Sam Hazledine, Doctor, wellbeing advocate, medical entrepreneur

Published in JHH 18.3-Shifting the paradigm

The magnitude of the problem

It doesn’t matter which country you consider, consistently more than 50% of doctors are experiencing symptoms of burnout; it is the largest problem facing doctors globally. And as we know, burnout isn’t just a problem for us as doctors; it leads to depersonalisation, an emotional disconnection from our patients, which leads to increases in major medical errors. It is causing doctors to harm patients (Motluk, 2018). As well as impacting our work, suicide rates in doctors have been reported to be 40% higher in males and 130% high in females compared with the general population (Kalmoe et al, 2019; Haikerwal, 2019).

The values of doctors worldwide

We must not under-estimate the magnitude of this issue and doing nothing is not an option.

In 2016, painfully aware of the size of this problem, I hypothesised that burnout was at least in part driven by our values as doctors; patient first at the expense of all else.

Many doctors swear some form of oath when they graduate, be it the Declaration of Geneva or the Hippocratic Oath. Some doctors argue that any form of oath is redundant. In their paper, Hippocratic oath: Losing relevance in today’s world?, Indla and Radhika pose ‘People who choose medicine usually have a strong sense of ethics and a higher purpose. Very few people take medicine to earn money. For medical students who arrive at the college with a strong sense of ethical values, the oath is redundant. For those who lack these values, the oath is just an exercise in hypocrisy’ (Indla & Radhika, 2019). But I believe that the value of taking an oath isn’t in signing up to an ethical contract but rather in stating clearly what’s important. In none of the Hippocratic Oath’s many versions does it form a legal contract. Yet might its self-sacificing assumption – so implicit and absorbed unconsciously at medical school whether or not we take the oath – be contributing to the beliefs and behaviours that perpetuate the international epidemic of burnout?

Businesses have to be clear about their goals. To achieve these goals they set out to prioritise what they value. The most successful businesses make their values coherent with these goals and express them authentically in their organisational culture. For example, the culture of a business that values stability and reliability will be very different from one that values innovation and originality. Workers in a stability business will probably behave differently and relate to one another and their customer base in ways that are not the same as in an innovation company. The parallel in medicine is that the ‘business’ prioritises wellbeing of the patient and attaches importance to practitioners’ wellbeing. This assumption is so strong that whether or not we actually take the Hippocratic Oath, our inherent ‘business ethic’ puts the welfare of the patient above all else and encourages us to conduct ourselves in ways that lead us to undervalue and even to neglect our own wellbeing.

That’s why I set out to change this balance through a campaign lobbying the World Medical Association to amend the modern-day Hippocratic Oath, the Declaration of Geneva, to include the health and wellbeing of doctors. More than 5,000 doctors lent their support in a petition and in 2017 I was invited to speak at the WMA’s annual general assembly in Taipei to present my research and proposal. Over the following year the wording was finalised and consulted on and in 2018, at the Annual General Assembly in Chicago, the WMA unanimously voted to include an amendment to the Declaration of Geneva:

I WILL ATTEND TO my own health, well-being, and abilities in order to provide care of the highest standard.

At last, I thought, now that it’s officially in our value-set something will be done. But alas, despite this change putting doctors’ wellbeing firmly on the agenda of every medical organisation, and despite getting a lot of focus, the problem is increasing (Chambers et al, 2016). And this is understandable because systemic change happens slowly, especially in our risk-averse medical culture. Yet in a system where more than 50% of doctors are burnt out, systemic change is clearly what’s needed. But in under resourced healthcare systems, where workloads are unreasonably high and organisations are being overwhelmed by demand, it would not be at all surprising if managers and politicians willfully turned a blind eye and colluded with overstretched staff determined to keep going the extra mile. And for a variety of reasons – which include our professional assumption that we are duty bound to do so – we do respond by trying harder, working longer and at times even ignoring poor practice and bullying.

However, even in the face of all this we must observe that some doctors are flourishing, and be curious as to how they do this. So, while we wait for or lobby for systemic change, let’s not forget that at an individual level doctors can play their part in their own rescue. What is now clear is that at a macro level beyond working conditions there are three factors that are significantly impacting individual doctor wellbeing: values, knowledge and motivation. Though the values in the oath are now in better balance, knowledge about what to do about paying better attention to one’s welfare hasn’t moved forward, so the motivation to act is low.

Doctor-intervention match

We don’t know what we can do personally, despite research and educational efforts. So as a profession we have barely begun to address the issues. There is, however, a body of evidence about interventions for burnout in doctors, but in order to be scientifically credible this evidence looks at populations of doctors and gropes around for statistically significant changes in this amorphous group. Consequently there are no evidence-based off-the-shelf one-size-fits all solutions. Though organisational prevention and mitigation measures seem starkly obvious, for a person who is struggling with it, burnout is a very personal and individual issue.

‘The literature indicates that both individual focused and structural or organisational strategies can result in clinically meaningful reductions in burnout among physicians. Further research is needed to establish which interventions are most effective in specific populations, as well as how individual and organisational solutions might be combined to deliver even greater improvements in physician wellbeing than those achieved with individual solutions’
(West et al, 2016)

Qualitative research conducted by Medworld discovered that of the many possible interventions reported to work, the majority don’t work for most doctors. Doctors reported that what has been a solution for them has, in most instances, been recommended by a doctor working in a similar environment who suggested something that had been suitable for them. This supports the need to tailor solutions to the individual doctor.

This, I believe, is where our focus needs to move. We need to acknowledge that we aren’t an amorphous population, we are a group of individuals, so we must move from blanket solutions to tailored interventions.

Begin

We are in the toughest period right now. We’ve acknowledged the magnitude of burnout, so we’re becoming more open about our vulnerability and we want change, but change isn’t coming quickly. Because of this differential between our working conditions and our expectations we are struggling even more. The feeling that we are not able to do good work may itself be both an effect of burnout but also a felt sense that fuels moral injury and self-blame.

But there is hope. Strongly held but self-limiting beliefs can change. Before 1954 it was believed to be impossible for the human body to run a four-minute mile. Doctors, in our ultimate wisdom, actually proclaimed that the human body was not capable of this feat, and that the heart could not handle it. Then on 6 May 1954, Dr Roger Bannister, after completing his ward rounds in the morning, ran the mile in 3 minutes and 59 seconds. Just 46 days later, John Landy ran a mile in under four minutes, and the following year 16 people achieved the feat. Nowadays, high school kids are running the mile in under four minutes. It took one person, a doctor as it happens, to go first and change the paradigm of what is possible. Because one person did it, others began to believe, and change happened.

Not all doctors are struggling. Some are in fact thriving. Can we open our mind to believe that change can happen for us and start looking for personal solutions? The answers lie in the collective intelligence of our profession; we must heal from within, and I believe we can. My digital project Medworld is aiming to connect doctors and provide practical steps to improve the wellbeing of the medical profession and every doctor in it. The journey has begun.

References

Chambers C, Frampton C, Barclay M, McKee M (2016) Burnout prevalence in New Zealand’s public hospital senior medical workforce:a cross-sectional mixed methods study. BMJ Open 6(11).

Haikerwal M (2019) The national mental health survey of doctors and medical students. Beyond Blue.

Indla V & Radhika MS (2019) Hippocratic oath: Losing relevance in today’s world?, 61 (Suppl 4) s773–s775.

Kalmoe MC, Chapman MB, Gold JA & Giedinghagern AM (2019) Physician suicide: A call to action. Missouri Medicine, 116(3) 211–216.

Motluk A (2018) Do doctors experiencing burnout make more errors? CMAJ, 190(40) e1216–1217.

West C, Dyrbye L, Erwin P, Shanafelt T (2016) Interventions to prevent and reduce physician burnout: a systematic review and meta-analysis. The Lancet, 388(10057): 2272–2281.