Clinical Review

The unbearable unhappiness of the ObGyn: A crisis looms

OBG Manag. 2008 December;20(12):34-42

References

1. Holsinger JW, Jr, Beaton B. Physician professionalism for a new century. Clin Anat. 2006;19:473-479.

2. Buchbinder SB, Wilson M, Melick CF, Powe NR. Primary care physician job satisfaction and turnover. Am J Manag Care. 2001;7:701-713.

3. Leigh JP, Kravitz RL, Schembri M, Samuels SJ, Mobley S. Physician career satisfaction across specialties. Arch Intern Med. 2002;162:1577-1584.

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7. Carr PL, Ash AS, Friedman RH, et al. Relation of family responsibilities and gender to the productivity and career satisfaction of medical faculty. Ann Intern Med. 1998;129:532-538.

8. Jovic E, Wallace JE, Lemaire J. The generation and gender shifts in medicine: an exploratory survey of internal medicine physicians. BMC Health Serv Res. 2006;6:55-71.

9. Schroen AT, Brownstein MR, Sheldon GF. Women in academic general surgery. Acad Med. 2004;79:310-318.

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11. Pearse WH, Haffner WHJ, Primack A. Effect of gender on the obstetric-gynecologic work force. Obstet Gynecol. 2001;97:794-797.

12. Grandis JR, Gooding WF, Zamboni BA, et al. The gender gap in a surgical subspecialty. Arch Otolaryngol Head Neck Surg. 2004;130:695-702.

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16. Weinstein L, Wolfe H. The downward spiral of physician satisfaction: an attempt to avert a crisis within the medical profession. Obstet Gynecol. 2007;109:1181-1183.

17. Zaré SM, Galanko JA, Behrns KE, et al. Psychologic well-being of surgery residents after inception of the 80-hour workweek: a multi-institutional study. Surgery. 2005;138:150-157.

18. Goitein L, Shanafelt TD, Wipf JE, Slatore CG, Back AL. The effects of work-hour limitations on resident well-being, patient care, and education in an internal medicine residency program. Arch Intern Med. 2005;165:2601-2606.

19. Karamanoukian RL, Ku JK, DeLaRosa J, Karamanoukian HL, Evans GR. The effects of restricted work hours on clinical training. Am Surg. 2006;72:19-21.

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21. Gabbe SG, Webb LE, Moore DE, Jr, Mandel LS, Melville JL, Spickard WA, Jr. Can mentors prevent and reduce burnout in new chairs of departments of obstetrics and gynecology: results from a prospective, randomized pilot study. Am J Obstet Gynecol. 2008;198:653.e1-653.e7.

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Enter, the 80-hour workweek

In 2003, the Accreditation Council for Graduate Medical Education instituted the 80-hour workweek in an attempt to improve patient safety and the lifestyle of physicians in training. Many senior physicians believed that work-hour restriction would erode the quality of training, but this does not appear to have occurred.

Work-hour restriction among surgical residents has had no effect on academic performance but has markedly decreased psychological distress.¹⁷ Among medical residents, work-hour restriction has improved career satisfaction and decreased emotional exhaustion—but residents perceive restrictions to have impinged on patient care and resident education.¹⁸ Although surgical residents believe that restriction has reduced overall stress, improved quality of life, and provided time in which to manage their personal life, they are concerned about the limitation on exposure to patients—yet 96% of these residents would not be willing to add an additional year to their training.¹⁹

There is evidence that about one third of a resident’s time is spent performing activities of marginal or no educational value.²⁰ By eliminating these activities and making better use of simulators and patient surrogates, the workweek could be reduced even further, allowing the physician in training more time for interaction with patients and providing a better balance between work and personal life.

Burnout is widespread

If the goal is to retain physicians in the work-force, it is more important to reduce dissatisfaction than to increase satisfaction. Why? People who are dissatisfied are more likely to change what they are doing than those with any level of satisfaction.⁴

The profession must understand that burnout is common and directly related to increasing dissatisfaction.²¹

Burnout typically occurs when one has a highly demanding position with limited autonomy. A physician experiences burnout when one or more of the following is present:

emotional exhaustion
feelings of inadequacy in terms of personal accomplishment
depersonalization
increasing cynicism in personal interactions.²¹

This is an accurate description of the current state of medical practice.

Because “the times they are a-changin’,” it is necessary that leaders within the medical profession drastically change the way that medicine is taught and practiced.^22-24

Any further changes—beyond work-hour limitations—should be carefully designed with a mechanism in place to evaluate effects on both physicians and patients. A new approach to the practice of medicine is desperately needed to allow a better work-life balance while maintaining the focus on quality and safety.

Ways to reduce dissatisfaction

Dr. Abigail Zuger summed up the feelings of many when she wrote: “The profession of medicine has taken its members on a wild ride during the past century: a slow, glorious climb in well-being, followed by a steep, stomach-churning fall.”²⁵

I offer the following proposals for discussion. My primary aim in developing these suggestions was to give physicians more of that most precious of commodities: time. More time has the potential to change the work-life balance and improve both professional and personal satisfaction at the same time that it decreases dissatisfaction.

Again: The key to retaining physicians in the workforce is to decrease dissatisfaction. That is more likely to have the desired effect of a larger, stable workforce than is increasing the number of medical students and physicians in training. As is true in most aspects of life, it is easier and cheaper to improve what you already have, recycle what you can, and replace only what is absolutely necessary.

Recommendations—for practitioners, academic and private

Limit work hours to 50 or fewer per week. Many physicians work too many hours; this is not beneficial to them, their families, and their patients.²⁶ For both patient safety and physician well-being, it is time to voluntarily restrict our work hours before federal legislation creates limits for us.
Develop new models of practice, such as the use of a laborist for obstetric coverage. The implementation of a hospital-based laborist program allows a safer environment for the patient, a rapid-response team presence, and a controlled lifestyle for physicians who desire to practice obstetrics.²⁷ Structured properly, such models are revenue-neutral for the institution. (See OBG Management’s recent article, “The laborists are here, but can they thrive in US hospitals?” in the August 2008 issue, available at www.obgmanagement.com.)
Create part-time professional liability insurance policies. Premiums for these policies should be prorated according to the amount of clinical time worked and the physician’s work record. Insurance policies also need to be written to cover a slot rather than a particular individual, so that several physicians can share the same position to equal one full-time practitioner.
Increase job sharing and part-time employment so that these options become more attractive. With job sharing, two physicians work 50% of the time, adding up to one full-time practitioner. This option will reduce physician dissatisfaction and has the potential to increase the work life of the practitioner while improving patient safety.²⁸ Job sharing will also facilitate recruitment and retention of the current workforce.²⁹
Acquire time- and money-management skills. Most practitioners need to develop these abilities because so many stressors are related to limits on time and money.
In academic medicine, revamp the current career trajectory. The timeline that includes tenure and unrealistic expectations for promotion is archaic and needs to be eliminated. Most Generations X and Y physicians find it to be inflexible at exactly the wrong time in their life. Forced to choose between work on one hand and family and personal well-being on the other, they will almost always choose family and personal life first.³⁰ Similar changes are recommended for the private practitioner under consideration for partnership.