activity, healthy eating, and resiliency training.
Large scale changes in culture and operational efficiency happen at a relatively slow pace, even in the most well-resourced and efficient organizations. This is because the drivers of unhealthy cultures and inefficient operations are multifactorial and often involve factors beyond the control of an organization’s leadership. Delivering quality outcomes alone is a herculean task. However, at the root of our current woes lie society’s additional expectation that we simultaneously deliver concierge-level service at an affordable price.
To be specific, despite widespread acknowledgement that we are already working unsustainable hours to deliver quality care and access times that are medically appropriate, we have been further burdened by service initiatives that cater to patient demands for more convenient care. This prioritization of patient wants over the essential survival needs of physicians is short-sighted and dangerous. It directly leads to physician disengagement, burnout, inferior outcomes, and gaping holes in the physician workforce through reduction in hours, early retirements, and transitions to other types of work.
What does it look like for us to responsibly advocate for ourselves when faced with unrealistic demands? Consider the following scenario: You work in a large, capitated group practice and two of the partners in your group of three abruptly quit due to burnout. The order from above is that you will maintain quality, service, and access until leadership is able to backfill the positions.
Let’s begin with how you will answer to your superiors. You have a couple of potential responses: 1) After getting over the initial shock, your INFJ personality type decides that you can take one for the team and somehow get the job done. Besides, you don’t want to be seen as weak or whiny; 2) Determined to fight for the career you have earned through your hard work and steady commitment, you finally care enough about yourself and your patients to advocate for what you need to survive the current crisis. You ask for a meeting with your supervisor. You build a dialogue around a “win-win” situation in which everyone is working towards a common goal. In the name of delivering quality and access, you request support from other physicians in your network for inbox management and virtual encounters and the immediate hiring of a 1.0 FTE locums to help with in-person office visits.
While such self-advocacy with others can feel awkward and self-serving, it is really your only option if you want to stay in the game and consistently be the best version of yourself for your patients. Like any new behavior, you will get better at it with practice.
The bigger challenge with physician self-advocacy is overcoming your reluctance to speak up for yourself despite that familiar inner voice that tells you to not complain and to just put your head down and work harder to overcome obstacles. That may be an effective strategy for studying for the MCAT or surviving a one-month rotation in the surgical ICU, but it is ineffective when applied to a 30-year career in which you have important competing demands for your time and energy, such as family and the passionate pursuits that make you whole.
Seasoned counselors and coaches who specialize in such matters encourage you to think of someone who cares deeply about you, and to imagine how they would help you under your current dire circumstances. That person would listen without judgment to your concerns, be compassionate, and recommend basic self-care tips such as good sleep, healthy eating, and balancing your busy work life with meaningful personal pursuits. Of course, the end goal of such counseling and coaching is that you would come to love yourself enough to be your own self-advocate. Easier said than done, but it is essential for your personal wellness journey.
“The culture is flawed in the supposition that [physicians] are somehow superhuman, without the fundamental personal need for self-care and a life outside of medicine,” says Taylor Riall, MD of the University of Arizona. “Even more flawed is the supposition that [physicians] who dare to be fully human and vulnerable are not worthy of trust and respect.”
I have personally benefited from a simple self-forgiveness exercise recommended by my wellness coach, and I think it is “just what the doctor ordered” to get the ball rolling on your self-advocacy journey. It calls out the harmful and inaccurate conversation that dominates our self-talk and reminds us that what we are doing on a daily basis is making a positive difference in the world. To start, take a piece of blank white paper and draw a vertical line down the middle. On the left, create a column titled “Judgments About Myself” and list some of those. Common examples among contemporary physicians include, “I’m not good enough,” “I am ashamed of being less than,” and “No one appreciates how hard I am working.”
Now create a column on the right side titled “Self-forgiving Truths.” Try these self-affirming exhortations on for size: “I am plenty damn good,” “Comparison is the thief of joy,” and “My patients, colleagues, and family value me for my contributions to their lives.”
I leave you with these final comments and thoughts:
Thank you for choosing to be a physician and for your commitment to use your talents, time, and energy to serve the needs of our patients. What you do matters and is appreciated by those who bask in the warmth of your loving concern.
This is a difficult time in medicine. The simultaneous demands for quality, service, access, and cost-containment have created an untenable and unsustainable dilemma for those choosing to stay in the profession.
Better days lie ahead. People are working feverishly to create superior models of care delivery that better align payers, hospitals, and providers; leverage technology to liberate human beings to deliver the people-based elements of care; and integrate new discoveries into more efficient personalized care plans.
Bright spots of innovation and change will emerge. I invite you to either be a bright spot or adopt the best practices of others.
Keep up any work you are doing to improve the culture and operations of medicine. You are part of the wellness solution.
At the same time, invest deeply in exploring how you can best respond to your circumstances. As Viktor Frankl describes in Man’s Search for Meaning, you have options. You can go swine by focusing externally and blaming everything on others. Or you can go saint, take a good look at yourself, and explore how you can change in ways that will help you make the best of a difficult situation.
Self-advocacy is essential to your survival. But it is also scary because it is unfamiliar and filled with risk and vulnerability. For this reason, I highly recommend that physicians engage in professional counseling or coaching; I have found it to be extremely helpful for the past ten years of my career. Members of SSVMS are eligible for six free sessions from a list of highly qualified professionals. For information about this service and other components of the Joy of Medicine program, visit joyofmedicine.org.
John Chuck, MD - johnchuck1@gmail.com
