Alone or Together? Addressing Physician Isolation

A new study published in JAMA Internal Medicine [1] and its accompanying commentary [2] (both are linked to the right) raise several critical points about physician wellbeing. Both are brief and deserve to be read in full. Despite that physician burnout has been well-documented, very few interventions to address it have been tested in a controlled fashion (i.e., the sample is randomized to an intervention and control arm). Using a randomized controlled trial design, West and colleagues tested a small group intervention targeted at improving physician distress. In the West et al study, every other week for 9 months, 8 or 9 internal medicine physicians met together in small groups with a facilitator for an hour. The groups included time for check-in, reflection, and a discussion of topics relevant to medical practice such as meaning at work, medical mistakes, and caring for patients. Control arm physicians received an hour of protected time to use as they chose every other week.

Compared to the control condition, the intervention increased physicians’ sense of meaning and empowerment at work and decreased their reports of burnout. These gains were maintained at 12-month follow-up. One of the strongest and most sustained effects of the intervention was a reduction in feelings of depersonalization, one of three domains of the burnout construct [3]. The high rates of depersonalization reported by physicians should be a critical concern to us all, because depersonalization indicates the degree to which others feel like objects rather than people and the degree to which one avoids and withdraws from interpersonal contacts. The Maslach Burnout Scale’s depersonalization items include, “I don’t really care about what happens to some of my patients,” and “I have become more insensitive to people since I’ve been working.” These are terrible feelings to endure while trying to care for patients; and it’s hard to imagine delivering high-quality care when feeling cynical and alienated from others. It is heartening to see that the West et al intervention improved measures of depersonalization.

As Goitein’s commentary points out, one of the most disturbing findings of the study is that the non-participating physicians – almost 350 physicians who declined to be randomized to the small group or control arms but who provided data on measures of wellbeing – showed substantial declines in wellbeing over a one-year period. (These data confirm that It is a Tough Time To be a Clinician.) Goitein provides several reasonable hypotheses to explain this striking increase in physician distress over a short period of time. She primarily suspects that physicians feel demoralized by the forces beyond their control that undermine their ability to provide humanistic care to their patients. She pointedly concludes that physicians, “like their patients, have a sense that our titanic health care system no longer primarily supports the physician-patient dyad but serves myriad external interests.”

Nonetheless, the West et al study highlights that some aspects of the problem of physician wellbeing may be quite tractable. It suggests that burnout can be ameliorated through strategies that counteract physician isolation.

Is physician isolation a problem? Are physicians uniquely alone or lonely? Does the physician sometimes feel, even without wanting to, that she is no more than an island unto herself? It’s worth considering.

On the one hand, the physician culture is highly communal [4]. Physicians can have strong feelings of solidarity with one another (every physician has had many experiences of being taken “under the wing” of another). Physicians tend to have an authentic and immediate friendliness and sociability with one another (for the grumpier among us, there is at least a rather quick sense of recognition). This communalism is forged, in part, in training. Without question, medical training is a time of intense togetherness and, at its best, an experience of profound shared purpose and cooperation. For many, the memories of working together toward a meaningful goal are among the most pleasurable recollections of medical training.

But on the other hand, after we leave training, many physicians find that building and sustaining a sense of community is not easy. Time for hanging out and checking in is not really available. Yes, you can find a trusted co-attending, a colleague to call for advice on tough cases, and another colleague to call in moments of panic or great doubt about a case. But many physicians find that colleagues are suddenly also competitors. We can experience competition in the simple, everyday ways that we have our work measured against others’ work. At the extreme, colleagues can take patients from your practice when you are away on vacation. They can get promoted instead of you. They can even end up taking over what you feel you have built. Hopefully these kinds of experiences are rare, but they are not paranoid fantasies. They reflect the realities of the complex settings in which physicians work. It can be hard to keep track of the shared purpose and strong teamwork that felt so valuable in training.

West and colleagues’ intervention aimed to “promote meaning at work through collegiality, community, shared experience, and reflection centered on discussions of topics related to the experience of being a physician, within the safety of a confidential small group.” Eight or 9 physicians got together every other week. I am a broken record about this: it is very important for physicians to get together on a regular basis with other physicians. Let’s say quarterly. Do whatever you’d like. Learn to cook soul food, read science fiction, critique the latest journal articles, play softball, do a Balint group, hike, quilt, garden, attend Meaning in Medicine groups, watch your kids play together in the park, learn Spanish, work at a food bank, or build a treehouse. An adult version of all of those clubs we joined in college. Feelings of isolation can be insidious and self-fulfilling, but they can be prevented, and countering isolation can help us to enjoy and engage in the work of doctoring.

Further Reading:

1. RWest, C.P., et al., Intervention to promote physician well-being, job satisfaction, and professionalism: A randomized clinical trial. JAMA Internal Medicine, 2014.
2. Goitein, L., Physician well-being: Addressing downstream effect, but looking upstream. JAMA Internal Medicine, 2014.

3. Maslach, C. and S.E. Jackson, Burnout in organizational settings. Applied Social Psychology Annual, 1984. 5: p. 133-53.

4. Wilson, H. and W. Cunningham, Being a Doctor: Understanding Medical Practice. 2013, Dunedin, New Zealand: Otago University Press.