Introduction
In the book Ender’s Game, humans face a time-dilation war in which they must travel light-years into the future to face an enemy of unknown strength and scale. The weapons and technology they possess for the journey may be outdated by their arrival, because relativity minimizes the passage of time. The same dilemma is true for medical and premedical students who can spend decades in training, only to emerge without the proper knowledge or tools to navigate a win-or-die marketplace. The arena within which physicians operate is governed by cultural, economic, and natural forces of reality that create unique and incredible demands on physicians. In this article, we will examine these three elemental forces, analyze how they shape the medical profession to contribute to burnout, and offer new styles of training to mitigate their effects. The next generation of student doctors must be armed with tactical information about their future careers.
Physician burnout
The discrepancy between the demands of the job and the training physicians receive has fueled a tidal wave of burnout in physicians—a syndrome characterized by a sense of diminished personal achievement and emotional exhaustion that almost 50 percent of all doctors experience. Many students enter medicine with honorable and practical ideations: that they will ply science to help others and have a relatively secure and respected place in society. While these circumstances may be partially true, the fundamentals of the profession have shifted from the honored and independent application of medicine with excellent compensation, to employment models with reduced compensation, autonomy, and respect. When confronted with the rigors of the job (which have not changed) and meager payback, physicians understandably can become burnt out.
Physician burnout is very harmful to society. Physician burnout leads to workforce attrition, reduced care hours, and even physician suicide. As such, interest in “physician wellness” has surged—albeit as nebulous corporate-speak for physician mental, physical, and social health/well-being. Physician wellness focuses on individual practices such as mindfulness and small-group therapy, but, while helpful, these practices lack the power to overcome the elemental forces of the job. Corporate initiatives to help with burnout can actually harm physicians by not addressing its root causes.
It’s obvious why physician burnout is so detrimental. Although some will shrug off burnout as “the cost of being a doctor,” the financial implications on society and the healthcare industry resulting from loss of productivity and physician turnover are estimated at $5 billion annually. There is no more critical work force in society than physicians, who orchestrate the health care of millions of Americans, particularly the elderly. Currently, many patients struggle to access primary and specialty care in America, and this problem is only expected to expand in the future. A physician shortage has the two-fold effect of leaving vulnerable communities without treatment and inspiring societal maneuvers to dilute the physician work force with other healthcare providers that are easier to train than physicians.
Burnout is caused by unrelenting, emotionally intensive work and its effects stem from the industrialization of medicine, as physicians are increasingly charged with caring for more and more patients but given less control and fewer resources. We need physicians who are engaged and at their best rather than dejected and looking for a career change. Furthermore, we need to inspire the best and brightest to see a career in medicine as a still-attractive option, even though tech and finance jobs may offer better work-life balance. Finally, we must understand that burnout affects patients, not just through physician shortages, but also by lowering the quality of care, raising the cost of care, and by changing physicians into depersonalized worker bots.
Three elemental forces—economic, cultural, and natural—currently work in perfect unison to create a hazardous and unforgiving environment for physicians. A typical civilian job would have to contend with one or maybe two of these forces (see Table 1), but not all three daily. In medicine, these three forces combine to create incredible demands on the physician.
Cultural forces
For our purposes, we define cultural forces as trends in social acceptance/inclusion, organizational politics, and medicolegal conventions. For example, physicians must empathetically guide their patients through arduous treatment regimens and disease states. They must please the public and get along well with coworkers, assistants, and administrators, while staying within the bounds of legal and organizational rules.
Physicians must navigate an intense cultural relationship with patients who come from many different backgrounds. For instance, more than 25 million Americans speak English as a second language, which can lead to intrinsic communication difficulties. Doctors are tasked with treating complex diseases in ways that are palatable for patients, their families, and society. The delivery of medical care is also often fraught with human inconsistency as patients fail to take their medications, neglect to show up for appointments, and generally have difficulty following instructions.
Physicians occupy a unique, idealized role in society. Due to the high burden of trust placed in them and the enormous amount of education they must attain, an aura of perfection is projected onto them by society. Whereas human flaws are understandably tolerated in other fields, the same leniency is often not granted to doctors, of whom only excellence is expected. Doctors must be perfectly kind and cordial, adept at swiftly making the correct diagnosis and prescribing an effective treatment, skilled enough to perform surgery without complications or mishaps, and nimble enough to juggle an infinite variety of clerical tasks, all with often incomplete knowledge and human bodies with an inexhaustible number of ways that things can go wrong. Of course, high professional expectations are not unique to the medical field, but for doctors, mistakes and blemishes are not tolerated in the same way they are for other fields. These expectations can take on a moral dimension, as doctors are expected to be paragons of virtue and knowledge, deftly handling complex moral dilemmas with life-or-death consequences. As a result, perfectionism, a trait which manifests as overly unattainable standards for oneself and others, is prevalent among physicians and is implicated in physician burnout, depression, and suicide.
Finally, the culture of medicine has shifted significantly through its democratization and through increasing corporate-physician employment. In a corporate structure, all employees are considered assets, which erodes physician authority to guide clinic workflow. Instead of directing the operations of a medical practice, physicians instead must barter with administrators to get what they need. This loss of autonomy contributes to physician burnout. Furthermore, in this type of environment, physicians are relegated to activities such as entering orders into a computerized system, answering unlimited emails, or doing other secretarial work related to the electronic medical record. These tasks only add to the already arduous pre-existing workload physicians must shoulder. Thus, physicians must walk the tightrope of trying to get their enormous burden of work completed and deal with market and natural forces (see table below) with assistants who are no longer obligated to help. To do this, physicians must delicately ply social understanding and become masters of politics to get the attention of administrations who may be unwilling to help. These political battles weigh heavily on physicians who are already significantly burdened with the care of the sick, and they can be some of the most demoralizing factors in a physician’s life. Organizational climate, namely structures in which physicians have increased control, have been shown to reduce burnout. However, recent years have seen increasing erosion of physician control in medical structures across nearly every specialty.
Economic forces
For our purposes, economic forces will be defined as the compensation rates of physician services determined by supply and demand, and are driven by factors such as governmental regulation and value/productivity measures.
Physicians are not shielded from economic forces. Most physicians will enter the marketplace with considerably more debt than previous generations of doctors. Medical student debt has risen to $170,000 on average in 2014 from $50,000 in 1992. For comparison, according to the Bureau of Labor Statistics, the debt of a medical student in 1992 would be equal to $86,115 in 2014 and $113,972 in today’s money. In 2022, more than 76 percent of students had medical school debt greater than $200,000. Not only do they carry this debt, but they also lose out on a decade of income productivity while they are in school and training.
Accompanying this rise in debt level, the return on investment in medical education is steadily dropping with imposed fee schedules. To be compensated for their work, physicians must be contracted with insurance companies. In this system, private physicians have no leverage against large healthcare corporations that can command rich contracts from payers. Combined with the debt they face, most doctors will thus be forced into an employed model where they work for a corporate hospital system.
Even employed physician compensation is typically tied to some form of production-based salary linked to national averages. What this means is that most physicians will have to contend with volume delivery of patient care to generate income. In this way, doctors must face supply and demand, which can be affected by competition, clinic efficiency, and geography. The prospect of diagnosing and curing illness is what drives most to choose medicine rather than seeing as many patients as possible. However, medicine has become like a car manufacturing company: producing more units brings in more salary. If the value of those units drops, the physician will need to produce higher unit numbers at a more efficient rate to maintain a particular salary. In turn, this has a negative effect on the quality of care that doctors can provide.
Furthermore, physicians are not compensated for a significant portion of work that is either not billable or simply not paid by insurance companies. In the United States, physicians undertake an estimated $54 billion of uncompensated work. Dealing with so-called prior authorizations, where insurance companies insert themselves into the patient-physician relationship, requires an army of administrative staff, driving up the cost of providing care and leaving physicians to foot the bill.
All these issues combine to make medical practice very challenging from a business perspective and limits physicians’ ability to provide well-rounded care to patients.
Forces of nature
The forces of nature, for our purposes, are defined as the powerful elements in disease, treatment, and prognosis that are beyond human control. These include things such as the uncertainty and randomness of pathological events, and our inability to alter their course.
Medicine care is fraught with variability and volatility. Just like a wildfire may be blown in different directions by a changeable wind and available fuel sources, the same disease progression will be different in every patient. Medical treatments are subject to individual efficacy, working well for some but not all. Medical emergencies happen at all hours, not just between 9 a.m. and 5 p.m. There is a distinction between the forces of nature that affect physicians and those that affect other careers. Occasionally, natural disasters will ravage large portions of society and obviously affect all jobs, but the natural forces that doctors contend with in a day-to-day work environment are unlike those faced in any other field.
Physicians must contend with the forces of nature in treating their patients daily, as nothing in clinical medicine is 100-percent guaranteed. Furthermore, all humans eventually succumb to nature either through disease, aging, or trauma, and sometimes our modern medical armamentaria are useless.
Using scientific knowledge and experience, physicians must battle the forces of natural disease and are expected (often by their own will) to win every time. Many areas of medicine are still not totally understood and cannot be predicted with absolute certainty. Despite best efforts, medical errors are an inescapable reality of medicine and occur at a rate of 3–16 percent per encounter with a patient. Many of these errors are largely beyond physician control, occurring because of patient, organizational, or other staffing factors. Medical errors and poor patient safety result in devastating blows to physician morale and increase the risk of burnout.
Uncertainty in dealing with the forces of nature causes anguish in physicians because of a sometimes-total lack of control (19). This can be in the diagnosis, treatment, or even the prognosis of a disease. Total understanding of any situation is impossible, considering we may be ignorant of hidden variables or may lack the means to alter their natural course. Physicians must work through harrowing situations, sometimes daily, where patients suffer terrible fates or perish. They must bear the burden of comforting patients or families who have suffered great loss. Doctors often consider these losses as personal defeats in their war against nature.
| Table 1: How Elemental Forces Influence Various Professions | |||||
| Forces | Firefighter | Lawyer | Engineer | Business | Physician |
| Cultural | NO
Firefighters are generally well respected and protected in society. For example, they do not need to battle administration or insurance in order to put out fires in the way that doctors do |
YES
Lawyers serve a critical role in society but are not always seen in a positive light. They must contend with human forces daily (working with judges, juries, clients, etc.) |
YES
Engineers make products and systems for consumer use and thus are exposed to cultural forces |
YES
Businessmen sell to the public and must contend with cultural forces both within and outside the company |
YES
Physicians must skillfully interact with patients, their families, and the public. They must also navigate complex workplace cultures |
| Economic | NO
Firefighters are protected by robust workers’ compensation and pension plans. Their salaries are not tied to market forces |
YES
Lawyers are paid by number of cases and thus are exposed to productivity and market forces |
NO
Most engineers are salaried and are not exposed to raw market forces |
YES
The business of selling products and services is strictly governed by market forces |
YES
Physicians are reimbursed by production volume and are subject to market forces |
| Nature | YES
Firefighters must deal with natural disasters and thus contend with the forces of nature |
NO
Law is a human construct and not subject to the forces of nature. While they deal with uncertainty, they are not batting the fundamental intractability of nature itself |
YES
Engineers must contend with the laws of science and nature, and the uncertainty that comes with it |
NO
Like law, business is a human construct and does not typically require raw interaction with natural forces |
YES
Physicians must interact with the natural world of disease science daily and deal with its inherent uncertainty |
New training tools are needed
Learning to shine your shoes and make your bed to specification are part of learning military discipline but do little to help soldiers on the front lines when bullets are flying. Similarly, our current training regimens in medicine focus on learning discipline: rounding early, performing copious menial tasks, presenting cases for superiors, staying late, and working long hours. While these things build character and are important for creating the culture of medicine, they focus on individual expenditure of energy, which may be finite. Furthermore, they do not prepare doctors for the heartbreak and sometimes terror that await them as attending physicians.
As we journey further into the era of industrialized medicine, doctors need new training tools to change the power balance of the elemental forces they contend with. This will lead not only to happier and safer patients who will benefit from capable doctors who are armed well to fight disease, but also to doctors who are happier, have longer careers, and who bring the best version of themselves to work every day. Medicine is a holy calling, to which the best and brightest answer with significant sacrifice and dedication. These individuals must be protected and promoted at all costs.
At the Surgical Fitness Research Pod, we are currently developing these tools and giving them to premedical students before they even start training, so the skills have time to develop and mature. Our hope is that with these tools and information, they will have a better expectation of medicine as a career and will have the means to prepare themselves for the fight when they exit their training. The research and training are centered on dealing with the elemental cultural, economic, and natural forces, and augment traditional medical study of science and disease.
Yoshihiro Katsuura is an orthopedic surgeon and author of The Spine Encyclopedia: Everything You’ve Wanted to Know about Back and Neck Pain but Were Too Afraid to Ask. Andrew Roos, James Schmit, and Rebecca Hu are premedical students.
